English 2

DR. JENITA DT DONSU, SKM, MSi

TRI PRABOWO, SKp, MSc
NURUN LAASARA, SKep, Ns

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN JURUSAN KEPERAWATAN
YOGYAKARTA

ISBN: 978-602-8873-48-2

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 DAFTAR ISI

Halaman
HALAMAN JUDUL. i
DAFTAR ISI . ii
KATA PENGANTAR iii

BAB I TOEFL PREPARATION

A. Vocabulary & Reading Comprehension
B. Nursing Case Analysis

BAB II NUTRITIONAL SYNDROMES OF MAJOR PUBLIC HEALTH

IMPORTANCE
A. Endemic Goiter
B. Appendectomy
C. Chronic Renal Failure
D. Sectio Caesaria
E. Tonsillectomy
F. Cataract Surgery

BAB III CHRONIC DISABLING CONDITION

A. Cancer
B. Heart Disease
C. Fracture
D. The Gift

BAB IV NURSING CARE PLAN

A. Client With Post Operative Craniotomy
B. Case Study

DAFTAR PUSTAKA

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 KATA PENGANTAR

Puji syukur dipanjatkan ke hadirat Tuhan Yang Maha Kuasa, semoga rahmat dan
keselamatan dilimpahkan kepada kita semua. Buku ini disusun untuk melengkapi
bahan ajar pada mata kuliah Bahasa Inggris II pada Program D-IV Keperawatan Alih
Jenjang yang telah disesuaikan dengan kurikulum berbasis kompetensi.
Diktat ini menguraikan tentang reading comprehension yaitu konsep dan praktek
membaca dalam bahasa Inggris dengan tujuan untuk melatih bagaimana membaca
bahasa Inggris dalam konteks penyakit dan kasus. Tujuan lainnya yaitu agar mahasiswa
dapat mengenal lebih jauh tentang berbagai penyakit dengan vocabulary yang
dikolaborasi dengan bahasa Latin.
Demikian informasi seputar isi buku ini, semoga dapat digunakan oleh kalangan
mahasiswa dan peminat bahasa Inggris untuk menambah wawasan tentang cara
membaca dengan mengenal berbagai penyakit serta kasus dalam bentuk nursing care
plan.

Yogyakarta, September 2015

Tim Penyusun

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 BAB I
TOEFL PREPARATION

A. STRUCTURE AND WRITTEN EXPRESSION

Words (kata-kata) Phrases (kumpulan kata Clauses (kumpulan kata
Morning yg tdk ada fungsi S P/V) yg mempunyai fungsi S P/V)
In the morning I go
S P/V

S V

Sisipan (apposition)

SENTENCES

SIMPLE COMPOUND COMPLEX

S V Kalimat majemuk setara Kalimatmajemuk bertingkat
And, but, or. -Mainclause(independent cl)
(conjunctions, coordinator) - Sub clause (dependent cl)

Example :
Jogja is located in central Java ----------- It has many tourist destinations

Subordinate cl = dependent cl =cl pendukung

Jogja which is located in central java has many tourist destinations

Main cl = independent cl = cl utama

Jogja=main cl which=connector is located=sub v has=main v

Sebelum although----main cl
Setelah although ----sub cl
Jogja .in central Java has many tourist destinations
located

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The man is my brother -------------- He stands on the corner

Sub cl
The man who stands on the corner is my brother

Main cl

The man ..on the corner is my brother

Standing

Subordinate cl

Adj cl Adverb cl Noun cl

(sifat) (kerja) (benda)

Adj cl : - Selalu berada dibelakang kata benda yg diterangkan

- Kata sifat menerangkan kata benda

The hotel which was built near the beach is full of foreigners

The hotel . built near the beach is full of foreigners

a. was built c. building

b. was building d. built

Connector : - penghubung (semua kata tanya ; who, when, what, where, how), that
- Setelah connector langsung subject

Example : Why did you study TOEFL ?------I want to know why you studied TOEFL
S V O
I want to know.studied TOEFL
a. why you c. where do you
b. why did youd. how does you

went is a mistery
a. the dog c. where the dog

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 b. he d. where do the dog

(hilang tanpa konsekuensi apapun)

The book that I borrow is written by Anna
cs

main cl

Cleft sentence
It is important that you go to the doctor
It was in 1985 that the star was born
It was in new York that the conference was held
to be adj

Infinitive phrase-----tidak ada subjek predikat(v)

Noun cl

(subject/object) that
v
The news shocked the world-------------- The star was dead shocked the world
s v s v
v
The teacher announces when the exam will take place
s v o

was dead shocked the world

a. the star c. that the star
b. a star d. they

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 COMPLEKS SENTENCES

Main Cl Subordinate Cl

djective Cl Adverb Cl Noun Cl

Modify Noun/Noun phrase time,cause result S / O

condition, etc

reduced cl reduced cl
Examples

- A student who has the best mark will get the prize
adj cl
- A student having the best mark will get the prize
phrase
- The package which was delivered yesterday is from New York
Adj cl
- The package delivered yesterday is from New York
Phrase

Jadi---adj cl present participles/V ing------aktif------yang me

ber
past participles/V3-------pasif-------------yang di
ter

V1 V2 V3
deliver delivered delivered
do did done

The guy delivered the package yesterday

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B. VOCABULARY AND READING COMPREHENSION

Directions :
In this section you will read several passages. Each passage is followed by questions
about it. Choose the one best answer : (A(,(B),(C), or (D) for each question. Then, on
your answer sheet find the number of the question and fill in the oval that corresponds
to the letter of your answer choice. Answer all questions based on what is staled or
implied in the passage.

EXERCISE 1
Who should pay for the presidential campaigns ? The election
campaigns cost millions of dollars, paid for in part by contributions from
individuals and organizations. These contributions are criticized because it is
felt that big businesses and wealthy individuals might be able to
Line (5) buy the candidate of their choice by making a large donation.
Congress is considering many proposals on how to limit contribution and
equalize the cost of campaigns, but a solution to the problem has still not been
found.

QUESTION 1 5

1. What is the main purpose of the passage ?

(A) To discuss a question of policy
(B) To make a suggestion to candidates
(C) To discuss presidential candidates
(D) To note a reduction in the cost of
campaigns

2. What did the paragraph preceding the passage most probably discuss ?
(A) The role of congress in government
(B) Procedures for making donation
(C) Biographies of presidential candidates

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 (D)Election campaigns

3. In the second sentence, the phrase paid for in part means paid for
(A)A little at a time
(B) In the traditional manner
(C) To a certain extent
(D)Under special circumstances

4. According to the passage, the practice of making campaign contributions has been
criticized because it is possible that
A. Too many business executives might be encouraged to run for presiden
B. The candidate with the greatest financial support might have a better chance to
win
C. The candidates might not be able to run adequate campaigns
D. Campaigns funds might be donated to other causes

5. The proposals to congress mentioned in the passage would

A. Limit campaign contributions
B. Force candidates to find their own campaign funds
C. Make it illegal to accept funds from big business
D. Remove limits on individual donations

EXERCISE 2

Perhaps the most striking quality of satiric literature is its freshness,

its originality perspective. Satire rarely offers original ideas. Instead, it
presents the familiar in a new form. Satirists do not over the world new
philosophies. What they do is look at familiar conditions from a perspective
that makes these conditions seem foolish, harmful or
Line (5) affected. Satire jars us out of complacence into a pleasantly shock edrealization
that any of the values we unquestioningly accept are false. Don Quixote
makes chivalry seem absurd; Brave New World ridicules the pretentions of
science before Aldous Huxley, and people were aware of famine before Swift.
It was not originality of the idea that made

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Line (10) these satires popular. It was the manner of expression, the satiric method,
that made them interesting and entertaining. Satire are read because they are
aesthetically satisfying works of art, not because they are morally wholesome
or ethically instructive. They are stimulating and refreshing because with
commonsense briskness they brush
Line (15) away illusions and secondhand opinions. With spontaneous, irreverence,
satire rearranges perspectives, scrambles familiar objects into incongruous
juxtaposition and peaks in a personal idiom instead of abstract platitude.
Satire exists because there is need for it. It has lived because readers
appreciate a refreshing stimulus, an irreverent that they live in a world of
platitudinous thinking, cheap moralizing, and foolish philosophy. Satire
serves to prod people into an awareness
Line (20) of truth, though rarely to any action on behalf of truth. Satire tends to remind
people that much of what they see, hear and read in popular media is
sanctimonious, sentimental, and only partially true. Life resembles in only a
slight degree the people image of it. Soldiers rarely hold the ideals that
movies attribute to them, nor do ordinary citizens devote their lives to
unselfish service of humanity. Intelligent people know these things but tend
to forget them when they do not hear them expressed.

QUESTIONS 1 - 9
1. What does the passage mainly discuss ?
(A)Difficulties of writing satiric literature
(B) Popular topics of satire
(C) New philosophies emerging from satiric literature
(D)Reasons for the popularity of satire

2. The word realization in line 5 is closest in meaning to

(A)Certainly
(B) Awareness
(C) Surprise
(D)Confusion

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3. Why does the author mention Don Quixote, Brave New World and A Modest Proposal in
lines 5-7 ?
(A)They are famous examples of satiric literature
(B) They present commonsense solutions to problems
(C) They are appropriate for readers of all ages
(D)They are books with similar stories

4. The word aesthetically in line 11 is closest in meaning to

(A)Artistically
(B) Exceptionally
(C) Realistically
(D)Dependably

5. Which of the following can be found in satiric literature ?

(A)Newly emerging philosophies
(B) Odd combination of objects and ideas
(C) Abstract discussion of morals and ethics
(D)Wholesome characters who are unselfish

6. According to the passage, there is a need for satire because people need to be
(A)Informed about new scientific developments
(B) Exposed to original philosophies when they are formulated
(C) Reminded that popular ideas are often inaccurate
(D)Told how they can be of service to their communities

7. As a result of reading satiric literature, readers will be most likely to

(A)Teach themselves to write fiction
(B) Accept conventional points of view
(C) Become better informed about current affairs
(D)Reexamine their opinions and values

8. The various purposes of satire include all of the following EXCEPT

(A)Introducing readers to unfamiliar situations
(B) Brushing away illusions

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 (C) Reminding readers of the truth
(D) Exposing false values

9. Why does the author mention a service of humanity in line 22-23 ?

(A)People need to be reminded to take action
(B) Readers appreciate knowing about it
(C) It is an ideal that is rarely achieved
(D)Popular media often distort such stories

EXERCISE 3
Social parasitism involves one species relying on another to raise its
young. Among vertebrates, the best known social parasites are such birds
as cuckoos and cowbirds; the female lays an egg in a nest belonging to
another species and leaves it for the host to rear.
Line (5) The dulotic species of ants, however, are the supreme social parasites.
Consider, for example, the unusual behavior of belonging to the genus
Polyergus. All species of this ant have lost the ability to care for
themselves. The workers do not forage for food, feed their brood or queen,
or even clean their own nest. To compensate for deficits, Polyergus has
become specialized at obtaining workers from the related genus Formica
to do these chores. In a raid, several thousand Polyergus workers will
travel up to 500 feet in
Line (10) Search of a Formica nest, penetrate it, drive off the queen and her workers,
capture the pupal brood, and transport it back to their nest. The captured
brood is then reared by the resident Formica workers until the developing
pupae emerge to add to the Formica population, which maintains the
mixed-species nest. The Formica workers forage for food and give it to
colony members of both species. They also remove wastes and excavate
new chambers as the population increases.
Line (15) The true extent of the Polyergus ants dependence on the Formica becomes.
Apparent when the worker population grows too large for the existing
nest. Formica Scouts locate a new nesting site, return to the mixed-species
colony, and recruit

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 additional Formica nest mates. During a period that may last seven days,
the Formica workers carry to the new nest all the Polyergus eggs, larvae,
and pupae, Every Polyergus adult, and the Polyergus queen.
Line (20) Of the approximately 8.000 species of ants in the world, all 5 species of
Polyergus and some 200 species in other genera have evolved some degree
of parasitic relationship with other ants.

QUESTIONS 1-10

1. Which of the following statement best represents the main idea of the passage ?
(A)Ants belonging to the genus Formica are incapable of performing certain tasks

(B) The genus Polyergus is quite similar to the genus Formica

(C) Ants belonging to the genus Polyergus have a unusual relationship with ants
belonging to the genus Formica
(D)Polyergus ants frequently leave their nests to build new colonies

2. The word raise in the line 1 is closest in meaning to

(A)Rear (C) Collect
(B) Lift (D) Increase

3. The author mentions cuckoos and cowbirds in line 2 because they

(A)Share their nest with each other (C) Raise the young of other birds
(B) Are closely related species (D) Are social parasites

4. The word it in line 3 refers to

(A)Species (C) Eggs
(B) Nest (D) Female

5. What does the author mean by stating that The dulotic species of ants..are the
supreme social parasites (Line 4) ?
(A)The Polyergus are more highly developed than the Formica the Formica
(B) The Formica have developed specialized roles enough to care for themselves
(C) The Polyergus are heavily dependent on
(D)The Formica do not reproduce rapidly

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 6. Which of the following is a task that an ant of the genus Polyergus might do ?
(A)Look for food (C) Care for the young
(B) Raid another nest (D) Clean its own nest

7. The word excavate in line 14 is closest in meaning to

(A)Find (C) Repair
(B) Clean (D) Dig

8. The word recruit in line 17 is closest in meaning to

(A)Create (C) Endure
(B) Enlist (D) Capture

9. What happens when a mixed colony of Polyergus and Formica ants becomes too
large ?
(A)The Polyergus workers enlarge the Existing nest separate nest
(B) The captured Formica workers return to their original nest anew nest
(C) The Polyergus and the Formica build
(D)The Polyergus and the Formica move to

10. According to the information in the passage, all of the following terms refer to ants
belonging to the genus Formica EXCEPT
(A)Dulotic species of ants (line 4) (C) Developing pupae (line 12)
(B) Captured brood (line 11) (D) Worker population (line16)

C. Nursing Case Analysis

Introduction
Susan is a 50-year-old woman who has been in an accident. After surgery, it was
found that she will be paralyzed for the rest of her life from the waist down. This paper
analyzes what the nurse can do, using Dorothea Orems theory of self-help, to aid Susan
through her acute period of nursing care while in the hospital, and in her subsequent
road to rehabilitation.
For purposes of clarity and brevity, we will give Susans nurse the name Jean,
which will be used throughout the paper.
Orems Theory of Self-Help Nursing

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 Dorothea Orem began formulating her theory of self-help nursing in 1947
(Hartweg, 1991), completing her first phase of analysis in the late 1950s. Hers is an
essentially positive codification of nursing, which assumes that all patients have the
innate ability to take care of themselves. Orem postulated that those who could not take
care of themselves due to sickness or injury suffered from a self-care deficit, which the
nurse could help to correct (Bruce et al., n.d.). The patients ability to care for
her/himself falls into three phases in Orems model:
1. Total compensatory support, where the patient is unable to take care of his/her
needs.
2. Partial compensatory support, in which the nurse and the patient work together
for the patients support, and
3. Educative/supportive compensatory support, in which the nurse acts as
consultant, coach, teacher and support.
Orem essentially codified what good nurses had been doing instinctively in the
past. By laying out the phases of nursing, Dorothea Orem created a blueprint which can
be followed even in difficult cases, like Susans.
Jeans challenge with Susan was to understand her patients mental processes
while coaching her to take charge of her own care.
Susans Case
Susan case is a good illustration of how the patient goes through all three stages
of Orems theory of nursing. Although the case does not mention the pre- and
perioperation portion of Susans care, we will assume that the nurse enters Susans care
just after the operation has been completed. In addition, we will assume that the nurse
remains the main medical support through the critical care portion (post-op), in-
hospital rehabilitation, and longer-term rehabilitation.
Post-Op Critical Care Phase
Jeans first role in Susans care is to assure that she awakes from anesthesia
properlyis aware, has no memory deficit, and that her first symptoms (nausea, pain)
are dealt with in a competent way. No doubt Susan is confused. With little knowledge
of how she got to the hospital or what has been done to her, she needs reassurance and
honesty from Jean.
Jeans role in the first phase is threefold: (1) be palliative; (2) be alert to important
markers in Susans condition, notifying medical staff of any problems; and (3) help the
patient to understand her condition and next steps.

