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CHAPTER IV

DISCUSSION

In this chapter, the writer would discuss about “Nursing Care to Mr. J

with Post Operation of ORIF on Fracture Humerus Dextra on the Second day. In

this matter, the writer found three nursing diagnose that appeared in Mr. J that

would be discussed one by one.

1. Pain related to discontinuity of tissue.

According to Carpenito (2001), pain is a condition where the

individual get sensation that doesn’t satisfying in response a danger stimulus.

And according to Smeltzer (2001), pain is sensory and an emotional

experience that doesn’t satisfying caused by impaired of tissue that actual and

potential.

According to Carpenito, 2001, acute pain is a condition where the

individual sensation or mention there is feel great uncomfortable or sensation

that doesn’t satisfying during 6 month or less than it.

According to Smetlzer & Bare (2001:2281), muscle spasm is increased

of muscle tone is caused by tissue response of trauma tissue discontinuity that

interrupt of tissue continuity are in bone caused by injury.

In this patient it was found problem of disturbance of comfortable pain

that is caused by interrupt of bone tissue continuity that stimulated nociseptor

in nerve tip for released chemistry mediator that consist of amount of

substance that influenced sensitivity of nerve tip or pain receptor that released

to the extracelluler tissue as caused by tissue damage. Chemistry substance

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that increase of pain transmission or perception such us histamine, bradikinin,

asetilkolin, and prostaglandin substance it’s apparently can increasing the

effect that make pain from bradikinin (Smeltzer, 2001:215)

Nursing diagnose of disturbance of comfortability (pain) can be

exitenced if there are characteristic limitedness are major characteristic (80%-

100%) is expressing about pain description. Minor characteristic (60%-79%),

are clasped his/her jaw or wrist, change of skill for continue the henceforth

activity, agitation, anxiety, sensitive of stimulus, rub in part of pain, inactivity

of physical or immobilization, concentration problem, changes of sleep

pattern, feel afraid get injury repetly, pull if touched (Carpenito, 2001:45).

In Mr. J this problem appeared because it was found the subjective

data, he said that pain in post operation wound, pain appeared at humerus if

moved, pain was as sticked, pain at humerus dextra, with pain scale was 5,

and time continuously. The objective data appeared was seen grimace in pain,

a strained face. And with that data could support for appointment the nursing

diagnose disturbance of comfortable (pain) because there was criteria between

assessments with characteristic limitation.

Disturbance of comfortability as a first priority because that problem

made the patient uncomfortable if that problem didn’t overcome as soon as it

could cause suffering and disturbance of individual psychology (Potter, 2005:

1521). Where in basic human need according to Maslow in Potter & Perry

(2005: 616), pain is necessity of second sequence in welfare and safety where

maintained of physical welfare involve the situation that increase or remove of

threat in the body or life. Like pain, infection, and fail from bed because
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however the people that get sick will be threatened the physical safety and

emotional.

For overcoming that problem, implementation was done were assess

the pain characteristic again for know anxiety level because could influenced

the perception or reaction of pain, measured the vital signs, the rational was if

there was pain that didn’t overcome adequately have effect of response of

simpatic stimulated that was occurred increased respiratory and heart

frequency, and also periphery vasoconstriction (Potter & Perry, 2005: 1508).

Teaching relaxation take a deep breath and distraction technique with joined

chat, the rational, according to Potter & Perry (2005: 1528), relaxation is

freedom of mental and physical from strained and stress, the relaxation take a

deep breath technique was done with exercised the patient for localization of

each area that got muscle strained.

Effect or relaxation such as creasing of blood pressure, pulse rate,

respiration, muscle strained, metabolism speed and feel peace and comfort,

while distraction used for shifter the patient attained to the other one and with

that decreased of pain vigilance, more over increasing the tolerance of pain.

While according o Doenges (2000: 764) increasing of felt controlled and

could increasing coping skill in pain management. The implementation was

suggested the patient so constant for immobilization in fracture area, the

rational prevent bone position mistake/tension of injury tissue (Doenges,

2000: 764), while according to Smeltzer & Bare (2001: 2366), immobilization

in fracture area purposed for speed up Bone recovering and decreased of

moved of bone fragment that slow of callus forming.

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The last evaluation was done on Thursday, April 29nd, 2010 at 14.00

am with subjective data, patient said that still felt pain in post operation wound

with pain assessment P: pain in post operation if moved Q: pain still as

sticked , R : pain in post operation of ORIF at humerus dextra, pain scale 3,

time : sometime, face expression rilek, and still grimace in pain, problem was

not overcome. From the data above, analyze that concluded that the patient

problem was overcome a part, it was caused in result criteria made in

purposed of nursing intervention were pain decreased, pain scale 5, face

expression wasn’t strained and the patient wasn’t grimace in pain, while in

pain scale that was reached was 3.

