General Assessment Example

CHAPTER 3
URSI G CARE REPORT
3.1
Case Description
Client is Mr. J, he is 43 years old. Client lives in Langgeng Muara Makmur,
East Kalimantan. Client is married and he has 2 children. The last education
of client was Elementary School, and Mr. J is a worker in palm oil company.
Clients religion is Islam, his tribe is Javanese , his nationality is Indonesia.
Client was entered to Ulin General Hospital Banjarmasin with medical
diagnosis pterygium. Clients medical record is 1004341. He was hospitalized
in Seroja ward on April 26th , 2013 at 11.33 pm.
Next of kin is Mrs. M, she is 39 years old, she is a worker in palm oil
company, she is clients wife , she lives in Langgeng Muara Makmur, East
Kalimantan. Her last education was Elementary School.
Main complaint of client on assessment on April 26th , 2013. Client said that
there was something white growing in left and right on his eyes and it was
disturbing his appearance. Client also complained he felt afraid with surgery
resulting in blind eyes.
History of disease, client said that about 10 years ago, client worked in palm
oil company and he was often exposed with palm spollen, because he was not
wearing protective equipments such as goggles while at work. And on
November 12th, 2011.Client saw something white on the left and right eyes
but size was not too big as it is now. And Client went to the clinic in
Langgeng Muara Makmur to check his complaint, and the medical advised
31
32
client to do eye surgery, but Client refused it because Client felt the complaint
did not interfere with his vision. As time went that white thing continued to
grow and entered to circles brown eye (cornea) in October 2012. Then in
March 2013 Client experienced symptoms of itching and redness in the eyes.
After that client checked his state to Langgeng Muara Makmur clinic and
clients got INSTO eye drops medication for 3 times a day. Until May 2013,
that white thing was not lost and increasingly disturbing visions and also the
appearance of the client. Client decided to check up his eyes on Ulin Hospital
Banjarmasin and he got medical diagnosis pterygium. Then client was treated
in the Seroja ward (eye ward) on April 26th , 2013 at 11.33 pm.
History of previous disease, Client said that he had never experienced the
same disease like now, but Client had experienced a stroke in left side body
section and treated in Ulin Hospital Banjarmasin on April 18th , 2013 then he
came out on April 24th, 2013 and two years ago client had been treated in the
hospital with head trauma from a car accident.
History of family disease, Client said that no one of his family members who
suffered the same disease with Client experiencing now. On client's family
there was no hereditary diseases such as diabetes mellitus, asthma or heart and
also infectious disease like pulmonary tuberculosis, hepatitis and others.
On physical examination on April 26th , 2013 at 11.40 pm. The general
condition was good, client awareness was composmentic proved that client
could oriented his name, the place and time right now. Clients GCS was
4 5 6 (spontaneous eyes opened, verbal orientation was clear and good,
motoric respons was good and could obey the order). On vital signs
examination the result was : blood pressure was 130/90 mmHg, pulse was
33
80x/minute, respiration was 25x/minute, and clients body temperature was

