EMERGENCY & CRITICAL NURSING CARE DOCUMENTATIONHIGH CARE UNIT

CASE STUDY #1DISEASE DEFINITIONHyponatremia is a condition that occurs when the level of sodium in the blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to severe. Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous fluids and medications. Source: http://www.mayoclinic.com/health/hyponatremia/DS00974

ETIOLOGYCauses of hyponatremiaMany possible conditions and lifestyle factors can lead to hyponatremia, including:

Certain medications. Some medications, such as some antidepressants and pain medications, can cause you to urinate or perspire more than normal.

Water pills (diuretics) — especially thiazide diuretics. Diuretics work by making your body get rid of more sodium in urine. Cirrhosis. Liver disease can cause fluids to accumulate in your body. Kidney problems. Kidney failure and other kidney disease may make it hard to efficiently remove extra fluids from your body. Congestive heart failure. This condition causes your body to retain fluids. Syndrome of inappropriate anti-diuretic hormone (SIADH). In this condition, high levels of the anti-diuretic hormone (ADH) are

produced, causing your body to retain water instead of excreting it normally in your urine. Drinking too much water during exercise (exertional hyponatremia). Because you lose sodium through sweat, drinking too much

water during endurance activities, such as marathons and triathlons, can dilute the sodium content of your blood. Hormonal changes due to adrenal gland insufficiency (Addison's disease). Your adrenal glands produce hormones that help maintain

your body's balance of sodium, potassium and water. Hormonal changes due to an underactive thyroid (hypothyroidism). Hypothyroidism may result in a low blood-sodium level. Primary polydipsia. In this condition, your thirst increases significantly, causing you to drink too much fluid. The recreational drug Ecstasy. This amphetamine increases the risk of severe and even fatal cases of hyponatremia. Chronic, severe vomiting or diarrhea. This causes your body to lose fluids and electrolytes, such as sodium.

Dehydration. In dehydration, your body loses fluids and electrolytes. Diet. A low-sodium, high-water diet can sometimes disturb the proper balance between sodium and fluids in your blood.

Source: http://www.mayoclinic.com/health/hyponatremia/DS00974

CLINICAL MANIFESTATION

BIO DATAA. Client’s Name: K., Mrs.

Age: 63 yearsReligion: MoslemEducation: High School graduateJob: House-wifeTribe: Sundaese Date entered: 09/09/2012Assessment date: 10/09/2012-13/09/2012R. M. No.:Gender: FemaleMedical Diagnose: Imbalance electrolites (Hyponatremia, Hypopotassium, Hypocalcium)Doctor in charge: Dr. Eddy Taliwongso, Sp.DAddress: Padjajaran RT 004/RW 004, Bandung

B. Responsible person for the clientName: D. M., Mrs.Age: 62 yearsReligion: MoslemEducation: High SchoolJob: House-wifeTribe: SundaeseRelation w/ client: Younger sibling

Main Complaint: pain at the waist, nausea and weakPresent health Illness (03/09/2012): Pain at the hip for about three months, patient also has been fall down by accident about 2 months a go. Complain of cephalgia since last night.Health history: Client got hyperthyroid about 30-35 years ago; then heart disease (complication result from hyperthyroid).Client has been admitted to SW 2 since 03/09/2012 and entered HCU on 09/09/2012 due to over drinking water (> 3 Liters/day).

BIO-PHYSICAL DATADAILY HABITS (before sick)

1. SLEEP: 6-8 hours/day2. ELIMINATION: once in every 1- 2 days; soft stools, commonly.3. EXERCISE: home exercise by stretching and walking slowly with crutches.4. PERSONAL HYGIENE: daily bath.5. FOOD: Three times / day. Compose of: rice, veggie and fish/tofu/Tempe; fruits and no milk but warm water.6. WATER: 3L/day

DAILY HABITS (during sickness)1. SLEEP: 7-13 hours/day2. ELIMINATION: once in every 2 days; soft stools, commonly.3. EXERCISE: received twice/day physiotherapy.4. PERSONAL HYGIENE: daily bath at bed.5. FOOD: Three times/ day; soft diet.6. WATER: 1.5-2 L/day

PHYSICAL ASSESSMENT: 1. BLOOD PRESSURE: 112/54-120/69 mmHg2. HAIR: clean, gray in color, dandruff (-), course and dry.3. EYE: exophalamus. Eye Lid: Ptosis.4. NOSE: hair distribution fair, clean, medial septum deviate (-), NGT (+).

5. MOUTH: clean7. TEETH: teeth (29). False teeth(-).8. FACE: long, pigmented dots (+), dry skin9. NECK: jugular vein extended (-), lymph nodes palpable, soft, moveable; thyroid gland palpable at the lateral lobes.10. CHEST: breath shallow, trachea deviate (-)11. LUNG: crackles (-), ronchi (+), wheezing (+)12. HEART: jugular vein distended (-), beats soft, S1/S213. ABDOMEN: striae (+), round obese, bowel sound (+), bruits (-)14. UPPER EXTREMITIES: hematoma at dextra and sinistra arms, edema (-); clubbing nails (-), nails pale.15. LOWER EXTREMITIES: edema (-), ulcers at the ciruris dextra and sinistra.16. SKIN: dry and wrinkle17. GENITALIA: dirty; urine catheter (+) and under pad (+).

