TBC Ms. M 12 years old, admitted to Dr. Soetomo Hospital. Her chief complain is severe cough hardly at night!

since t"o year ago, very severe cough. She had #een ta$e medicine from pu#lic hospital, #ut she hasn%t recovered from her illness, and she still suffering and hardly to normal #reathing. She has allergic "ith seafood and cold "eather. &espiratory rate '()*mnt, #reathing #ronchovesiculer, ronchi +! on let right lo#us of lung, adm , 2, mucus secretion yello" viscous. A. Assessment Nursing history -dmission date 0o. &eg Hospital Date of assessment I. Patienty identity a. 0ame #. -ge c. Se) d. &ace e. &eligion f. 8ducation g. ,ccupation h. -ddress II.

. Sept 2/th, 2(1' . 12'1/234 . &S5D Dr. Soetomo . Sept 2/th, 2(1' . . . . . . . . Ms. M 12 years 6emale 7ava Moslem 7unior high school 9 Sura#aya

Time Medical D)

. 11.(( am . TB

History of present illness 1. Chief complain Severe cough hardly at night! 2. :resent illness history :atient had #een severe cough hardy at night! since t"o year ago, very severe cough. She had #een ta$en medicine from pu#lic hospital, #ut she hasn%t recovered from her illness, and she still suffering and hardly to normal #reathing. Past nursing history History of contagious disease Hereditary disease -llergic History

III.

. ;es, "ith the same symptoms li$e no" . 0one . food sea food!, ,ther cold "eather!

IV.

Family health history <randmother and her father had #een suffered tu#erculosis disease. Genogram of family E S S
4 2 E S

2 0

1 2 S

-dvert . . Male . 6emale ES . 8ver sic$ "ith TB . :atient V. Observation And Physi al E!amination =ital sign > T ? '2,/(C, : ? 44 )*min, && ? '()*min, B: ? 11(*4( mmHg. Environment Of Home :atient living in a polluted environment, house is in #ad condition "ith #ad ventilation. Her family lived "ith grandmother%s. Physi al Assessment 1. B1 . Breathing &espiratory system! a. Complain . cough hardly at night! #. && pattern . dyspnea> fre$uensi. '( times*mnt> &hythm. @reguler> Breathing. #ronchovesi$uler> Sounds. ronchi +! on let right lo#us of lung> , 2 adm. yes> mucus secretion. yello" viscous. c. Support fot #reathing. 0asal prong 2 ltr*mnt PROBLEM: Ineffective Airway Clearance related to increased viscous secretions. 2. B2 . Bleeding Cardiovascular System! a. Complain . Aittle pain on her chest, "hen she is coughing #. Heart sounds . 0ormal c. 8dema . 0one d. ,thers . C&T B ' second> "arm e)tremities> cyanosis. none PROBLEM: -

VI.

VII.

'. B' . Brain 0ervous system! a. ,rientation . :erson. good> Time. good> :lace. good #. Complain . 0one c. -"areness . Compos mentis <CS. 8?1, M?/, =?2! d. 8ye . :upil. ishocor> sclera. normal, conCungtiva. normal light red e. 0erves distur#ance. Trismus. none> paralyDe. none> sensory PROBLEM: 1. B1 . Bladder <enitourinary System! a. Complain . 0one #. 5rine output . /(( ml*day> Color. light yello"> smell. none c. 6luid inta$e . ,ral. "ater 1((( cc*day> :arenteral . 0one PROBLEM: /. B/ . Bo"el <astrointestinal system9<@ Tract! a. Mouth . 0ormal #. -#domen . Soepel> :eristaltis. 12 )*m c. -lvi elimination . once*day> normal> consistency. soft> color. yello"> loss apptite d. Diet . 12(( $cal + 1/ gr protein e. Eeight . 2' $g #efore ill. 2/ $g! PROBLEM : Altered nutrition: Less than ody re!uire"ents related to inade!uate inta#e of nutrition 2. B2 . Bone Bone Muscle @ntegument! a. 7oint activity . 6ree #. 8)tremities complain . 0one c. Bac$ inCury . 0one d. @nteguments . 0ormal #ro"n!> acral. "arm> turgor. <ood PROBLEM : VIII. Phsy oso ial Assessment 1. Client perception a#out her disease parent perception! . <od struggle 2. Client e)pression to"ar his*her disease. Fuit and sad> loo$ li$e. sleepy and "ea$ness may cause hard coughing at night. '. ;ear reaction . Cooperative 1. Self Concept Distur#ance . not e)plain #iagnosti $est And %edi al $reatment 1. Aa#oratory 2/ Sept 2(1'. H#> 12,4 grG 11,191/,1 grG!, leu$ocyte ? 1(4(( 1'((911'((!> Aed ? 'H I 2( 292(!> Trom#ocyte ? '1/.((( 1/(.(((91/(.(((!> A6T ,T*:T ? '(*2(!> Bill T*@*D ? (,13*(,11*(,(2> -l#umin ? 2,2> electrolyte ? 0a. 1'2> J. 2,/> Cl. H(. 2. BT- @ 9! and BT- @@ +! '. &o Thora$s. TB

I".