36.3o C.
On anthropometric assessment got the result was , clients body height was
164 cm, clients body weight was 59 kg, clients ideal body weight was 58.6
70.4 kg. the client's right arm circumference was 36 cm and the left arm
circumference was 35.8 cm.
Client's skin looked clean and felt warm. There was no injuries on the client's
skin. Skins turgor was good (back in <2 seconds). There was invisible
presence of cyanosis on the nail the client. The clients nail shape was normal,
there was no form of nail disorders such as clubbing, etc.
The distribution of client's hair were complete. There was no any gray hair,
the color of clients hair was black. There was no lesion or scalp wound on the
client. There was no scar, injury or trauma on the scalp area of the client.
Client's hair looked clean, no dandruff. The clients neck was symmetric,
there was no limitations of neck movement. This was proven by the ability of
Client to turn to the right and to the left, down or up. On the client's neck,
there was no an enlarged thyroid gland.
The clients left and right eyes were symmetric . Eyes skelera was white,
there was fibrovascular growth on the right eye nasal conjunctiva 2 mm and
temporal conjunctiva 1 mm and there was fibrovascular growth on nasal
conjunctiva in the left eye and 1.5 mm and temporal conjunctiva 1 mm. The
conjunctiva was not anemic, no hifema, or trauma on the eye. Pupillary
function was well, pupils can dilate and shrink with light stimulation. No
palpable mass and pressure pain on the eyes. the client's decreased visual
function. Client could not see objects clearly at near distances, and the client's
was able to see distant objects between 1-2 meters. Visus orbital dextra
34
(VOD) was 6/60, visus orbital sinistra (VOS) was 6/60. Clients did not use
visual tools such as glasses or eyes contact.
The nose shape was normal, nasal septum of client was straight in the middle.
There was no blood, polyps, trauma or inflammation that makes Client looked
difficult to breath. Smelling function was good. This proved by the ability of
Client to smell the distinctive aroma of eucalyptus oil and alcohol although
the client's eyes were closed.
Clients ear looked symmetrical. There was no abnormalities in both ear.
There was no secrete, bleeding or stock of wax in the ear hole of client that
could interfered with the function of hearing clients. Hearing fuctiom was
good. This proved by the ability of Client to be able to hear clearly and client
could answered nurse questions with clearly without any repetition of
questions by the nurse. Clients did not use hearing tools.
The clients mouth was symmetric, no edema, no bleeding or trauma. Clients
mucous membranes looked moist. There was no signs of cyanosis (bluish) on
clients lips. There was no stomatitis in the mouth that could interfere the
comfortable and adequate nutrition for clients. Clients did not wear artificial
tooth. Clients teeth were not completed. Client could chew food until smooth,
no complained about trouble chewing. Client did not have a swallowing
disorder.
The clients chest looked symmetrical shape. There was no any trauma on
chest area. Client did not have chest deformities such as barrel chest, pigeon
chest or other. Client chest expansion looked symmetrical. Client respiration
frequency was 20 x / minute. When palpation was there were tatctil premitus
palpable symmetric left and right, no pressure pain or mass, and when
auscultated was done breathing sounds was vesicular, there was no additional
breath sounds such as wheezing or ronchi. Client did not use oxygen to
35
breath. Armpit was warm. Pulse was 80 x / minute. Pulse palpable strong and
regular. CRT clients return <2 seconds. Blood circulation to peripheral was
not disturbed, peripheral felt warm and there was no signs of cyanosis, no
palpitations and Client did not get blurred view while change the current
position.
Abdominal structures looked symmetric, there was no ascites, hemorrhage,
edema and inflammation. skin turgor was good (return <2 seconds). On
assessment by palpation is not palpable enlargement of the liver
(hepatomegaly), no pressure pain or mass. While in the percussion sounds
was timfany, and bowel sounds 12x/minute (normal 7 - 15x/minute).
Client is 43 years old man. Clients did not wear a catheter. No complained on
the genital or difficulty in urinate.
The clients upper and lower extremities structure looked symmetric. No
abnormalities and deformity on the upper or lower extremities . There were
no ulcers or lesions on upper or lower extremity. The Infusion was not
installed on the upper and lower extremities. Muscle scale :
Right
Left
5555
5555
5555
5555
Activity scale of client was 0 (independent and did not need help by tools or
people to do activities).
36
3.2
Physical, Psychological, Social and Spiritual eeds

3.2.1 Activity and rest
At home
:Client is a worker in palm oil company, he did his

activities without limited, client could walk with range
100 300 meters and client could lift the load until 60
kg. Client often slept 6-8 hours a day, client slept at
afternoon and night. Client has enough rest and slept a
day.
At the hospital :The clients activities was not limited, client could
move from bed to toilet and around the ward. Client
could sleep about 6-8 hours a day.
3.2.2 Personal hygiene
At home
:Client usually took a bath two times a day. Client often

