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NURSING CARE FOR TN. R WITH PULMONARY TUBERCULOSIS IN TERATAI

ROOM A RSUD CIAWI BOGOR DISTRICT

Submitted to fulfill the clerkship assignment for the medical-surgical nursing I course.

Supervisor:

Ns. Camalia S. S., M.Kep., Sp.Kom

Prepared by:

Mirna Nurlita (P17320321055)

Level 2B

Group A

HEALTH POLYTECHNIC KEMENKES BANDUNG

DIII NURSING STUDY PROGRAM BOGOR

2023
 NURSING CARE
I. REVIEW
A. Identity
1. Client
- Nam e : Mr. R
- Ag e : 33 years and 2 months
- Gender : Men
- Marital Status : Mating
- Last education : S1
- Religio n : Islam
- Job s : Entrepreneur
- Addres s : Compound radio/49A
- No. RM : 00.78.89.03
- Medical Diagnosis : Tuberculosis
- Date of entry : 12-04-2023
- Date of assessment : 12-04-2023
2. Person in Charge
- Nam e : Mrs. D
- Ag e : 43 years old
- Gender : Women
- Last Education : S1
- Job s : IRT
- Addres s : Compound radio/49A
- Hub with patients : Wife
B. Chief Complaint
Shortness of breath accompanied by secretions
C. Current Medical History
The client came to the emergency room of Ciawi Hospital escorted by the cadre on
Friday, March 11, 2023 at 14.00 WIB with complaints of shortness of breath felt 2 weeks
before entering the hospital especially at night, the client said coughing with phlegm. The
client said he had received pulmonary TB drug therapy in Jakarta according to BPJS
domicile. However, the client dropped out of the drug for 4 months and only applied the
1
 therapy for 1 month, the reason for dropping out of the drug was because the client felt too
far from the referral hospital to control the disease. The client said he felt weak and the
client's weight had decreased, the client's initial weight was 53 kg, the current weight was
50 kg, the client said his appetite had decreased from 2 weeks before entering the hospital
until now, the client said the pain was in the lower abdomen near the testicles, the pain was
aggravated when walking and coughing, the pain was relieved when resting, the client said
the pain was like being stabbed by a blunt object, the client said the pain radiated from near
the testicles to the waist, the client said the pain scale was 4, the client said the pain
appeared with a duration of 1-3 minutes.
After observation on Wednesday, April 12, 2023, the results of TD were obtained:
110/70 mmHg N: 80x/min RR: 25 x/min S : 36.90 SPO2: 96 %.
D. Previous Medical History
The client said that in high school he had undergone an appendectomy, the client said he had
a motorcycle accident, the client said he had no history of food or drug allergies, the client
was sick with pulmonary TB detected 1 year ago.
E. Family Health History and Genogram
The client said no one in the family had infectious diseases such as pulmonary TB or
pneumonia, no one in the family had hypertension, and no one had heart disease. However,
the client said her mother has a history of type two diabetes.

2
F. Physical Examination
1. Awareness Level
a. Quality : Compos Mentis
b. Quantias :
I. Eye Response :6
II. Verbal Response :5
III. Eye-opening Response : 4
Total: 15 2.
Vital signs
a. Blood Pressure: 110/70 mmHg
b. Pulse : 80 x/min
c. Breathing : 25 x/min
d. Temperature : 36.9 C 0
3. Antopometry
a. Weight :
- Before illness : 53 kg
- After illness : 50 kg
b. Height : 165 cmn
c. BMI : 18.5 (normal weight)
G. Systematic physical examination
1. Head
a. Head and hair
Inspection : Normocepali, black hair color, and clean hair.
Palpation : No lumps and no tenderness.
b. Eye
Inspection : Symmetrical movement of the right and left eyes, pink
conjunctiva, non icteric sclera, isocorrected pupils, clean eye hygiene c. Nose
Inspection: No nasal polyps, no nostril breathing, clean nostrils.

