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NURSING CARE PATIENT "GP" WITH EAR INFECTION AT BLUE

CROSS MEDICA CLINIC IN ROYAL BEACH HOTEL SEMINYAK


MAY 8TH MAY 2015

A. Assessment
The initial assessment was conducted on May 8th, 2015 at 10:00 am
in Royal Beach Hotel Seminyak. Data were obtained through interviews
with patients, observation, and physical examination. The results of data
collection that has been done is :
1. Identity
Patient Patients Family
Name : GP : JP
MRN : 143957
Age : 3 years old : 28 years old
Gender : Male : Male
Nationality : Australia : Australia
Address : Sydney : Sydney
Relation with Patient : Father
Insurance : Allianz International
Medical Diagnose : Ear Infection

2. Health History
a. Main Complain
Father of the patient said that patient complaint that his ear was so itch
and feel paint sometimes.
b. History Of Recent Illness
Two days ago patient has swimming in kuta beach, a day after he
swimming he complaint that his right ear was itch until to day, because
the itches didnt become better his parent decided to call blue cross
medica clinic. Allergy: patient dont have allergy with medicine, food,
etc.
Medical Diagnose : Right ear infection.
c. Past Medical History
None

3. Bio - Psycho - Social Spiritual Data


Breathing

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Before hospitalize and when assessments patient havent complain in
breathing
Meal and Drink
Patient said that his last meal at 10.00 am this morning and he drunk 2
glasses of water (500 ml) since this morning
Elimination
1) Defecate
When assessment patient said that he havent defecate yet since
this morning
2) Urination
When assessment patient said that he had urination once (300 cc)
since this morning
Movement and Activity
Self Care Ability 0 1 2 3 4
Eating/Drinking
Bathing
Toileting
Dressing
Walking
Mobilization on
bed

0 : Independent 3 : Needs help and tools


1 : Using Tools 4 : Does not do
2 : Needs Help

Rest and Sleep


His parents said that patient can sleep well.
Body Temperature
When assessment his body temperature is 370C (36,50C 37,50C)
Personal Hygiene
Patient said that he take a bath twice in a day.
Comfort
Patient said that he feel itches in his right ear and some times fell pain.
Security
Patient fell so secured because his parents always there for him.

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Social/Communication
Patient usually use English to communication and patient able to
communicate without interruption
Recreation
Parents of patient said that he usually going to beach for refreshing
Physical Examination
1. Vital Sign
BP : - mmHg
T : 37 0C
Pulse : 85 x/mnt
HR : 18 x/mnt
2. Conscious :
GCS : 15
Eye :4
Motorik :5
Verbal :6

3. General Condition
a. Illness / Pain: -
b. Nutritional Status: Normal
BW: 15 kg Height: 120 cm
Attitude: Calm
c. Personal hygene: clean enough
d. Orientation time / place / person: Good
4. Head To Toe Examination
a. Head
Mesochepale form, there are no lesions, there is no tenderness, there
are no second-hand trauma, blonde hair color, hair equitable
distribution
b. Eye
Normal vision, sclera no jaundice, no conjunctival pallor, pupils isokor
c. Nose
Smell normal, there is no secret, there is no pull nostril
d. Ear
There is no bleeding, there are secret and fluid in right ear, blood (-),
e. Mouth and Teeth
Moist lips, oral hygiene sufficient, complete teeth
f. Neck
There is no enlargement of the thyroid gland, there are no lesions,
there are no lymphoid gland enlargement

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g. Thorax
Heart
1. Pulse: 96 x / min
2. Strength: Strong
3. Rhythm: Regular
Inspections: There pulsation
Palpation: Palpable pulses, strong heartbeat,
Percussion: dullness / dim (+) does not occur hepatomegaly
Auscultation: S1 S2 regular single
Pulmonary
1. Breath Frequency: 18 x / min
2. Quality: Normal
3. Sound Breath: Vesicular
4. Cough: None
5. The blockage of the airway: None
Chest retraction: None
Inspections: There is no chest muscle spasm, breath effort (-)
Palpation: Inspiration is longer than the expiratory
Percussion: Sonor / resonant
Auscultation: Vesicular + / +
h. Abdomen
Peristaltic Guts: 8 x / min
Bloating: None
Pain Press: None
Ascites: None
Inspections: There is no lesions, skin colour lighter
Auscultation: bowel sounds normal
Palpation: Tenderness (-)
Percussion: Sound tympani (+)
i. Genitalia
Unobservable
j. Skin
Turgor: Good
Laceration: Yes, on the right leg
Skin Colour: White
k. Extremity
Lesi (-), dirty (-), edema , CRT <2 sec,

Supporting Data
1. Laboratory
-

Patient had therapy:


1) Otopain Drop 2tts/6 jam

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PROBLEM ANALYSIS

Pre Surgery
No Data Etiology Nursing Diagnose
1 DS : Bacteri Comfort problem :
The patient said that he feel itches Itch
Inflamate the ear
in his right ear,
Ear Inflamation
DO :
The patient looked scratch his ear, Comfort problem : Itch
and not confortable.