took a shampoo if it needed. And brushed teeth usually
while taking a bath and cut the nails if it long. And he
did these activities by himself
At the hospital :Client took a bath two times a day, client never took a
shampoo before, client brushed teeth after eating the
food and used hair oil everyday.
3.2.3 Nutrition
At home
:Client usually ate three time a day with the menu rice,
fish, meat , ice tea or sweet tea and water. Client did
not have allergic or forbidden food. Client drank 6-8
a day.
37
At the hospital :Client ate the food that given by the hospital three
times a day with full portion, clients appetite was good
and there was not disturbance when swelling the food.
Client drank 6-8 glass of water in a day.
3.2.4 Elimination
At home
: Client urinate 4-5 times a day and defecate once

time in a day. Client said that there was no problem
with defecate or urinate such as frequently urinate,
rarely urinate, constipation, defecate with liquid form
or defecate with bleeding.
At the hospital: Client urinate 4-5 times a day and defecate once
time in a day. Client did not have complaint with his
urinate or defecate.
3.2.5 Sexuality
Client is a male, he is married once and has 2 children from his
marriage.
3.2.6 Psychosocial
Client looked anxious and fear of something. Anxiety level was 2
(moderate). Client often asked about his disease and operation result.
Client looked avoided to see his eyes, client looked as if he felt shy
with his eyes with said his eyes were not perfect like before. But client
was cooperative with the nurse or other medical team. The relationship
between client and family, nurse, doctor was good.
38
3.2.7 Spiritual
Client believed with Allah and client pray for his healing from disease.
3.3
Supporting Data
Table 3.1
Laboratory result on April 24th, 2013.
Examination
Result
References
Hematology
Hemoglobin
15,6
14,00 18,00 g/dL
Leukocyte
14,2
4,0 10,5 thousand/ul
Erythrocyte
5,45
4,50 6,00 million/ul
Hematocrit
46,4
42,00 52,00 vol %
Thrombocyte
383
150 450 thousand/ul
RDWCV
14,2
11,5 14,7 %
MCH
28,6
27,0 32,0 pg
MCV
85,2
80,0 97,0 fl
MCHC
33,5
32,0 38,0 %
Gran %
75,7
50,0 70,0 %
Lymphocyte %
20,1
25,0 40,0 %
MID %
4,2
4,5 11,0 %
Gran #
10,70
2,5 7,0 thousand/ul
Lymphocyte #
2,9
1,25 4,0 thousand/ul
MID #
0,6 thousand/ul
MCH, MCV, MCHC
Count
39
3.4
Pharmacology Therapy
Table 3.2
List medication therapy.
ame
Drug
Dosage
Via
Mr. J
Time
Documentation
Bio Retin
2 x 1 tab (200 mg)
Oral
08
18
Given
Mr. J
As. mefenamat
2x1 tab (1000mg)
Oral
08
18
If it needed
Mr. J
Gentamicin 0,3 %
2x 1 drop (2 ml)
Oral
08
After surgery
Mr. J
Cobazam
1 tab (10 mg)
Oral
08
If it needed
Mr. J
Vasocon - A
4 x 1 drop (4 ml)
topical
08
12
18
Given
Table 3.3
List indication for medicine.
o.
1.
2.
3.
4.
5.
3.5
Drugs name
Bio Retin
As. mefenamat
Gentamicin
Clobazam
Vasocon - A
Indication
To keep the health of eyes function.
To reduce mild and moderate pain.
To inflammation and as eyes antibiotic.
To make client more relax and as anti anxiety drug
To avoid eyes irritation, redness eyes and photophobia
Focus Data
3.5.1 Subjective data
3.5.1.1 Client said that there was something white growing in left and
right on his eyes and it was disturbing his appearance.
3.5.1.2 Client also complained he felt afraid with surgery resulting in
blind eyes.
40
3.5.2 Objective data