Palpation: No tenderness
d. Ears

3
 Inspection : The shape of the right and left ears are symmetrical, no lesions,
clean ear holes.
Palpation : No tenderness and no lump.

e. Mouth
Inspection : Lips slightly dry, mouth clean, teeth clean no caries, teeth
complete, no gum swelling.
f. Neck
Inspection: no swelling of the thyroid gland and no jugular vein enlargement.
Palpation : no tenderness
2. Thoracic and respiratory function
a. Thorak
Inspection: Chest wall retraction (-), rapid and deep breathing rate, cough with
phlegm, sputum product (+) white in color, RR: 25 x/min, SPO2:
96%, vocal fremitus palpable in both lung fields.

Auscultation: Ronchi (+)

3. Heart Check
Inspection : no swelling and visible ictus cordis, and
Percussion : hoarse sound
Auscultation: heard S1 and S2 regular "lup dup" no additional sound, blood pressure
110/70 mmHg.
Palpation : no tenderness and pulse 80x/minute
4. Abdominal Examination
Inspection: skin color appears normal, there is no swelling and there is an
appendectomy scar.
Palpation : No tenderness
Auscultation : normal bowel noise 18x/minute
Percussion : no bloating

5. Skin and extremities

4
 Inspection Movement of upper and lower extremities is normal, an IV is
attached to the left hand.
Palpation : CRT < 2 seconds, no edema, and acral warmth.

6. Genitalia

Inspection: there is a lump in the testicle, the client is male H. Daily habits
No. Basic stakes Before illness After illness
1. NUTRITION POLE
a. Meal frequency: The client said that at The client said that his
... x/day home he ate three times a meals during illness had
b. Appetite day, was not nauseous, become 1x a day since 2
: good/no the portion of the meal weeks before entering the
Reason : was always spent, there hospital, felt nauseous,
nausea/vomiting etc. were no foods that were the portion of food spent
c. Portion of meal spent not reduced, there were was only ½ portion, there
d. Unfavorable food no foods that made were no foods that were
e. Allergenic foods allergies, the client had not reduced, there were
f. Food restrictions restrictions on eating no foods that made
g. Diet food sweet foods, the client did allergies, the client had
h. Use of medication not have any drugs before restrictions on eating
before meals eating and the client did sweet foods, the client did
i. Use of assistive not eat. not have any drugs before
devices (NGT)
using tools eating and the client did
not have any allergies.
using tools

5
2. ELIMINATION POLE a. BAK a. BAK
a. BAK Client urinates at home Client urinates at home
1. Frequency: 46 times a day with a salama 46 times a day
...x/day clear yellow color, no with a clear yellow color,
2. Color complaints and no use of no complaints and no use
3. Complaint assistive devices. of assistive devices.
4. Use of assistive
devices
(catheters, etc.) b. BAB b. BAB
b. BAB Clients defecate at home The client defecates at the
1. Frequency: 1-2 times / day with a hospital 1 time / day with
...x/day yellowish brown color, a yellowish brown color,
2. Color solid soft consistency and solid soft consistency and
3. Complaint do not use up does not use
4. consistency lactifacient drugs lactifacient drugs
5. Usage
lactasif
(yes/no) if yes
write the name
of the medicine

3. PERSONAL POLE
HYGINE
a. Bathing a. Take a shower a. Bathing
1. Frequency The client takes 2 Clients bathe once a
2. Time showers a day in the day with a washcloth
b. Oral hygine morning and evening b. Oral hygine
1. Frequency b. Oral hygine Client brushes teeth 2
2. Time Client brushes teeth 2 times a day in the
c. Wash your hair times a day in the morning and night
1. frequency morning and at night c. Wash your hair

6
 c. Wash hair

Client washes Client does not wash

rambyt 2x/week hair

4. REST PATTERNS AND

SLEEP The client said the nap The client says napping
was 2 hours and the night
a. nap length for 2 hours and sleeping at
sleep was 8 hours before
b. length of night sleep going to bed at night the night 6-7 hours often
c. habits before client likes to watch tv.
wakes up, before going to
sleep bed at night.
client likes to watch tv