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 It is likely that Jean will be the one to tell the patient that she is currently
paralyzed, and that the doctors are hopeful of improvement. This empowers the patient
to begin the process of understanding her condition, and prepares her for what may
come next. Using Orems theories of nursing, Jean must decide how much Susan is
prepared to accept and understand, and mete out information as she is ready to absorb
it (Biley, 1992).
Hospital Care Phase
It is likely that Susan will start to feel phantom pain as a part of her spinal cord
injury (Weaver, 2005). Part of Orems theory of nursing would concern pain
management. Modern methods of morphine administration have expanded beyond
terminal cancer patients to those suffering from more usual post-op pain (Valentino,
Pillay, & Walker, 1998). As per Orems theories, Jean would both help Susan with her
colostomy procedures and teach her how to connect, disconnect and keep herself clean
and free of infection (Buergi & Stocker, 2000). She would also need to assure that Susan
was able to start moving againhelping with range-of-motion to start using those
muscles that can be used (Mayo Clinic Staff, 2005).
As Susans medical prognosis becomes clearer, Jean must inform the patient of
what she can and cannot do. This disclosure is a very difficult but necessary step in
Susans eventual rehabilitation (Veatch, 1980):
Some nurses not only find it right to disclose, but also in their professional
interest. In such settings, honesty may be necessary to avoid conflicting messages to the
patient. These shifts may signal underlying shifts in the sick role and in the medical
professional role with the patient more active and more knowledgeable in medical
decisions and the physician serving as a source of information and counsel.
Thus, by sharing the situation with Susan, Jean empowers her patient to face the next
steps in her recovery (Craig Hospital, n.d.).

Recovery and Rehabilitation Phase

Susans therapy will begin in the hospital, and will involve both psychological
and physical healing. Susan will be full of questions about her future. Using Orems
theory of care, Jean can both inform her of her state, and help her to discover what
research is on-going in working with those who have suffered spinal cord injury.
The psychological stages of Susans adjustments will need to be dealt with. Jeans
role is to both understand and help Susan through those phases: denial, sadness, anger

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and bargaining, eventually leading to acceptance and learning to live with her disability
(Klebine, 2004).
Jeans primary role as a rehabilitation nurse is to assist Susan in the coordination
of her rehab team. This team will typically include a physical therapist, an occupational
therapist, and a psychologist.
Jeans role during this rehab phase will involve dealing with the real physical
problems Susan encounters, monitoring her pain, and monitoring her psychological
progress. Jeans measure of success will not be to heal Susanthe present level of
medical technology does not make that possible. Rather, Jeans role is to assure that
Susan undertakes the following:
- Learns how to function on her own, including
o Handling the aspects of colostomy and urination
o Using a wheelchair
o Assuring that she develops the muscles that can work, and maintains a
level of physical conditioning, and
o Develops dietary habits which sustain her health
- Is able to face the reality of her condition with as positive an attitude as
possible. She does this by
o Monitoring Susans psychological progress through to acceptance
o Assuring that Susans short-term depression is diagnosed and dealt
with in a medically-valid manner
o Coaching and encouraging Susan to maintain her physical therapy
appointments and monitors her progress.
- Learns the tools she needs to cope with her on-going issues. Jean does this by
o Referring Susan to self-help groups that deal with spinal injuries.
o Sharing appropriate information with Susans family, particularly
preparing them for what Susan will encounter as she recovers from the
acute symptoms.
Jeans also must monitor Susan medically, insuring that the pains she undergoes are not
beyond the norms and assuring that Susan is able to deal with anti-infection practices.
Conclusion
Jeans natural inclination is to make it all better for Susan. Her role, under
Orems precepts, is to help Susan to become a functioning adult, capable of caring for
herself. This is a crucial differenceproper nursing can make a tremendous difference
in Susans outcome.

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 Orems theories of nursing provide a guide and an eventual outcome to Susans
nursing care. All along the recovery process, Orems principles give the patient the
knowledge needed, respect the patients ability to care for herself as much as possible,
and look forward to the patients eventual independence. This positive theory of
rehabilitation is much better, and more realistic, even for patients whose prognosis will
continue to be difficult for the rest of their lives.

BAB II
NUTRITIONAL SYNDROMES

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 OF MAJOR PUBLIC HEALTH IMPORTANCE

A. Endemic Goiter

This is a chronic enlargement of the thyroid gland with a variety of causes and
is most frequent in regions where the iodine content of food and water is low. As in
other deficiency diseases, an iodine deficiency may occur even though the intake
appears to be adequate. This may be for a variety of reasons, such as an unusually
high requirement, failure of adequate absorption, or poor utilization. Also, the
presence of cyanate lowers the iodine content of the thyroid. The excessive
consumption of foods high in cyanate, such as cabbage, or the use of the medicine
containing cyanate, may result in goiter.
The thyroid gland has an affinity for iodine. Iodine taken into the body is
combined with the amino acid thyroxine in the thyroid to form diiodotyroxine. Two
molecules of diIodothyrosine combine to form the hormone thyroxine. The thyroid
gland normally contains 15 to 20 mg of iodine. There are three diseases state caused
by disturbed function of the thyroid gland; hypothyroidism, hyperthyroidism and
simple goiter. The two important hyperthyroid conditions are cretinism and
myxedema. Where endemic goiter is highly prevalent, some pregnant women give
birth to children who are deaf mutes, feeble-minded, or cretins because of fetal iodine
deficiency. In cretins the mental physical and sexual development is greatly retarded.
If they live to be adults, they retain their childhood body build and may not mature
sexually.
Hyperthyroid is enlargement of the thyroid gland with increase
functional activity. The chief symptoms are rapid heartbeat, exophthalmos, tremor
and nervousness, high creased metabolic rate. The symptoms are associated with
increased activity of the thyroid called thyrotoxicosis. Secondary toxic goiter also
follows simple goiter as a complication. Usually, hyperthyroidism are not occur until
after about 15 years of simple goiter. The simple adenomatous goiter for unknown
reasons. If simple goiter were avoided by adequate iodine intake, there would be no
secondary toxic goiter.
Simple goiter is by far the comment form of thyroid disease and occurs in
all parts of the world. The enlargement in simple goiter which may be accompanied
by a mild degree of hypothyroidism, or under activity, represents an effort to

19
 manufacture adequate amounts of thyroxine. The first stage is called parenchymatous
goiter. This may go on to a complete exhaustion or wearing out of the cells , or the
increasing process may stop and the follicles become filled with colloid. When the
latter happens, a colloid goiter results. These are usually symmetrical and somewhat
soft. They may be very large, because each of the many additional follicles becomes
distended with colloid. The total quantity of iodine in the entire gland ma be close to
normal, but because of the enlarged size, the ratio of iodine per gram of gland tissue
is low.
Simple goiter is medically important because noduler or adenomatous
goiter may frequently have its origin in a preexisting colloid become toxic; also
symptoms due to pressure on neighboring structures such as the trachea may
occasionally be bothersome in some patient with colloid goiter. From a health
standpoint, colloid goiter can be completely prevented by including a small but
adequate amount of iodine in the food regularly. Where iodized salt is used from
infancy, simple goiter is avoided, with very few exceptions.
Prevention is best achieved through the iodization of salt on a nation scale
at a level of 1 part of iodine in 10.000 to 20.000 parts of salt. In industrialized
countries, potassium iodide is used with a stabilizer and protective packaging, but
potassium iodated is stable even when added to crude moist salt without protection.
Both methods are equally effective. Where it is impossible to reach isolated
population with iodinated oil can be given every 6 month to women of childbearing
age.

B. Appendectomy

Appendectomy is the surgical removal of the appendix. This procedure is most often
performed as an emergency operation. In some patients undergoing abdominal
surgery for another reason, may have their appendix removed prophylactic so
that appendicitis does not develop in the future; this option can be discussed with
your surgeon.

The appendix is a small, pouch-like sac of tissue that is located in the first part of the
colon (cecum) in the lower- right abdomen. Lymphatic tissue in the appendix aids in

20
 immune function. The official name of the appendix is veriform appendix, which
means "worm-like appendage." The appendix harbors bacteria.

Appendicitis Picture - Inflammation of the Appendix

Prepare for an appendectomy

The majority of appendectomy operations are typically emergency surgeries so the

patient needs to follow the instructions given by the surgeon. In general, the patient is
advised not to eat food or take any medicines (for example, aspirin) that may affect
blood clotting before surgery. The patient may be treated with medications to reduce or
eliminate nausea and vomiting; IV antibiotics may also be initiated before surgery.

Appendectomy performed

Appendectomy is most often done in the operating room after the patient's skin has
been shaved to remove hair and swabbed with a germ killing solution; sterility
precautions are taken to prevent infection. The appendix may be removed by an open
method or the laparoscopic technique. The open method requires a 2 to 3 inch incision
in the lower righthand side of the abdomen to remove the appendix, while the

21
laparoscopic method uses several small incisions in the abdomen and the use of a
laparoscope to visualize and then remove the appendix.

Recovery time for an appendectomy

The recovery time for an appendectomy is variable and depends on the type of the
procedure, type of anesthesia, and any complications that may have developed. For
example, laparoscopic appendectomy may be done on an outpatient basis so that the
patient can be discharged to recover at home, while an open method may require an
overnight stay or an even longer time to be discharged to go home. Normal activities
can resume in a few days but full recovery may take 4 to 6 weeks during which time
strenuous activity should be avoided

Complications and risks of appendectomy

Wound infection and perforation (rupture) are the most common complications of
an appendectomy.

Abscess formation in the area of the removed appendix or surgical incision site may
also occur.

Other relatively infrequent or rare complications may include ileus (lack of

intestinal peristalsis), surgical injuries to internal organs or structures, gangrene of
the bowel, peritonitis (infection in the peritoneal cavity) and bowel obstruction.

Long-term consequences of removing the appendix

For most individuals there are no long-term consequences of removing the appendix.
However, some individuals may have an increased risk of developing an
incisional hernia, stump appendicitis (infections due to a retained portion of the
appendix), and bowel obstruction.

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Apendicitis & Appendectomy Pictures

Nursing Diagnosis Interventions for Appendicitis: Risk for Infection

Risk factors include:
Inadequate primary defense, perforation / rupture of the appendix; peritonitis;
abscess formation.
Invasive procedures, surgical incisions.

Intervention:
Independent:
Monitor vital signs noticed fever, chills, sweating, mental changes, increased
abdominal pain.
Do a good hand washing and aseptic wound care. Provide complete care.
See incision and bandage. Write down the characteristics andwound drainage / drain
(if included), the erythema.
Provide appropriate information, be honest with the patient / parent close.

Collaboration
Take for example the drainage when indicated.
Give antibiotics, are as indicated.

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C. CHRONIC RENAL FAILURE
Definition

Chronic renal failure exists when the kidneys are no longer capable of
maintaining an internal environment consistent with life and when return of function
is not anticipated. For the majority of individuals the transition from health to a state
of chronic of permanent disease is a slow one extending over a number of years.
Recurrent infection and exacerbation of nephritis, obstruction of the urinary tract,
destruction of vessels from diabetes and long standing hypertension lead to scarring
of kidney tissue and progressive loss of renal function. Some individuals, however,
develop total irreversible loss of renal function acutely, such loss of renal function
usually develop in a matter of a few hours or days and follow a direct traumatic
insult to the kidneys.
Chronic renal failure exists as a major health problem in the United States.
Approximately 8 million individuals now have chronic kidney disease,
approximately 60.000 person die each year as the result of renal failure.

24
Pathophysiologi

During chronic renal failure some of the nephrons (including the glomerulus
and tubules) are thought to remain intact while others are destroyed (intact nephron
hypothesis). The intact nephrons hypertrophy and tubular reabsorption in spite of
decreased GFR. This adaptive method permits the kidney to function until about
three fourths of the nephrons become destroyed. The solute load then becomes
greater than can be reabsorbed, producing an osmotic dieresis with polyuria and
thirst. Eventually, as more nephrons are damaged, oliguria occurs with retention of
waste products.

Prognosis

The individuals with chronic renal failure can to some axtent control and
manage the symptoms of the disease. Although renal function that has been lost as a
results of destruction of kidney tissue cannot be recovered, the life of the person can
be maintained by limiting the intake of substances that reguire renal axretion and by

25
providing alternative routes of excretion for waste products and electrolytes. By
adhering to a prescribed management routine, albeit guite strict.

Prevention

Obstruction and infection of the urinary tract and hypertensive disease are
common and often asymptomatic causes of renal failure can be affected through
increasing attention to general health promotion. Yearly physical examinations in
which blood pleasure is determined, urinalysis is performed and the person is
questioned about dysuria or pain in the urinary tract assist in early detection of
diseases that my lead to renal failure.
General health maintenance can reduce the number of individuals progressing
from renal insufficiency into frank renal failure. Care is aimed toward adequately
treating medical problems and closely supervising the persons health status in times
of stress (infection, pregnancy).

Intervention

Major problems for the patient in chronic renal failure include

1. Inability to appropriately control fluid balance
2. Inability to regulate electrolyte balance
3. Inability to excrete metabolic wastes
4. Inability to transport oxygen to cells
5. Inability to maintain normal rest and sleep pate
6. Difficulty in maintaining adequate nutrition
7. Increased potential for physical injury
8. Discomfort
9. Alterations in fertility
10. Change in life style, group membership and feeling regarding self.

Medical treatment of patients with end stage renal disease

The medical management of patients with chronic renal failure can be

classified as to the following :

26
1. Conservative management

Conservative medical management is primarily directed toward relief of

symptoms.
The focus is on the following :
a. Fluid and electrolyte regulation by control of diet and fluid intake
b. Blood pressure control by medication
c. Patient comfort

2. Dialysis

Dialysis involves the movement of fluid and particles across a semipermeable

membrane. It is a treatment that can help restore normal fluid and electrolyte
balance, control acid base balance and remove waste and toxic material from the
body.

3. Renal transplantation

Kidney transplantation, kidney transplants are being performad with increasing

frequency in an effort to prolong the lives of persons with CRF. At present the
ability to completely overcome the bodys tendency to reject the gratted kidney
has not been achieved.

Nutrition

27
 Maintaining a good nutritional intake can be difficult for persons with chronic
renal failure. Anorexia, nausea and vomiting frequently accur and diets can be so
severely restricted that they bear little resemblance to normal dietary patterns.
Modifying the dies as possible to the preferences of the individual can also help
to maintain intake of food. Dietary teaching and meal planning can be approached
according to an exchange system similar to that used for individuals with diabetes.
With this approached there is greater ability to modify the diet according to personal
preferences the pattern of meals during the day is also a matter of personal
preference. Some individuals prefer two or three meals a day. When eating patterns
are known and used in dietary instruction and meal planning, intake of food is likely
to increase. Actual eating of prepared food can promoted through attempting to
decrease emosional tension at the dinner table. Periods other than mealtime should
be used to discuss family and individual problems. Food that is attractively arranged
and plavored is likely to be more acceptable to the patient. Herbs and other flavorings
can add variety to foods that are prepared without sodium. It is interesting that most
persons relate that their taste for salt disappears once they have adhered to a low.
Sodium diet for several weeks. When the 61 tract is ulcerated, blands foods maybe
tired in an attempt to increase ingestion of food.

CONVERSATION,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Nurse : Good morning miss Nita.

Patient : Good morning nurse.
Nurse : Iam nurse Abby. I will take care of you today. May I help you?
Patient : Of course.
Nurse : You look tired and pain.
Patient : Yes, doctor said that I got CRF. What is CRF nurse?
Nurse : CRF exist when the kidneys are no longer capable of maintaining an
internal environment consistent with life and when return of function is
not anticipated.
Patient : How could this happen to me?

28
 Nurse : It many causes there are infection and exacerbations of nephritis,
obstruction of the urinary tract, destruction of vessels from diabetes and
long standing hypertension.
Patient : Than, what I have to do?
Nurse : You must change your life style.
Patient : Can you explain it for me?
Nurse : Yes, of course. Its my duty. You must control your diet and fluid intake
and its impossible for you to continue to be employed because you will
often tired and not feeling well. The most important thing is you must
obey the doctor.
Patient : OK. I will try to do it, but can I recover from this illness?
Nurse : I apologize, until now there is not medicine for CRF. But our country has
developed hemodyalisis to reduce your pain. In otherwise, there is kidney
transplantation in order to become a normal person.
Patient : Really, you mean that I can live normally. If I do that.
Nurse : Maybe, but it is not easily to find suitable kidney for donor recipient.
Patient : Iam affraid that I will die.
Nurse : Dont give up, you must struggle for your life, nobody knows when well
die. We surrender it to God.
Patient : Thank you for your information and your support.
Nurse : Its my pleasure miss. Maybe, any question?
Patient : No, Im very confuse now.
Nurse : OK! I think thats enough. Ill give you time to think alone. Maybe next
time we can share together again.
Patient : OK nurse.
Nurse : Thank you for your attention. If you need some help, you can press the
call button at beside you. Ill coming soon.

