I.

Client Identitiy

Name Age Trible/nation Religion Educatoin Medical record number Address Occupation Enterance date Assessment date Medical diagnose

: : : : : : : :

Mr. S 68 years old Banjarise Indonesia Muslim Junior high school 1062719 Kelayan B Private goverment

: Augustus 26 2013 : Augustus 29 2013 : Anemia

II.

The next of kind Name Sex Age Addres Relationship with client : Mr. R : Male : 36 year old

: Kelayan B : Children

III.

Health History A. Main Complaint: When assessment client said that he feel weakness and breathing shorrness and can.t sleep and disturbance for swallowing B. Health History Of Current Disease When assessment client said that before he enter the ulin general hospital he feel fatigue and weakness and sometimes breathing shortness that condition make he disturbance for do activity. Remember that condition he after a few days he feel that

of body condition is not recovery client finally decided to check herself in the hospital after getting the results of the examination client said that he suffered of anemia and get suggested from docter for hospitalization for get a treatment and recover from he disease C. Health History Of Previous Client said that saince 3 year ago he was when do devicate sometime that feces mixced with blood the colour feces is black and after do devicate he feel that body weaknees D. Family Health History Client said that in the family never was suffered like he disease like he suffered right now IV. 1. Phyisical Examination A. General Condition And Conciousness Client looked weaknees and just lie down and sit down on the bad cient conciousness is was composmenthis with gcs 4, 5, 5 Information: Eyes : 4 eyes open response spontaneous Verbal : 5 verbal response good can introduce / Orientation Morotic response : 5 motor response can follow order but no to have energy B. Vital signs: Blood Pressure Pulse

: 110/80mmHg : 68X/minute

Respiration Temperature

: 28x/minute : 36,8.C

C. Antropometrik Data Body Weight Body Hight 2. Skin Client skin white texture is a bit abrosive but there looked cynosis of the skin no looked lesions on the skins. Skin turgor no looked edema while in the press back (-) 2 second there looked little dirt on the skin. Body temerature is 36,8c while measurement using digital thermometer and when do palapation the client skin feel warm : 48.kg : 160.cm Ideal Body Weight : 43.kg Body Maximum Ideal : 45.kg

3. Head And Neck Structure of the head and neack are symmetric. In the head there is no trauma, lession, and lumps. The color hair white and blac, distribution hair is good. In the neck there is no enlargement of the thyroid gland and lymph nodes, normal neck movement 4. vision And Eye Structure of the eye is symmectric between left and right. The eyeball could be moved in any direction, there is looked dark circles around the eyes, amd conjunctiva anemis, and client did not use glasses. Client can not see name tag 2 meter, visus client can see 2 meter. 5. Olfactory and nose Structure of the nose is symmectric. There is no use nasal canula in the nose, no blood out of the nose. Client can distinguish a either the smell of perfume and alcohol, client had no complaint about olfactory problem

6. Hearing and ear Structure of the ear is symmectric between right and lift. Client does not use hering aid, client can be heard talking around client, and client can heard what nurse instruction. Client had no complaint about hearing, in the ear ther is no lession, trauma, massa, and blood.

7. Mouth and theeth Structure of the mouth and theeth are symmectric. teeth client looked clean, there is no inflammation. Lip mokus is good, in lip is no stomatitis, palatum is redness, and client do not use dentures.

8. Chest, breathing, and circulation Structure of the chest is symmectric. Client is 24 times/minute, tactil premetus is normal when palpation, the sound sonor when percussion, when auscultation is sound visikuler. Client do not use oxygen, in the chest there is no inflammation, edema, lession, and trauma

9. Heart and ciculation Inspection : Palpation : Auscultatio : heart spead is normal The heart sound dim The heart sound is S1, S2, and S3 is no addional heart. Circulation priphal blood perfussion to the fast.

10. Abdomen Inspection : General state abdomen looked clean no lession and trauma, shape normal breathing movement Auscultatio : Perictaltic intestine 6/ minute Palpation Percussion : Skin turgur back in 2 second, there is no tendress in hepar : The sound is timpany

11. Genetalia and reproduction Client is male. 60 years old was marreid and have 1 children, client looked no use cateter and pempres to elimination. Client there is no complaint about genetalia and reproduction.