5. ACTIVITY PATTERNS
AND
EXERCISE Client's working hours client does not work, and
a. working time are 8-10 hours, client likes
does not walk in the
to exercise by walking
b. type of sport
every morning. morning due to tightness
c. frequency
and pain when
d. complaints in
move
move

7
 6. HABIT PATTERNS THAT
INFLUENCE
HEALTH The client before The client does not cork
a. smoking contracting pulmonary TB when sick
1. frequency was a smoker, the client
2. amount had smoked again but at
3. length of use most only 5 cigarettes /
b. Drinks day
hard drugs/drugs
yes/no
The client has never The client has never
1. Frequency consumed drugs / hard consumed drugs / hard
drugs drugs
2. Total
3. Length of use

I. Psychosocial and Social Data

1. The client said the relationship with family, and neighbors is good there is no problem
2. The client said he lives with his wife, and three children
J. Spiritual Data
1. The client said that he performed the 5 daily prayers, and before he was admitted, he fasted
during the month of Ramadan.
K. Supporting data
1. Laboratory Results
Nam e : Mr. R
Gender : Men
Ag e : 33 years
old
Dat e :
11/04/2023
Parameters Results Reference Unit
Value

8
A. HEMATOLOGY
Whole Blood
- Hemoglobin 15,4 13,2-17,3 u/dL
- Hematocrit 51 45-52 %
- Erythrocytes 6,3 4,5-6,5 10˄9L
- Lekocytes 9,3 4-11 Thousand/uL
- Platelets 336 150-440

Count Type
- Basophils 1 0-1 %
- Easinophils 7 2-4 %
- Lymposites - 71 40-72 %
Monocytes 14 24-40 %
7 2-8 %
81 80-100 Pq
MCV
25 26-34 Pq
MCHC
30 32-36 %
LED
33 0-10 Mm/hour
NLR

9
 ALC 5,24 <= 3.13 %
1.260 >1500 /uL

B. GD
CHEMISTRY 272 80-120 mq/dL
during 23,3 10,0- mq/dL
0,72 50,0
Ureum mq/dL
0,60-
Creatinine 1,30 mq/dL
10
SGOT 8 U/L
0-50
SGPT 134 U/L mq/dL
0-50
- Sodium 3,7 mq/dL
135-145
- Potassium 3,5-5,3

L. Therapy program and management

Name of Medicine Dosage Route Usage
4 FDC 1x3 PO Used to treat tuberculosis and
infection by mycobacterium
bacteria.
certain opportunistic
Vitamin B6 1x1 PO Drugs that can prevent the side
effects of insoiazine (anti-
tuberculosis), namely the effects
of peripheral neutritis)

Omeprazole 1x40 mg IV Used to treat excess stomach acid

and the complaints that follow.

Ondansentron 1x4 mg IV Used to prevent nausea and

vomiting.

10
 Desketoprofen 1x50 mg IV Used to relieve mild to moderate
pain due to certain conditions.

II. DATA ANALYSIS

No. Data Gap Etiology Nursing Problems

1. DS: Mycobacterium
- Client says shortness of Tuberculosis
breath and coughing up ↓
phlegm Droplet
- The client said it was ↓
difficult to remove the Settling in the air
sputum. ↓
- The client said he was Inhalation
admitted to the hospital ↓
Ineffective airway
because he stopped taking his Sticking to the
clearance
TB medication 4 months ago, airway
consuming his medication ↓
for only 1 month. Bronchial
inhalation
- The client says he is an
↓
active DO smoker:
Irritation of the
- The client appears to be
bronchi
breathing quickly and deeply
↓
- The client appears to be Sputum production
coughing
↓
- Client appears limp
Cough
- Client is not on oxygen
↓
- The sound of the TTV ronkhi
Ineffective airway
was heard:
clearance
BP: 110/70 mmHg
N : 80 x/min
S : 36.6 C 0