Supporting factor of problem could overcome partly, the patient was

very cooperative that marked by patient would do pain management

technique, relaxation with take a deep breath, distraction by joining chating

with his friends and family, and heard the favorite muscle if pain appear stand

alone.

2. Impaired of physical mobility related to muscle spasm.

According to Carpenito (2001), impaired of physical mobility is

condition of somewhere someone get or risk for physical limitedness but isn’t

immobility. The factor that related, lack of or decreasing of tired and weakness

motivation, musculoskeletal damage, and closure environment (Nanda, 2005).

Decreasing of ability movement is decreasing of mobility ability that

influence the muscle and can cause lose of stamina, decreasing of ability

movement can cause the large musculoskeletal damage because there are
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patofisiology change is atropi. Atropi is a disease and decreasing of activity

everyday (Potter & Perry, 2005: 1195).

In this case occurred impaired physical mobility or occurred decreased

of ability of movement, caused by direct trauma cause occur movement and

generation of bone fragment and than occur fracture, if didn’t appeare hinge

muscle contraction so the muscle didn’t appeared a movement and recently

caused bone dysfunction. So the first sign usually participated this impaired

were, the patient get muscle weakness or limitedness so decrease ability for

doing the activity everyday (Smeltzer & Bare, 2001: 2264).

Nursing diagnose the impaired physical mobility can be existence if

there are major characteristic limitedness (80%-100%), decreased of ability

for moved with expressly in environment (such us mobility on the bed,

moved, and limitedness of move). Minor characteristic (50%-80%) limited

movement that forced and will not to move (Carpenito, 2000: 243).

In Mr. J this problem appeared because it was found the subjective

data the patient couldn’t move right hand until palm. Objective data that

appeared was arm and wrist right hand felt stiff, attached pin at humerus. And

with that data could supported for appointment the nursing diagnose impaired

of physical mobility because there was criteria between assessments with

mobility characteristic limitation.

The writer priority of this nursing diagnose as the second diagnose

because in human basic concept according to Hirarki Maslow in Potter &

Perry (2005: 6150) impaired of included in need of second is physical safety.

Activity necessity included in depth and as supported in ambulation early after

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surgery. The caused if this problem didn’t overcome, so could occur

disturbance in activity.

For surpassed that problem, soothe writer done implementation given

motivated for the patient eat foods that many contained protein, calcium and

mineral like fish, egg, tempe, fruits, milk that many calcium rational according

to Doenges (2000: 764) for fulfill the nutrient of bone so the bone recovering

process can occur pastly and on time. While according to Potter & Perry

(2005: 1426) function of protein is for synthesis the damage tissue and cells of

the body in growth, safeguarding and repair. Calcium function and contraction

of muscle fibrous and mineral function as regulator substance in the body.

Exercised the mobility with active movement in member of movement that

didn’t sick in wrist rational, according to Doenges (2000: 764) increasing of

blood flow to muscle for increasing otot tone. While according to Potter &

Perry (2005: 1231) exercised movement doing for strongly the muscles and

prevent occur contractor. Suggested the patient for immobility in fracture area

for preventing occur movement between bone fragment (Doenges, 2000: 764).

Motivated his family would fulfill the necessity of the patient activity daily

living during sick like tapid sponge, changed the dirty clothes with clean and

dry clothes rational helped the patient personal hygiene. According to Potter &

Perry (2005: 1334) fulfillness the patient daily living activity like taking a

bath, shampooing, etc, purposed for increasing the patient comfortable, safety

and healthy.

Evaluation was done on Thursday, May 22nd, 2008 at 12.00 am that

was found the subjective data of patient said that could move his wrist and
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arms slowly, wrist wasn’t felt rigid, wrist could be moved with flexi,

extension, opposition and rotation movement with slowly, patient look could

take his hand phone by right hand but still helped by left hand, with the data

problem was overcome partly, continued intervention with practice mobility /

active motion that didn’t sick at wrist.

With that data it can be concluded that the problem was overcome

partly because in result criteria that is hoped, the fracture heal. And bone can

move to the normal position appropriate to bone recovering process, hard and

wrist wasn’t rigid. And in patient just could moved his wrist and didn’t rigid

again. According to Smeltzer & Bare (2001: 2369) bone recovering process

that occur in fracture humeri need time 6 until 10 weeks so the patient must

avoid the activity remains such us tennis, during 4 weeks ago.

In solving physical mobility problem, the writer found some

supporting and inhibiting factor. The supporting factors of this problem were

the patient was very cooperative in mobility exercise or active movement in

wrist with flexi, extension, rotation, and opposition movement. While the

inhibiting factor was didn’t done mobility therapy by his family continuity so

often occur rigid again because his family inclined allowed and felt afraid if

his child pain fullness.

3. Impaired of skin integrity related to laceration and post operation wound

According to Nanda (2005: 97) impaired of skin integrity is changes of

epidermis and dermis. According to Carpenito (2001: 351) impaired of skin

integrity was condition where the individu suffers integument damage, cornea,

or mucus membrane tissue. While according to Doenges (2000: 762) impaired

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of skin integrity caused by skin laceration, tissue ovulation, hemorrhage.