12. Upper and lower extremities Structure of the upper and lower extremities are good. In lower extremities in right use infuse Nacl, join movement in upper and lower extremities are abnormal because guot, the client said there is limition of motion because gout, client said that pain in lower right and lift because gout since 1 year ago. Still weak, client do its own mobility whit muscle scale :

4444

4444

0 : Paralysis total 1 : Movement palpable or visible muscle contraction

4444

4444 2 : Full muscle movement against gravity and endorsement 3 : Normal movement against gravity and endorsement 4 : Normal movement against gravity whit little resistance 5 : Full normal movement against gravity whit full eustady

V.

Need physical, psychological, scocial, and spiritual 1. Activity and rest At home : Activity at home is not heavy. Client can sleep 7 until hours. Client said that sometimes help by his family do activity At hospital : Clien said that just laying on the bed for rest, activity not to heavy and client said that activity help by clients family. And said he cant sleep because light to brighter, client said that he sleep 2-3 hour at night client scale activity is 3 0 : Unable to care for them selves in full 1 : Require tools 2 : Require assistance, or supervision of another person 3 : Require assistance, monitor and supervision of another 4 : Very dependent and unableto perfrom or practipaeta intreatment

2. Personal Hygine At home : Client said that he took a bath two times / day at home, used shampoo once every two days, brushed her teeth after a meal, client said that the nail food and hand are restong since 1 years ago At hospital : Client said that just swabbed by her son twice a day.

3. Nutrition At home : Client said that eat 3 a day, client said that have food allergies like beans, abbage, belinjo, and water spinach because have gout. Drink water 8 glasses a day At hospital : Client said that cant eat because any stomatitis in the tongue client just eat of spood

4. Elimination At home : Client said that defecation 1 a day, and urinate 4 6 a day At hospital : Client said that to day defecation is never 1 a day, and urinate 3 a day

5. Sexuality Client is male 60 years old. Client was marreid and have 2 children

6. Psychosocial Client relationship is harmonious, many families that come to visit. Relationship whit nurse, doctor and medical team looked good

7. Spiritual Client is a moslem, client and family alwasy pray to Allah SWT hope fully speady recovery from disease.

VI.

Focus data Subjective date Client said that he feel weakness Client said that he cant sleep because light to brighter Client said tat e cant swallowing te food Client said that he just eat spood of food Client said that he cant do personal hygiene idependenly Client said that e activity helped by famly client said that he sleep 2-3 hour at night

Objective data inspection Client HB 2,9 Client lekosit 93,2 Looked client cant do activity independenly Looked client just lie down on te bad Looked client breathing sortness Looked stomatitis on the client tongue Additional data BP: 110/80mmHg RR: 26X/Minute P: 68x/minute T : 36,8c

Looked black cycle under client eyes and anemis

looked cynosis of the client skin looked client sleeply wen morning looked stomatitis on te client tongue looked client just can eat slightly looked there is dirt on the client body looked client just lie down on te bad

VII.

Diagnostic examination Laboratorium examination on august 26 2013

Parameter Hemoglobin Leucosit Eritrosit Hematokrit Trombosit Rdw Rcv Mcv Mch Mchc Gran % Limfosit % Mid % Gran # Limfosit # Mid # SI TIBC STI

Result 2,9 93,2 2,95 21,9 358 13,6 74,3 26,4 34,3 83,7 4,9 6,7 11,87 4,9 0,9 55 350 35

Limit 14,00 18,00 4,0 10,5 4,50 6,00 42,00 52,00 150 450 11,5 14,7 80,0 97,0 27,0 32,0 32,0 38,0 50,0 70,0 25,0 40,0 4,0 11,0 2,50 7,00 1,25 4,0 55 175 300 400 20 - 45

VIIII.

Therapy farmokology Nam e Mr. s Medicine Lasix Cefriaxone Infuse Nacl Blood transfustion Type Diuretic Antibiotic elektrolite Dose 1x1 amp 1x1 amp 20 minute M 08.00 08.00 08.00 11.00 Time E 12.00 12.00 12.00 N 21.00 21.00 21.00

IX .

Analysis data No 1. Data -Subjective data: -Client said that he feel weakness Problem Ineffective Tissue perfussion Etiology In adequate oxygen Requement body need

Objective date: -Client HB 2,9 -Client lekosit 93,2 l-ooked cynosis of the client skin

2.