11
RR: 25x/min

SPO2: 96%

12
2. DS:
- Lifting heavy weights
The client said the pain was
↓
in the lower abdomen near
TIA increased
the testicles, the pain was
↓
aggravated when walking
The process does
and coughing, the pain was
not undergo
relieved when resting, the
obliteration
client said the pain was like
↓
being poked by a blunt Acute pain
Inguinal hernia
object, the client said the pain
↓
radiated from near the
testicles to the waist, the
Hernia sac
client said the pain scale was
entering the
4, the client said the pain
ingual cleft
appeared with a duration of
↓
1-3 minutes.
DO: Posterior dinting of
- the ingunal canalis
The client appears to be
- grimacing the weak

The client looked weak and ↓

- restless because of the pain Scrotal enlargement
TTV ↓
BP: 110/70 mmHg Sense of well-being
N : 80x/min disorder
S : 36.6 C 0 ↓
RR: 25x/min Acute Pain

13
3. DS: The client said nausea The Pain perception
- client said that when he was ↓
- sick his appetite decreased Stimulate
The client said he sympathetic activity
- only ate 1x / day ↓
when at home Effects on GI
↓
DO: Client appears limp Slow food movement
- Risk of nutritional
The client's pre-sick weight ↓
- Food stuck in the deficits
was 53 kg after the illness
became 50 kg with a BMI of stomach
18.5. ↓
- TB: 165 cm Stretch reflex in the
- TD: 110/70 stomach
- N : 80x/min ↓
Feeling of vomiting
onset
↓
Anorexia
↓
Risk of nutritional
deficits

14
III. PRIORITY OF NURSING DIAGNOSES
1. (D. 0001) Ineffective airway clearance b/d airway hypersecretion d/d cough with phlegm
2. (D. 0077) Acute pain due to physical injury agents
3. (D. 0032) Risk of nutritional deficits due to psychological factors such as reluctance to eat
due to pain.
IV. NURSING INTERVENTION
Date Nursing Objectives and
diagnosis outcome criteria Intervention Rational

15
Wednesday, I (L. 01001) Clean (I. 0101011) Road
12/04/2023 Ineffective Management
Path of Breathing
airway After being treated for Breath Observation
clearance Observation
3x24 hours, it is 1. Can find out the state of
1. Monitor breath patterns patient regarding their
expected that airway
(frequency, depth, breath breathing pattern
clearance will improve 2. May be aware of additional
effort)
with the outcome sounds that could be a detection
2. Monitor for additional
criteria: of respiratory distress
breath sounds
- Effective cough 3. Can determine the patient's
(e.g. gurgling, condition through sputum or
- Decreased
wheezing, wheezing, dry for lab checks
sputum production
ronchi) 4. May reduce shortness of
- Rongkhi downhill
breath
3. Monitor sputum (amount,
- Breathing
5. May loosen and thin phlegm
frequency color, smell) Therapeutic
improves
4. Position the semi-fowler or
fowler

16
- Improved 5. Give a warm drink 6. Can meet client's fluid
breathing pattern Education needs
6. Recommend fluid intake 7. May help clear the airway of
2000 ml.day, if there are no secretions that are difficult
to expel
contraindications
7. Teach coughing techniques
effective

17
 (L.08066) Pain (I.08238) Pain management
Acute Pain Level Observation 1. Can determine the location,
(D.0077) After taking treatment 1. Identify the location, characteristics, duration,
for 3x24 characteristics, frequency, intensity of
hours, it is duration, search to determine the next
expected that the frequency, intensity of plan.
pain level will pain 2. Can determine the level of

improve with the 2. Identify the pain scale pain felt by the client

outcome criteria: 3. Identify non-verbal pain 3. Can determine the true level

- Decreased pain responses of pain from the client's

complaints 4. Identify aggravating nonverbal response.

