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    Resume of Respiratory Problem

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    Ibi Yulia Setyani
    1) The document describes a 30-year-old male client named Mr. H who was admitted to the ward with difficulty breathing and a diagnosis of pleural effusion. 2) Objective findings included low vital signs, decreased breath sounds on the left lung, and diagnostic tests showing anemia and low oxygen saturation. 3) The nursing care plan involved positioning the client in a semi-Fowler position, providing supplemental oxygen, educating on deep breathing techniques, and monitoring vital signs and oxygen saturation.

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    Resume of Respiratory Problem

    Uploaded by

    Ibi Yulia Setyani
    24 views5 pages
    1) The document describes a 30-year-old male client named Mr. H who was admitted to the ward with difficulty breathing and a diagnosis of pleural effusion. 2) Objective findings included low vital signs, decreased breath sounds on the left lung, and diagnostic tests showing anemia and low oxygen saturation. 3) The nursing care plan involved positioning the client in a semi-Fowler position, providing supplemental oxygen, educating on deep breathing techniques, and monitoring vital signs and oxygen saturation.

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    1) The document describes a 30-year-old male client named Mr. H who was admitted to the ward with difficulty breathing and a diagnosis of pleural effusion. 2) Objective findings included low vital signs, decreased breath sounds on the left lung, and diagnostic tests showing anemia and low oxygen saturation. 3) The nursing care plan involved positioning the client in a semi-Fowler position, providing supplemental oxygen, educating on deep breathing techniques, and monitoring vital signs and oxygen saturation.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    24 views5 pages

    Resume of Respiratory Problem

    Uploaded by

    Ibi Yulia Setyani
    1) The document describes a 30-year-old male client named Mr. H who was admitted to the ward with difficulty breathing and a diagnosis of pleural effusion. 2) Objective findings included low vital signs, decreased breath sounds on the left lung, and diagnostic tests showing anemia and low oxygen saturation. 3) The nursing care plan involved positioning the client in a semi-Fowler position, providing supplemental oxygen, educating on deep breathing techniques, and monitoring vital signs and oxygen saturation.

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    RESUME OF RESPIRATORY PROBLEM

    CLIENT WITH PLEURA EFFUSION


    Name : Ferishandy Bagaskara

    NIM : P1337420617026

    Ward : Elang II (Men)

    A. Client Biodata
    1. Name : Mr. H
    2. Age : 30 YO
    3. Gender : Male
    4. Religion : Islam
    5. Tribes/nation : Javaneese/Indonesia
    6. Pendidikan : Senior Highschool
    7. Pekerjaan : employee
    8. Alamat : Weleri, Kendal regioon, Central Java
    9. Tanggal masuk : 13 May 2019
    B. Main Complaint
    Client Mr. H feels difficulty to breath (dyspnea)
    C. Health History
    1. Now Health History
    At the first time client has diagnosed by doctor in RSUD Kendal
    that he has the Lymphoma desease that attack his lymphatic system. He
    had been sugery before because his disease in RSUD kendal. but lately he
    felt short of breath and breathing very fast, after that he was treated at the
    Muhammadiyah RSI kendal. However, RSI referred him to Kariadi
    Hospital, and here he was diagnosed with pleural effusion.
    2. Health History Before
    Client has done the lymphoma surgeon before
    3. Family Health History
    Client’s family has no desease related to MR.H

    D. The Obtained data

    Subjective Data Objective Data


    1. Client feels weak 1. Vital Sign measuring:
    2. Dyspnea  BP: 120/90 mmHg
     HR: 120 x/min
     RR: 40 x/min
     T: 36,6 C
     SPO2: 91%
    2. Compos Mentis
    3. Thorax (Lungs)Assesment
     Inspection: rapid movement of
    chest, the chest’s form is
    normal
     Palpation: after client said
    “tujuh puluh”, found that left
    lung does not vibrate
     Percussion: Found “pekak”
    sound at left lung
     Auscultation: weak vesicular
    sound in the left lung
    4. Diagnostic assesment (lab)
    (date of assesment:13/5/2019)
     Hemoglobin 9.3 gr/dl (Low)
     Hematokrit 29% (Low)
     Eritrocytre 3.71 10^6/uL (low)
     MCH 25.1 pg (low)
     MCV 78.2 fL
     MCHC 32.1 g/dL
     Leukocyte 6.8 10^3/uL
     Trombocyte 561 10^3/uL (H)

    E. Therapy Program
    X May 14th
    PO Clindamycin 300 mg/ 8 h
    N Acetylcystein 200 mg/ 8h
    PCT 500 mg/ 8 h
    Inj. IV Levofloxacyn 750 mg/ 24 h
    Ondansetron 4 mg/8 h
    Omeprazole 40 mg/12 h
    Parenteral NaCl 20 Drips/m

    F. Nursing Diagnose and Data Analysis

    Nursing Diagnose Data Analysis

    Ineffective breath patterns related Decreased rate of absorption of


    to the effect of hypoventilation lymph vessels due to lymphoma
    due to the pressence of pleural
    Pleural Effusion
    effusion
    The lungs cannot do a complete
    expansion

    Hypoventilation

    Ineffective breath patterns

    G. Nursing Intervention

    Date Nursing Purposes Intervention Rational


    /time
    Diagnose

    13 Ineffective within 1x24 1. Semi-fowler 1. Semi-fowler


    May breath patterns hours it is positioning position give
    2. Give enough
    2019 related to the expected that patient’s lung
    oxygen that
    effect of the breath an extra spcae
    enough to
    hypoventilation pattern will to expand
    fulfill the body 2. With an
    due to the be effective
    needs enough oxygen
    pressence of with the
    3. Educate the
    patient wont
    pleural results
    client about
    complain of
    effusion criteria:
    deep breathing
    1. The weakness
    4. Monitor the
    3. Deep breathing
    client is
    Vital sign
    has a role to
    able to
    (SPO2
    decrease the
    breathe
    included)
    high RR rate,
    without
    dyspnea so the patient
    2. Clients
    could be relax
    get 4. vital sign
    adequate monitor has a
    oxygen function to
    3. The
    monitor the
    client
    extent of the
    expresses
    patient's
    comfort
    development
    after
    missing
    dyspnea

    H. Implementation
    Implemetation Patient’s respond
    1. Educates the patient about the 1.
    benefits of semi fowler position,
    and ask them to lay down in semi
    fowler position

    2. Give rebreathing mask with O2


    velocity 9 l/m

    3. Educating the patient about deep


    breathing

    4. Monitoring the oxygenation status

    I. Evaluation (14 May 2019)


    Nursing Diagnose Evsluation
    Ineffective breath patterns related to
    the effect of hypoventilation due to
    the pressence of pleural effusion
    J. Practical Reflection
    Today, I do simple assesment and intervention with the patient with
    breathing difficulty. I hope I can reduce the patient’s problem. For the next
    time I hope I could find an oxygenation problem with a unique condition

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