3.5.2.1 Inspection
a.
There was fibrovascular growth on the right eye nasal

conjunctiva 2 mm and temporal conjunctiva 1 mm.
b.
There was fibrovascular growth on the left eye nasal

conjunctiva 1,5 mm and temporal conjunctiva 1 mm.
c.
Visus orbital dextra (VOD) was 6/60.
d.
Visus orbital sinistra (VOS) was 6/60.
e.
Client looked he avoided to see his eyes.
f.
Client looked as if he felt shy with his eyes with said

his eyes was not perfect like before.
h.
Client looked anxious and fear something.
i.
Client often asked about his disease and operation

result. Anxiety level was 2 (moderate anxiety)
j.
Respiration was 25x/minute.
3.5.2.2 Palpation
There was no mass and pressure pain on eyes , abdomen and
chest. Pulse was 80x/minute.
3.5.2.3 Percussion
Breathing sound was vesicular. Abdomen sounded timpani.
41
3.5.2.4 Auscultation
Clients body temperature was 36,3o C and his blood
pressure was 130/90 mmHg.
3.6
Data Analysis
Table 3.4
Data analysis
Data
Problem
Etiology
Anxiety
Situational crisis:
(NANDA 2012 2013)
Operative procedure.
Body image disturbance
Appearance change .
Pre operative
SD : Client complained he
felt afraid with surgery
OD : 1. Client looked
anxiety and fear
something.
2. Client often asked about
his disease and operation
result.
3. BP: 130/90 mmHg.
P: 80x/minute.
R: 25x/minute
T: 36,3o C.
3. Anxiety level was 2
(moderate)
SD : Client said that there

was something white
growing in left and right on
his eyes and it was
(Cynthia. 2011)
42
disturbing his appearance.

OD : 1. There was
fibrovascular growth on
the right eye nasal
conjunctiva 2 mm and
temporal conjunctiva 1 mm
2. There was fibrovascular
growth on the left eye
nasal conjunctiva 1,5 mm
and temporal conjunctiva 1
mm.
3. Client looked if he avoid
to see his eyes.
4. Client looked he felt shy
with his eyes with said his
eyes was not perfect like
before.
Post operative right

pterygium extervation on
April 29th, 2013
SD : Client said that he felt
pain in his right eye.
P : Pain because of eye
surgery..
Q : sores pain
R : right eye.
S : 2 (moderate)
T : 30 seconds when
opened eye and looked
above, pain reduce when
client closed the eye and
drank mefenamat acid
drug.
Acute pain
Injury agent : post op pterygium
(NANDA 2012 2013)
extervation
43
OD : 1. Client looked he
felt painful and held the
bandage.
2. There was bleeding on
medial and lateral of
scelera.
growth.
4. BP: 140/90 mmHg.
P: 84x/minute.
R: 20x/minute
T: 36,0o C.
SD : Client said that he
Sensory perception
Sensory reception
couldnt see because his
disturbances.
interference : Post operative
right eye was operated.
(Cynthia. 2011)
pterygium extervation.
OD : 1. Installed bandage
on right eye.
2. VOD could not be
assessed because of wore
bandage.
3. VOS was 6/60.
SD : OD : 1. Installed bandage
on right eye .
2. VOD could not be
bandage.
3. Client was did right eye
surgery on first day.
Risk for infection

(NANDA 2012 2013)
44
Post operative left

April 30th, 2013
Acute pain
Injury agent : post op pterygium
(NANDA 2012 2013)
extervation
pain in his left eye.

surgery..
Q : sores pain
R : left eye.
S : 2 (moderate)
T : 30 seconds when
drug.
bandage.
scelera.
growth.
4. BP: 120/80 mmHg.
P: 90x/minute.
R: 21x/minute
T: 36,5o C.
45
Sensory perception
Sensory reception
disturbances.
interference : Post operative
(Cynthia. 2011)
left eye was operated.

on left eye.
2. VOS couldnt assess
because wore bandage.
3. VOD 6/60.
SD :
Risk for infection
(NANDA 2012 - 2013)
on left eye .
2. VOS could not be
bandage.
3. Client was did left eye
3.7
Priority Problem
3.7.1 Pre operative, on Friday April 26th , 2013.
3.7.1.1 Anxiety related to situational crisis : operative
procedure.
3.7.1.2
Body image disturbance related to appearance change
3.7.2 Post operative extervation right eye, on Monday April 29th , 2013.
3.7.2.1 Acute pain related to injury agent : post op pterygium
extervation.
3.7.2.2 Sensory perception disturbances related to sensory reception
interference : Post operative pterygium extervation.
46
3.7.2.3 Risk for infection.