- Decreased and as from the look on his face

grimace therapeutic pain relief 4. In order to reduce factors

that can aggravate pain
5. Facilitate rest and sleep
Education

18
6. Teach nonpharmacologic 5. For clients to get
techniques Collaboration comfortable
7. Collaborative 6. Can alleviate client pain
administration of with non-pharmacological
analgesics techniques
7. Can reduce / eliminate the
pain experienced by
clients with therapy
Pharmacological

19
3 Deficit (L. 06053) (I. 03119)
risk Nutrition Status Nutrition Management
nutrition After taking nursing Observation
(D. 0032) actions for 3x24 hours, it 1. Identification of 1. Can know the nutritional
is expected that nutritional status needs needed so that it can
2. Identify preferred foods determine the appropriate
nutritional status will
3. Monitor food intake diet
improve with the
4. Therapeutic weight
outcome criteria: 2. In order to be able to
monitor
- Portion of food determine the type of food
spent increases 5. Serve food attractively that is suitable and does not
and in a suu trigger allergies or nausea
as per and vomiting on
patient

20
- Eating 6. Feed high-calorie, high- 3. Can facilitate the
frequency protein foods fulfillment of patient
- improves Education nutrition
Appetite. 7. Encourage sitting position 4. Can monitor food intake that
- improve 8. Teach the may increase weight.
Mucous membrane programmed diet 5. May increase appetite
improves
Collaboration 6. Can meet the client's protein
9. Collaboration on and caloric needs
medication administration 7. May aspirate, food enters the
before tract
eat, if necessary breathing
8. For the client to understand
the diet that will be given
9. May reduce nausea before
meals

21
V. NURSING INTERVENTION AND EVALUATION
Date and No.Dx Implementation Evaluation TTD
time

22
Wednesday, I - Monitor breath patterns (frequency,
12/04/2023 S: Mirna
depth, breath effort)
14.00 R : Rr: 25 x/min, client appears to be -
breathing fast and deep. -
- Monitor for additional breath sounds (e.g.
gurgling, wheezing, wheezing, dry ronchi) R -
: audible ronchi the client says it feels tight
Monitor sputum (amount, color, smell) R : client says comfortable
- There is 5 ml of sputum, with yellowish with semi-fowler position
white color. O: The client said he could expel his
Positioning semi-fowler or fowler R: client - phlegm after drinking warm
- says comfortable with semi-fowler position. water and coughing.
Giving a warm drink - Effective
R : The client said he was able to expel his -

- phlegm after drinking warm water. the client appears to be breathing

Recommended fluid intake 2000 ml.day , if - fast and deep sounding ronchi
there are no contraindications there is sputum as much as 5 ml,
- yellowish in color
-
The client appears to be able to
cough effectively RR: 24x/min

23
- Teaching effective coughing A : Airway clearance issues
techniques partially resolved
R : The client appears to be able to cough P : Intervention continued
effectively, but the client says it still feels a
little tight. - Monitor breath patterns (frequency,
depth, breath effort)
- Monitor for additional breath
sounds (eg: gurgling, wheezing,
wheezing, dry ronchi)
- Monitor sputum (amount, color,
smell)
- Give a warm drink
- Encourage fluid intake of 2000
ml.day, if there is no
contraindications
- Evaluation Effective cough
technique

24
 II - Identify the location, characteristics, duration, S :
Wednesday, - The client says the pain is in the Mirna
frequency, intensity of pain
12/04/2023 lower abdomen near the
R: the client said the pain was in the lower testicles, the pain is aggravated
14.00 abdomen near the testicles, the client said the when walking and coughing, the
pain appeared with a duration of 1-3 minutes, pain is relieved when resting, the
the client said the pain was like being stabbed client said the pain
by a blunt object, the client stated the pain.

