NURSING CARE IN "ND" PATIENTS

WITH COPD + DIABETES MELLITUS

IN KLUNGKUNG HOSPITAL

DATED OF MAY 12st -14st 2015

I. Identity of Client
Name : ND
Place, Date of birth: Karangasem, December, 30st 1950
Ages : 65 years old
Sex : Female
Education background : Elementary school
Job/Work : Farmer
Date of hospitalized : May, 10st 2015
Religions : Hindu
Status : Married
Nationality : Indonesia
Address : Padang Bay, Karangasem.
Resources : Pasient, patient's family and medical records

1. The closest family to contact

Name : KK
Ages : 40 years ago
Sex : Male
Education background : Senior High School
Job/Work : laborer
Religions : Hindu
Status : Married
Nationality : Bali
Address : Padang Bay, Karangasem
Resources : patient's child
2. Reason of hospitalized :
During the study, the patient said MRS due to shortness of breath.
3. Main Complaints
During the study the patient said that they were short of breath, had
difficulty catching their breath, patients complained of weakness, often
drank and wanted to eat continuously, knew they had to use insulin before
eating but did not routinely use insulin at home, felt tired and felt weak,
difficulty moving their bodies , take a shower, good, because it is easy to
feel tired (weak)
4. Current disease history
Day / Date: Sunday, May 10 2015
 The patient is a dispatch from the Klungkung Hospital emergency
department and received therapy: NaCl (16tpm), Lameson 2x1 / 2, PCT
flash 2x1 amp. Then the patient gets hospitalization to Room F at 16:17
WITA in a conscious state with a weak KU. Shortness of breath, O2 (+),
cough (+), fever (+). Therapy obtained by the patient at that time in room F,
namely:
0.9 0.9% NaCl (16 tpm)
 Lameson 2x1 / 2
 Farbivent @ 8 Hours
5. Past Disease History
During the study the patient said that he had been treated in room E of the
Klungkung Hospital about 4 months ago with heart disease + DM.
6. Family Health History
When reviewing the patient said he had a history of hypertension. All his
siblings have a history of hypertension that was passed on from his father.
Patients say they have no history of DM. No family has DM. The new
patient has been known to have DM since he was treated in room E of
RSUD Klungkung 4 months ago.
7. Allergies:
Patients say they have no history of allergies
8. Habits:
Patients say they have coffee. In one day the patient used to drink coffee as
much as 2x but since he was hospitalized, the patient did not drink coffee
anymore.
9. Medicines:
The patient said that since being treated in Room E of the Klungkung
District Hospital 4 months ago with heart disease + DM, patients used
insulin injections before eating but patients did not routinely use it because
they were unable to use it themselves.
10. Nutrition Pattern:
Frequency / portion of meal:
The patient said to eat 3 times / day with a portion of one plate
Weight: 60 kg
Height: 155 cm
a. Food Type:
Rice, vegetables, tofu, tempeh, fish, bananas.
b. Preferred food:
Patients say the preferred food is pastries and tempeh.
c. Unwanted food:
The patient said that the unwanted food was eggplant.
d. Abstinence:
 There are no dietary restrictions
e. Appetite :
Patients say that their appetite is good, they often drink and continue to
want to eat.
f. Change in BB for the last 3 months:
The patient said weight was reduced by 6 kg from the previous body
weight: 60 kg, so now the patient's weight was 54 kg.
11. Elimination Pattern:
a. Defecate
Frequency: Once a day
Time: Morning
Color: Brownish Yellow
Consistency: Soft
Use of Laxatives: None
b. Urination
Frequency: 4-5 times a day
Color: clear yellow
Odor: A typical odor of urine
12. Sleep and Rest Pattern:
Sleep time (hours): Patients say that they sleep at 8:30 p.m. to 5:00 p.m.
Duration of sleep / day: The patient said the duration of tidurnys was ± 8
hours / day.
Bedtime habits: None
Sleeping habits: Sleeping on your back or sloping left / right
Difficulty in sleeping: The patient says he has no difficulty in sleeping
because he is already using oxygen.
13. Activity and training patterns:
a. Work activities:
Patients say they are no longer working because they are old.
b. Sports :
Patients say they never exercise
c. Leisure activities:
Patients say spend free time by keeping their grandchildren at home.
d. Difficulties / complaints in terms of:
The patient said that it was rather difficult to move his body, take a
shower, he wanted to, because it was easy to feel tired (weak).

