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NURSING CARE PLAN with CLIENT SIXTH DAYS POST OP HERNIA

INGUINALIS LATERALIS INCASERATA with HYSTORY of DIABETES

MELLITUS MULTAZAM WARD PKU MUHAMMADIYAH HOSPITAL

SURAKATA

By :

MUHAMMAD SYAFIQI A M (J210102001)

ANNISA DANNI KARTIKA (J210102005 )

NII NU NAESEE (J210100035)

Bachelor of International Nursing Health Science Faculty

Muhammadiyah University of Surakarta

2012


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NURSING CARE PLAN MR. S SIXTH DAYS POST OP HERNIA INGUINALIS

LATERALIS INCASERATA with HYSTORY of DIABETES MELLITUS

MULTAZAM WARD PKU MUHAMMADIYAH HOSPITAL SURAKARTA

ASSESSMENT

A. SELF IDENTITY

1. Client

Name : Mr. S

Age : 61 years old

Gender : Male

Religion : Islam

Education : Senior high school

Job : Jobless

Marriage status : Married

Address : Karangasem 1/VIIILaweyan Surakarta

No CM : 234481

Informant : Client, family, and medical status

Date of assessment : December, 4th

2012Date come to hospital : November, 30 th 2012

Medical diagnose :Hernia Incarcerata, DM, and CKD

2. Care - taker

Name : Mr. B

Age : 34 years old

Job : Private / laborer

Address : Karangasem 1/VIII Laweyan SurakartaClients relation : Child

B. HEALTH HISTORY

1. Chief complaint : Client complaint that he has dypsnea, no cough,

no sputum, pain on the wound in lower right abdomen if he want to move ,

intermittent, like stab of needle, sometimes at the morning, at noon or night,

scale 4.


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2. Current health history : before hospitalization client is suffered diabetes

mellitus, enter to emergency room with mass on scrotum, then enter to multazam

ward post op hernia incaserata.

3. Past health history : Diabetes mellitus since 10 years ago

Genogram : Explanation :

: Female

: Male

: Death

: Close family

: One house

: Client

4. Family health history :

Family havent health history like client.

5. Case management History :

DateDx.

MedicalDiagnostic support

Therapy /

interventionNovember,

30 th 2012

Hernia

InguinalisMass in testis Operation

November,

30 th 2012CKD Increasing Blood Ureum Nitrogen Hemodialisis

December,

30 th 2012

Diabetes

MelitusGDS : 175,3 Insulin therapy

C. CURRENT ASSESMENT ( GORDON FUNCTIONAL PATTERN )

1. Health perception health management :

Health is godness, if client is sick, he come to family docter.

2. Nutritional metabolic pattern: Food Intake:

a. Before hospitalization :client eats anything 3 times / day full portion.


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b. During hospitalization : client eats diet porridge rice DM 3 times / day

plus extra fooding one times.

Drink Intake :

a. Before hospitalization : client drink 4 glass 200cc / day, mineral water or

tea

b. During hospitalization : client drink 3 glass 200cc / day, mineral water or

tea, infusion ringer laktat 20 drop / minute on right hand.

3. Elimination pattern

a. Bowel movement Before hospitalization : 1 times / week, color : yellow, odor : tipically,

tekstur : soft.

During hospitalization : 1 times, color : yellow, odor : tipically, tekstur :

soft

b. Urination Before hospitalization : 10 times / day drippings, color : yellow During hospitalization : using catheter 500cc per / 12 hour , color :

orange

4. Activity exercise pattern:Capability self - hygiene 0 1 2 3 4

Eat / drink

Bathing

Toileting

Dressing

Mobilization on bed

mobilization

Ambulation / ROM

Explanation :

0 : Independent 3 : Assissted Other And Tool

1 : Support Tools 4 : Totally Depending

2 : Assissted Others

- Oxsigenasion: client using nasal canul

5. Sleep rest pattern:


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Before hospitalization : take a nap 2 hour, sleep 7 hour / day, deep sleep,

rare wake up at night

During hospitalization : take a nap 3 hour, sleep 8 hour / day, easy to

wake up

6. Perceptual pattern :

During illness :

Vision : client said blurred vision Hearing : client said hear chiming clock Tasting : client can taste sweet and salt Smelling : client can smell eucalyptus oil Sensasion : client can feel pain in lower right abdomen if want to move,

scale 4, intermittent and like stab of needle, sometimes at the

morning, at noon or night,.