3.7.3 Post operative extervation left eye, Monday April 29th , 2013.
3.7.3.1 Acute pain related to injury agent : post op pterygium
extervation.
3.7.3.2 Sensory perception disturbances related to sensory reception
interference : Post operative pterygium extervation.
3.7.3.3 Risk for infection.
(Reference : NANDA 2012 2013 & Cynthia 2011. Diagnosis keperawatan. )
3.8
ursing Intervention
Table 3.5
Nursing intervention.
o
Planning
ursing diagnosis
Purpose
Intervention
Rational
Pre op, April 26th, 2013.

1.
Anxiety
related
to
After nursing
situational crisis: operative
intervention is
procedure.
done in 12 hours
anxiety in
SD : Client complained he
the criteria is
generally.
felt afraid with surgery
found :
1. Client did
OD : 1. Client looked
1. Asses the cause

of anxiety.
2. Explain about
1. To know
clients
2. To give
clients disease
knowledge to
not have
and surgery
client about
anxiety and fear
complaint
procedure.
his disease
something.
that he felt
2. Client often asked about
afraid with
his disease and operation
surgery.
and surgery
procedure.
3.
Teach
relaxation
3. To reduce
47
result.
2. Client didnt
3. BP: 130/90 mmHg.
asked about
P: 80x/minute.
his disease
R: 25x/minute
and he will
4.
technique :
anxiety of
deep breathing.
client.
Observe vital
signs.
4. To know the
vital signs
T: 36,3 C.
not look
change when
4. Anxiety level was 2
anxious and
client felt
(moderate)
fear.
anxiety with
sign by :
3. Vital signs
increasing
are normal.
BP, pulse, or
4. Anxiety level
respiration.
is 1 (mild) or
0 (moderate)
2.
Body image disturbance
After nursing
related
intervention is
to
appearance
change.
done in 4 days the
SD : Client said that there
criteria is found :
was something white
1.
Client said
1.
Give a change
to client to
judge himself.
1. To help
client to
validate his
felting.
2.
Asses clients
2. To know the
growing in left and right
that there was
on his eyes and it was
no something
disturbing his appearance.
white
OD : 1. There was
growing in
fibrovascular growth on
left and right
the right eye nasal
on his eyes
and self
conjunctiva 2 mm and
Client will
control.
temporal conjunctiva 1
get adaptive
mm
coping
mechanism.
growth on the left eye
2.
There was
nasal conjunctiva 1,5 mm
fibrovascular
and temporal conjunctiva 1
growth on the
mm.
right eye
3. Client looked avoid to
nasal and
see his eyes.
temporal.
coping
mechanism.
ability of
individual
coping
3.
Suggest client
to do self care.
4.
3. To increase
independent
Give positive
4. To increase
reinforcement
clients
if client can
motivation
accept his
and self
condition.
acceptance.
48
4. Client looked he felt shy
3.
There was
with his eyes with said his
fibrovascular
eyes was not perfect like
growth on the
before.
right eye
nasal and
temporal.
4.
Client didnt
look he felt
shy
3.
Post operative right

April 29th, 2013
1.
Asses verbal
1. To know pain
Acute pain related to
After nursing
injury agent : post op
intervention is
and non verbal
level and
done in 3 hours
of pain.
location .
the criteria is
pain in his right eye.
found :
1.
2.
Observe vital
signs.
3.
Arrange
that pain lost
Q : sores pain
or reduce.
comfortable
Pain scale is
position to
S : 2 (moderate)
0 (no pain) or
client.
T : 30 seconds when
1 (mild pain)
2.
general
condition.
Client said
surgery..
R : right eye.
2. To clients
4.
Teach
3. To reduce
local pain.
4. To change
Client
relaxation and
focus of client
doesnt look
distraction
from pain and
pain.
technique.
reduce it..
3.
4.
Vital sign
5.
Collaborate in
5. To remove
was normal.
giving
and reduce
The analgesic
analgesic
pain.
medicine will
medicine.
bandage.
stopped
drug.