CONSCIOUSNESS DEGREE1. QUANTITATIF CONS: 152. MOTORIK RESPONSE: 6 3. SPEECH RESPONSE: 5 4. DEXTRA/SINISTRA PUPIL RESPONSE: 4 5. CONSCIOUSNESS: Compos Mentis (CM)

SOCIAL AND PSYCHOLOGYCAL DATA1. EXPRESSION: depressed2. EMOTION: stabile 3. COMMUNICATION: eye contact; talkative4. COUPING MECHANISM: eat low sodium and consume healthy foods.5. SOCIAL STATUS: married6. SOLE/HOUSE MATE: stayed with youngest daughter7. SOCIAL ACTIVITY: before sick active at gym. After sick stay at home and pray at the mosque.

SUPPORTING DATA

LABORATORIUM DATACXR (03/09/2012) CHEST EXAMINATION: Left ventricle hyperthropia with aorta sclerosis.

IMUNOLOGY / ENDOCRINE METABOLISM (03/09/2012)Free T3 Result: 1.24pg/mL Reference value: 2.6-5.4pg/mLMethod used: ELFA

CT SCAN (04/09/2012)MSCT EXAMINATION W/O CONTRAST MEDIA:tidak menunjukkan lesi iskemik, perdarahan, SOL/massa, malformasi vaskuler maupun kelainan lainnya.

CXR (06/09/2012)PELVIC (VERT-LUMBO SACRAL. AP-LAT) EXAMINATION:PELVIC AP: Rontgenologist pelvis saat ini tidak menunjukkan kelainan.

LUMBO-SACRAL AP-LAT: compresi fraktur corpus vertebrata L3 disetai penyempitan foramen intervertebralis L3-L4. Spondilosis deformasus.

CXR (06/09/2012)PATELLA (R-L-AP-LAT) EXAMINATION:GENU BILATERAL: Rontgenologist genu dextra saat ini tidak menunjukkan kelainan. Osteoarthritis (OA) genu sinistra grade I.

CHEMISTRY LAB EXAMINATION (09/09/2012)Sodium (Na) Result (specimen: blood): 110 mmol/L Reference value: 135-148 mmol/LPotassium (K) Result (specimen: blood): 3.17 mmol/L Reference value: 3.50-5.30 mmol/L

MEDICINESCefipime 2x1 grInpepsa 3x1 CILasix 2x2 ampTimol 1x1 tetes ODSLyteers 3x4 tetes/hr ODSDorzol 1x1 tetes ODSOndencentron 3x1ampCa.lactat 1x1 tabPanloc 2x 1 grNaCL 2x3 tabAspar K 2x3 tab

NURSING CARE PLAN(10/09/2012) Nursing Diagnosis:I. Gangguan rasa nyaman s/d nyeri pinggang.

Tujuan & Kriteria hasil:Agar nyeri pinggang dapat menurun dengan criteria:

- Pasien merasa nyaman

Intervensi:- Member posisi yang nyaman kepada pasien- Mmberikan therapy obat Ketoprofene salep sesuai order dokter- Membalur punggung pasien dengan alcohol rub

Rational:- Posisi yang nyaman dapat mengurangi rasa nyeri pd pasien- Ketoprofren bersifat analgetik yang dapat menghilangkan rasa nyeri - Dengan alcohol rub dapat melancarkan peredaran darah.

II. Gangguan keseimbangan elekrolit: hyponatrium s/d pemakaian diuretic ditandai dengan:

DS: “ badan lemas, mual”DO: keadaan umum pasien lemah

Tujuan & Kriteria hasil:Gangguan elektrolit tidak terjadi/ teratasi setelah tindakan keperawatan menunjukan:

- Klien tidak megeluh badan lemah, mual, dan tidak nafsu makan- Serum sodium 135-140 meq/liter- pH urine normal

Intervensi:- monitor I & O- hitung keseimbangan cairan- amati tingkat kesadaran respond neuromuscular- anjurkan makan minum tinggi sodium (susu, telur, wortel, juice buah-buahan dan kaldu)- kolaborasi dengan dokter dalam pemeriksaan: elektrolit dan osmoliaty, pemberian dan pembatasan cairan dan untuk pemberian obat-

obatan: NaCl tablet atau NS 0.9%

Rational:- memantau keseimbangan cairan tubuh- untuk mengetahui balance cairan yang masuk dan cairan tubuh yang keluar- output urine yang terlalu banyak dapat menyebabkan dehidrasi atau penurunan kesadaran- untuk menigkatkan kadar sodium pada pasien- terlalu banyak minum air dapat mengurangi kadar sodium dalam darah ps sehingga input cairan harus dibatasi. Pemberian tablet Nacl

atau infuse NS dapat meningkatkan kadar sodium dalam darah.

PATHOPHYSIOLOGY

CASE STUDY #2DISEASE DEFINITION

ETIOLOGY

CLINICAL MANIFESTATIONSTREATMENT Eating, Diet, and Nutrition

Analisa data Pathophysiology Nursing Diagnose