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NURSING DIAGNOSIS

1. Comfortable Problem : Itch related to ear infection evidenced by patient said that he feel itches in his right ear, The patient
looked scratch his ear, and not confortable.

NURSING CARE PLAN


PRE SURGERY
Date /
No Diagnose Goals and Criteria Results Nursing care plan Rational
Time
1 Sunday, 8 1. Comfortable After given for 1x15 menute of - Recommend that the patient's to - To measure the cardiac
May 2015 Problem : Itch nursing care expected the itch keep ear remains dry. condition of patient
10.00 am related to ear can be controlled with
infection outcomes : - Instruct the patient to keep - To prevent infection
evidenced by - Vital sign within normal clothes, toiletries, and bed clean.
patient said that limit
he feel itches in - Patient didnt fell itch - Advise not to scratch the itchy - To prevent injury
his right ear, The - Patient verbalize said that area but rub it.
patient looked he isnt fell itch anymore
scratch his ear, - Delegate to give of drugs to

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and not overcome the infection. - Decrease the infection
confortable.

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IMPLEMENTATION
Pre Surgery
NO Date / NO
NURSING ACTIVITY FORMATIVE EVALUATION SIGN
Time DX
1 Sunday, 1 - Observation patient vital sign T : 36,3C, P: 96 x / minute, RR 18 x / menit,
8 May
2015
10.00 am

10.05 am 1 - Instruct the patient parent to keep clothes, Patient parent understand and said that they will do it
toiletries, and bed clean.

10.08 am 1 - Advise to dont scratch the itchy area but Patient understand and said that he will do it
rub it.

10.12 pm 1 - Delegate to give of drugs to overcome the Drugs in and allergies (-)
infection.
- Otopain ED (2tts/6hour)

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EVALUATION

No
Date / NO
SUMATIF EVALUATION SIGN
Time DX
1 Sunday, 1 S : Patient said that he still feel itch but much better than before,
8 May
2015 O : Patient looked still not comfortable, T : 36,2 C, P : 90 x / menit, RR 18 x / menit.
10.15 am
A : comfortable problem was not resolve

P : Continue therapy

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ASSESSMENT
Post Surgery

The surgery started from 06.15 and finished at 08.45 on Saturday, May 31 st 2015.
The assessment carried out on May 31st 2015 at 09.00 am after the surgery
process.

Bio - Psycho - Social Spiritual Data


Breathing
After surgery patient doesnt have any difficulty of breathing
Meal and Drink
After surgery patient just drink water 100 ml
Elimination
1) Defecate
Patient havent defecate yet after surgery
2) Urination
Patient havent urination yet after surgery
Movement and Activity
Self Care 0 1 2 3 4
Ability
Eating/Drinking
Bathing
Toileting
Dressing
Walking
Mobilization on
bed
0 : Independent 3 : Needs help and tools
1 : Using Tools 4 : Does not do
2 : Needs Help
Patient said that he could not move as usual, the ROM was limited,
and also patients ADL was not fully independent
Body Temperature
After the surgery his body temperature is 36,20C (36,50C 37,50C)
Comfort

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Patient said he feel pain in his right leg after surgery, pain scale 4 (0-
10), patient looked grimace

Physical Examination
1. Vital Sign
BP : 130/80 mmHg
T : 36,20C
Pulse : 86 x/mnt
HR : 18 x/mnt
2. Conscious :
GCS : 15
Eye :4
Motorik :5
Verbal :6

3. General Condition
e. Illness / Pain: Medium
P : surgery wound
Q : Patient feel sharp pain
R : pain on the right leg
S : Pain scale 4 (0-10)
T : patient feel pain when he move his leg
f. Nutritional Status: Normal
BW: 75 kg Height: 175 cm
Attitude: Calm
g. Personal hygene: clean enough
h. Orientation time / place / person: Good
4. Head To Toe Examination
a. Head
Mesochepale form, there are no lesions, there is no tenderness, there
are no second-hand trauma, blonde hair color, hair equitable
distribution
b. Eye
Normal vision, sclera no jaundice, no conjunctival pallor, pupils isokor
c. Nose
Smell normal, there is no secret, there is no pull nostril
d. Ear
There is no bleeding, there are no secret, fluid or blood
e. Mouth and Teeth
Moist lips, oral hygiene sufficient, complete teeth
f. Neck

