Identification done on:

Date of : 22 nd July 2013

The time of day: 15. 00
College student name:
Practicing hall: seruni
I. Identification
Client name : Mrs.. M
Age: 64 yr
Marital status: get married
Gender: female
Religion: islam
Tribe or nation : banjar / Indonesian
Education: SD
Work: IRT
Address: Jl., Padat karya , gang pelangi Samarinda.
Hospitalize: 20th July 2013
No. register: 13. 035xxx
Clinical diagnosis / medical: brongkial's asthma
B. History To Care
1. Main complaint
a. While comes in( 20th July 2013, the time of day 16.30)
client says breath congested
b. while is identification ( 22nd July 2013, the time of day 16.30)
client says breath congested, giddiness and bellyful, breathing congested client if
beraktiftas, client also says not can't sleep Because lamp light and situation or
atmosphere at hospital, client says to want homewards quick because wants flock with
family
2. Present diseased history
Before hospitalizes client have asthma disease history, client feels its breath congested
increase acute since 3 the day before salkit's house input, frequent client gets doctor and
consultation go to poliklinik.
 - While hospitalizes client complain breath congested
- While is identification , pale observable client and effortless
3. Preceding diseased history
 Asthma since client is still little
 Hypertension
4. Families Diseased history
Patient oldster atient mother, asthma history( while deceased is is nursed at hospital)
Patient father, hypertension history Patient husband oldster not have disease history
5. Genogram is family

Information : = Deceased

= male

= female

= patient

= stay one house

= patient

C. Psiko's data – social – economy

- psiko: patient says to want issue quick of hospital because wants quick flock with
family.
- Social: patient gets good communication with family and another medical energy.
- economy: hospital cost utilizes JAMKESDA
D. Spiritual's data
- patient says always pray and recite for its recovery.
E. Day-to-day custom pattern
1. Nutrisi (eating – drink)
a. At house
- eating: rice, vegetable, temped an knows
- Drink: white water and tea, frequency 4 – 5 glasses / days
- Abstention: Chicken and Egg
b. At hospital
- Eating: not very like hospital foods
- Drink: white water and tea, frequency 4 – 5 glasses / days
2. Elimination
a. at house
Chapter: 2x / days
Font: 5 – 6x / days
b. at hospital
Chapter: 1x / days
Font: 4 – 5x / days
3 . Rest and Sleep
a.At home
nap : 1 hour : 13:00 to 14:00
night's sleep : 8 hours : 21:00 to 05:00
b.At Hospital
nap : 2 hours : 12:00 to 14:00
night's sleep : insomnia patients say
4 . Activities and Motion
a. At home : clients reduce motor activity due to shortness of breath
b . Hospital : the client only to the bathroom during the hospital
5. Personal Hygiene
a At Home: 2x/day shower , brush your teeth 3 times daily , change clothes 2x/day .
b.At Hospital: 2x/day bath , brush teeth 2x/day , change clothes 2x/day .
F. Physical Examination ( inspection, palpation , percussion , auscultation )
01. . The General State
consciousness ( GCS ) : E : 4 V : 5 M : 6 = 15 cm
b . height : 153 cm
c . weight : 45 kg
02. TTV :
Blood Pressure : 150/100 mmhg
Heart Rate : 112x/i
Respiration Rate : 30x/i
Temperature : 37◦C
03. Head
a. Hair : color : black and gray
texture : uniform distribution and corrugated
b. Scalp : no lesions, no lumps, no dandruff
c. Face : left - right symmetric, weak expression
d. Eye : conjunctiva : pink
sclera : white turbid
lid : there are dark circles
e. Mouth : Looks clean
Is in the middle palate
Complete tooth and tidy
No thrush
f. Lip : mucosa moist, no cyanosis
g. Nose : symmetric, septum in the middle, use the nostril
h. Ear : Symmetric the same left- right size, auditory functioning well
04. Neck : there is no enlargement of the thyroid gland, there is no enlargement of the
jugular vein
05. Chest : symmetric, ronchi contained breath sounds
06. Abdomen : not bloating, not enlargement of the liver, not abdominal distension
07. Genetalia : not inspection
08. Leg : symmetric, not edema of the lower extremities,
 09. Spine : no lesions, there are no abnormalities in the spine
10. Arm : attached to the left infusion, in the upper extremity is not swollen
11. Skin : brown, moist skin, skin turgor back less than 2 seconds

TEST DIAGNOSTIC (20 JULI 2013)

Normal
GDS : 117 mg/dl 60-150
Ureum : 29,8 mg/dl 10-40
Creatinin : 0,7 mg/dl 0,5-1,5
Natrium : 137 mmol/L 135-155
Calium : 4,0 mmol/L 3,6-5,5
Cloride : 108 mmol/L 95-108
WBC : 142,2 4,0-10,0