D. Post Operation Sectio Caesaria

Understanding Sectio Caesaria (cesarean section). There is some understanding of

Caesaria sectio:
Sectio Caesaria is a means of delivery of a fetus by incision in the wall of the uterus
through the abdominal wall. (Rustam Mochtar, 1992).

29
 Sectio Caesaria is an artificial childbirth where the fetus was born through an
incision in the abdominal wall and uterine walls with the terms intact uterus and
fetal weight above 500 grams (Sarwono, 1991).

Operation cesarean section (sectio Caesarea) is a surgery to give birth to the fetus
(artificial birth), through an incision in the abdominal wall and uterus so that the front
of the babies to be born through the abdominal wall and the abdominal and uterine
wall so that children born with intact and healthy.

Indications Sectio Caesaria

Operation sectio Caesarea done if birth pervaginal might cause risks to the mother or
the fetus, with consideration of the things that need to act normal childbirth old SC /
failure of the normal birth process (Dystasia)

Indications sectio Caesaria on Mother

Cevalo-pelvic disproportion (imbalance between the size of the head and pelvis)
Uterine dysfunction
Soft tissue dystocia
Placenta previa
His weak / weakening
Threatening uterine rupture
Young or old primi
Parturition with complications
Placental problems
Indications Sectio Caesaria In Children
Large fetus
Fetal distress
Fetus in a breech or transverse position
Fetal distress
Hydrocephalus

Sectio Caesaria Contra Indications:

Caesarian sectio generally not performed on a dead fetus, shock, severe anemia before
addressed, severe congenital abnormalities (Sarwono, 1991).

Type - Type Operations Sectio Caesarea

1. Abdomen (abdominal sectio Caesarea)
a. Sectio Caesarea transperitonealis

30
 SC classic or corporal (with longitudinal incision on the corpus uteri)
Performed by making an incision along the length of the corpus uteri is
approximately 10 cm.

Pros:
Quickly remove the fetus
Not lead to complications of bladder interested
The incision can be extended proximally or distally

Shortage
Infection is easily spread because there is no intra-abdominal reperitonealis good
For subsequent births are more common spontaneous uterine rupture
SC ismika or profundal (low servical with an incision in the lower segment of the
uterus)

b. SC ektra peritonealis ie without opening the parietal peritoneum thus opening the
abdominal cavity. Is done by conducting konkat transverse incision on the lower
segment of the uterus (low transverse servical) is approximately 10 cm.

Pros:
Wound suturing easier
Wound closure with a good reperitonealisasi
Overlap of the peritoneal flap splendidly to contain the spread of uterine contents
into the peritoneal cavity
Bleeding is not so much
The possibility of spontaneous uterine rupture decreases or smaller

Disadvantages:
Wounds can be widened to the left, right, and bottom so it can cause uterine
rupture, resulting in bleeding a lot
Complaints on high postoperative bladder

2. Vagina (section Caesarea vaginalis)

According to the incision on the uterus, sectio Caesarea can be done as follows
(Mochtar, Rustam, 1992):

1. Incision lengthwise (longitudinal)

2. Transverse incision (Transversal)
3. Incision letter T (T insicion)

31
Prognosis Operations Sectio Caesarea

On Mother
First morbidity and mortality for the mother and fetus high. At the present time due
to rapid advances in surgery techniques, anesthesia, provision of fluids and blood,
and antibiotic indications this figure is declining.

Maternal mortality in hospitals with good facilities and operations by force-force

that deft is less than 2 per 1000.

In children
As is the case with his mother, the fate of children born with a lot depending on the
sectio Caesaria state the reason for doing sectio Caesarea. According to statistics in
the country - a country with antenatal surveillance and good intra-natal, perinatal
mortality post Caesaria sectio ranged between 4 and 7% (Sarwono, 1999).

Complications Operations Sectio Caesarea

Possibilities that arise after this surgery include:
1. Puerperal infection (Ruling)
Lightweight, with a temperature rise within a few days
Medium, higher temperatures increase accompanied by dehydration and
slight stomach bloating
Weight, peritonealis, sepsis and bowel paralytic

2. Bleeding
Many blood vessels are severed and open
Bleeding in the placental bed

3. Bladder injury, pulmonary embolism and bladder complaints when

peritonealisasi too high

4. High likelihood of spontaneous rupture in subsequent pregnancies

Diagnostic Examination
Fetal monitoring fetal health
ECG monitoring
JDL with differential
Electrolyte
Hemoglobin / Hematocrit

32
 Blood group
Urinalysis
Amniocentesis for fetal lung maturity as indicated
X-ray examinations as indicated.
Ultrasound to order
(Tucker, Susan Martin, 1998)

Nursing Care Plan

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out
through the mother's abdomen. In the United States, about one in four women have
their babies this way. Most C-sections are done when unexpected problems happen
during delivery. These include;

Health problems in the mother

The position of the baby
Not enough room for the baby to go through the vagina
Signs of distress in the baby

C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries
risks. It also takes longer to recover from a C-section than from vaginal birth. After
healing, the incision may leave a weak spot in the wall of the uterus. This could cause
problems with an attempted vaginal birth later. However, more than half of women who
have a C-section can give vaginal birth later.

33
Nursing Assessment for Cesarean Section

Assessment is the systematic process of gathering, verification, and communication of

client data (Potter & Perry, 2005).

The assessment results are found on the client by cesarean section on nursing care
plan maternal / infant (Doenges & Moorhouse, 2001) namely:
1. Assessment of client data base
Review the record of prenatal and intraoperative and indications for cesarean birth.
2. Circulation
Blood loss during surgical procedures of approximately 600-800 ml.
3. Ego integrity
Can show emotional lability of excitement to fear, anger or withdrawn. Client /
partner may have questions or wrongly accept a role in the birth experience. Perhaps
expressing inability to deal with new situations.

4. Elimination
Urinary catheter may be inserted, clear urine and pale bowel sounds absent, vague
or unclear.

34
5. Food / fluid
Abdomen soft with no distension at baseline.

6. Neuro sensory
Damage to the movement and sensation below the level of spinal epidural
anesthesia.

7. Pain
Discomfort may complain of a variety of sources such as surgical trauma, incision
and accompanying pain, distended bladder-abdominal, the effects of anesthesia. The
mouth may be dry.

8. Respiratory
The sound is clear and vesicular lung.

9. Security
Abdominal bandage may seem a little stain or dry and intact. Line parenteral, when
used patent-free and hand erythema, swelling and tenderness.

10. Sexuality
Fundus contractions stronger and located at the umbilicus. Lochea is free flow and
excessive clot / lot.

11. Diagnostic tests

Complete blood count, hemoglobin/hematocrit (Hb / Ht): assessing the change
from preoperative levels and evaluate the effects of blood loss in surgery. Urinalysis:
urine culture, blood, vaginal, and lochea.

Nursing Diagnosis for Cesarean section (C-section)

1. Acute pain related to postoperative wound
2. Risk for infection related to invasive procedures, skin damage, decrease in Hb
3. Risk for injury (mother) related to tissue trauma
4. Risk for impaired gas exchange (the fetus)
5. Deficient Knowledge : up to surgery
6. Anxiety

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Risk for infection

35
Related to :
bleeding
postoperative wound

Goal :
There were no infections, bleeding and wounds, after surgery.

Nursing Intervention for Cesarean Section Postoperative

1. Assess the condition of output/dischart out; number, color, and odor from the
operation wound.
R / recording the changes in output. The existence of a darker color with a bad smell
may be a sign of infection.

2. Tell the client the importance of wound care during the postoperative period.
R / Infection can arise from lack of cleanliness of the wound.

3. Have a general culture in the output.

R / Various bacteria can be identified through the output.

4. Perform wound care.

R / Incubation germs in the wound area can cause infection.

5. Tell the client how to identify signs of infection.

R / Various clinical manifestations can be nonspecific sign of infection, fever and
increased pain may be symptoms of infection.

Nursing Diagnosis

Acute Pain

Related to
postoperative wound
Goal :
Pain is reduced / no pain

Nursing Intervention for Cesarean Section Postoperative

36
 1. Assess the condition of pain experienced by the client.
R / Measurement of the level of pain can be performed with pain scales.

2. Tell the client suffered pain and its causes.

R / Improving coping clients, in dealing with pain.

3. Teach relaxation techniques.

R / Reduced perception of pain.

4. Collaboration of analgesics.
R / Reduced pain can be done by giving oral or systemic analgesics, in a broad
spectrum/specific.

E. TONSILLECTOMY

Tonsillectomy is surgery to remove the tonsils. These glands are at the back of your
throat. Often, tonsillectomy is done at the same time as adenoidectomy, surgery to
remove the adenoid glands.

Etiology of Tonsillectomy

The cause of tonsillitis is viral and bekteri, mostly caused by a virus which is also a
predisposing factor of bacterial infection.

Virus Type:
Adenovirus
Virus echo
The influenza virus

Bacteria Type:
Streptococcus
Mycrococcus
Corine bacterium diphterial

The degree of tonsillar enlargement:

a. Grade I (Normal)

37
 Tonsils are behind tonsil pillars (soft structure, cut by the soft palatine).
b. Grade II
Tonsils are among the pillars and uvula.
c. Grade III
Touching tonsils uvula.
d. Grade IV
One or two tonsil extends in the middle of uvofaring.

Nursing Assessment of Tonsillectomy

Assess difficulty swallowing, easy to choke.

Assess sore throat acute / chronic.
Assess the history of sore throats and influenza.
Assess allergy history.
Assess the bleeding by mouth.
Assess the presence of asthma, cystic fibrosis.
Nanda Nursing Diagnoses for Tonsillectomy
1. Risk for infection related to the factors of surgery
2. Acute Pain related to surgical operations
3. Fluid Volume Deficit related to decreased fluid intake secondary to pain on
swallowing
4. Imbalanced Nutrition Less Than Body Requirements related to reduced input
secondary to pain on swallowing

38
5. Risks to the ineffectiveness of therapeutic management related to inadequate
knowledge about the complications, pain, positioning and management activities.

Interventions Nursing Care Plan Tonsillectomy

Risk for infection related to the factors of surgery

Objectives:
There is no infection.
There were no complications.
Intervention:
Monitor temperature every 4 hours, the state of injury when performing
maintenance.
Give an antibiotic is prescribed, give at least 2 liters of fluid every day while
implementing antibiotic therapy.
Give antipyretics are prescribed if there is fever.
Pain related to surgical operations
Objectives:
The client states lost pain / controlled.
The client indicates to relax, rest / sleep and increased activity
Appropriately Intervention:
Monitor vital signs
Provide comfort measures, eg changes in position, music, relaxation.
If prescribed analgesics, analgesics are routinely set during the first 24 hours, not
waiting for patients to ask for it.
Tell your doctor if analgesics cant eliminate the pain.

F. Cataract

A cataract is an eye disease in which the normally clear lens of the eye becomes
cloudy or opaque, causing a decrease in vision. The lens focuses light onto the back of
the eye (the retina) so images appear clear and without distortion. The clouding of
this lens during cataract formation distorts vision. Cataracts are usually a very
gradual process of normal aging but can occasionally develop rapidly. They

39
commonly affect both eyes, but it is not uncommon for a cataract in one eye to
advance more rapidly. Cataracts are very common, especially among the elderly.

Precisely why cataracts occur is unknown. However, most cataracts appear to be

caused by changes in the protein structures within the lens that occur over many
years and cause the lens to become cloudy. Rarely, cataracts can present at birth or in
early childhood as a result of hereditary enzyme defects, other genetic disease, or
systemic congenital infections. Severe trauma to the eye, eye surgery,
or intraocular inflammation can also cause cataracts to develop more rapidly. Other
factors that may lead to development of cataracts at an earlier age include excessive
ultraviolet light exposure, exposure to ionizing radiation, diabetes, smoking, or the
use of certain medications, such as oral, topical, or inhaled steroids. Other
medications that may be associated with cataracts include the long-term use
of statins and phenothiazines.

The total number of people who have cataracts is estimated to increase to 30.1 million
by 2020. When people develop cataracts, they begin to have difficulty doing activities
they enjoy. Some of the most common complaints include difficulty driving at night,
reading, or traveling. These are all activities for which clear vision is essential.

What are the symptoms and signs of cataracts?

Cataract development is like looking through a dirty windshield of a car or smearing
grease over the lens of a camera. Cataracts may cause a variety of complaints and
visual changes, including blurred vision, difficulty with glare (often with bright sun
or automobile headlights while driving at night), dull color vision,
increased nearsightedness accompanied by frequent changes in eyeglass prescription,
and occasionally, double vision in one eye. A change in glasses may initially help
once vision begins to change from a cataract. However, as the cataract continues to
become denser, vision also becomes more cloudy, and stronger glasses or contact
lenses will no longer improve sight.

Cataracts typically develop gradually and are usually not painful or associated with
any eye redness or other symptoms unless they become extremely advanced. Rapid
and/or painful changes in vision raise suspicion for other eye diseases and should be
evaluated by an eye-care professional.

40
How are cataracts diagnosed?
Cataracts are detected by finding lens opacification during a medical eye examination
by an eye-care professional. The abnormal lens can be seen using a variety of specialized
viewing instruments. Using a variety of tests, a doctor is able to tell how much a cataract
may be affecting vision. Usual eye tests include testing visual acuity, glare sensitivity,
color vision, contrast sensitivity, and a thorough examination of all other parts of the
eye. A thorough eye examination will make sure vision loss is not due to other
common eye problems, including diabetes, glaucoma, or macular degeneration.

Most cataracts associated with aging develop slowly, and many patients may not notice
visual loss until it is fairly advanced. It is not imperative to have surgery to remove them
until they begin to affect vision. The development of cataracts is unpredictable; some
cataracts remain less dense and never progress to the point where they cause cloudy
vision and require treatment, while others progress more quickly. Thus, the decision
and timing to proceed with cataract surgery is individualized for each patient. Your
doctor will be able to tell you how much of your vision loss is due to cataracts and the
type of visual recovery that may be expected if surgery is chosen.

Who is a candidate for cataract surgery?

Eye-care professionals may mention during a routine eye exam that you have early
cataract development even if you are not yet experiencing visual symptoms. Although
your doctor will be able to tell when you first begin to develop cataracts, you will

41
generally be the first person to notice changes in your vision that may require cataract
surgery. Clouding of the lens may start to be seen at any age, but it is uncommon before
the age of 40. However, a large majority of people will not begin to have symptoms from
their cataracts until many years after they begin to develop. Cataracts can be safely
observed without treatment until you notice changes in your vision.

Surgery is recommended for most individuals who have significant vision loss and are
symptomatic secondary to cataract. If you have significant other eye disease unrelated to
cataracts that limits your vision, your ophthalmologist may not recommend surgery.
Sometimes after trauma to the eye or previous eye surgery, a cataract may make it
difficult for your eye-care professional to see the retina at the back of the eye. In these
cases, it may still be appropriate to remove the cataract so that further retinal or optic
nerve evaluation and treatment can occur. The mode of surgery can be tailored to
individuals based on coexisting medical problems. Cataract surgery is generally
performed with minimal sedation and typically takes less than 30 minutes. Therefore
the surgery does not put significant strain on the heart or the lungs.

Prior refractive surgery such as LASIK is not a contraindication to cataract surgery.

A cataract is a medical condition, and insurance companies usually cover part or all of
the cost of cataract surgery, including pre- and postoperative care. Ask your physician
any questions you may have about the cost involved.

What are the different types of cataract surgery?

The standard cataract surgical procedure is performed in a hospital or in an ambulatory

surgery center on an outpatient basis. The most common form of cataract surgery today
involves a process called phacoemulsification. With the use of an operating microscope,
your surgeon will make a very small incision in the surface of the eye in or near
the cornea. A thin ultrasound probe, which is often confused with a laser by patients, is
inserted into the eye and uses ultrasonic vibrations to dissolve (phacoemulsify) the
clouded lens. These tiny fragmented pieces are then suctioned out through the same
ultrasound probe. Once the cataract is removed, an artificial lens is placed into the thin
capsular bag that the cataract previously occupied. This lens is essential to help your eye
focus after surgery.