14. Working Pattern:

a. Type of work :
The patient said that he no longer worked as a farmer.
b. Number of hours worked: -
c. Duration: -
d. Work schedule :-
 II. History of Family
III. Genogram :

= Male = dead

= Female = stay at home

= Pasient

IV. Environmental History

Environmental cleanliness: The patient's room environment looks clean
Danger: There is no visible danger around the patient's environment
Pollution: No pollution

V. Psychosocial Aspects:
1. Mindset and perception
a. Tools used:
The patient does not use assistive devices such as glasses and hearing
aids
b. Difficulties experienced:
Patients say there are no difficulties experienced by patients at this time
2. Self perception
a. What is currently estimated:
The patient said the thing he was thinking about right now was about the
current healing process.
b. Hope after undergoing treatment:
The patient said his hope after undergoing treatment was that the
tightness he experienced could heal and his blood sugar did not rise.
c. Mood :
The patient said his mood was nervous because he was thinking about
his current health condition.
1. Communication relations:
a. Talk
Patients can speak clearly using Balinese.
b. Residence
Have your own house that is occupied with the extended family.
c. Family life
• The customs adopted:
Patients say they usually take part in activities in their homes such as
traditional ceremonies or banjar activities.
• Decision making in the family:
Patients say decisions are taken more often by their sons as family in
charge.
• Communication patterns:
Patients are able to communicate with family, doctors and nurses.
• Finance;
The patient said that his financial problems were all sufficient and borne
by his son.
• Difficulties in the family:
Patients say relationships with children, son-in-law, grandchildren and
siblings have no obstacles / difficulties.
2. Sexual habits
a. Disorders of sexual relations are due to the following conditions:
The patient said her husband had died 7 years ago.
b. Understanding of sexual function:
Patients say they already understand sexual function.
3. Defense of coping
a. Decision-making
The patient says decision making is assisted by his son.
b. What you like about yourself:
The patient said that even though he was now sick but he was proud of
him who had been 75 years old and still able to live and gather with his
children and grandchildren.
c. What you want to change from life:
The patient said he wanted to reduce the consumption of sweets and
sweet foods.
d. What is done when under stress:
Patients say that if they are stressed the patient is usually angry and
nags the people around him.
 1. System of trust value
 a. Who or what is a source of strength:
 Patients say the source of strength is family and God.
 b. Is God, Religion, Trust important to you:
 Yes. The patient says thanks to God's grace, He can still live
and be given time to gather with his family.
 c. Religious activities or beliefs carried out (types and
frequencies) state:
 Patients say they usually pray / mebanten every afternoon.
 d. Religious activities or beliefs that you want to do while in
the hospital, state:
 The patient said that during the hospital he wanted to do it only
to pray in the heart.
 IV. Physical Study
 A. Vital sign
 Blood pressure: 140/80 mmHg
 Temperature: 36.50C
 Pulse: 96 x / minute
 Breathing: 36 x / minute
 B. Awareness: Compos Mentis GCS: 15
 Eye: 4
 Motor: 5
 Verbal: 6
 C. General conditions:
  Pain / pain: -
  Nutritional status: Normal
 BB: 56 kg TB: 155 cm
  Attitude: Calm down
  Personal hygiene: Clean
  Time / place / person orientation: Good
 D. Physical Head To Toe Examination
 1. Head
  Form: Mesochepale
  Lesions / wounds: There are no lesions / wounds on the head
 2. Hair
  Color: White gray
  Abnormalities: not fall out or dandruff
 3. Eyes
  Vision: Normal
  Sclera: No icteric
  Conjunctiva: Not anemic
  Pupil: Isokor
  Efficacy: There are no abnormalities in the patient's vision
 4. Nose
  Irritation: Normal
  Secret / blood / polyp: There is no secretions, blood, or
polyps in the patient's nose
  Nasal lobe pull: There is no pull of the nostrils when the
patient breathes
 3. Ears
  Hearing: Normal
  Scret / fluid / blood: There are no secretions, fluids, or
blood in the patient's ear
 6. Mouth and Teeth
  Lips: Moist
   Mouth and throat: Normal
  Tooth: Full / normal
 7. Neck
  Thyroid enlargement: No thyroid enlargement
  Lesions: There are no lesions
  Carotid pulse: Tinged with carotid pulse
  Lymphoid enlargement: There is no lymphoid
enlargement
 1. Thorax
  Heart: 1. Pulse: 96x / minute, 2. Strength: Strong
 3. Rhythm: Regular
  Lungs: 1. Frequency of Breath: Fast
 2. Quality: Normal
 3. Breath Sound: Vesicular
 4. Cough: No
 5. Airway obstruction: There is no airway obstruction
  Chest retraction: None
 2. Abdomen
  Peristaltic intestine: There are, 10 times / minute
  Bloating: No
  Press pain: No.
  Ascites: No.
 3. Genetalia
  Pimosis: No.
  Tools: No
  Abnormalities: No.
 4. Skin
  Turgor: Elastic
  Lacerations: No.
  Skin color: Normal (brown)
 12. Extremities
  Muscle Strength: 4 4 4 4 4 4
 444444
  R O M: Limited
  Hemiplegi / parase: No
  Accrual: Warm
  C R T: <3 seconds
  Edema: None
  An IV is inserted in the right hand