MANAGEMENT / DIET THERAPY

Infusion RL : 20 tpm
Aminophilin : 1,5 amp/kolf
Bricasma : 3x1/2 amp
Dexametason : 3x1 amp
Ranitidine : 2xi amp
Nebulizer Ventolin : 3x1
Oxygen : 3L

I. Subjektive Data
1. Patient complained of shortness of breath
2. Patients completed the move say every breath felt tight
3. Said patients can not sleep
4. Patients say dizzy and not accustomed to the atmosphere of the hospital
II. Objektive Data
1. Unable to move the maximum because of tightness
2. Lid looks dark circles
 3. Pale face
4. Patient looks anxious
5. Patient’s sweaty and limp
6. Breath in quickly
7. Ronchi breath sounds
8. Blood Pressure : 150/100 mmhg
Heart Rate : 112x/i
Respiration Rate : 30x/i
Temperature : 37◦C
III. Data Analysis
Grouping of data Problem Cause
DS : patient complained of Ineffective airway Accumulation of
shortness of breath clearence secretions
DO : - patient looks anxious
- Ronchi breath sounds

DS : patients completed the move activity intolerance Physical weakness

say every breath felt tight
DO : - Unable to move the
maximum because of
tightness
- breath in quickly
- pale face
- TD = 150/100mmhg
T= 37◦C
N= 112 x/i
RR= 30x/i

DS : - said patients can not sleep disturbances in sleep effects of hospitalization

- patients say dizzy and not patterns
accustomed to the
 atmosphere of the hospital

IV. Nursing diagnose

1. Ineffective airway clearance related to accumulation of secret associated with the
accumulation of airway secretions characterized by retention of secretions or
secretions in the airway Ronchi and frequency changes
2. Activity intolerance related to physical weakness characterized by tightness after the
move was not optimal
3. Disturbances in sleep patterns associated with the effects of hospitalization marked by
changes in sleep patterns and sleep dissatisfaction

V. Nursing Intervention
Name Client : Ny.M
Old : 64 years old
Diagnoses : Asma Bronchiale
Room : Seruni
No. Register : 13035697
1. Ineffective airway clearance related to accumulation of secret.
Destination : Within 3x24 hours effective airway clearance criteria results :
- Easy to breathe
- Frequency and rhythm of normal breathing ( RR = 16 - 20x / I)
- Having a normal breath sounds lung function ( vesicular )
- Secret out of the airway
intervention :
1.1 Assess the frequency of respiratory
1.2 Teach effective coughing and breathing techniques to remove secretions
1.3 Set the position of the patient
1.4 Help nebulizer therapy

2. Activity intolerance related of physical weakness.

 Destination : Within 2x24 hours tolerance criteria for the activity with :
- No shortness of breathing during activity
- Balance activity and rest ( lane hours worth )
intervention :
2.1 Assess the patient's level of ability to move from the bed and stood
TTV monitor
2.2 Client before and after the move
2.3 Encourage rest and activity periods to alternately

3. Disturbances in sleep patterns associated with the effects of hospitalization marked

by changes in sleep patterns and sleep dissatisfaction
Destination : in 1x24 hours sleep patterns by the criteria of the results :
- Client says can sleep soundly
- The client was refreshed
intervention :
3.1 Monitor the patient's sleep patterns
3.2 Create a comfortable environment for patients
3.3 Adjust position as comfortable as possible

VI. Implementation
1.1 Assess the frequency and clients breathing effort
S = client said her breathing was still congested
O = clients look weak , Respiration Rate = 33X / i
1.4 Help nebulizer therapy
S = client said sometimes a little cough and a secret exit
O = client looks comfortable , and enthusiastic about the therapy that is given
1.3 Change the position of the client
S = the client more comfortable half-sitting position
O = client looks comfortable
2.1 Assess the patient's ability to move
S = the client says to the bathroom feeling claustrophobic
O = clients seen wearing a nasal cannula
 2.1 Monitor the client's vital signs before and after the move
S = ..
O = before 130/90 mm Hg
2.3 Advocated rest and activity interchangeably or regular
S = client said bias
O = clients look nod
3.1 Monitor the client's sleep pattern
S=
O = clients during sleep , but if the night did not sleep , nap just 2 hours
3.2 Creating a comfortable environment for patients
S = client says more convenient
O = turn off the lights , close the door , set the position of the patient to be more comfortable
VII. Evaluation
1. Ineffective airway clearance related to accumulation of secret.
S= client said after in -patient in a nebulizer and shortness of breath decrease client
O = client looks calmer
A = problem solved partially
P = intervention stopped the clients home
2. Activity intolerance b / d of physical weakness.
S = the client says it can not move much / maximum of suffocation because they grow
O = clients often shortness of breath when walking to the toilet
A = problem solved partially
P = intervention stopped the clients home
3. Disruption of sleep patterns b / d effects of hospitalization
S = the client more comfortable saying turn off the lights , closed the door and half-sitting
position
O = the client more comfortable rested , refreshed when you wake up client
A = problem condiment
P = intervention stopped the clients home