25
 It extends from near the testicles to the like being stabbed by a blunt
waist. object, the client stated that the
Identifying the pain scale pain radiated from near the
R: scale 4 (mild pain) testicles to the waist.
-
Identify non-verbal pain responses After giving medication the
R: client looks grimacing in pain client said the pain scale was 3
-
Identify factors that aggravate and alleviate clients said the pain appeared
-
pain with a duration of 1-2 minutes.
-
R: pain is aggravated when walking and The client said it was difficult to
coughing, pain is relieved when resting. sleep
Facilitate rest and sleep
-
Teaching nonpharmacological techniques The client appears to be
-
with deep breathing techniques grimacing
- O:
R: the client said the pain was a little in pain
-
defeated. The client appeared agitated due

Collaborate on analgesic administration to the pain

-
R : Desketoprofen 1x50 mg IV Client appears limp
-
Therapy: Desketoprofen 1x50
- mg
- IV
- N : 112x/min

26
 - BP: 110/80 mmHg
A : Acute pain problem partially
resolved
P : Intervention continued

- Identify the location,

characteristics, duration,
frequency, intensity of pain
- Identify the pain scale
- Identify non-verbal pain
responses

- Identify factors that

aggravate and alleviate pain

- Facilitate rest and sleep

- Teach nonpharmacological
techniques with deep breathing
techniques
- Collaborative administration of
analgesics

27
 III - Identifying nutritional status S: The client stated that he only
Wednesday, R : BMI: 18.5 client noted feeling nauseous - finished ½ portion of his food The
12/04/2023
- Monitor food intake client said he felt nauseous and his Mirna
14.00 -
R: client said he only finished ½ portion of appetite was reduced from 2
his food Monitor weight. weeks before entering the house
- R : Weight before illness 53 kg after illness sick
50 kg
Serving food attractively and at an O : Client appears limp
- appropriate temperature -

28
- Feeding high-calorie and high-protein foods - The client exhausts the meaning ½
Recommended sitting position portion
- Teaching the programmed diet - Body weight before illness 53 kg
- R : The client said he understood the nurse's after illness 50 kg
advice - BMI: 18.5 patients were within the
Collaborate on medication normal BMI range.
administration
- - Omeprazole 1x40 mg and
before meals, if necessary
ondansentron 1x4 mg
R : Omeprazole 1x40 mg and ondansentron
A : Problem partially resolved
1x4 mg
P : Intervention continued
- Identifying nutritional status
- Monitoring food intake
- Weight monitor
- Serve food attractively and at an
appropriate temperature
- Feed high-calorie, high-protein
foods
- Encourage sitting position
- Teach programmed diet
- Collaborate on medication
administration before meals, if
necessary

29
30
VI. PROGRESS NOTES
Date and No. SOAPIE TTD
Time DX
Kamnis, I S: the client says the tightness is reduced
13/04/2023 Mirna
- client says comfortable in semi fowler position
14.00 - The client said he could expel his phlegm after drinking warm water and coughing
- effectively.

O: the client appears to be breathing rapidly and

- deeply with ronchi sounds.
- there is sputum as much as 3 ml, yellowish in color
- The client appears to be able to cough
- effectively RR: 22 x/min
-
Airway clearance problem partially resolved
A : Intervention continued
P : Monitor breath patterns (frequency, depth, breath effort)
- Monitor for additional breath sounds (e.g. gurgling, wheezing, wheezing, dry ronchi)
- Monitor sputum (amount, color, smell)
- Give a warm drink
- Teach effective coughing techniques
-

31
I : - Monitor breath patterns (frequency, depth, breath effort)

R : RR: 24 x/min
- Monitor for additional breath sounds (e.g. gurgling, wheezing, wheezing, dry ronchi)
R : There is still ronchi sound
- Monitor sputum (amount, color, smell)
R : There is 3 ml of sputum with a brassy color.
- Giving a warm drink
R : The client said he felt relieved after drinking warm water.
- Evaluating effective coughing techniques
R : The client said he always did the effective cough technique when it was difficult to
remove the sputum.