7. Self perception pattern

a. Self image : client fell comfort with all his body although had

amputation on left leg.

b. Self esteem : client had good relation wit his environment.

c. Self Ideal : client hopes health so he can stay at home.

d. Self role : client as father

e. Self identity : client is a male, married and has 6 childrens

8. Role relationship pattern

Client cant met neighbor and can share story with them at home

9. Coping stress tolerance pattern

Client never angry, just be patient with all situation.

10. Value believe patternClient is religious people, he believe to God that he will get well soon and never

hope to die, he always does pray fifth times / day.

D. PHYSICAL EXAMINATION

1. General appearance : composmentis

2. Consciousness : E 4M6V5 = 15

3. Vital Sign : BP : 140 / 90 mmHg T : 36,5o

C


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RR : 22 x/ minute HR : 92 x/minute

4. Head : mesocephal Hair : color : black and white, no dandruf, rare hair almost

bald

Eye : pupil isokor, conjugctiva : no anemis, sklera : no ikteric Nose : simetric, clean no secret Ear : clean no secret, no lesion

5. Mouth : no stomatities, teeth loss 8, upper 3 lower 5

6. Neck : no enlargement tyroid gland

7. Thorax : symmetric

a. Lung : I : Chest expansion symetric

Pal : No pain, bloating lung power 3 cm

Per : Dim

Aus : Dry ronchi

b. Hearth : I : I ctus cordis didnt show

Pal : No pulsation

Per : Dim

Aus : Regular

8. Abdomen : I : abdomen surface is flat and symetric

Aus : Intestine Peristaltic 14 times/minute

Pal : liver and lien cant touch

Per : Tympanic

9. Inguinal : no enlargement lymph gland

10. Genital : genital is clean, no mass

11. Extremities :5 5

Amputation

55

E. THERAPY PROGRAM

1. Furozemid : 2 ml / 12 hour

2.

Ceftriaxone : 1 gr / 12 hour


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3. Ketorolac : 1 gr / 12 hour

4. Ranitidine : 50 mg / 2 ml / 12 hour

5. Methylprednisolone : 2 ml / 8 hour

6. Nebulizer / 8 hour

Antropen : 10 drops

Birotex : 10 drops

Pulmicord : 1 flash

7. Fargoxin 25mg : 1 x 1/2

8. Spironolactane 25 mg : 1 x 1

9. Amlodipine 10 mg : 1 x 1

10. Nocid : 3 x 211. ISDN : 3 x 1

12. Euphylin : 3 x 1

13. Norbirapid :

Ciprofloxaxin : 2 x 1

Ca.CO 3 5 gr : 2 x 1

14. RL 20 drop / minute

15. Insulin therapyF. DIAGOSTIC PROGRAM

Date Examination Result Unit Referral

November

30 th 2012

Hematologi

Lekosit

Eritrosit

Hemoglobin

RetikolositFeritin

Urine

SGOT

SGPT

Ureum

Kreatinin

8,20

2,79

8.0

2.1622,41

14

8

73,2

3,58

%Mg / ml

U / L

U / L

0,5 1,568 434

< 35

< 41

December, Radiology on 1. Increasing


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2n 2012 the thorax area vesicular

movement

2. Both of sinus

costofrenicus

are dull

3. Both Of

Diaphragma are

slick

Impression :

cardiomegali with

pulmonum edema

and bilateral

effusion pleura.

November

30 th

December,

1th

2th

3th

4th 2012

GDS

175,3

187

198335

74

156

308

360

Mg/dl 70 115

G. DATA ANALYSIS

No. Data Etiology Probleme

1 DS: Patient said that he got

dyspnea

DO: 140/90

RR/: 16/m

T:36,5 0

Obstruction

(secrets) in

airway

Ineffective Airway

clearence


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HR : 92/m

2

DS : Patient said that he feel pain

in abdomen area

DO: Patient looks weak

Biologic Agent

of Injury (Hernia)

Acute Pain

3 DS : Patient is less of knowledge

of his disease

DO : Patient looks anxiety

Lack of science

about the disease

Deficit knowledge

H. NURSING DIAGNOSE

1. Inneffective airway clearance related to obstructions in airway manifested

by dyspnea RR : 22/M

2. Pain related to Biologic Agent of Injury (Hernia)Manifested by pain in

abdomen area

3. Anxiety related to lack of science about the disease manifested by Deficit

Knowledge about the disesae

I. INTERVENTION

No Nursing

diagnose

Goal & outcome Planning Rationale

1 Inneffectiv

e airway

clearance

related toobstructio

ns in

airway

manifested

by dyspnea

RR : 22/M

After 3 x 24 Client will

demonstrate the ability to

improve and maintain the

effectiveness of airwayExpected outcomes:

- The sound of breathing clean

- Ronchi (-)

- Tracheal tube obstruction-free

1.Auskultasi

breath sounds

every 2-4 hours or

as needed2.Lakukan

sucking sound

when ronchi by:

a. explain to

clients about the

purpose of

sucking action

1. Evaluating the

effectiveness of

airway clearance

a. Improve

understanding to

facilitate client

participation


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b. give

oxygenation with

100% O2 prior to

inhalation, at least

4-5 x respiratory

c. attended aseptic

technique, use of

sterile gloves, a

sterile suction

catheter

d. enter catheter

into the ETT tube

in a state does not

suck, sucking long

no more 10

seconds

e. no more

suction pressures100-120 mmHg

f.Lakukan

oxygenation again

with 100% O2

before the nextinhalation

g.Lakukan

exploitation

repeatedly until

breath sounds

clean

3.Pertahankan

b. Give up

oxygen to prevent

hypoxia

c. Preventing

nosocomial

infections

d. Aspiration can

lead to long

hypoxia cause

sucking action

will issue

secretions and

oxygen

e. Excessivenegative

pressures can

damage the

airway mucosa

f. Giving up

oxygen in the

lungs

g. Ensuring the

effectiveness of

the airway

3. Help thin

secretions


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humidifier warm

temperatures (35

to 37.8 C)

No Nursing

diagnose


2 Pain

related to

Biologic

Agent of

Injury

(Hernia)M

anifested

by pain in

abdomen

area

pain levels can be reduced /

eliminated after receiving

treatment for (3 x 24 hours).

1) Assess the

location of pain,

pain

characteristics and

quality.

2) Observation of

the non-verbal

signs of

discomfort

3) Provide

information about

the pain, the

cause, and plans

anticipated.

4) Teach the use

of non

pharmacologic

techniques.

5) Provide relief /

pain relief with

analgesics


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prescribed.

6) Increase the

proximity of rest /

sleep

7.Monitor patients

for pain

management

satisfaction.

8) Perform

preoperative

preparation if

causes pain

requires surgery

No Nursing

diagnose


3 Anxiety

related to

lack of

science

about the

disease

manifestedby deficit

knowlet

about the

disease

anxiety is reduced or absent

after nursing actions during the

(1 x 24 hours).

1) Assess the level

of anxiety the

client / family.

2) Assess the level

of knowledge of

the client / familyabout the hernia

and the actions

that need to be

done.

3) Explain to the

client / family

about the disease,


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hernia (definition,

cause and effect)

and the operative

measures

necessary for the

client.

4) Allow the

client / family to

ask questions after

explanation nurse.

5) Explain the

result of anxiety

experienced by

the client.

6) Record the

signs of anxiety

that appears on

the client / family7) Assess vital

signs

8) Describe the

flow of operations

and prepare the

operating permit.

9) Provide mentaland spiritual

support to clients

and families.

10) Collaboration

Religious

leaders

appropriate


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religious

affiliation

Physicians for

sedation

J. IMPLEMENTATION

DX Date / Time Intervention Response Signature

I-II December,

4th 2012 /

08.30 am

Nursing assessment

Observe client

condition.

S : client share about the condition

O: client cooperative answer all

question

client complaint dyspnea, pain

in the wound, blurred vision.

BP : 140 / 90

T : 37 oC

RR : 23 x/ minute

HR : 94 x/ minute

Niinu

II 09.00 am Wound care S : client fell comfort, still pain

but intermittent

O:the wound hadnt odor, redness,

and pus.