IV. Supporting data

a. Supporting investigation
Laboratory examination :
May 12st 2015

Blood Chemistry/ Spektrofotometri

BEI Hasil Nilai Normal
Ureum = mg/dl 10-50
Creatinin = mg/dl 0,6 -1,2
Asam Urat = mg/dl 3,4 – 7,5
GULA DARAH
BS Puasa = 196 mg/dl 80-100
BS 2 jam = 142 mg/dl 80-140
BS Sewaktu = mg/dl 80-200
% HbA1c = % 4,0-6,5
LFT
Bil Direk = mg/dl 0-0,6
Bil Total = mg/dl 0,2-1,2
SGOT = U/L < 37
SGPT = U/L <42
Alk. Fosfatase = U/L 64-306
Total Protein = g/dl 6,0-8,5
Albumin = g/dl 3,5-5,0
Globulin = g/dl 2,5 – 3,5
LIPID PROFILE
Chol. Total = mg/dl <200
HDL = mg/dl > 50
LDL.Chol = mg/dl <150
Trigliserida = mg/dl <150
 a. Therapy

- NaCL 0,9% 16 tpm

- Lantus 1 x 10 sc
- Navorapid 3x8 iv/sc
- Farbivent @8 jam

A. DATA ANALYSIS

No FOCUS DATA ANALYSIS PROBLEM

1. Data Subjectivity: Decreased insulin Ineffectiveness of

- Patients say shortness breathing patterns
of breath, difficulty
Glucose in cells
circle when inhaling.
Objective Data:
Cells dont give
- The patient looks
nutrients
difficult when breathing
cellularStarvasi
- Using nose nose nose
- O2 installed 6 liters
Glycogen disassembly,
- Respiration of 36 x / fatty acids, ketones for
energy
minute

COPD
B. DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH

1) Ineffectiveness of breathing patterns associated with the disease

process is indicated by the patient saying shortness of breath, having
difficulty when breathing, the patient is seen having difficulty
breathing, using nasal lobe breathing, and 6 liters of O2 installed,
respiration 36x / minute.
1) Planning

No Purpose Intervention Rational

1 After being given Airway Management  Knowing the
nursing care for 3x24 • Position the patient general
hours, problems are to maximize condition of the
expected ventilation (semi- patient
shortness of breath fowler position)  Provide

experienced by the • Auscultation of appropriate

patient decreases / breath sounds, note nursing care to

decreases with KH: additional sounds overcome

• Demonstrate a patent • Monitor respiration shortness of

airway (the client does and O2 status breath

 Know the state
not feel suffocated, Oxygen Therapy
of the patient
breathing rhythm, • O2 flow monitor  Knowing the
breathing frequency in • Maintain the accuracy of
the normal range no patient's position treatment
abnormal breath Vital sign Monitoring  Knowing the
sounds). • Monitor vital sign general
 • Vital signs in the condition of the

normal range (blood patient

pressure, pulse,
breathing).