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There is no enlargement of the thyroid gland, there are no lesions,
theres no lymphoid gland enlargement
g. Thorax
Heart
4. Pulse: 86 x / min
5. Strength: Strong
6. Rhythm: Regular
Inspections: There pulsation
Palpation: Palpable pulses, strong heartbeat,
Percussion: dullness / dim (+) does not occur hepatomegaly
Auscultation: S1 S2 regular single
Pulmonary
6. Breath Frequency: 18 x / min
7. Quality: Normal
8. Sound Breath: Vesicular
9. Cough: None
10. The blockage of the airway: None
Chest retraction: None
Inspections: There is no chest muscle spasm, breath effort (-)
Palpation: Inspiration is longer than the expiratory
Percussion: Sonor / resonant
Auscultation: Vesicular + / +

h. Abdomen
Peristaltic Guts: 8 x / min
Bloating: None
Pain Press: None
Ascites: None
Inspections: There is no lesions, skin colour lighter
Auscultation: bowel sounds normal
Palpation: Tenderness (-)
Percussion: Sound tympani (+)
i. Genitalia
Unobservable
j. Skin
Skin turgor was good, laceration on the right leg, skin colour is white
k. Extremity
There is a wound on the right leg, post debridement and ORIF,
bleeding (-) CRT <2 sec, length 10 cm

PROBLEM ANALYSIS
Post Surgery
No Data Etiology Nursing diagnose
1 DS : Bacteri Comfort problem :

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The patient said that he feel Itch
Inflamate the ear
itches in his right ear,
Ear Inflamation
DO :
The patient looked scratch his Comfort problem : Itch
ear, and not confortable.

NURSING DIAGNOSIS
Post Surgery
1. Acute pain related to damage of physical agents
with evidenced by patient said feel pain on his right leg after surgery, pain
scale 4 (0-10), patient feel sharp pain when he move his leg, patient looked
grimace, there is a wound on the right leg, post debridement and ORIF
2. Impaired physical mobility related to low of
strength and withstand cause of fractures is characterized by the patient said
that he could not move as usual, ROM was limited, and also patients ADL
was not fully independent
3. The risk for infection related to invasive
procedure/surgery

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NURSING CARE PLAN
Post Surgery
Date / Goals and Criteria
No Diagnose Nursing Care Plans Rational
Time Results
1 Saturday, Acute pain related to After given for 1x24 hours - Observe vital sign To measure the cardiac
30 May damage to physical agents of nursing care expected condition of patient
2015 with evidenced by patient the pain can be controlled
12.30 pm said feel pain on his right with outcomes : - Monitoring pain scale - To know affectivity of the
leg after surgery, pain scale - Vital sign within before and after give medicine for the pain of the
4 (0-10), patient looked normal limit medication patient
grin - Patient not grimace
- Patient verbalize a - Train the patient with pain - To make the patient relax
decrease of pain from 4 management like deep
to 2 (0-10) breathing relaxation
techniques and distracts
techniques

- Delegate to give analgesic - Pain killer

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Fentanyl 300mcg + NS
0,9% 50 ml, in 24 hours,
running 2,1 ml/hour

2 Saturday, Impaired physical mobility After given for 2x24 hour - Help the patient perform - Fulfilling needs of the patient
30 May related to low of strength of nursing care expected to self-care as needed self-care
2015 and withstand cause of the patient is able to
12.30 pm fractures is characterized increase / maintain mobility - Facilitating patient comfort - Make the patient feel
by the patient said that he at the highest level with the (room, position) comfortable and quiet
could not move as usual, Criteria result :
ROM was limited, and also - ADL of patients can be - Teach patient active- - Train the patient and avoid
patients ADL was not fully fulfilled independently passive ROM muscle atrophy
independent - ROM can be done
actively
3 Saturday, The risk for infection After given for 2x24 hour - Observe the wound and - To know sign of infection on
30 May related to invasive nursing care expected to signs of infection wound (dolor pain, kalor
2015 procedure / surgery prevent infection with feell hot, rubor redness,
12.30 pm Criteria Results : tumor swelling, funsio laesa
- The wound is clean change of function
- There is no sign of - Perform wound dressing - Wound care with aseptic

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infection with aseptic technique technique will reduce bacterial
- Dry wounds pathogens in the wound area