32
E : Airway clearance problem partially resolved, intervention continued
- Monitor breath patterns (frequency, depth, breath effort)
- Monitor for additional breath sounds (e.g. gurgling, wheezing, wheezing, dry ronchi)
- Monitor sputum (amount, color, smell)
- Give a warm drink
- Evaluation Effective cough technique

33
Thursday, II S:
13/04/2023 Mirna
-
14.00
The client said the pain was in the lower abdomen near the testicles, the pain was
aggravated when walking and coughing, the pain was relieved when resting, the client

- said the pain was like pinching, the client said the pain radiated from near the testicles
to the waist.

- O After giving medication the client said the pain scale was 2 clients said the pain
: appeared with a duration of 1-2 minutes. The client said it was difficult to sleep

-
- The client's grimace appears reduced
- The client's restlessness seemed to decrease and the client seemed calm
- Client appears limp
- Therapy: Desketoprofen 1x50 mg IV
- A N : 90 x/min
: BP: 110/70 mmHg

P : Acute pain problem partially resolved

- Intervention continued
Identify the location, characteristics, duration, frequency, intensity of pain
-
Identify the pain scale
-
Identify non-verbal pain responses
-
Identify factors that aggravate and alleviate pain
-
Facilitate rest and sleep

34
 - Teach nonpharmacological techniques with deep breathing techniques

I:
-
Identify the location, characteristics, duration, frequency, intensity of pain
R:: the client said the pain was in the lower abdomen near the testicles, the client said
the pain appeared with a duration of 1-3 minutes, the client said the pain was like being
stabbed by a blunt object, the client said the pain radiated from near the testicles to the
waist.
- Identifying the pain scale
R : Pain scale 3

- Identifying non-verbal pain responses

R : The client appears to occasionally grimace and fidget due to the pain.

- Identify factors that aggravate and alleviate pain

R: pain is aggravated when walking and coughing, pain is relieved when resting.

- Facilitate rest and sleep

- Teaching nonpharmacological techniques with deep breathing techniques

R: the client said the nesting was slightly reduced after the deep breath technique.

35
E : Acute pain problem partially resolved intervention continued
- Identify the location, characteristics, duration, frequency, intensity of pain
- Identify the pain scale
- Identify non-verbal pain responses
- Identify factors that aggravate and alleviate pain
- Facilitate rest and sleep

- Teach nonpharmacological techniques with deep breathing techniques

36
 S:
Thursday, III Mirna
13/04/2023
- The client said he ate one breakfast and one lunch.
- The client said the nausea had decreased
14.00
- The client says his appetite is starting to improve O :
- The client does not appear limp
- The client finishes the meaning of 1 serving
- Body weight before illness 53 kg after illness 50 kg
- BMI: 18.5 patients were within the normal BMI range.
A : Problem partially resolved
P : Intervention continued
- Identification of nutritional status
- Monitor food intake
- Weight monitor
- Serve food attractively and at an appropriate temperature
- Feed high-calorie, high-protein foods
- Encourage sitting position
- Teach programmed diet
- Collaborate on medication administration before meals, if necessary
I:
- Identify nutritional status

37
 R : BMI: 18,5
- Monitoring food intake
R : The client said that this morning he ate 1 portion but was still a little nauseous.
- Monitoring body weight
R : WEIGHT: 50 kg
- Serving food attractively and at an appropriate temperature
- Feeding high-calorie and high-protein foods
- Recommended sitting position
- Collaborate on medication administration before meals, if necessary R: Omeprazole
1x40 mg and ondansentron 1x4 mg
E : Nutritional deficit problem partially resolved, intervention continued
- Identification of nutritional status
- Monitor food intake
- Weight monitor
- Serve food attractively and at an appropriate temperature
- Feed high-calorie, high-protein foods
- Encourage sitting position
- Teach programmed diet
- Collaborate on medication administration before meals, if necessary