1. Therapy . ,2 0asal 21*mnt> Streptomycin 1)/(( mg> Ceftria)one 2)/(( mg> :rednison 1( mg (9(91> 0H 1)2(( mg> &ifampisin 1)2(( mg> :iraDinamide 1)/(( mg> =it. -*C*8> ')1 #$s> KnSo1 Syr 1)1 cth> =entolin ne#ul 2)*day. &. #ata Analysis #ata Subjektive Data: She said that she suffer cough, dispnea #ecause viscous secret in respiratory tract.

Etiologi @nvation of TB Hipersecretion mucus respiratory tractus

Problem @neffective -ir"ay Clearance

Objective Data: @ncreasing viscous secretion Sound of #reathing . &onchi 9* +!> secret . yello" viscous @neffective -ir"ay Clearance && ? '( )*min Subjektive Data: Distress meta#olic She sad that she loss her Compresing of 0. =agus on appetite gaster Objektive Data: Eeight ? 2' $g #efore ill. 2/> -l#? 2,2 portion of eating ? L : <astrin Disorder of gastric HCA of <astric increase @nadeMuate nutrisition inta$e @nvation of BTMeta#olisme of #ody -$tivity of TB Severe coughing at 0ight Sleep pattern Distur#ance

@nadeMuate nutrition inta$e

Subjective Data : She said that she can%t sleep "ell #ecause hard cough and dyspnea at night Objective Data : She loo$ li$e sleepy> "ea$ness, =ital sign. T ? '2,/(C, : ? 44 )*min, && ? '(, B: ? 11(*4( mmHg.

Sleep pattern Distur#ance

'. Nursing #iagnosis 1. @neffective air"ay clearance related to increased viscous secretion 2. -ltered nutrition . less than #ody reMuirements related to inadeMuate nutrition inta$e '. Sleep pattern distur#ance related to hard coughing at night.

#. Planning

(oal and Ob)e tive Nursing Order *NO'+ *NI'+ @neffective air"ay clearance Eithin 14932 hours. a. :osition. Semi 6o"ler or related to increased viscous a. Aung clear to 6o"ler secretion auscultation #. Teach . effective cough #. && ? 12921 )*m and deep #reath c. :ulse ? 4(9H()*min c. 8ncourage to drin$ much "arm "ater d. -dminister ,2 and ne#uliDation -ltered nutrition . less than Eithin 14932 hours. a. Monitor inta$e and #ody reMuirements related a. 8ating portion N until 1 output every day to inadeMuate nutrition portion each meal #. Jeep the oral hygiene of inta$e #. BB increased O 9 L $g patient c. -l#umin . normal c. 8ncourage to eat "arm food d. To create a comforta#le environment e. =er#aliDe improved appetite f. =er#aliDe importance of adeMuate nutrition g. Maintain present "eight Sleep pattern distur#ance Eithin 14932 hours. a. To create a comforta#le related to hard coughing at a. She can sleep "ell environment night #. Coughing at night #. 8ncourage to drin$ decreased muc$ "arm "ater! at c. 0o "ea$ness night, #efore sleep d. She doesn%t loo$ li$e c. =er#aliDing importance sleepy treatment from doctor Nursing #iagnosis

E. Implementation Problem Implementation @neffective air"ay a. <ive a the semi fo"ler clearance related to and fo"ler position increased viscous secretion #. Teaching deep #reath and effective cough c. <ive and encourage to drin$. "arm drin$ d. -dminister ,2 and ne#uliDation -ltered nutrition . less than a. Creating the comforta#le #ody reMuirements related environment

Evaluation a. She is to a#le have effective cough #. =iscous secret change to liMuid secretion c. =ital sign . normal d. Dyspnea . 9

a. @ncreasing her appetite #. 8ating N portion each

to inadeMuate inta$e

nutrition #. <ive and encourage to eat . "arm food c. Demonstrate to $eep her personal hygiene d. Teaching a#out importance of nutrition for her healthy e. @ncreasing her appetite "ith as$ the favorite food Sleep pattern distur#ance a. Creating the comforta#le related to hard coughing at environment night #. Teaching the importance routine treatment from a doctor c. <iving and encouraging to drin$ much "arm "ater! at night #efore sleep

meals. drin$ mil$ ? 2(( cc t"ice a day> consume three egg a day c. :ersonal hygiene is good d. -l#umin . 2,3 e. -nemia . 9

a. She can sleep "ell #. She loo$s fresh c. She o#eys all the treatment for her disease d. Decreasing cough at night