- Observe phlebitis scores - Monitoring the presence or


absence of infection in the area
is attached IVFD

- Delegate to give - Antibiotics can fight bacteria


antibiotics that cause infections in wound
Ceftriaxone
(Terfacef) 2gr IV
OD
Sagestam
(Gentamycine) 80
mg diluted with NS
0,9% 100 ml/hour
BID IV

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IMPLEMENTAION
Post Surgery
NO Date / NO
NURSING ACTIVITY FORMATIVE EVALUATION SIGN
Time DX
1 Sunday, 1 Observe vital sign T : 36,5 C, P : 88 x / menit, RR 20 x / menit, BP : 110 / 80
31 May mmHg.
2015
09.00 am

09.30 am 3 Observe phlebitis score Phlebitis score 0 (0-5)

10.00 am 3 Delegate in giving antibiotic medications Medication been inject by IV line, no allergy reaction
Sagestam (Gentamycine) 80 mg diluted with NS
0,9% 100 ml/hour BID IV

11.00 pm 2 Observe pain scale before give medication Pain scale is 4 (0-10)

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12.35 pm Delegate in giving analgesic medication Fentanyl Patient looked relax
300mcg + NS 0,9% 50 ml, in 24 hours, running
2,1 ml/hour

12.40 pm Observe pain scale after given medication Pain scale is 2 (0-10)

04.00 pm Give a comfortable position to the patient (elevate Patient looked comfortable
1 pillow)

10.00 pm Delegate in giving antibiotic medications Medication been inject by IV line, no allergy reaction
- Ceftriaxone (Terfacef) 2gr IV OD
- Sagestam (Gentamycine) 80 mg diluted
with NS 0,9% 100 ml/hour BID IV

2 Monday, 1,2 Observe vital sign T : 36,5 C, P : 84 x / menit, RR 20 x / menit, BP : 130/70

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1 June mmHg.
2015
05.30 am

06.00 am 3 Observe the wound and signs of infection There is no sign - a sign of infection in the wound (dolor -
pain, calor - heat, rubor - redness, tumor - swelling, funsio
laesa - change function

10.00 am 3 Delegate in giving antibiotic medications Medication been inject by IV line, no allergy reaction
Sagestam (Gentamycine) 80 mg diluted with NS
0,9% 100 ml/hour BID IV

11.00 am 3 Asses phlebitis score Phlebitis score 0 (0-5)

12.00 am 1 Observe pain scale before give medication Pain scale is 3 (0-10)

12.35 pm 1 Delegate in giving analgesic medication Fentanyl Patient looked relax


300mcg + NS 0,9% 50 ml, in 24 hours, running

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2,1 ml/hour

01.00 pm 1 Observe pain scale after medication Pain scale is 2 (0-10)

03.00 pm 2 Train the patient passive active ROM patient cooperative

03.30 pm 3 Dressing the wound Wound dressing by dr. Wien Sp.OT, wound maintained

10.00 pm 3 Delegate in giving antibiotic medications Medication been inject by IV line, no allergy reaction
- Ceftriaxone (Terfacef) 2gr IV OD
- Sagestam (Gentamycine) 80 mg diluted
with NS 0,9% 100 ml/hour BID IV

Tuesday, 1 Observe vital sign T : 36,5 C, P : 84 x / menit, RR 20 x / menit, BP : 130/70


2nd June mmHg.
2015
05.30 am

06.00 am 3 Observe the wound and signs of infection There is no sign - a sign of infection in the wound (dolor -

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pain, calor - heat, rubor - kemeraham, tumor - swelling, funsio
laesa - change function

11.00 am 1 Observe pain scale Pain scale 2 (0-10)

10.00 am 3 Delegate in giving antibiotic medications Medication been inject by IV line, no allergy reaction
Sagestam (Gentamycine) 80 mg diluted with NS
0,9% 100 ml/hour BID IV

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EVALUATION

Post Surgery
No NO
Date / Time SUMMATIVE EVALUATION SIGN
DX
1 Tuesday, 2nd 1 S: The patient said that the pain had decreas,pain scale 2 (0-10)
June 2015 O: The patient was calm and relaxed
10.30 pm A: Acute pain is resolved
Q: Maintain the patient condition
2 Tuesday, 2nd 2 S : Patient said his still had limited in movement
June 2015 O : Patient used crutches to walk and toileting
10.30 pm A : Impaired physical mobility is not resolved
P : Continue therapy
3 Tuesday, 2nd 3 S :-
June 2015 O : There is no sign of infection at the wound (dolor, calor, rubor, tumor, funsio laesa)
10.30 pm A : The risk for infection does not occur
P : Maintain the patient's condition

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