42
There are three basic techniques for cataract surgery:

1. Phacoemulsification: This is the most common form of cataract removal as

explained above. In this most modern method, cataract surgery can usually be
performed in less than 30 minutes and usually requires only minimal sedation.
Numbing eye drops or an injection around the eye is used and, in general,
no stitches are used to close the wound, and often no eye patch is required after
surgery.
2. Extra capsular cataract surgery: This procedure is used mainly for very advanced
cataracts where the lens is too dense to dissolve into fragments (phacoemulsify).
This technique requires a larger incision so that the cataract can be removed in one
piece without being fragmented inside the eye. An artificial lens is placed in the
same capsular bag as with the phacoemulsification technique. This surgical
technique requires a various number of sutures to close the larger wound, and visual
recovery is often slower. Extra capsular cataract extraction usually requires an
injection of numbing medication around the eye and an eye patch after surgery.
3. Intra capsular cataract surgery: This surgical technique requires an even larger
wound than extra capsular surgery, and the surgeon removes the entire lens and the
surrounding capsule together. This technique requires the intraocular lens to be
placed in a different location, in front of the iris. This method is rarely used today
but can still be useful in cases of significant trauma

What are the different types of intraocular lenses implanted after cataract surgery?

As the natural lens plays a vital role in focusing light for clear vision, artificial lens
implantation at the time of cataract surgery is necessary as a replacement for the natural
lens to yield the best visual results. Because the implant is placed in or near the original
position of the removed natural lens, vision is restored, and peripheral vision, depth
perception, and image size are not affected. Artificial lenses usually remain permanently
in place, require no maintenance or handling, and are neither felt by the patient nor
noticed by others.

There are a variety of intraocular lens styles available for implantation, including
monofocal, toric, and multifocal intraocular lenses.

43
1. Monofocal lens: These lenses are the most commonly implanted lenses today. They
have equal power in all regions of the lens and can provide high-quality distance
vision, usually with only a light pair of spectacles. Monofocal lenses are in sharpest
focus at only one distance. They do not correct pre-existing astigmatism, a result of
irregular corneal shape that can distort vision at all distances. Your surgeon may
correct the astigmatism at the time of cataract surgery by making one or two
additional incisions in the periphery of the cornea. This does not make the surgery
more dangerous. People with significant astigmatism require corrective lenses for
sharpest vision at all distances. Patients who have had monofocal intraocular lenses
implanted usually require reading glasses.
2. Toric lens: Toric lenses have more power in one specific region in the lens to correct
astigmatism as well as distance vision. Due to the difference in lens power in
different areas, the correction of astigmatism with a toric lens requires that the lens
be positioned in a very specific configuration. While toric lenses can improve
distance vision and astigmatism, the patient still will require corrective lenses for all
near tasks, such as reading or writing.
3. Multifocal lens: Multifocal intraocular lenses are one of the latest advancements in
lens technology. These lenses have a variety of regions with different power that
allows some individuals to see at a variety of distances, including distance,
intermediate, and near. While promising, multifocal lenses are not for everyone.
They can cause significantly more glare than monofocal or toric lenses. Multifocal
lenses cannot correct astigmatism, and some patients still require spectacles or
contact lenses for clearest vision

What should one expect prior to and on the day of cataract surgery?

Prior to the day of surgery, your ophthalmologist will discuss the steps that will occur
during surgery. Your ophthalmologist or a staff member will ask you a variety of
questions about your medical history and perform a brief physical exam. You should
discuss with your ophthalmologist which, if any, of your routine medications you
should avoid prior to surgery. Prior to surgery, several calculations will be made to
determine the appropriate power of intraocular lens to implant. A specific artificial lens
is chosen based on the length of the eye and the curvature of the cornea (the clear
portion of the front of the eye).

44
It is important to remember to follow all of your preoperative instructions, which will
usually include not eating or drinking anything after midnight the day prior to your
surgery. As cataract surgery is an outpatient procedure, arrangements should be made
with family or friends to transport you home after the surgery is complete. Most cataract
surgery occurs in either an ambulatory surgery center or a hospital. You will be
required to report several hours before the scheduled time for your surgery. You will
meet with theanesthesiologist who will work with the ophthalmologist to determine the
type of sedation that will be necessary. Most cataract surgery is done with only minimal
sedation without having to put you to sleep. Numbing drops or an injection around the
eye will be used to decrease sensation of the eye.

During the actual procedure, there will be several people in the operating room in
addition to your ophthalmologist. These include anesthesiologists and operating-room
technicians. While cataract surgery does not normally involve a significant amount
of pain, medications are used to minimize the amount of discomfort. The actual removal
of the clouded lens will take approximately 20 minutes. You may notice the sensation of
pressure from the various instruments used during the procedure. After leaving the
operating room, you will be brought to a recovery room where your doctor will
prescribe several eye drops that you will need to take for a few weeks postoperatively.
While you may notice some discomfort, most patients do not experience
significant pain following surgery; if you do you experience decreasing vision or
significant pain, you should contact your ophthalmologist immediately.

What should one expect after the cataract surgery?

Following surgery, you will need to return for visits within the first few days and again
within the first few weeks after surgery. During this time period, you will be using
several eye drops which help protect against infection and inflammation. Within several
days, most people notice that their vision is improving and that they are able to return
to work. During the several office visits that follow, your doctor will monitor for
complications. Once vision has stabilized, your doctor will fit you with glasses if
needed. The type of intraocular lens you have implanted will determine to some extent
the type of glasses required for optimal vision.

45
What are potential complications of cataract surgery?

While cataract surgery is one of the safest procedures available with a high rate of
success, rare complications can arise. Your ophthalmologist will discuss the specific
potential complications of the procedures that are unique to your eye prior to having
you sign a consent form. The most common difficulties arising after surgery are
persistent inflammation, changes in eye pressure, infection, or swelling of the retina at
the back of the eye (cystoid macular edema), and retinal detachment. If the delicate bag
the lens sits in is injured, then the artificial lens may need to be placed in a different
location. In some cases, the intraocular lens moves or does not function properly and
may need to be repositioned, exchanged, or removed. All of these complications are rare
but can lead to significant visual loss; thus, close follow-up is required after surgery. If
you have pre-existing macular degeneration or floaters, these will not be made better by
cataract surgery.

In some cases, within months to years after surgery, the thin lens capsule may become
cloudy, causing blurred vision after cataract surgery. You may have the sensation that
the cataract is returning because your vision is becoming blurry again. This process is
termed posterior capsular opacification, or a "secondary cataract." To restore vision, a
laser is used in the office to painlessly create a hole in the cloudy bag. This procedure
takes only a few minutes in the office, and vision usually improves rapidly.

46
Types of Cataract Surgery
The most common type of cataract surgery is known as phacoemulsification (phaco). In
this procedure, the doctor makes a tiny incision in the eye and breaks up the lens using
ultrasound waves. The lens is then taken out and replaced with an intraocular lens
(IOL). Another type of cataract surgery is called extra capsular cataract surgery. This
procedure involves a larger incision and removal of the cloudy lens in one piece. In most
cases, placement of an IOL eliminates the need for thick eyeglasses or contact lenses.

Nursing Care Plan (NCP) for Cataract

Preoperatively:
Anxiety related to lack of knowledge of cataract surgery procedures

Intraoperative:
Acute pain related to surgery

Postoperative:
Risk for infection related to inflammation of postoperative wound

Nursing Outcome and Interventions Nursing Care Plan (NCP) for Cataract

47
Anxiety decreased after nursing actions, with expected outcomes:
1. The patient calm and relaxed
2. Can reveal the cause of anxiety
3. Patients were able to control anxiety
4. Patients may explain the action operations

Interventions:
1. Examine the patient's anxiety level, measuring vital signs
2. Give patients the information needed prior to surgery
3. Provide mental relaxation techniques as well as support involving elements of
religious
4. Give patients the opportunity to express his feelings before surgery

Acute pain decreased after nursing actions, with expected outcomes:

1. Patients expressed reduced pain
2. The patient's face looked relaxed

Interventions:
1. Recommended for, uses management techniques of relaxation, visualization, and
breathing

Infections do not occur during nursing actions

Interventions:
1. Discuss the importance of washing hands before touching or treating the eye
2. Show the proper techniques to clean the eye from the inside out with a wet tissue
3. Cotton ball for each swabs, bandages and anti-insert contact lenses when using
4. Observation/discuss examples of signs of infection redness, eyelid swelling, purulent
drainage.

48
 BAB III
CHRONIC DISABLING CONDITION

A. Cancer
Seculer Trends
The incidence and mortality trends of a discase over a period of time are
particular interest to the epidemiologist. Several interesting facts should be noted.
First, there were many changes in mortality rates for several sites during this period.
Before interpreting these changes in the frequency of disease, it is necessary to
estimate how much of the change resulted from improvements in diagnostic facilities

49
and medical care during this time. For example, the declining trend may well reflect
improvements in diagnosis, since the liver is an organ where metastasis from other
cancer sites frequently occur. It is possible that earlier years many deaths atributed to
cancer of the liver were in fact secondary or metastatic cancers.

Sex differences
One of the well-substantiated epidemiologic observation of cancer is the
variation in the sex distribution for cancer of different sites. It shows a general pattern
of higher mortality among males than females, particularly for cancer of the
respiratory and upper gastrointestinal tracts. Cancer of only to sites the thyroid and
biliary passages have an increased mortality in the female as indicated by the low
male/female ratio. This pattern of mortality rates is generally consistent with that
observed for morbidity rates.

Physical Agents
The major physical agent that has been implicated in carcinogenesis is that of
various forms of radiation, such as X-rays and ultraviolet rays. In fact, radiation has
been the most extensively studied environmental carcinogenic agent because of its
public health importance, resulting from the increased use of radioactive substances
in medicine and industry and the use of nuclear energy. It is also believed that a
better understanding of the knowledge of the mechanisms in general.

Biologic Agents
Viruses. The results of experimental studies in animals have suggested that
viruses may be of etiologic significance in human cancers. A herpes-type virus, the
Ebstein Barr virus is suspected of being one of the causes of Burkitts tumor, a cancer
that occurs primarily among children in selected areas of Africa with elevations
below 1800 meters, average temperatures above 16 0C, and where the annual rainfall
exceeds 60 cm.

Primary Prevention
Our ability at present to achieve primary prevention is extremely limited. The
most outstanding success lies in the area of reduced exposure to industrial

50
 carcinogens, although unfortunately only a relatively small proportion of cancers
actually result from such exposures. Our knowledge of the etiology of cancer,
however, does provide a sufficient basis for applying preventive measures to those
cancers caused by exposure to various forms of tobacco, particularly lung cancer. The
carcinogenic effects of exposure to ionizing radiation have been amply demonstrated.

Secondary Prevention
A secondary approach to prevention consists of detecting those individuals who
have the disease at a stage early enough in its natural history to prevent further
progression and to increase survivorship by the early institution of the treatment.
Secondary prevention is well illustrated in the case of skin or lip cancer, where
detection of an early lesion and the application of proper therapy result in complete
cure. If there is a delay in diagnosis, the cancer may spread to adjacent lymph nodes,
requiring extensive surgery with susquent disability and a decreased chance of
survival.

B. Heart Disease

Much is known about the causes and the potential for prevention of coronary
heart disease. This knowledge derives from clinical pathological observations,
laboratory-experimental studies and systemic population studies. The evidence from
these three major disciplines is largely congruent. Certainly, much remains to be
learned of fundamental cellular mechanisms in atherosclerosis. and about condition
which precipitate myocardial infarctions or sudden death in high-risk population.

Epidemiology
Comparisons of population show large differences in CHD incidence and
mortality and in the axtent of its underlying vascular disease, atherosclerosis.
Differences found in the levels and distributions of risk characteristic are generally
consistent with population differences in disease incidence. Within populations,
several risk characteristics are strongly and continously related to future risk of a
CHD event. Population differences in risk characteristic are already apparent in
childhood and childrens values tend to track into adult years.

51
Risk Factors
Diet and dietary fat. Habitual diet, largely a socio culturally determined
characteristic, is a central influence on the population distribution of elevated blood
lipids and thus on the risk, frequency and potential for prevention of CHD. Several
dietary factors are significant : composition in vegetable protein and complex
carbohydrate, caloric excess and a high intake of salt. Others may also be important.
Many investigators consider that composition of the habitual diet is the essential
factor in mass hyperlipidemia and mass atherosclerosis and CHD. Without the diet-
lipid factor, CHD is uncommon.
Combined Risk Factors
Clinical, laboratory and epidemiologic studies on individual cardiovascular risk
factors have been oriented toward determining specific causal roles for each factor.
However, cardiovascular disease in individuals and communities is related to a
multitude of circumstances operating together. The concept of multiple factors is
firmly established for atherosclerosis, CHD and stroke. The risk ratio between highest
and lowest categories for combined risk within populations is on the order of 10 20
fold, where as the ratio for single risk factors is on the order of 2 to 4 fold.

Preventive Practice
The counterpart of medical diagnosis in preventive practice is risk assessment
applied to the individual, the immediate family and the environment. The
counterpart of traditional therapy in preventive practice is a preventive prescription
with follow-up and maintenance with the individual the primary unit and the
immediate family and environment as important variables.

Community Prevention Programs

A useful and needed stage between evidence for public health action and its
implementation is a community demonstration program. These models of health
education involve education about single of multiple risk factors approached with
single or multiple strategies, each of which has potential and each possiblyenhanced
by the other. Two prominent community programs in cardiovasculer disease
prevention and health promotion are the Stanford Three Community Study and the
North Karelia Project in Finland.

52
C. FRACTURE

Meaning

A fracture is a break in the continuity of bone. A fracture occures when the stress
place on bone is greather than the bone can absorb. Muscles, blood, vessels, nerves,
tendons joint and other organs may be injured when fracture occurs.

Ethiology
Most common cause it from fall
Usually diapyseal and result from accidental trauma
Trauma is the most common cause of fracture in people and is usually due to
automatic injury or falling from a height. Since direct trauma is rarely delivered
in a calibrated amount to a specific place.

Pathologic

Though an area of diseased bone (ostheophorosis, bone cyst, bone tumor, bone
metastasis).

A pathologic fracture usually occurs with normal activities patient may be doing very
routine activities when their bone suddenly fracture. The reason the bone to the point
when the bone is unable to perform it is normal function.

Management

Factor influencing choice of fracture management

1. Type, location and severity of fracture
2. Soft tissue damage
3. Age and health status of patient ,including type and extend of other injuries.
Goals
1. To regain and maintain correct position and alignment
2. To regain the function of the involved part
3. To return the patient to usual activities activities in the shortest time and the
least expense.
Approach

53
 1. Closed reduction
2. Traction
Skin traction
Skeletal traction
3. Open reduction with internal fixation
a. Operative intervention to achieve reduction, alignment and
stabilization.
Bone fragments are direcly visualized
Internal fixation devices (metal pins, wires, screw, plates, nail,
rods) used to hole bone pragments in position until solid bone
healing occurs (may be removed when bone is healed)
After closure of the wound, splints or cast may be used for
additional stabilization and support.
4. Endoprosthetic replacement
a. Replacement of fracture fragment with an implanted metal device .
b. Used when fracture disrupts nutrition of the bone or treatment of
choice is bone replacement.
c. Stabilization of complex and open fracture with use a metal frame and
pin system
d. Permits active treatment of injured soft tissue
Wound may be left open (delayed primary wound closure)
Repair of damage to blood vessels, soft tissue, muscles, nerves
and tendon as indicated.
Reconstructive surgery may be necessary.
Medical Care
1. Laboratory :

CBC used to identity presence of infection, loss of blood, or platelet dysfunction:

coagulation profiles use to identity presence of coagulopathy or to determine
efficacy of coagulant therapy, alkaline phosphate levels may be used to identity
imbalances, metastatic disease, or endocrine disorder, electrolyte profile used to
identity deficiencies or imbalances.
2. Radiography :

Used to identity the presence, site and type of fracture.

3. CT scan :

54
 May used as an adjunctive test to show occult fractures and to determine extent
of artiolar surface distruption with joint fractures : CT Scan may also be used to
identity bone distruction or soft tissue masses.

4. Magnetic Resonance Imaging :

MRIs show soft tissue damage and can identity occult fractures, pathological
fractures, and asteonecrosis and osteomylitis that mimiz fractures.

5. Bone Scan :

May be done to detect focal injury; occult fractures can be identified

3-5 days after injury; used to evaluate for metastatic and metabolic bone disease
in pathologic fracture is diagnosed or suspected.

6. Analgesics :

Buprenorphine hidrochlorine (buprenex), butaphanol tartrate (stadol), codeine

phosphate, hydromorphone hydrochloride (Dilaudid), meperidine hydroclorine
(Demenol), methadone hydroclorine (Dolophine), morphine hydroclorine or
sulfate (Duramorph, Infumorph, Morphine, Ms Cortin, Roxanol, Statex) etc.