scelera.
5.
49

growth.
4. BP: 140/90 mmHg.
P: 84x/minute.
R: 20x/minute
T: 36,0o C.
4.
1.
Asses visual
1. To determine
Sensory perception
After nursing
disturbances related to
intervention is
sharpness of
visual
sensory reception
done in 1 day the
client.
sharpness .
interference : Post
criteria is found :
2.
Orient client
2. To increase
Client said
with the
adaptation
extervation.
that he can
environment.
process with
see well
operative pterygium
1.
2.
The bandage
environment.
3.
Put the thing
3. To make
right eye was operated.
is not
nearest from
client easy to
installed on
client side.
fulfill his
on right eye.
right eye.
2. VOD could not be
3.

bandage.
4.
3. VOS was 6/60.
Can assess
needed.
4.
Observe
4. To prevent
VOD
disorientation
injury and
VOD result
of client with
fall.
is 6/60
environment.
1. To reduce
5.
Risk for infection.

SD : OD : 1. Installed bandage
on right eye .
2. VOD could not be
After nursing
to client about
done in 2 days the
the important
criteria is found :
1.
thing to do
Does not
hand washing
installed the
before and
bandage on
bandage.
after treatment.
right eye.
3. Client was did right eye

2.
There was no
signs of
Give
understanding
intervention is
1.
2.
Teach aseptic
technique.
microorganism and
bacteria on
clients hand
and prevent
transmitting
of that microorganism.
2. To prevent
micro-
50
3.
infection on
organism and
eye.
infection.
The surgery
3.
Suggest client
3. To avoid eye
will done and
to do not touch
irritation and
VOD can
surgery area.
pterygium
assess.
recurrent.
4.
Do eye
dressing.
4. To clear eye
area and keep
it moist.
5.
Observe signs
5. To detect
and symptoms
sign of
of infection.
infection as
early.
6.
Collaborate in
6. To help
give antibiotic
prevent
medicine.
infection on
eye.
6.
Post operative left

April 30th, 2013
After nursing
pain in his left eye.
intervention is
and non verbal
level and
done in 3 hours
of pain.
location .
surgery..
the criteria is
Q : sores pain
found :
R : left eye.
1.
1.
2.
Asses verbal
Observe vital
signs.
Client said
that pain lost
T : 10 seconds when
or reduce.
comfortable
Pain scale is
position to
0 (no pain) or
client.
1 (mild pain)
2.
general
3.
4.
Arrange
Teach
3. To reduce
local pain.
4. To change
Client
relaxation and
focus of client
drug.
doesnt look
distraction
from pain and
pain.
technique.
reduce it..
3.
2. To clients
condition.
S : 2 (moderate)
1. To know pain
51
painful and held the
4.
bandage.
Vital sign
5.
Collaborate in
5. To remove
was normal
giving
and reduce
The analgesic
analgesic
pain.
medicine will
medicine.
scelera.
stopped
5.

growth.
4. BP: 120/80 mmHg.
P: 90x/minute.
R: 21x/minute
T: 36,5o C.
7.
Sensory perception
disturbances related to
sensory reception
interference : Post
operative pterygium
extervation.
After nursing
done in 1 day the

criteria is found :
1.
2.
3.
sharpness of
visual
client.
sharpness .
Orient client