Niinu

I-II 09.30 am Injection drug IV S : client no complaint

O : drug enter by IV

Niinu

I-II 12. 00 am Lunch S : client feel full

O : client completed all diet

Niinu

I-II 01.00 am Take a nap S : client feel fresh

O : client look calm

Niinu

I-II 02.30 pm Bathing S : client feel fresh Annisa


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O : client look clean

I-II 03.00 pm Observe condition

of client, vital sign

S : client said still little dyspnea

O : BP : 140 / 80 mmHg

T : 37 oC

RR : 22 x / minute

HR : 90 x / minute

Annisa

I 04.00 pm Deep breathing

exercise

S : client said better

O : client cooperative do exercise

Annisa

II 04.15 pm Relaxation

technique

S : client said better

O : client calm, do by self

Annisa

I-II 04.35 pm Dinner

Oral drug

S : client feel full

O : diet completed, drug enter by

oral

Annisa

I-II 05.00 pm Injection IV drug

Furozemid

Ceftriaxone

S : client no complaint


Annisa

II 06.45 pm Create calm

situation

S : no complaint

O: client look calm

Annisa

I -

II

09.00 pm Giving Injectio

Ketorolac, 5 ml

Ranitidine, 2 ml

S : No complaint

O : Client is patient

Savi

I 09.00 pmGiving Nebulizer

S: diyspneu is decreased

O : Patient fell comfort

Savi

II 5 t 2012

December05.00 am

Injection

Furosemid

S : No complaint

O : Client is patient

Savi

III 06.00 am

Monitor VS

S : No complaint

O : BP : 160/100,RR : 16, HR : 72

T :36,5 0

Savi

DX Date / Time Intervention Response Signature


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I-II 5 t 2012

December

02.30 pm

Bathing S : client feel fresh


Niinu




O : BP : 140 / 80 mmHg

T : 37 oC

RR : 22 x / minute

HR : 90 x / minute

Niinu


Oral drug



oral

Niinu

I-II 05.00 pm Injection IV drug S : client no complaint


Niinu


situation

S : no complaint

O: client look calm

Niinu

I-

III

08.30 pm Observe general

condition


O : composmentis, look calm

Annisa

I -

III

09.00 pm Injection drug via

IV

1. Ketorolac

2. Ranitidine

3. Metil

prednizolon

S : client said no pain

O : drug enter via IV

Annisa

I 09.00 pm 1. NebulizerAntropen : 10

drops

Birotex : 10

drops

Pulmicord : 1

flash

S : client was relievedO : nebulizer run well

Annisa


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III 09.30 pm Educating disease S : client said always hungry

O : client understand the reason

Annisa

III 11.00 pm Observe Sleeping S : -

O : client deep sleep

Annisa

I-II 01.00 pmControl fluid intake

S : -

O : infusion run well

Annisa

II 6 th 2012

December

05.00 am

Bathing

S : client said cold

O : client look fresh, no change

the cloth

Annisa

I-

III

06.15 am

Fooding

Oral drug (8)

S : client said so many drug that

he want drink

O : diet completely

Drug enter via oral

Annisa

07.00 am Savii

Savi

Savi

Savi

Savi

02. 00 pm Savi

I-II 02.30 pm Bathing S : client feel fresh


Niinu




O : BP : 160 / 80 mmHg

T : 37 oC

RR : 20 x / minuteHR : 90 x / minute

Niinu


Oral drug



oral

Niinu

I-II 05.00 pm Injection IV drug

Furozemid

Ceftriaxone



Niinu


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situation

S : no complaint

O: client look calm

Niinu

I-

III

7t 2012

December

08.00 am

Observe general

condition

S : no dypsnea

O : didnt use nasal canul

Annisa

10.00 amExtra food

S : client still hungry

O : diet completely

Annisa

11.00 amMonitor intake fluid

S : client drank 1 glass 200cc

O : infusion wida ns 20 drop/m

Annisa

11.30 am Check blood

glucose level


O : 149

Annisa

01.00 pmInsulin injection

S : no pain

O : insulin enter via SC

Annisa

Vi tadi qm satu shift ma aq

nglakuin apa tulis urut jam ya vi

K. EVALUASI

Date /

time

Dx Evaluasion Signature

December,

4th 2012 /

02.00 pm

I

II

Goal is achived in part, continued intervention:

- Deep breathing exercise

- Relaxation technique

Niinu

December,

4th 2012 /

08.00 pm

I

II

III


- Observe clients condition

- Create comfort environment

- Health education

Annisa

5th

2012 Savi


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December

07.00 am

5t 2012

December

08.00 pm

I

II


Control oxigenasion

Maintain fluid intake

Niinu

6th 2012

December

07.00 am

III


Educate condition to client

Annisa

6t 2012

December

02.00 pm

Savi

6t 2012

December

02.00 pm

I

III


Observe condition

Relaxation or ROM

Niinu

7t 2012

December

02.00 pm

I

Goal is achived in part, continued intervention :

Client up nasal canul

Annisa

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