7. Casting :

Used to mountain aligment of the bones while they neal; cast should extend one
joint above and one joint below the fracture sito.

8. Traction :

Should be used when casting or surgery contraindicated for the elderly patient
because fracture is too fragmented or the patients medical conditions make them
unstable and poor surgical risks, traction in the extremely haxardous because of
potential for complications, such as PE, DVT, pressure sores and pulmonary
infection

9. Surgency :

55
 May be required to realign the bones or stabilize the fracture in order to restore
function; may be required if compartment syndrome occurs to release pressure to
preserve tissue and muscle integrity; joint replacement may be required
depending on the site of fracture.

Conversation,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Nurse : Good morning
Patient : Good morning nurse
Nurse : I am nurse X in this ward. Its really with Bayu Krisna?
Patient : Yes, I am. Please call me Bayu
Nurse : How do you feel today?
Patient : Not very well I think.
Nurse : Why?
Patient : I feel painful in my leg
Nurse : You feel painful because you have fracture in the right of your thigh
Patient : What is the meaning of fracture?
Nurse : Fracture is a break or distruption in the continuity of bone. Fracture in
children differ from those in adult. The anatomy, biomechanics,and
physiology of the childs skeleton is different than that of adult. Fracture in
the right of your thigh causes you got an accident. Fracture thigh usually
causes diaphyseal and result from accidental trauma
Patient : Why my thigh was bandaged?
Nurse : Your thigh was bandaged to keep your leg from mobilitation. If you
want to get well soon, you must to take your medicine
Patient : Just like that?
Nurse : No, we will teach appropriate ambulation techniques using aids, such as
crutches, walkers, or whell chair as indicated. And you can drink a milk
and eat food high calcium.
Patient : Why I must drink a milk and eat food high calcium?
Nurse : Because calcium can accelerate bone growth.
Patient : What is the kind of food that contains high calcium?
Nurse : There are egg, fish, spinach, meat, etc.
Patient : Ehm
Nurse : Do you have question?

56
Patient : No. its clear for me.
Nurse : I think its enough.
Patient : Thank you for your information.
Nurse : Your welcome, if you need something press the call botton, nurse will
help you.
Patient : Ok.
Nurse : See you
Patient : See you too

D. The Gift
Donna Ashlock, a 14 years old girl from California, was very sick. She had a bad
heart. Donna needs a new heart, her doctors said. She must have a new heart or she
will die soon.
Felipe Garza, 15, was worried about Donna. Felipe was Donnas friend. He liked
Donna very much. He liked her freckles and he liked her smile. Felipe didnt want
Donna to die.
Felipe talked to his mother about Donna. Im going to die, Felipe told to his
mother and Im going to give my heart to Donna. Felipes mother didnt pay much
attention to Felipe. Felipe is just kidding, she thought. Felipe is not going to die.
Hes strong and healthy.
But Felipe was not healthy. He had terrible headaches sometimes. My head really
hurts, he often told his friends. Felipe never told his parents about his headaches.
One morning Felipe work up with a sharp pain in his head. He was dizzy and he
couldnt breathe. The Garzas rushed Felipe to the hospital. Doctors at the hospital
had terrible news for the Garzas. Felipes brain is dead, the doctors said, we cant
save him

57
 The Garzas were very sad. But they remembered Felipes words. Felipe wanted
to give his heart to Donna they told the doctors. The doctors did several tests. Then
they told the Garzas, we can give Felipes heart to Donna.
The doctors took out Felipes heart and rushed the heart to Donna. Other doctors
took out Donnas heart and put Felipes heart in her chest. In a short time the heart
began to beat.
The operation was a success. Felipes heart was beating in Donnas chest, but
Donna didnt know it. Her parents and doctors didnt tell her. They waited until she
was stronger, then they told her about Felipe. I feel very sad Dona said , but Im
thankful to Felipe.
Three months after the operation Donna Ashlock went back to school. She has to
have regular checkups and she has to take medicine every day. But she living a
normal life.
Felipes brother John says, every time we see Donna, we think of Felipe. She has
Felipes heart in her. That gives us great peace.

VOCABULARY

Complete the sentences with the words below

Checkup Sharp rushed kidding dizzy

1. When Felipe told his mother, Im going to die she thought. Felipe is not
serious. Hes only joking. She thought Felipe was just
2. Felipe had a sudden, terrible pain in his head. It was apain
3. Felipe thought, The room is going around and around. He felt
4. When Felipes parents took him to the hospital, they drove fast. They
.him to the hospital
5. Donna goes to the doctor sometimes. The doctor listens to her heart and makes
sure it is working well. Donna goes to the doctor for a

UNDERSTANDING THE MAIN IDEA

Circle the letter of the best answer
1. The title of the story is The Gift What was the give ?
58
 a. The toys and balloons in the picture
b. Felipes heart
c. The operation
2. Why did Donna feel sad and thankful ?
a. She had an operation but she went back to school three months later
b. She has to take medicine every day, but she is living a normal life
c. Her friend Felipe died but he gave Dona his heart

UNDERSTANDING PRONOUNS
Look at the pronouns. What do they mean? Write the letter of your answer on the
line
1. ..They said Donna needed a new heart. a. Felipe Garza
2. .. He was Donnas friend b. Felipes friends
3. . Felipe told them his head hurt c. Medicine
4They told the doctors, Felipe wanted to d. The Garzas
give his heart to Donna. e. Doctors
5. ..It was a success f. Donnas operation
6. ..Donna has to take it every day

FINDING MORE INFORMATION

Read each sentences on the left. Which sentences on the right gives you more
information ? Write the letter of your answer on the line

1. Donna was very sick a. He had terrible headaches

2. Felipe was not healthy sometimes
3. Doctors at the hospital b. Im going to give my heart to Donna
had terrible news for the c. We cant save Felipe, they said.
Garzas d. She had a bad heart
4. The Garzas
remembered Felipes words

DISCUSSION
Many people carry donor cards in their wallets. A donor card says, If I die in an
accident take my heart and other important organs. Give to sick people.

59
Do you want a donor card ? Check (V) your answer.
Yes
No

Im not sure

In a small group, explain your answer

BAB IV
NURSING CARE PLAN

60
A. CLIENT WITH POST OPERATIVE CRANIOTOMY e.c. SUBDURAL
HEMATOMA, EPIDURAL HEMATOMA AND EDEMA CEREBRI IN HIGH
CARE UNIT CIPTO MANGUNKUSUMO HOSPITAL JAKARTA

TRAUMATIC BRAIN INJURY

1. DEFINITION

Traumatic Brain Injury definition is a blow or jolt to the head, which can disrupt
the normal function of the brain (Hall cit.The center for disease control and
prevention)

2. ETIOLOGY
Closed head injury is the result of variety of mechanism, including motor vehicle
and motorcycle accident, falls from height, assaults, and pedestrian being suck by
motorcycle vehicles. Brain injury may result from blast effect of proximal missile
wounds or, rarely as a thermal complication in burn patients. Most commontly,
traumatic brain injury occurs in the presence of additionals injuries to the other
major organ systems, but it can occur in isolation.

3. CLASSIFICATION (Ferrand and Bloom, 111-112)

61
 1) CLOSED HEAD INJURY

a. Acceleration/Deceleration
1) If a moving object hits a movable head (e.g., head gets hit with a
bat).
2) If a moving head hits something stationary (e.g., if you have a car
wreck and your head hits the dashboard).
3) Shaken type of movement (e.g., Shaken Baby Syndrome when head
rocks back and forth in skull).
4) Two types are:
Linear- brain moves straight along a linear path.
Angular- Brain rotates at an angle, twists, or rolls.
b. Non-Acceleration
1) Much more rare, referred to as a crushing injury
2) If a moving object hits a head that is fixed (e.g., car falls on head
while youre working under it).

2) PENETRATING HEAD INJURY

a. Low Velocity
1) Skull is no longer in tact, part of skull or debri gets into the brain (Ferrand
and Bloom).
2) An example is if you get hit so hard with a baseball that it breaks skull and
causes part of it to lay on the brain.
b. High Velocity
1) Skull is no longer in fact, part of skull or debri gets into the brain (Ferrand
and Bloom).
2) An example is if during a gun shot wound the bullet penetrates the skull
and goes into the brain matter.

4. PATOPHYSIOLOGY

The pathophysiology of brain injury can divided into two causes:

62
 1. Primary Brain injury is the direct result of disruptive forces that are
transmitted during impact. Hematomas can occur in any intracranial space or
potential space. Forms of damage:
Primary Damage- (These all occur right away)
a. Lacerations- cuts, more likely to occur in frontal or temporal lobe where
skull is jagged. As a result there may be some areas of bleeding.
b. Contusions- bruises, little areas of bruising where tissue changes then may
actually die.
c. Skull Fractures- problem with this is that the part of the skull that
fractures falls down and lays on the brain surface. These people are more
at risk for infection.
d. Diffuse Axonal Injury (DAI)- axons have been ripped apart. This damage
is very diffuse and widespread. This is the biggest factor in determining
the severity of the head injury.
2. Secondary Brain Injury is the term used to encompass all of the events after he
actual traumatic event that exacerbate the brain injury and combine to worsen
patient outcome. Forms of damage:
a. Hemorrhage- vessel is ripped during injury and slowly bleeds out.
b. Hematoma-occurs after massive bleeding, puts pressure on the brain and
can displace the brain from its normal position.
c. Cerebral Edema- swelling
d. Hypoxic-Ischemic Damage- you dont have enough oxygen in the blood.
Even if the brain gets blood it still wont have enough oxygen. This will
cause the area not receiving it to be damaged or die out.
e. Seizures- one part of brain has a tremendous amount of electrostatic, it
sucks oxygen away. So some parts lose oxygen.

Traumatic injury can occur to a focal brain region or more diffusely, affecting
both hemispheres and the brain stem. Inracranial hemorrage occurs commonly in
association with moderate and severe head injury and usually produces mass
lession. The therapy often is surgical, directed at removing the hematoma and
therapy decreasing intracranial volume.

63
 Cerebral edema and brain swelling are examples of pathologic diffuse injuries
that increase intracranial pressure (ICP) and alter conscioussness. Epidural
hematomas occuring on the outer surface of the brains protective coverings in
association with skull fractures, are usually of arterial origin. With prompt
evacuation of epidural hematomas, patient often have a relatively favorable
outcome. With subdural hematomas, however the force of impact is often
transmitted to the brain itself. In approximately, 80 % of subdural hematomas, it
is the underlying brain injury that determines the patient s course and outcome.

5. CRANIOTOMY

Craniotomy is a sugery to open into the cranium with removal of a bone flap and
opening the dura to remove a lesion, repair a damaged area, drain blood, or
relieve increased ICP. Indication for craniotomy may be related to brain tumor,
CNS infection, vascular abnormalities, craniocerebral trauma, epilepsy, and
intracable pain (Lewis, et al., 2000)

Depending on the location of the pathologic condition, a craniotomy may be

frontal, parietal, occipital, or a combination of any of these. A set of burr holes is
drilled, and saw it use to connect the holes to remove the bone flap. After surgery,
the bone flap is wired or sutured. Sometimes drain are placed to remove fluid
and blood. Patients are usually cared for in a critical care unit untill stable.

6. CRITICAL CARE MANAGEMENT

The treatment of head injury must emphasize prevention of secondary insults to
the already compromized brain tissue. ICP monitoring is instituted in patients
with severe head injuries and in those with moderate injuries who manifest
abnormal CT scans sugestive of raised ICP. Monitoring can be accomplished with
either a fiber optic intraparenchymal monitor of the camino type of
ventriculostomy. Treatment is institued for ICP of 20 mmHg or higher may
involve a combination of modalities, such as sedation, pharmacologic paralysis,
mannitol, barbiturates and cautious hyperventilation. ICP is optimized in order
to maximize cerebral perfusion. Cerebral Perfusion Pressure (CPP) is calculated
by substracting the ICP value from MAP value. Studies suggest that the goal

64
 keeping ICP is less than 20 mmHg while maintaining the CPP at more than 65 to
70 mmHg. This goal can usually be attained trough fluid rescucitation and
careful supplementation with small quantities of vasopressor.
The therapies for traumatic brain injury are:
1. Initial therapy to the lower elevated ICP include nursing patients with the
head of bed elevated 30 and ascertaining that the cervical collar is well fitting
and is not obstructing venous drainage
2. Pharmacologic therapy begins with the use of sedatives
3. External drainage of cerebrospinal fluid is direct maneuver to treat
intracranial hypertension. Decreasing the intracranial volume by even a few
milliliters causes an exponential decrement in ICP.
4. Mannitol is an osmotic diuretic that effectively reduces ICP. It must be
cautiously, with strict attention to the patients volume status and electolyte
balance. Intermittent boluses more effective than continuous infusion.
Prolonged use of mannitol leads to elevations in serum osmolarity and
hypernatremia. The patient may also have an adequate starting intravascular
volume, least the mannitol cause precipitous decrease in blood pressure and
secondary brain injury.
5. Hyperventilation reduces arterial carbon dioxide tension (PaCO2), leading to
vasoconstriction of the cerebral vessels. The vasoconstriction diminished
intracranial volume and correspondingly the ICP. Formerly a mainstay of ICP
management, hyperventilation is used today on a more limited basis.
6. Barbiturates are used in selected instances for ICP reduction and perhaps for
brain protection. These agent also induces hypothermia and decrease brain
metabolic demands.
7. Propofol, a sedative hypnotic agent, reduces cerebral metabolism, cerebral
blood flow and ICP.

7. PROGNOSIS AND OUTCOME

The extent of recovery from traumatic brain injury varies with the patients age,
the severity of the injury, and the type of intracranial disorder. In general,
recovery is slow, outcome is usually assesed 6 months after injury and is based
on patients cognitive function, independence, ability to care for self and motor
coordination.

65
 Cognitive impairments resulting from traumatic brain injury:
Have problems concentrating for varying periods of time.
Have trouble organizing thoughts.
Become easily confused or forgetful.
Often have STM problems.
Difficulty solving problems, making decisions, and planning.
Language problems
Word finding difficulty
Poor sentence formatting
Lengthy and faulty explanations.
Difficulty understanding multiple meanings in jokes, sarcasm, and
figurative expression.
Reading and writing abilities are often worse than those for speaking and
understanding spoken words.
Speech Problems
Slow, slurred, and difficult or impossible to understand.
This type of speech is called dysarthria- difficulty in articulating words
caused by impairment of the muscles used in speech.
May have problems swallowing called dysphagia

NURSING CARE TO THE CLIENT WITH POST OPERATIVE CRANIOTOMY e.c.

SUBDURAL HEMATOMA, EPIDURAL HEMATOMA AND EDEMA CEREBRI

I. NURSING ASSESMENT
A. CLIENTS IDENTITY
Name : Mr. ME.
MR number : 06.025837
Age : 32 y.o.
Sex : male
Religion : Islam
Adress : Jakarta
Insurance :-

66
 Marital Status : not married
Date of hospitalized : September 1st , 2006
Medical Diagnosis : Post operative craniotomy e.c. Subdural Hematoma,
Epidural Hematoma, and Cerebral edema

B. PRESENT HEALTH HISTORY

Mr ME is suffered from severe head injury because of an accident. He has hit by a

car on September 1st 2006. He has some injuries at frontal head band both of his
eyes. He was unconscious when somebody accompany him to the hospital,
bleeding was present, nausea and vomiting (+). He bought to the Emergency
Room RSCM on that day and then the doctor did craniotomy surgery on
September 2nd 2006. After surgery, the client referred to High Care unit in RSCM.

C. PAST HEALTH HISTORY

There is no data about his previous disease

D.PHYSICAL ASSESMENT

(this assesment did on September 4th,2006. second day post op.)

