Name: M.

Arif Widiyana

NPM: 1614201110088

Class: 5 B

A. THE IDENTITY OF THE CLIENT

Name: An.R
Age: 2 years 7 months
Address: Boyolali
Religion: islam
Room: bangsal Bakung
RM: 17 85 98
Medical Diagnosis: ISPA

Person in charge
Name: Mr. S
Age: 37 years
Education: SLTA
Occupation: self employed
relationship : father

B. The STUDY of

1. Client health history

the main complaint perceived by the client is the mother says An r. cough

phlegm so. Family health history is now a client says 4 days before entering the

hospital client heat, especially at night, coughing a little over 3 weeks, the phlegm so.

On April 22, 2013 clients brought by his family to poly Home Sick Parlors Waluyo

Surakarta and doctors advise to clients in treatment, IGD get therapy infuse RL 10

tpm, Bactesyn injection 250 mg given via IV, then the client moved into Ward

Daffodils. The study done by mobilising the results the client difficult breathing,
 cough cough, phlegm so at any time, the client looks limp, pergerakanya is free but

limited, looks lie, performed vital sign with results, Nadi : 102 times per minute, the

rhythm of regular, palpable in the carotid pulse , temperature: 39.1 degrees Celsius,

Respiration: 36 times per minute, irregular and rapid breath shallow.

Past medical history pregnancy: partus, the two have never been abortion,

the client was born on August 22, 2010, gestation when born 9 months, while

containing mother clients not taking the drug. Labor, delivery type in sectio caesaria,

labor in NEAR Slamet Riyadi Surakarta with indication of narrow pelvis. Post

Christmas, newborn weight 2800 grams, length born 49 cm, out of the treatment

room on 30 Aug 2010 and on clients there is no congenital abnormalities. The family

says the full client immunization but forgot the date pemberianya. The family says

the client has a habit of specialized in behavior that is sucking your thumb. Growth

and development, newborn weight of 2,800 grams, while the age of 6 months 6 kg,

weight 11 kg, the current gear is incomplete. The growth and development of the

patient in a State of normalcy.

Family health history is the family says there is no hereditary or contagious,

previous health history is the family says the patient ever treated at Home Pain in

may 2012 with the same diseases namely RESPIRATORY.

2. examination of the Physical

 circumstances is quite

 awareness composmentis

 Head of client mesosefal

 thin hair
  the eyes of the client konjunctiva not anemis

 pupil isokor

 sklera not ikterik

 Symmetrical Nose, no polyps, no sekre t

 The mouth is symmetrical

 dental not complete

 mucosa dry lips

 Chest inspection: inspection of pulmonary right-symmetric chest

development, vocal fremitus palpation. same left-right, percussion : sonar,

Lung sound auscultation of breath sounds is heard: additional ronkhi (grok-

grok).

 Examination of the heart inspection: pulsation ictus cordis does not seem,

palpation: ictus cordis palpated in SIC V, percussion: pekak sound

auscultation , sound pure heart I & II there is no noise.

 Examination of the abdomen inspection : the shape of the flat, there is no

jejas, auscultation : peristaltic gut 36x/min, percussion: the sound of the

abdomen hipertimpani, palpation : no pains hit.

 Vital signs on 22 April 2013 Temperature 39.1 degrees Celsius, Respiration

36 times per minute, the rhythm of the breath, irregular pulse 102 times per

minute and regular rhythms, palpable pulse in the carotid.

C. INTERVENTION
Diagnosis Nursing Care Plan
No.
nursing NOC NIC Rational
1. ineffectiveness of cleavage In 2 x 24 hours:  observations  to know the
way breath lies diparu of acceleration
pulmonary Respiration, of client's
secretions of frequency, breath
 patients will be rhythm  for the
reduced  auscultation presence of
The criteria of the sound of additional
the results: the breath sounds
 Indicates a  for
patent removing
airway phlegm
 teach
effective
cough

D. The IMPLEMENTATION of the

No. Day/date Time Nursing the implementation the paraf
diagnosis of the evaluation of
the
1 ineffectiveness  Mengobservation  S ...: clients
of cleavage Respiration, say breath
way breath frequency, already
rhythm relieved
by way of o ...: client
observing the seems
client's breath comfortable
 mengauscultation with his
the sound of the breath
breath  S. ..:
clients say
breath
already
relieved
 teach effective o ...: no
cough additional
sound
 S ...: client
says there
is no longer
the
blockage
o ...: there
is no
obstruction
 in the way
breath
again

E. The evaluation of the

No. Day/date Time Nursing The
diagnosis evaluation of
the
1 ineffectiveness S...: klien
of cleavage way mengatakan
breath sudah nyaman
dengan
pernafasannya
O...: klien
tampak tenang
A...: masalah
teratasi
P...: intervensi
dihentikan