Subjective data: -Client said that e activity helped by famly -Client said that he feel weakness Objective data: -looked client just lie down on te bad -Looked client cant do activity independenly subjective data -Client said tat e cant swallowing te food -Client said that he just eat spood of food

Activity Intolerance

General weakness

3.

Inbalence nutrition lees than body requement

Swallowing disoder

Objective data: -Looked stomatitis on the client tongue -looked client just can eat slightly

4.

Subjective data: -Client said that he cant sleep because light to brighter -client said that he sleep 2-3 hour at night Objective data : -Looked black cycle under client eyes and anemis -looked client sleeply wen morning

Insomia

Hospitalization

5.

Subjective data: -Client said that he cant do personal hygiene idependenly -Client said that e activity helped by famly

Deficit of personal hygiene self care bating

weakness

Objective data -looked there is dirt on the client body

X.

Problem Periorty 1) 2) 3) 4) 5) Ineffective tissue perfussion related to inaequat oxygen requement body need Activity intolerance relate to general weakness Inbalance nutrition less than body requement related to swallowing disoder Insomnia related to hospitalization Deficit personal hygeiene self care bating related to weakness

XI.

Intervention

No 1.

Nursing diagnose Ineffective tissue perfussion related to inaequat oxygen requement body need Subjective data: -Client said that he feel weakness Objective date: -Client HB 2,9 -Client lekosit 93,2 l-ooked cynosis of the client skin looked client sometimes breating shortness

Goal After do nusing action 1x24 hour expected ineffective tissue perfusion can be resoved with out come: -Client said that e not feel weakness agains -Client HB 14,00 18,00 Client lekosit 4,0 10,5 No looked cynosis in te client skin

Intervention 1).examine of cause ineffective tissue perfussion on the client 2 set client position semi fowler

Rasional 1). for easy determine next intervention

2).smooth the the entry of oxygen in to the body

3).pullpilled oxygen on the client body need

3).for comply oxygen body need

4).set the petilizaton of air on te client room

4).to maximun of 02 in air on the client room

5). Set fluid intake 5).optimize the the body needs balance of O2 status in the client body

2.

Activity intolerance After do related to general Nusing action weakness 1x24 hour expected Subjective data: activity -Client said that e intolerance activity helped by can be famly resloved -Client said that he without come: feel weakness -client said he Objective data: cant do -looked client just activity witout lie down on te bad helped -Looked client cant by family do activity

1).Examine cause of activity intolerance

1).for easy determine next intervention

2).provide client 2).for make client eat food that many have energy do carbohydrate Activity 3).Encourage client rest more 4).Provide client food high iron substance 5).give blood

3).for collect client energy 4).fullpiled client evenue base material of hemoglobin

Independently

-clint said he transfusion feel energy for do activity looked client can walking looked client can do activty independently

5).increase of hemoglobin on the client blood for binds nutrition in the blood

3.

inbalance nutrition less than body requement related to swallowing disoder subjective data -Client said tat he cant swallowing te food -Client said that he just eat spood of food Objective data: -Looked stomatitis on the client tongue -looked client just can eat slightly

After do Nusing action 1x24 hour expected inbalance nutrition can be resolved with out come: -client said that he can swallowing food

1).examine cause of inbalance nutrition 2)ecorage client eat slightly but often

1).for easy determine nex intervention 2).maxsimalize fulpiled nutrition on the client body need in slowlly

3).give client food 3).to improve client warm test 4).help client on oral ygiene 4). Give frest felling On the clint mouth

-client said he 5).give client food 5).For increase can eat all high nutrition and client imune food portion vitamin system -no looked stomatitis on the client tongue

4.

Insomnia related to hospitalization Subjective data: -Client said that he cant sleep because light to brighter -client said that he sleep 2-3 hour at night

After do Nusing action 1 x shift expected insomnia can be resolved with out come

1).Examine cause of insomenia on the client 2).explaint to the client inportance sleep for heality

1).For easy determine next intervention 2).for client understand about very infortance sleep for heality 3).for provide client

client said that 3).position client

Objective data : -Looked black cycle under client eyes and anemis -looked client sleeply wen morning

he can sleep at night client said he can sleep 6-7 hour no looked black cycle under client eyes and anemis

as a comfortable when try to sleep 4). Set ambiance a quet environtment

comfotable wen sleep 4)for give client quetness when sleep 5).for make client not dhydration when sleep

5).set client room temperature

5.