Neurology : General condition is severe sickness, GCS : E1M6VT, Pupil size 2/2,
pupil reaction +/+, extrimity strengthness 5/5-5/5, very active in motoric, pain
respon +/+. He has a postoperative wound in his frontal head, drain + product:
red blood, hematoma and redness around both of his eyes, edema palpebra +/+.
Respiration : his breathing is supported by ventilator, mode PC 12, PEEP 8, FiO2 :
50%, breathing sound : vesicular (N), RR 28-40x / mnt, dyspnea sometimes
occur, wheezing -, crackles -, chest expansion : symetric
Cardiovascular : heart sound S1,S2 normal, no additional sounds, HR 84 100 x /
mnt, BP 116/61 142/80 mmHg, pulse perifer is strong, warm acral , iv line is
inserted in his right leg, capilary refill < 3 seconds
Gastrointestinal : mouth : dry, intake supported by enteral nurition using
nasogastric tube, residu NGT (+), abdomen supple, bowel sound (+) normal,
defecation : normal

67
 Urinary : Dower Catheter is inserted, urine flow is normal
Integumen ; skin colour is black, redness in both of his eyes and his axilla, pale
(-), skin turgor is elastic, except in extrimity on right arm there is an edema
(phlebitis), tatoo on his arms, Skin temperature : 36,7 C

E. LABORATORY RESULT AND SUPPORTING DATA

Date : Date : Date : Date : Date :

09/01/06 09/02/06 09/03/06 09/04/06 09/05/06
Hb : 12,6 pH : 7,32 pH : 7,325 pH : 7,257 pH : 7,260
HCT : 37 PCO2: 27,5 PCO2: 35,7 PCO2: 44,6 PCO2:32,8
WBC :18.000 PO2 : 205 PO2 : 166,5 PO2 : 190,1 PO2 : 68,9
PLT : 181 HCO3-:14,4 HCO3-:18,7 HCO3:20,0 HCO3-:14,8
MCV : 88 BE :-9,4 BE :-7,5 BE :-7,4 BE :-12,5
MCH : 30 Sat : 99,7% Sat :99,4% Sat :99,5% Sat :90,9 %
MCHC 34
PT : 14,4
APTT : 44,1
Ur : 18
Cr : 0,8
SGOT : 40
SGPT : 30
Alb : 3,5
BG : 122
Na : 138
K : 4,6
Cl : 103
CT Scan Brain (09/01/06) there are : subdural hematoma, epidural hematoma and
edema cerebri.

F. NUTRITION AND THERAPY

Enteral Nutrition : 4 x 200 cc (24 hours)
Iv fluid: Asering 500cc / 24 hours
Therapy:

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 Morphin 1 ug in D5 % 50 cc (5cc/hour)
Tramal 3 A in D5 % 50 cc
Ceftriaxone 3 x 1 gr
Vit K 3 x 1 A
Vit C 1 x 1 gr
Transamin 3 x 1 A
Ranitidin 2 x 50 mg
Mannitol 4 x 150 cc
Piracetam 1 x 12 gr
Impepsa 3 x 1 C
Miloz inj 5 mg/iv p.r.n.
Norcuron inj 5 mg/iv p.r.n.

II. DATA ANALYZE

Date DA T A PROBLEM ETIOLOGY

09/04 DS : - Impaired Mechanical
DO : a postoperative wound in his tissue factor
1 frontal head, hematoma and redness integrity
around both of his eyes, edema
palpebra +/+, lacerative wound in his
axilla
09/04 DS : - Impaired gas Imbalanced
DO : RR increased 40-60x/mnt, exchange ventilation-
2 dyspnea, HR 120-140x/mnt, BGA perfusion
result:
pH : 7,32, PCO2: 27,5
PO2 : 205, HCO3-:14,4
BE :-9,4, Sat : 99,7%
09/04 DS : - Inneffective Hyperven-
DO : breathing is supported by Breathing tilation
3 ventilator, mode PC 12, PEEP 8, FiO2 : pattern
50%, breathing sound : vesicular (N),
RR 28-40x / mnt, dyspnea sometimes

69
 occur
09/04 DS : Inneffective Retained
DO : ETT is inserted in airway, a lot of airway secretion
4 mucous product are present clearance
09/04 DS : - Risk for Hypervo-lumia
DO : CT Scan result : there are inneffective
subdural hematoma, epidural cerebral
5 hematoma, and edema cerebri . The tissue
client has followed cranio-tomy perfusion
surgery. drain product is red blood
50cc/24 hours
09/04 DS : Risk for Invasive
DO : an injury in his frontal head, infection procedure
6 wound in both of his eyes,client is
installed with endotracheal tube, cvp
line, urinary catheter, WBC :18.000
09/04 DS : - Self care Weakness &
DO : GCS : E1M6VT, client is deficit unconscious-
restlesness, he cannot do personal syndrome ness
7 hygiene, feeding, and toileting. his
skin is dirty, his hair are shaved, his
mouth is smell not pleasant, his
nouse are full of secretion, his nails
are long and dirty

III. NURSING DIAGNOSES

1. Ineffective airway clearance related to retained secretion
2. Ineffective breathing pattern related to hyperventilation
3. Impaired gas exchange related to imbalanced ventilation-perfusion
4. Risk for in effective cerebral tissue perfusion related to hypervolumia
5. Impaired tissue integrity related to mechanical factor
6. Self care deficit syndrome related to weakness

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 7. Risk for infection related to invasive procedure

IV. NURSING CARE PLAN

No. Nursing Nursing Goals Nursing Intervention

Diagnosis
1. Ineffective airway During installed by 1. Maintain airway
clearance related ETT, client will patency
to retained perform: airway 2. Determine the need of
secretion patency is good, by oral or tracheal suctioning
criteria : secret from 3. Auscultate breathing
airway can be sounds before and after
cleaned, ronchi suctioning
sound can be 4. Do airway suction
minimize using universal
precautions : gloves,
googles, and mask as
appropriate
5. Hyperoxygenate with
100% oxygen using the
ventilator or manual
resucitation bag
6. Use sterile disposable
equipment for each
tracheal suction procedure
7. Hyperinflate at 1 to 1,5
times the preset tidal
volume using mechanical
ventilator, as appropriate
8. Monitor patients
oxygen status and
haemodynamic status
immediately before, during
and after suctioning

71
 9. Stop tracheal
suctionng and provide
supplemen-tal oxygen if
patient experiences :
bradycar-dia, an increase in
ventricular ectopy or
desaturation
10. Note type and amount
of secretion obtained

2. Ineffective During the client 1. Maintain airway

breathing pat-tern installed ETT and 24 patency
related to hour after ex-tubate, 2. Clear oral, nasal, and
hyperventilation client will perform tracheal secretion as
effective breathing apropiate
pattern by criteria: 3. Administer
RR 12-24 x/mnt, supplemental oxygen, as
there are no ordered
dyspnea, no pursed 4. Monitor the oxygen
lip breathing, no liter flow and position of
chest retraction oxygen delivery device
5. Position client to
maximize ventilation
potential
6. Auscultate breath
sounds, noting areas of
decreased or absent
ventilation and presence of
adventitious sounds
7. Monitor rate, rhythm,
depth and effort of
respirations
8. Monitor clients ability
to cough effectively

72
 9. Monitor for dyspnea
and events that improve
and worsen it monitor
chest X Ray reports

3. Impaired gas During the client 1. Obtain

exchange related installed ETT and 24 specimen for laboratory
to imbalanced hour after ex-tubate, analysis of acid balance
ventilation- client will perform (Blood Gas Analysis =
perfusion optimal gas BGA)
exchange, by criteria 2. Maintain
: patient iv access and
- Blood gas administer prescribed
analyze leading to alkali medication (e.g.
normal range sodium bicarbonate) as
- Client appropiate, based on ABG
consciousness : result
composmentis 3. Monitor intake
- Skin colour : and output
normal 4. Position patient
- HR 60- to facilitate ventilation
100x /mnt 5. Monitor
- No hypoxia decreasing bicarbonate
and hypercarbia from excessive nonvolatile
acids
6. Administer
fluid as prescribed
7. Monitor for
cardiopulmonary
manifestations of metabolic
acidosis (e.g. hypotension,
hypoxia, arythmia, and
kussmaul respiration)

73
4. Risk for During 7 post 1. Monitor neurological
ineffective operative, client will status
cerebral tissue perform effective 2. Monitor Central
perfusion related cerebral tissue Venous Pressure and Mean
to hypervolemia perfusion, by Arterial Pressure (MAP)
criteria: level of 3. Monitor respiratory
consciousness is status
increased, 4. Monitor signs of
neurological status bleeding
is stable, 5. Monitor intake and
hemodynamic in output
normal range (no 6. Consult with
hypertension) physician to determine
hemodynamic parameters,
and maintain
hemodynamic parameters
within this range
7. Induce hypertension
with volume expansion or
in atrophic or vaso
constrictive agents, as
ordered
8. Administer Mannitol
4x150 cc
9. Administer Transamin
inj 3x1A /iv
10. Administer Piracetam
inj 1x12 gr/iv
11. Administer Miloz inj.
5mg/iv p.r.n.
12. Administer Norcuron
inj. 5mg/iv p.r.n.

74
5. Impaired tissue After the 1. Remove adhesive tape
integrity related intervention, client and debris
to mechanical will perform tissue 2. Shave the hair
factor integrity is increa- surrounding the affected
sed, by criteria : area, as needed
- the post op 3. Note characteristis of
wound is dry, no the wound and any
exudat drainage
- drainage 4. Do wound care :Clean
colour is yellowish, with povidone iodine, soak
drain product is in saline solution, apply
stopped sufratule. Dress with
- no appropriate mesh gauze, as
hematoma around needed. Bandage
the eyes appropriately
- Edema 5. Maintain sterile
palpebra can be dressing technique when
minimized doing wound care
- Lacerative 6. Especially for the
wound in axilla is eyes, do not use antiseptics,
dry and wound but give antibiotic zalf as
healing is good appropiate
7. Give kemicetine zalf
on the eyes, and close the
eyes
8. Apply a wet gauze
with normal saline on
palpebraes
9. Apply an appropriate
ointment to the skin

6. Self Care Deficit During the patient 1. Assess patient

Syndrome related got unconscious and self care abilities to
to weak, all self care determine level of care

75
 unconsciousness, needs meet, by needed and plan
weakness criteria : appropriate interventions
Skin is clean, mouth 2. Provide for total
is clean and not self care requirements of
smell unpleasant, patient, including hygiene
nose is clean, nails and skin care and tube
are cleaned feeding or total parenteral
nutrition
3. Turn patient at
least 2 hours to promote
effective circulation and
ventilation and to prevent
skin breakdown
4. Maintain
indwelling catheter patency
to facilitate bladder
emptying, assess need for
enema or suppository to
promote adequate bowel
elimination
5. Maintain range
of motion of all joints to
prevent contractures
6. Provide oral
hygiene to prevent
stomatitis and promote
comfort
7. Keep clients
eye closed or use artificial
tears if unconscious or
unable to blink to prevent
corneal damage

7. Risk for infection During installed by 1. Monitor for systemic

76
 related to invasive ETT, CVP or iv line, and localized signs and
procedure NGT and urine symptoms of infection
catheter client will 2. Monitor absolute
not suffered from granulatic count, WBC,
infection by criteria : and differential results
No edema, 3. Report sign and
erythema, and symptoms of infection to
hyperthermia occur, physician for evaluation:
the amount of WBC temperature elevation
is in normal range, above patients normal,
Hb in normal range erythema or edema
4. Maintain asepsis
technique when doing
dressing ETT, CVP or iv
line, NGT and urine
catheter
5. Administer
Ceftriaxone inj 3x1 g/iv
6. Promote sufficient
nutritional intake
7. Encourage rest
8. Wash hand before and
after the intervention
9. Encourage fluid intake
as aprpopriate

V. IMPLEMENTATION AND EVALUATION

NDx IMPLEMENTATION EVALUATION

Date &
time
NDx no.1 Auscultate breath sounds, S:-
09/04/06 insert and change oropharingeal O : breath sound : vesicular
09.00 a.m airway (N), a slow ronchi in right

77
10.00 a.m Monitor respiratory and lung, RR 20-30x/mnt,
10.15 a.m oxygenation status mucous in airway +
Do airway suctioning (tracheal A : the problem is not
10.20 a.m and oral), Monitor patients solved
oxygen status and P : Continue the
haemodynamic intervention
Give inhalation therapy (Nacl:
10.30 a.m Bisolvon = 1 cc : 1 cc)
Monitor mechanical ventilaion
Do airway suctioning (tracheal
11.00 a.m and oral), Moni-tor patientss
oxygen sta-tus and
13.00 a.m haemodynamic
NDx no.2 Auscultate breath sound, observe S: -
09/04/06 RR, chest retraction, or nasal O: RR 20-30 x/mnt,
08.00 a.m flaring dyspnea sometime occurs,
09.00 a.m Give Position patient to no chest retraction
maximize ventilation potential A: the problem is not solved
10.00 -14.00 Monitor respiratory and P : Continue the
a.m oxygenation status intervention

NDx no.3 Obtain blood specimen for BGA S:-

09/04/06 Checking BGA result O: pH : 7,257, PCO2: 44,6
11.30 a.m Manage the mechanical PO2 : 190,1, HCO3:20,0
12.00 a.m ventilation BE :-7,4, Sat :99,5%
Give Asering 500ml for A: the problem is not solved
13.00 a.m continuous infusion P : Continue the
intervention
NDx no.4 Check level of conscious-ness, S :
09/04/06 pupil size & reaction, extrimity O : general condition is
08.00 a.m strenthness, verbal severe sickness, GCS :
communication, vital sign, fluid E1M6VT, pupil reaction : +/
balance, sign of intracranial +, pupil size 2/2, extrimity
pressure strengthness : 5/5, pain

78
 Monitoring vital sign, bed of bed respons +/+, vital signs :
09.00 a.m elevated 300 BP stable 116/61142/80
Giving stricted IV therapy mmHg, HR : 84-100x/mnt,
09.30 a.m Monitor intake & output RR : 12-30x/mnt, fluid
Monitor vital sign balance (24 hours) = -975cc
10.00 a.m Giving miloz 5mg/iv, A : the problem is solved
10.30 a.m Giving iv therapy : mannitol 150 P : continue the
12.00 a.m cc/iv intervention
Monitoring vital sign
14.00 a.m Monitor intake and output
NDx no.5 Remove adhesive tape, note S : -
09/04/06 characteristic of wound, soak in O : post operative
08.30 a.m saline solution, give antiseptics, craniotomy wound is dry,
apply sufratule, dress with drain product + red, both of
appropriate mesh gauze eyes are injured, swallen,
Give kemicetine zalf for the eyes, and redness +. The injured
08.45 a.m close the eyes, apply moist gauze skin in both of axilla are
use normal salin on the wet.
palpebraes A : the problem is not
solved
P : continue the
intervention
NDx no.6 Bathing the client, doing oral S : -
09/04/06 care, perineal care. Help the O : the skin is clean, mouth
08.00 a.m client wearing clothes is clean, nose is clean,
Giving enteral nutrition via NGT perineum is clean, nails still
09.00 a.m Help the client position lie on left dirty, enteral nutrition can
side absorb, residu
10.00a.m Give parenteral nutrition: A : a part of problem is
Aminofusin 500 ml/iv solved
11.30 a.m Help the client position : supine P : continue the
12.00 a.m Remove urine from urine bag intervention

13.30 a.m

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NDx no.7 Do dressing ETT, iv line, NGT, S : -
09/04/06 and urinary catheter O : area around insertion
08.15 a.m Change the oropharingeal airway ETT, iv line, NGT and
Assess the sign and symptom of urinary catheter have no
08.35 a.m infection sign of infection S : 36,7 0C
Give ceftriaxone inj 1g/iv A : the problem is solved
12.00 a.m P :continue intervention
NDx no.1 Asses breathing sounds, S :
09/05/06 respiration rate, secretion of O : RR : 25 32 x/mnt,
08.00 a.m airway Monitor respiratory and breathing sound vesicular,
09.00 a.m oxygenation status slow ronchi + in right lung,
Do airway suctioning (tracheal airway secretion +
10.00 a.m and oral), Moni-tor patientss A : the problem is not
oxygen sta-tus and solved
haemodynamic P : continue the
10.15 a.m Position patient to maximize intervention
ventilation potential
11.00 a.m Give inhalation therapy (Nacl:
Bisolvon = 1 cc : 1 cc)
12.00 a.m Monitor mechanical ventilation
NDx no.2 Auscultate breath sound, observe S: -
09/05/06 RR, chest retraction, or nasal O: RR 20-30 x/mnt,
08.00 a.m flaring dyspnea rarely occurs, no
09.00 a.m Give Position patient to chest retraction
maximize ventilation potential A: the problem is not solved
10.00 -14.00 Monitor respiratory and P : Continue the
a.m oxygenation status intervention

NDx no.3 Obtain blood specimen for BGA S:-

09/05/06 Checking BGA result O: pH : 7,260, PCO2:32,8
11.30 a.m Manage the mechanical PO2 : 68,9, HCO3-:14,8
12.00 a.m ventilation BE :-12,5, Sat :90,9 %
Give Asering 500ml for A: the problem is not solved
13.00 a.m continuous infusion P : Continue the