38
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 Friday, I S:
14/04/2023 Mirna
- the client said it was not so tight
21.00 - The client said he could expel his phlegm after drinking warm water and coughing.
O
effective:
- the client appears to be breathing deeply and rapidly
- There is still sura ronchi but it has started to decrease
- There is 2 ml of sputum, yellowish in color
- Client appears to be able to cough effectively
- RR: 20 x/min
A : Airway clearance problem partially resolved
P : Intervention continued
- Monitor breathing pattern (frequency, depth, breath effort)
- Monitor for additional breath sounds (e.g. gurgling, wheezing, wheezing, dry ronchi)
- Monitor sputum (amount, color, smell)
- Give a warm drink
- Encourage fluid intake of 2000 ml.day, if there are no contraindications - Teach
effective coughing techniques
I:
- Monitor breath patterns (frequency, depth, breath effort)
R : RR: 22 x/minute is not so tight anymore
- Monitor for additional breath sounds (e.g. gurgling, wheezing, wheezing, dry ronchi)

40
 R : There is still sura ronchi but it has started to decrease.
- Monitor sputum (amount, color, smell)
R : There is 2 ml of sputum with a brassy color.
- Giving a warm drink
R : The client said he felt relieved after drinking warm water.
- Evaluating effective coughing techniques
R : The client said he always did the effective cough technique when it was
difficult to remove sputum.

E : Airway clearance problem resolved, intervention stopped

41
 Friday, II S:
14/04/2023 Mirna
-
21.00
The client said the pain was in the lower abdomen near the testicles, the pain was
aggravated when walking and coughing, the pain was relieved when resting, the client
said the pain was like pinching, the client said the pain radiated from near the testicles
-
to the waist.
After giving medication the client said the pain scale was 2 clients said the pain
-
appeared with a duration of 1-2 minutes. The client said it was difficult to sleep
O:
-
Clinician's grimace appears reduced
-
The client's restlessness has decreased and the client appears calm.
-
Client appears limp

- Therapy: Desketoprofen 1x50 mg IV

- N : 90 x/min
- BP: 110/70 mmHg
A : Acute pain problem partially resolved
P : Intervention continued
- Identify the location, characteristics, duration, frequency, intensity of pain

- Identify the pain scale

- Identify non-verbal pain responses

42
 - Identify factors that aggravate and alleviate pain

- Facilitate rest and sleep

- Teach nonpharmacological techniques with deep breathing techniques

I:
-
Identify the location, characteristics, duration, frequency, intensity of pain
R : The client said that he had no pain in the lower abdomen near the testicles, but
sometimes it still felt occasional pain like pinching, with a duration of 30 seconds-1
minute, the pain did not radiate.
- Identifying the pain scale
R : Pain scale 1

- Identify non-verbal pain responses

R : The client does not appear to be grimacing and is not agitated.

- Identify factors that aggravate and alleviate pain

R: no pain when walking

- Facilitate rest and sleep

- Teaching nonpharmacological techniques with deep breathing techniques R:
the client said it was no longer painful.
E : Acute pain problem resolved, intervention stopped

43
 Friday, III S:
14/04/2023 Mirna
- The client said he ate one breakfast and one lunch.
- The client said he no longer felt nauseous
- The client said his appetite had improved O :
- The client does not appear limp
- The client consumes the meaning of 1 serving in the morning and afternoon
- Weight before illness 53 kg after illness 51 kg
- BMI: 18.7 patients were within the normal BMI range.
A : Problem partially resolved
P : Intervention continued
- Identification of nutritional status
- Monitor food intake
- Weight monitor
- Serve food attractively and at an appropriate temperature
- Feed high-calorie, high-protein foods
- Encourage sitting position

- Teach programmed diet

- Collaborate on medication administration before meals, if necessary
I: -

Identifying nutritional status

R : BMI: 18,7

44
 - Monitoring dietary intake
R : The client said that in the morning and at noon he ate 1 portion and was not nauseous.
- Monitoring body weight
R : BW : 51 kg
- Serving food attractively and at an appropriate temperature
- Feeding high-calorie and high-protein foods
- Recommended sitting position
- Collaborate on medication administration before meals, if necessary.
R : Omeprazole 1x40 mg and ondansentron 1x4 mg
E : Nutritional deficit risk problem resolved, intervention stopped

45