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A ASSESMENT
DEMOGRAPHIC DATA
Sex : Female
Religion : Islam
Occupation : Housewife
Informant : Mrs D and Client
Relationship to Patient : Grand daughter
Date of Admission : November,02, 2016
Baseline Data
Height : 157 cm
Weight : 55 Kg
Dyspnea felt since 1 week before admission, vomitingfrom 3days ago anorexia, gets weaks,
all the body feel pain, headache, insomnia, sometime chestpain
Clinical Examination
VITAL SIGNS :
Temperature : 37, 0C1, Pulse : 112/mt., Respiration : 30/mt. Blood pressure : 120/80
mmhg
HEAD :
Scalp : No scar was seen but the scalp seems to be dry & having dandruff , Face :
Normal in shape , size and alignment ,a black mole was present on chin. Sinus area :
No tenderness present. Nodes : No nodes are enlarged
EYES :
Visual acuity : Normal , Visual field : Clear,6/6 , Ocular movement : Normal , moves
to both sides as well as towards the up and down . Lids : Eye Lides are normal no
edema or inflammation is being detected .
Lacrimal glands : The Lacrimal Glands are normal and secretes normally , Sclera :pale
Cornea : No Abnormality detected , Lens and media : Normal , the image forms
normally. Fundus : Normal
EARS :
External structure : Normal in alignment , Canal: Normal , no discharge is seen
Tympanic membrane : Normal. Hearing : Normal , checked by tunic fork.
NOSE :
External structure : normal in alignment , septum : No deviation seen, Mucus
membrane : Moist , no inflammation seen . Patency : Good , Olfactory sense : This
was normal , checked by using some dyspnea.
ORAL CAVITY :
Lips : Mildly cyanosed , cracked , dry . Buccal mucosa : Cyanosed and dry , Gums :
Pale Teeth : Unhygienic , yellow stain was present . Palates and uvula : Normal,
Tonsillar areas : No enlargement detected , Tongue : Cyanosed , dry . Floor :Normal .
Voice : No hoarseness was present . Breath : Dyspnoea present , the patient was on
oxygen .
NECK :
General structure : Normal in shape and size . Trachea : Present in central ,
Thyroid : Normal , no enlargement seen
CHEST AND RESPIRATORY SYSTEM :
Chest shape: Slightly heavy, Type of respiration : Thoraco- abdominal respiration was
present . Expansion : It was fast . General palpation : On palpation chest movement
wasnt present as well as apex impulse was felt on 5 th intercostals space. Percussion :
on percussion are fluid detected (Dulnnes). On Auscultation no detect sound of breath
in right chest. Breath sound : B/L +
CARDIOVASCULAR SYSTEM :
Dyspnoea : There was presence of marked yspnea on exertion ,even with mild
exertion . Expectoration : yes,expectoration was present .
Haemoptysis :There was no presence of haemoptysis , Palpitation :There was
presence of slightly palpitation, Build and nutrition :He was averagely nourished,
Nails and conjunctiva : Nails were cyanosed Thyroid : No enlargement detected,
Oedema : There was no presence of oedema,, Skin : The skin was
pallor & brittle .
ABDOMEN AND INGUINAL AREAS :
Contour and tone : Good contour and good muscle tone ., Scars marks : There is no
scar marks detected , Liver , Spleen, Kidneys and bladder: Normal ,Hernias :There is
no hardness or swelling over the groin Masses : No masses are felt on abdomen
Palpation : On palpation no mass or any kind of hardness is felt , abdomen was soft to
touch . Percussion : On percussion no fluid or gas collection detected . Auscultation :
On auscultation normal peristaltic movement heard .
MUSCULOSKELETAL SYSTEM :
Gait : Normal
Upper extremities : Both are in normal alignment no extra digits are present and
cyanosis were present on fingers .
Lower extremities: Both are in normal alignment .
Deformities : No such deformities detected .
Range of motion : He was so tired that could not perform the full ROM .
NERVOUS SYSTEM :
Mental status : He was well oriented to date , place and time , even he was
knowing the reasons for admission in hospital . .
Language : He has no problem in language , no sludge speech .
Motor co-ordination : Motor co-ordination was good .
Lower extremities : weakness of muscles , rigidity detected but well co- ordination
present , there is presence of cyanosis .
LABORATORY AND CHEST X-RAY
LABORATORY November,03, 2016
9. SGOT
10. SGPT
CHEST X-RAY :
Medial treatment : The medications which were being prescribed for him are listed
below :ciprofloxacin 2x200mg,cefotaxime 3 x 1gr, ranitidine 2 x 1amp, ondansentron
3 x 4mg, combivent 3 x pro Nebulizer,Vip Albumin 3x2, durogesic patch. Prosedur
therapy : punctie pleura, blood transfusion 3 lb 1lb/12 hours.
B ANALISIS DATA
Pain stimuli
C INTERVENTION
1 Ineffective Breathing Pattern
Ineffective breathing pattern occurs when inspiration and expiration does not provide
adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of
breathing, coughing and movement. This can result to shallow and rapid breathing pattern.
Distal airways and alveoli may not expand optimally with each breath, increasing the
possibility of atelectasis and impaired gas exchange.
1 Monitor and record vital signs 1 To gain pt/ SOs trust and
Short Term: After 3
cooperation - To obtain
hours of nursing
2 Assess breath sounds, baseline data
interventions the patient 2 To note for respiratory
respiratory rate, depth and
will demonstrate abnormalities that may
rhythm
appropriate coping indicate early respiratory
behaviors and methods compromise and hypoxia
3 Elevate head of the pt.
3 To promote lung expansion
to improve breathing 4 Provide relaxing environment
4 To promote adequate rest
pattern.
5 Administer supplemental periods to limit fatigue
5 To maximize oxygen
oxygen as ordered
Long term:
6 Assisst client in the use of available for cellular uptake
6 To provide relief of
relaxation technique
After 1 to 2 days of
7 Administer prescribed causative factors
nursing interventions, 7 For the pharmacological
medications as ordered
the patient would be 8 Maximize respiratory effort management of the patients
able to apply techniques with good posture and effective condition
8 To promote wellness
that would improve use if accessory muscles.
9 Encourage adequate rest
breathing pattern and be 9 To limit fatigue
periods between activities
free from signs and 10 To see the effectiveness of
10 Monitoring chest tube : fluid
symptoms of chest tube mounting
production
respiratory distress.
4 Acute Pain
Pain may be considered as Pleuritic chest pain. Pleuritic chest pain derives from
inflammation of the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom
is accompanied by an audible or palpable pleural rub, reflecting the movement of abnormal
pleural tissues.