Change of color and local edema. The factor that relation such us mechanic

pressure, sliced, friction, radiation, nutrition, lack of knowledge, chemistry

irritation (included body expression, secretion, and medication), impaired of

physical mobility, change of circulation, over hydration or lack of liquid

(Nanda, 2005: 232).

According to Smeltzer & Bare (2001: 2360) the fixation measured

done on the patient with fracture, to normally anatomic position (reduction),

maintain the reduction until occur healing (immobilization), speed up the

function recovering and normally strength of area that injured. (rehabilitation),

where one of the method that used was orif or open reduction and internal

fixation. A surgery method for repaired the function with return the movement

and disabilitation and decrease of plain and diability.

The fixation is pressure that is caused by gyps or the other equipment

that can cause skin impaired (Smeltzer, 2001). The fixation that exceedingly

can cause irritation on the skin and from it cause maceration on skin that

actually appeared the reddish or change of skin color and also pain. According

to Potter & Perry (2005, 1861) laceration wound is wound that usually there is

in surface of the skin and get hemorrhage and wound look wet. If this

laceration wound produced secret or fluid so high risk for infection and wound

will be remained opened until fill of wide scrape tissue, and can cause lose of

skin tissue function that permanent.

This nursing diagnose ca be existence if there are major characteristic

limitedness is impaired of epidermis and dermis, and minor characteristic

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limitedness consist of; skin shaving, eritema, lesion (primer and secondary),

pruritus (Carpenito, 2001: 302). While minor characteristic limitedness

according to Nanda (2005: 232), in impaired skin integrity is damage or

destroyed of tissue (cornea, mucus membrane, integument, and subcutan)

In Child E this diagnose appeared because it’s found the subjective

data, patient said that smart at area of around post operation and post

operation wound, seen existenced of changed of chocolate color at area of

around post operation wound, existenced of edema at metacarpal and under

elbow, there were12 wound stitching post op, with condition of post operation

wound was cleanness, but still wet, amount of leucocytes 10.500 mL, and

abrasion was nose with diameter 2 cm and length 3 cm at diameter waist 4 cm.

And with that data could be supporter for appointment the nursing diagnose

impaired of skin integrity because there was criteria between the assessment

with characteristic limitedness of impaired of skin integrity.

For overcoming that problem, the implementation was done changed

the patient bed sheet, the rational was according to Doenges (2000: 771)

prevented to impaired of skin integrity that caused by humidity because with

moist condition so enable to entry of microorganism. Gave Baquiner infusion

therapy 200mg 20 drips a minute for prevent occur of infection because this

drug was an antibiotic with procedure of it was decreased amount of bacteria

so all of microbe population can be controlled by mechanism of body defense.

With a wound can be a media that very is good for his growth in the wound.

Bacteria with off limits amount that more then one billion per gram, the tissue

can cause and henceforth spread in the blood flow and release the toxin reach
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for places (Smeltzer & Bare, 2001: 1933), observed in post operation wound

and skin around the post operation wound that was give an information about

skin circulation and problem that maybe caused by equipment or gyps

attached or traction, or edema forming that need forth intervention (Doenges,

2000: 771). Done wound care/change of post operation band with

aseptic/sterile technique and changed of drainage pocket, the rational

according to Doenges (2001:771) was prevent occurred infection or degree of

contaminated with microorganism. While according to Potter & Perry (2005:

1865), wound care done because of wound healing hang of wound condition

that clean and without contaminated so the healing process pastly.

The last evaluation was done on Thursday, May 22 nd, 2008, found the

subjective data patient said that the abrasion wound wasn’t felt smart again but

in post operation wound still felt smart, with objective data that were around

post operation wound have been dry, changed skin brown in area of post

operation wound, edema decreased, there were 12 stitching, condition of

stitching wet, cleanness wound, from the data problem overcome partly,

continued intervention by doing treatment of abrasion post operation wound

and skin every day, given antibiotic therapy appropriate advised. From that the

data, the writer concluded that the problem had been overcome partly because

in result criteria there were skin color normally again appropriate to before

being sick, decrease edema, the stitching wound was dry, the leukocyte still in

normally limits, and cleanness wound.

In doing the implementation above, the writer found some inhibiting

and supporting factor. The supporting factor, patient was very cooperative
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when doing wound care and wish of patient for hurried home early so easier in

wound healing processs, beside that, the patient also consumption foods with

high protein like egg, fish, etc. so the wound speed up heal. Protein consist of

amino essential acid to support the growth and maintained of nitrogen balance

where it saved in body and influence ability of cells and tissue for

regeneration or back to normal structure pass through cell growth also wound

healing (Potter &Perry, 2001: 1853). Beside that the inhibiting factor in this

nursing process was patient didn’t a lie down by nurse so potential occur

decubitus.