Deficit personal hygeiene self care bating related to weakness Subjective data: -Client said that he cant do personal hygiene idependenly -Client said that e activity helped by famly

After do Nusing action 1 x shift Expected deficit personal hygiene can be resloved with out come: client said that he can do personal hygiene independenly client said that he can do activity without helped with he family no looked there is dirt on the client body

1).Examine te 1).for easy cause of deficit of determine personal hygiene next intervention 2).helped client on 3).to easy client on the body personal do body personal ygiene her self ygiene 3).do secking on the client 1-2 times a day 4).Encourage client family for help client on client personal hygiene 5).change the client shirt and blacked 1 time a day 3).for maintain client body of hygiene 4).maximilize fullpiled personal hygiene on the client body 5).give comfortabe end fiiled clean on the client

Objective data -looked there is dirt on the client body

XIII.

Implementation and evaluation No Time No Diagnose Implementation with nursing action evaluation 1).assessing of cause ineffective tissue perfussion on the client E because Client HB 2,9 -Client lekosit 93,2 08.10 2).setting client position semi fowler E: Client said that e feel comfortable with this posttion because easy for brearthing Evaluation

1.

08.00

S: Client said that e feel comfortable with this posttion because easy for brearthing O: looked client no use asesory muscle for brething A: ineffective tissue Perfussion has been resolved P: Stop intervention

08.15

3).pullpiling oxygen on The client body need E: looked client no use asesory muscle for brething

09.00

4).setting the petilizaton of air on te client room E:loeeked client feel comfort when brthing

09.00

5). Setting fluid intake the body

2.

09.10

II

1).assessing cause of activity intolerance E: bcause supply nutrition no maximalize on the client body

S: client said that he just lie down and shit down one te band because still feel weakness for o activity independenly

09.33

2).providing client eat food that many carbohydrate and nutrition E looked client eat carbohydrate food

O: looked client just lie down and shit down one te band A : activity intolerance Has been not resoved P: countinue intervetion by nurse ward -providing client eat food that many carbohydrate and nutrition -Providing client food high iron substance -giving blood transfusion acrding doctor instrution

09.35

3)suggesting client rest more E: client said that he just lie down and shit down one te band

09.37

4).Providing client food high iron substance E;looked client eat food hight iron sbstance

09.40

5).giving blood transfusion E:Client HB begin increase Client HB 10,9 Client lekosit 93,6

3.

09.45

III

1).asessing cause of inbalance nutrition E:because on the client tongue any stomatitis

S: client said he have appetae for eat warm food O: looked client eat slightly but often after give warm food A: inbalance nutrition problem part has been resolved P: countinue intervetion by nurse ward

10.00

2)suggesting client eat slightly but often E: looked client eat slightly but often

10.12

3).giving client food Warm

10.18

E:client said he have giving client food Appetae for eating warm Warm food -helping client on 4).helping client on oral ygiene oral ygiene -giving client food high E: Client said he feel nutrition and vitamin Frest after get oral Hygiene 5).giving client food high nutrition and vitamin E: client said he feel have little energy for do activity

10.20

4.

10.21

IV.

1).Assessing cause of insomenia on the client E: Client said that he cant sleep because light to brighter

S: Client said he can sleep comfortble and calm O:looked client comfort when sleep A: Insomenia Has been resolved P: Stop intervention

10.23

2).explaint to the client inportance sleep for heality E: client said he understand with nurse explain

10.25

3).positioning client as a comfortable when try to sleep E: looke client cmfort when try to sleep

10.30

4). Setting ambiance a quet environtment E:Client said e feel calm when try to sleep

10.32

5).setting client room temperature E: Client said he not feel hot when sleep

10.35

V.

1).Assessing the cause of deficit of personal hygiene E:because client feel weakness for do activty

S: Client said he feel frest after get personal hygiene from nurse

10.37

O: looked client body is Client Looked client family 2).helpeing client on the collabortive in help body personal ygiene her client on do personal self hygiene E: client said he feel frest A: problem has been after get personal resolved hygiene rom nurse p: stop intervention 3).do secking on the client 1-2 times a day E: looked client bod y clean

10.40

10.50

4).suggesting client family for help client on client personal hygiene E: looked client familiy Collaborative in help client on personal hygiene

11.00

5).changing the client shirt and blacked 1 time a day E: looked client shirt is clean