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 intervention
NDx no.4 Check level of conscious-ness, S :
09/05/06 pupil size & reaction, extrimity O : general condition is
08.00 a.m strenthness, verbal severe sickness, GCS :
communication, vital sign, fluid E1M6VT, pupil reaction : +/
balance, sign of intracranial +, pupil size 2/2, extrimity
pressure strengthness : 5/5, pain
Monitoring vital sign, bed of bed respons +/+, vital signs :
09.00 a.m elevated 300 BP stable 116/55140/90
Giving stricted IV therapy mmHg, HR : 84-100x/mnt,
09.30 a.m Monitor intake & output RR : 12-20x/mnt, S : 36,7 0C
Monitor vital sign
10.00 a.m Giving miloz 5mg/iv, A : the problem is solved
10.30 a.m Giving iv therapy : mannitol 150
12.00 a.m cc/iv P : continue the
Monitoring vital sign intervention
14.00 a.m Monitor intake and output
NDx no.5 Remove adhesive tape, note S : -
09/05/06 characteristic of wound, soak in O : post operative
08.30 a.m saline solution, give antiseptics, craniotomy wound is dry,
apply sufratule, dress with drain product + red, both of
appropriate mesh gauze eyes are injured, swallen,
Give kemicetine zalf for the eyes, and redness +. The injured
close the eyes, apply moist gauze skin in both of axilla are
08.45 a.m use normal salin on the wet.
palpebraes A : the problem is not
solved
P : continue the
intervention

NDx no.6 Bathing the client, doing oral S : -

09/05/06 care, perineal care. Help the O : the skin is clean, mouth
08.00 a.m client wearing clothes is clean, nose is clean,
Giving enteral nutrition via NGT perineum is clean, nails still

81
09.00 a.m Help the client position lie on left dirty, enteral nutrition can
side be absorb, residu
10.00a.m Give parenteral nutrition: A : a part of problem is
11.30 a.m Aminofusin 500 ml/iv solved
Help the client position : supine P : continue the
12.00 a.m Remove urine from urine bag intervention

13.30 a.m
NDx no.7 Do dressing ETT, iv line, NGT, S : -
09/05/06 and urinary catheter O : area around insertion
08.15 a.m Change the oropharingeal airway ETT, iv line, NGT and
Assess the sign and symptom of urinary catheter have no
08.35 a.m infection sign of infection S : 36,7 0C
Give ceftriaxone inj 1g/iv A : the problem is solved
12.00 a.m P :continue intervention

B.CASE STUDY

1. ASSESMENT
Day and date : Tuesday, September, 12th 2015
Time : 08.00 a.m
Nurse :
Source: Patient, Patients family, Medical Record, Nurse

a. Identity
1) Patient
Name : Baby MZ
Age : 2 month 28 days old
Sex : Male
Religion : Moslem
Ethic/Nation : Java/ Indonesian

82
 Addres : Sawahan, Gamping, Sleman
Date of admission : Monday, 11th 2016
Medical Record : 01.33.66.45
2). Family
Name : Mr F
Age : 25 Years old
Address : Sawahan, Gamping, Sleman, Yogyakarta.
Related : Father

b. Health History
1) Main complaint
Patient ever got respell when he first day care in PICU and now he is
getting better, respell not present. The color of his body cyanosis especially
his mouth. Capillary refill > 3 , his acral cold.

2) The reason patient admission in hospital

Five days before hospitalized, when he breastfeeding, he was aspiration
then he had difficult to breath, his body became cyanosis but he didnt
fever. His parent bring him gone to the Pku Muhammadiyah hospital, he
care about three days. In this hospital he got therapy propanolol 3x 0.4 gr,
CPZ 3x5mg, and oxygenation 2lt/mnt. He care in there about three days
and his complaint didnt better, so he refer to Sardjito hospital.

3) Health History at past

The baby looks cyanosis when his age 1 month, if he breastfeeding
suddenly he got difficult to breath or the baby crying make his condition
worst. His parent ever check his complaint with midwife. The midwife
said the baby didnt happen anything, she just suggestion always keep the
baby with warm condition and keep the baby under sunlight every
morning.

4) Health history his mothers pregnancy

His mother during her pregnancy, She didnt have any complaint. She
never got hiperemesis gravidarum, she never sick and fever. She always

83
 check her pregnancy in the doctor or midwife near her home. she got
immunization Tetanus Toksoid completely. When she labor helped by
midwife spontaneous without Caesarea Cesar or vacuum. The babys
weight 3000 gram and Height 48 cm.

5) Growth and Developing history

a. Fine motorist
He can follow nurses hand 1800 C
b. Hard motorist
He can roll his body from back to side.
c. Language
He can laugh if his family play with him
d. Social development
He know his parent at 1 month old

6) Family health history

In his families have not disease like him, the families havent some disease
like Diabetes mellitus, asthma or Decompensasi cordis.

Genogram

: Female
: Male
: Wedding line
: Family line
: Patient

84
7) Physical examination
General condition
Blood pressure : 94/47 mmHg
Temperature : 36,50 C
Pulse : 110 beat/ mnt
Respiratory rate : 21 beat/mnt
Nutrition status : Weight 4.4 Kg
Height 55 cm
Chest circumference 36 cm
Head circumference 38 cm
Upper arm circumference 12 cm

i. Neurological system
Awareness patient compos mentis- apatic, GCS 14-15, pupil isochors, the
diameter pupil is 2mm, the reaction with light is positive and symmetric
right and left side..
ii. Cardiovascular system
His blood pressure 94/47 mmHg, heart rate 110 beat/ mnt, his pulse weak.
Capillary refill more than 3 second. Cardiac sound S1-S2 murmur, Gallop not
present. ECG in bedside monitor lead II shows normal sinus rhythm, the
result of ECG at September 11 2006 QRS wave shows right deviation.
iii. Respiration system
His sound of breath is vesicular, he breath with cannule binasal 2 lt/mnt.
iv. Urinary system
He can urine spontaneously, didnt apply Dower Catheter. The color of urine
clear yellow.

v. Gastrointestinal system
Peristaltic bowel sound positive, in his nose applied NGT, Defecate once a
day, the color is yellow and soft.
vi. Extremities
He have two arms and two legs, in his left hand applied IVFD with Ka EN IB
3cc/hour.

85
 vii. Integument system
His acral cold, he didnt have lacy, his skin moist, skin turgor is good, but the
skin looks dirty, from his eyes exit secret.
8) Reflex baby
i. Babinski reflex
When pen touch in his foot by nurse the result his foot finger is extension
ii. Sucking reflex
When kassa entered in his mouth, he often sucking its.
iii. Grasping reflex
He can grasping fingers nurse
iv. Rooting reflex
His head move right side when fingers nurse touch his chick

9) Immunization
The baby got BCG immunization when 1month old, DPT immunization 1x
when he 2 month, and he got polio immunization when 2 month old. He also
got immunization Hepatitis B when he 0 month.
10) Laboratory Result at 11th September 2015
Hb :11,8 gr/dl
PLT : 304.000 /mmk
WBC : 8.100/mmk
Protein total : 5,02 gr/dl (6,3 8,2)
Albumin : 3,09 gr% (3,5 5,1 )
Urea nitrogen : 5,3 mg/dl (7 20 )
Creatinin : 0,51 mg/dl (0,7 1,5 )
Calcium : 2,14 mmol/Lt (2,1 2,57)
Glucosa : 266 mg/dl (75 110 )
Natrium : 132 mmol/Lt (137 145)
Potasium : 4,32 mmol/Lt (3,6 5 )
Clorida : 105,5 mmol/Lt (98 107 )
Globulin : 1,9 gr/dl (2,4 3,5 )
Ne % : 35,1 %
Ly % : 53,1 %
BA : 0,2

86
 NE : 2,8
MO : 0,6
HCT : 38%
MCV : 80,7
MCH : 25,1
MCHC : 31,3
RDW : 23,8
PCT : 304
11) Radiology Result
From Pku Muhammadiyah hospital the result echocardiograph at September
9th 2006 is severe Tetralogy Of Fallot (TOF PA) duct dependent PFO and the
comment BT shunt.
Thorax X-Ray CTR 50% .

12) Medic Therapy

September 11th 2015
IVFD Ka EN 1B 3cc/hour
Propanolol 3x 0,4 mg
Morphin 0,1 mg/kg weight if necessary
Oxygenation 2Lt/mnt

2. ASSESTMENT POST OPERATIVE

His surgery called BT shunt

He operated at September, 14th 2015

a. Neurological system
Awareness patient under control with mylos 0.4/hour (0.1 mg). Pupil isokor, the
diameter pupil is less than 3 mm, the reaction of eyes right and left side with
light are positive.
b. Cardiovaskular system
Blood pressure : 83/40 mmHg
MAP : 62 mmHg
Heart rate : 102 beat/mnt

87
 Cardiac sound S1-S2 still murmur, gallop not present. ECG in bedside monitor
lead Il shows NSR. Capillary refill more than 3 second.

c. Respiratory system
From the surgery room the patient applied ETT in his mouth , size 4 cm and
level 11. He breath helped by ventilator mechanic Galileo, mode PSIMV. FiO 2 100
%, tidal volume 50, PEEP 5. He breath without accessory of muscle. Saturation 38
%. Respiratory rate 54 x/mnt.

d. Gastrointestinal system
He applied NGT but still fasting status. Peristaltic sound in bowel didn't founded.

e. Urinary system
From surgery room applied dower catheter and product of urine 20 cc, the color
is yellow and clear.

f. Integument system
His acral cold, his skin still cyanosis and the temperature is 32,9 o C. he gone to
surgery room at 6.45 a.m until 1.40 p.m. This condition surgery room very
cold.He have wound in his right chest.

g. Medical therapy September, 14th 2006

Ceftriaxone 1x250 mg
Antrain 3x40 mg
IVFD Consist of :
Line 1 Mylos 0.4 cc/hour (0.1 mg)
Line 2 Dobutamin 0.5 cc/hour (10 mg/kg weight/hour)
Line 3 D101/2 NS 4,5 cc/hour
Line 4 Aminofusin 0.9 cc/hour
Line 5 Dopamin 0.3 cc/hour

h. The result of blood gas analyze

PH: 7.27
PCO2: 37.9 mmHg

88
PO2: 24.7 mmHg

89
ANALYSIS DATA

Supporting Data Problem Etiology

Subjective data:- Decreased Altered after
Objective data: cardiac output load
Capillary refill more than 3 second
Pulse peripheral weak
Skin colour blue/ cyanosis
Blood pressure is 94/47 mmHg
Acral is cold
Pulse 110 bpm
Laboratory electrolyte result: Na 132
mmol/L, Cl: 105,5 mmol/L
Subjective data:- Self care deficit Unability
Objective data:
His skin look dirty
From the his eyes exit secret
He is still baby
Subjective data:- Impaired Metabolic
Objective data: spontaneous factor
The patient use ETT no.4 cm and level 11cm ventilation
in his mouth
He breath with ventilator mechanic
He breath without accessory muscle
Saturation 38%
Ph 7,27
PCO2 37,9 mmHg
PO2 24,7 mmHg
Respiratory rate 54 bpm
Mode ventilator PSIMV, Fi O2 100%, Tydal
volume 50, PEEP 5
Subjective data:- Risk infection Invasive
Objective data: procedures
He applied IVFD in left arm and left leg

90
 He applied NGT in left hole of his nose
The result laboratory value: WBC 8100/
mmk
Temperature is 36,50C

Subjective data:- Hypothermia Cold

Objective data: environment
He go to operating room at 06.45 am (operating
He come back in PICU room at 01.45 pm room)
0
His temperature is 32,9 C
His skin is cold
The operating room very cold

3. NURSING DIAGNOSIS
Nursing diagnosis pre operative to come a long from analysis data are:
1) Decreased cardiac output related to altered after load supporting data:
Subjective data:-
Objective data:
Capillary refill more than 3 second
Pulse peripheral weak
Skin color blue/ cyanosis
Blood pressure is 94/47 mmHg
Acral is cold
Pulse 110 bpm
Laboratory electrolyte result: Na 132 mmol/L, Cl: 105,5 mmol/L
2) Self care deficit related to unability, supporting data :
Subjective data:-
Objective data:
His skin look dirty
From the his eyes exit secret
He is still baby
3) Risk infection related to invasive procedures, supporting data:

91
 Subjective data:-
Objective data:
He applied IVFD in left hand
He applied NGT in left hole of his nose
The result laboratory value: WBC 8100/ mmk
Temperature is 36,50C
Nursing diagnosis post operative to come a long from analysis data are:
1) Impaired spontaneous ventilation related to metabolic factor, supporting data:
Subjective data:-
Objective data:
The patient use ETT no.4.5 cm and level 11cm in his mouth
He breath with ventilator mechanic
He breath without accessory muscle
Saturation 38%
Ph 7.27
PCO2 37.9 mmHg
PO2 24.7 mmHg
Respiratory rate 54 bpm
Mode ventilator PSIMV, Fi O2 100%, Tydal volume 50,PEEP 5
2) Hypothermia related to cold environment (operating room), supporting data:
Subjective data:-
Objective data:
He go to operating room at 06.45 am
He come back in PICU room at 01.45 pm
His temperature is 32,90C
His skin is cold
The operating room very cold

92
 PLANNING

No SUPPORTING DATA NURSING GOALS INTERVENTION

DIAGNOSIS
1 th
September, 12 2015, September, 12th 2015, September, 12th 2015, September, 12th 2015, 08.15 am
08.15 am 08.15 am 08.15 am
Subjective data:- Decreased cardiac After nurse care had done Monitor and documented
Objective data: output related to during 5 days, cardiac heart rate rhythm and pulse
Capillary refill more altered after load output normally, the Monitor electrolyte level
than 3 second criteria are: Administer positive
Pulse peripheral weak Blood pressure: isotropic/ contractility
Skin color blue/ 110- 120/70- 80 medications
cyanosis mmHg Evaluate side effects of
Blood pressure is 94/47 Acral extremities is negative isotropic
mmHg warm medications
Acral is cold Pulse peripheral is Monitor peripheral pulses
Pulse 110 bpm strong capillary refill temperature
Laboratory electrolyte Pulse: 125- 160 and color of extremities
result: Na 132 mmol/L, bpm Monitor intake and output
Cl: 105,5 mmol/L Monitor homodynamic

93
 Changes position every
2hours
Check flow oxygenations

94
 PLANNING

No SUPPORTING DATA NURSING GOALS INTERVENTION

DIAGNOSIS
2 th
September, 12 2015, September, 12th 2015, September, 12th 2015, September, 12th 2015,
08.15 am 08.15 am 08.15 am 08.15 am
Subjective data:- Self care deficit After nurse care had done Bath in water of a
Objective data: related to unability during 5 days, self care comfortable temperature
His skin look dirty patient fulfilled, the Assist with perineal care
From the his eyes exit criteria are: Help the baby take bath
secret His body look Apply oil baby
He is still baby .. clean every day Take a bath baby with soap
His eyes clean Do with antiseptic care to
from secret prevent infection
. After and before contact the
patient wash our hand
Provide personal hygiene/
. oral hygiene
Keep skin dry
Maintain adequate

95
 elimination
Change the blanked and bed
sheet

..

PLANNING

No SUPPORTING DATA NURSING GOALS INTERVENTION

DIAGNOSIS
3 th
September, 12 2015, September, 12th 2015, September, 12th 2015, September, 12th 2015,
08.15 am 08.15 am 08.15 am 08.15 am
Subjective data:- Risk infection After nurse care had done Dressing wound on where
Objective data: related to invasive during 3 days, didnt installed IVFD
He applied IVFD in left procedures happen infection, the Use aseptic technique

96
 hand criteria are: Washing hand before and
He applied NGT in left Temperature after touch patient
hole of his nose 0
normally (36- 37 C) Use gloves when take
The result laboratory No redness dolor bathing patient
value: WBC 8100/ mmk in where installed Monitor vital sign
Temperature is 36,50C IVFD Monitor WBC value
Laboratory result Change the infusion set
value of WBC every 3 days
normally (4- Observation with sign of
11.000/mmk) infection: dolor, color, tumor,
fungi

97
 PLANNING

No SUPPORTING DATA NURSING GOALS INTERVENTION

DIAGNOSIS
1 th
September, 14 2015, September, 14th 2015, September, 14th 2015, September, 14th 2015,
13.40 pm 13.40 pm 13.40 pm 13.40 pm
Subjective data:- Impaired After nurse care had done Monitor rate, rhythm, depth,
Objective data: spontaneous during 3 days, ventilation effort of respiration
The patient applied ETT ventilation related to patient stabile, the criteria Monitor breathing patters
no.4.5 cm and level metabolic factor are: bradypnea, tacypnea
11cm in his mouth Result of analyze Monitor for diaphragmatic
He breath with gas blood : Pa CO2: muscle fatigue
ventilator mechanic .. 34- 45 mmHg, Auscultation breath sound
He breath without PaO2: 80- 100 Monitor for decrease in
accessory muscle mmHg, HCO3: 23- exhale volume and increase
Saturation 38% 26 mEq/L, Ph: in inspiratory pressure
Ph 7,27 7,35- 7,45 Routinely monitor ventilator
PCO2 37,9 mmHg The patient breath setting
PO2 24,7 mmHg without use of Monitor patients progress
Respiratory rate 54 bpm accessory muscle on currents of mechanical
Tidal volume: 44-

98
 Mode ventilator PSIMV, 66 ventilation
Fi O2 100%, Tydal Respiratory rate: Provide on oropharingeal
volume 50, PEEP 5 35- 50 bpm airway or bite black to
prevent biting on the
endotracheal tube
.......... Administer therapy medic
Collaborate with laboratory

99
 PLANNING

No SUPPORTING DATA NURSING GOALS INTERVENTION

DIAGNOSIS
2 th
September, 14 2015, September, 14th 2006, September, 14th 2015, September, 14th 2015,
13.40 pm 13.40 pm 13.40 pm 13.40 pm
Subjective data:- Hypothermia After nurse care had done
Objective data: related to cold during 2 days, Remove the patient from the
He go to operating environment thermoregulation cold, and place in a warm
room at 06.45 am (operating room) normally, the criteria are: environment
He come back in PICU Temperature: (36- Remove cold, wet clothing
room at 01.45 pm 0
37 C) and replace with warm dry
His temperature is Skin warm clothing
32,90C . Monitor patients
His skin is cold temperature
The operating room Monitor for symptoms
very cold associated with
hypothermia: fatigue,
weakness, confusion, apatis,

100
 impaired coordination,
.. slurred speech, shivering
and change in skin color
Place on a cardiac monitor
Cover with warmed
blankets
Monitor vital sign

101
IMPLEMENTATION & EVALUATION NURSING PROGRES
Nursing diagnosis: Decrease cardiac output related to altered after load
DATE IMPLEMENTATION EVALUATION
Tuesday, Monitoring Tuesday, September 12th 2015, 09.10
Septembe homodynamic patient am
Monitoring heart rate, S: -
th
r 12
2015, rhythm, and pulse O:
09.00 am Monitoring peripheral Blood pressure is
pulses, capillary refill and 131/25mmHg
temperature HR: 123 bpm, regularly and
Monitoring color of skin weak
extremities Temperature 36,20C
Monitoring intake and Skin extremities cyanosis
output RR: 28 bpm
Giving the patient Propanolol 0,4 mg entered by
propanolol 0,4 mg ( by NGT) NGT with water 5 cc
Giving milk formula Milk SGM entry 25 cc
Keeping the baby didnt
crying .

10.00 am Monitoring 10.15 am

homodynamic patient S:
Monitoring hart rate, O:
rhythm, and pulse Blood pressure is 93/47 mmHg
Monitoring color of skin MAP: 63 mmHg
extremities Heart rate is 94 bpm, regularly
Monitoring intake and and weak
output Saturation is 42%
Keeping the baby didnt Respiratory rate 15 bpm
crying The skin still cyanosis
The urine110 cc the color is
yellow
 .. .
11.00 am Monitoring 11.15 am
homodynamic patient S:-
Monitoring hart rate, O:
rhythm, and pulse Blood pressure is 113/63
Monitoring color of skin mmHg
extremities MAP is 79 mmHg
Checking flow Heart rate is 92 bpm
oxygenations Regularly and weak
The flow of oxygenation is
.. 2l/mnt
The color of skin is cyanosis

..
12.00 am Monitoring 12.30 pm
homodynamic patient S:
Monitoring heart rate, O:
rhythm, and pulse Blood pressure 88/55 mmHg
Evaluation side effect of MAP 65 mmHg
negative neurotic HR: 114 bpm
medication (propanolol
giving at 09.00)
..
IMPLEMENTATION & EVALUATION NURSING PROGRES
Nursing diagnosis: Decrease cardiac output related to altered after load

DATE IMPLEMENTATION EVALUATION

Wednesday, Monitoring Wednesday, September 13th 2015,
September homodynamic patient 08.55 am
th
13 2015, Monitoring heart rate, S: -
08.00 am rhythm, and pulse O:
Monitoring peripheral Blood pressure is 115/59mmHg
pulses, capillary refill and HR: 120 bpm, regularly and weak
temperature Temperature 370C
Monitoring color of skin Skin extremities cyanosis
 extremities Pulses 112 bpm
Keeping the baby didnt Capillary refill more than 3 second
crying The baby sleep
. ..
09.00 am Monitoring 09.05 am
homodynamic patient S:
Monitoring heart rate, O : Blood pressure is 106/95 mmHg
rhythm, and peripheral MAP: 74 mmHg
pulse Pulse 128 bpm, regularly and rather
Monitoring changes weak and sinus rhythm
color of body Saturation is 30%
Give medicine propanol Propanolol oral 0,4 mg entered
0,4 mg by NGT


10.00 am Monitoring 10.05 am
homodynamic patient S:-
Monitoring hart rate, O : Blood pressure is 100/95 mmHg
rhythm, and pulse The baby still sleep
Monitoring peripheral MAP is 98 mmHg
pulses Pulse 128 bpm, regularly and rather
Monitoring capillary weak and sinus rhythm
refill Saturation is 35%
Keeping the baby ..
comfort and didnt crying At 10.15 he planed operate BT Shunt, so the
baby conducted in operating room 4th floor
in same building, but this plan is canceled
because he have not yet blood to transfusion
if needed. The baby come back from
operating room at 12.00 pm, so the surgery
planed tomorrow morning

12.00 am Monitoring 12.15 pm
homodynamic patient S: -
Monitoring heart rate, O : Blood pressure 83/51mmHg
 rhythm, and pulse Temperature 36,2 0C
Monitoring peripheral Pulse 140 bpm rather strong sinus
pulses rhythm
Monitoring capillary Capillary refill <3 second
refill Saturation 84 %
..
.

IMPLEMENTATION & EVALUATION NURSING PROGRES

Nursing diagnosis: Decrease cardiac output related to altered after load

01.00 pm Monitoring 01.15 pm

homodynamic patient S: -
Monitoring hart O:
rate, rhythm, and pulse Blood pressure is 100/61mmHg
Monitoring MAP 75 mmHg, saturation 85%
peripheral pulses Pulses 142 bpm sinus rhythm
Giving milk Milk enter 30 cc after that the baby
. sleep
.
02.00 pm Monitoring 02.20 pm
homodynamic patient S: -
Monitoring hart O:
rate, rhythm, and Blood pressure is 88/54 mmHg
peripheral pulse MAP: 64 mmHg
Monitoring Pulse 132 bpm and rather strong and
peripheral pulses sinus rhythm
Monitoring intake Saturation is 88%
and output Intake: 205 cc
Checking flow of Output: 190 cc
oxygenation IWL: 10 cc
Liquid balance: + 5 cc

Thursday, Monitoring th
Thursday, September 14 2015,07.20 am
September homodynamic S:-
th
14 2015, Keeping baby O:
06. 45 am comfort Blood pressure is 100/61 mmHg
Conduct the patient MAP is 73 mmHg
to operating room Pulse 142 bpm, rather weak and sinus
rhythm
Saturation is 88%
..
The patient start 06.45 am until 01.40 pm
in operating room
01.45 pm Accept the patient 01.45 pm
from operating room S: -
Monitoring O:
hemodynamic patient From operating room he applied ETT
Monitoring heart size 4 and. He awareness still under
rate, rhythm, and pulse muscle relaxation and sedative, he
Monitoring use ventilator PSIMV, position patient
capillary refill is side left
Monitoring color of Temperature is 34,90C
extremities his body This pulse regularly and weak
Blood pressure is 101/44mmHg
MAP 80 mmHg, his body still
cyanosis
Pulse70 bpm, regularly, sinus rhythm
Capillary refill still more than 3
second

..
IMPLEMENTATION & EVALUATION NURSING PROGRES
Nursing diagnosis: Decrease cardiac output related to altered after load

DATE IMPLEMENTATION EVALUATION

Friday, Monitoring Friday, September 15th 2015 08.55 am
Septembe homodynamic patient S: -
r 15th Monitoring hart rate, O:
08.00 am rhythm, and pulse Blood pressure is
Monitoring, capillary 88/54mmHg
refill and temperature MAP 64 mmHg
Monitoring color of skin HR: 132x/mnt, regularly and
extremities strong
Monitoring electrolyte Temperature 36,40C
level Skin extremities cyanosis
Pulses 112x/Mnt, sinus
rhythm
Capillary refill more than 3
second
Result of electrolyte Na: 135
mmol, Cl: 109 mmol/L, Ca: 1,95
mmol/l
A: Part of problem is solving
P: Continue the nursing care

Th
Friday, Monitoring Friday, September 15 2015, 09.30 am
Septembe homodynamic patient S:
Th
r 15 Monitoring heart rate, O:
2015, rhythm, and peripheral Blood pressure is 80/25
09.00 am pulse mmHg
Monitoring changes MAP: 48 mmHg
color of body Pulse 119 bpm, regularly and
Monitoring therapy rather weak and sinus
medic rhythm
Saturation is 25 %
 IVFD: Dobutamin 0,5
. cc/hour
Dopamine 0,2 cc/hour
Aminofusin 0.9
cc/hour
D10 NS 4.5 cc/hour
Aminofusin 0.9cc/hour
Mylos 0.4cc/hour
A: Part of problem is solving
P: Continue the nursing care

IMPLEMENTATION & EVALUATION NURSING PROGRES

Nursing diagnosis: deficit self care related to un ability

DATE IMPLEMENTATION EVALUATION

Tuesday,Septe Help the baby take a bath Tuesday, September12th 2015,
mber 12th Prepare warm water in 08.30 am
2015, wash basin S: -
08.00 am Prepare equipment suck O:
us: sap oil, bed set, The body is clean use new
blanketed cloth
Taking a bath baby with The mouth and his eyes clean
warm water using the soap from secret
Using the oil to prevent dry The baby urine in pampers
skin, clean perineal about 10cc
.. ..
Th
Wednesday, Helping the baby take a Wednesday, September 13 2015,
September bath 08.30 am
th
13 2015, Prepare warm water in S:
08.00 am wash basin O:
Prepare equipment suck The body is clean
 us: sap oil, bed set, His perinea became
blanketed clean he is urine and defecate
Taking a bath baby with about 15cc
warm water using the soap The mouth and his eyes
Using the oil to prevent dry clean from secret
skin, clean perineal
.. .
Thursday The patient still
September, in surgery room
th
14 2015
12.15 pm
Friday, Helping the baby take a Friday, September 15Th 2015, 08.30
September bath am
th
15 2015 Preparing warm water in S:
08.00 am wash basin O:
Preparing equipment suck His body after taking a bath is
us: sap oil, bed set, clean
blanketed The perinea became clean
Taking a bath baby with from defecate and mixci 20cc
warm water using the soap the color defecate is yellow
Using the oil to prevent dry and soft, the color of urine is
skin, clean perinea yellow
Keep the baby from cold Patient sleep with new clothes
Using oil to his body to blanket, bed sheet
prevent dry skin Patient comfortable
Giving injection ceftriaxone A: Problem is solving
250 mg/IV P: Continue intervention everyday

..
.
 IMPLEMENTATION & EVALUATION NURSING PROGRES
Nursing diagnosis: Risk for infection related to invasive procedures

DATE IMPLEMENTATION EVALUATION

Tuesday, Monitoring vital sign Tuesday, September 12Th 2015
September 12th Washing hands 09.30 am
2015 Using gloves S: -
09.00 am Using ethnic aseptic O:
Dressing infusion Blood pressure is 131/25
Observation sign of infection mmHg
HR: 123 bpm
Temperature 36,20C
.. Didnt happen dolor
color tumor fungtiolaesa
in left arm (where IVFD
installed)
..
Wednesday, Monitoring vital sign Wednesday, September 13th
September 13th Washing hands 2015
2015, 09.00 am Wearing cloth new and clean, 09.15 am
using gloves S:
Using technique aseptic O:
Dressing infusion Temperature: 370C
Observation sign of infection Pulse: 112x/mnt
Didnt happen sign of
.. infection
.
Thursday, Monitoring vital sign Thursday, September 14Th 2015,
September 14Th Washing hands 08.20 am
2015, 08.20 am Wearing cloth new and clean, S: -
using gloves O:
Using technique aseptic Temperature 36,80C
Dressing infusion Blood pressure
Observation sign of infection 88/54mmHg
Pulse 152x/mnt
 Charge infusion set with new Didnt happen sign of
infusion set infection suck as redness
Check laboratory WBC dolor tumor and
Giving injection ceftriaxone fungtiolasea
250 mg/IV WBC normally
9000/mmk
A: Problem is solving
P: Continue implementation
..
.

IMPLEMENTATION & EVALUATION NURSING PROGRES

Nursing diagnosis: Impaired spontaneous ventilation related to metabolic factor

DATE IMPLEMENTATION EVALUATION

Thursday, Monitoring rate rhythm Thursday, September 14Th 2015 10.15 am
September, depth S: -
14Th 2015 Monitoring O:
10.00 am diaphragmatic muscle Respires rate 90x/mnt
fatigue Patient didnt use muscle
accessory to breath
. .
Th
Friday, Checking value of analyze Friday, September, 15 2015 11.10 am
September, blood gas S:
15Th 2015 Monitoring rate rhythm O:
11.00 am depth Respires rate 38x/mnt regular
Monitoring nothing happen bradypnea or
diaphragmatic muscle thachipnea
fatigue Patient didnt use muscle
Monitoring breathing accessory to breath
pattern Breath sound vesicular
Auscultation breath Tidal volume 50 %
sound Patient use ventilator SMV, Fi O2
 Monitoring tidal volume 100%
Monitoring ventilator Oropharingeal airway clean
setting Ph: 7,32 mg/dl
Monitoring oropharingeal PO2: 42,8 mg/dl
airway PCO2: 32,8 mg/dl
HCO3: 16,6mg/dl
.... .
Friday, Checking value of analyze Friday, September16 2015 12.15 pm
Th

September blood gas S: -

Th
15 2015 Monitoring rate rhythm O:
11.30 am depth Respires rate 54x/mnt regular
Monitoring nothing happen bradypnea or
diaphragmatic muscle thachipnea
fatigue Patient didnt use muscle
Monitoring breathing accessory to breath
pattern Breath sound vesicular
Auscultation breath Tidal volume 54 %
sound Patient use ventilator PSIMV, Fi
Monitoring tidal volume O2 100%
Monitoring ventilator Oropharingeal airway clean
setting Ph: 7,30
Monitoring oropharingeal PO2: 29,6 mmHg
airway PCO2: 27,6 mmHg
Giving injection antrain HCO3: 14,3 mmHg
40 mg IV A: Part of problem is solving
P: Continue nursing intervention
..

IMPLEMENTATION & EVALUATION NURSING PROGRES

Nursing diagnosis: Hypothermia related to cold environment ( operating room)

DATE IMPLEMENTATION EVALUATION

Thursday, Installing a cardiac monitor Thursday, September 14Th 2015 13.55
September Removing the patient from pm
operating room to PICU S: -
Th
14 2015
13.50 pm room O:
Removing cold wet clothing Cardiac monitor installed
and replace with warm dry Baby using warmer blanket
clothing
Covering with warmer ..
blanket
..
14.00 pm Monitoring patient 14.15 pm
temperature S:
Monitoring for systems O:
associated with Alert patient sedation (sedation
hypothermia effect)
Monitoring vital sign Blood pressure 83/19 mmHg,
MAP 34 mmHg, RR 32 bpm,
HR 130 bpm, Temperature
.. 35,20C
A: problem not completely resolve
P: Continue the nursing care
..
Th
Friday, Monitoring patient Friday, September15 2015, 08.15 am
September temperature S:-
th
15 2015 Monitoring vital sign O:
08.00 am Keeping patient with warm Blood pressure 62/19 mmHg
condition (warmer blanket) MAP 34 mmHg
Respiratory rate 44 bpm
Heart rate 124 bpm
Temperature 35,70C

01.00 pm Monitoring patient 01.15 pm
temperature S:
Covering with warmer O:
blanket Temperature 37,70C
Acral of extremities warm
 Monitoring for symptoms A: problem is solving
associated with P: Keep patient warm condition
hypothermia .

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