4.
VOS result
is 6/60
2. To increase
with the
adaptation
environment.
process with
3.
Put the thing
3. To make
nearest from
client easy to
client side.
fulfill his
Can assess
VOS
1. To determine
environment.
the bandage
on left eye.
3. VOD was 6/60.
On left eye
did not install
bandage.
Asses visual
see well
2. VOS could not be
2.
Client said
that he can
left eye was operated.
1.
intervention is
needed.
4.
Observe
4. To prevent
disorientation
injury and
of client with
fall.
environment.
52
8.
Risk for infection.
After nursing
SD : -
intervention is
understanding
micro-
done in 2 days the
to client about
organism and
on left eye .
criteria is found :
the important
bacteria on
2. VOS could not be
1.
Infection is
thing to do
clients hands
not happen
hands washing
and prevent
There was no
before and
transmitting
3. Client was did left eye
signs of
after treatment.
of that micro-
infection on

bandage.
2.
eye.
3.
1.
Give
1. To reduce
organism.
2.
The surgery
Teach aseptic
technique
will done
2. To prevent
microorganism and
infection.
3.
Suggest client
3. To avoid eye
to do not touch
irritation and
surgery area.
pterygium
recurrent.
4.
Do eye
dressing.
4. To clear eye
area and keep
it moist.
5.
Observe signs
5. To detect
and symptoms
sign of
of infection.
infection as
early.
6.
Collaborate in
6. To help
giving
prevent
antibiotic
infection on
medicine.
eye.
53
3.9
Implementation
Table 3.6
Implementation
o
1.
Day/date
Time
Pre
11. 50
Dx o
Implementation
1. Assessing the
operative
Evaluation
1.
cause of anxiety.
Client
complained
Friday
he felt afraid
26/4/2013
with surgery
(first day)
resulting in
blind eyes.
2.00
2. Explaining about
2.
Client showed
clients disease
his enthusiasm
and surgery
and understood
procedure.
about the
disease and
surgery
procedure.
12.00
3.
Teaching
3.
Client looked
relaxation
he could do the
technique : deep
instruction to
breathing.
him and he
said he did not
feel anxious
and fear again
with surgery
procedure.
11.40
4.
Observing vital
signs.
4.
BP: 130/90
mmHg.
P: 80x/minute.
Signature
54
R: 25x/minute
T: 36,3o C.
11.35
1.
Giving a change
1.
Client said that
to client to judge
there was
himself.
something
white growing
in left and right
on his eyes and
it was
disturbing his
appearance.
11.50
2.
Assessing
2.
There was
clients coping
fibrovascular
mechanism.
growth on the
right eye nasal
conjunctiva 2
mm and
temporal
conjunctiva 1
mm
There was
fibrovascular
growth on the
left eye nasal
conjunctiva 1,5
mm and
temporal
conjunctiva 1
mm.
14.30
3.
Suggesting client
to do self care.
3.
Client looked
he did not care
with his eyes
treatment.
BP: 130/90
55
mmHg.
P: 80x/minute.
R: 25x/minute
T: 36,3o C.
3.10
Progress ote
Table 3.7
Progress note.
o
1.
Day/date
Time
Pre -
8.00
o Dx
Implementation
1.
Giving a change
Evaluation
S : Client said that if
operative
to client to judge
he felt little shy
Saturday
himself.
with his eyes
27/04/2013
8.15
8.30
8.30
9.00
2.
3.
4.
5.
Assessing
O : There was
clients coping
fibrovascular
mechanism.
growth on the
Suggesting
right eye nasal
client to do self
conjunctiva 2
care.
mm and
Involving the
temporal
clients family
conjunctiva 1
in making
mm. There was
decisions about
fibrovascular
self-care.
growth on the
Giving positive
left eye nasal
reinforcement if
conjunctiva 1,5
client can accept
mm and
his condition.
temporal
conjunctiva 1
mm.
- Clients coping
mechanism still
Signature
56
maladaptive.
A : Body image
disturbance
problem had
been half solved.
P : Intervention
continued :
1.
Give a change
to client to
judge himself.
2.
Suggest client
to do self care.
3.
Give positive
reinforcement
if client can
accept his
condition.
2.
Pre
8.20
1.
operative
Sunday
28/04/2013
8.30
10.00
2.
3.
Giving a change
S : Client said that
to client to judge
he could accept
himself.
his eyes
Assessing
condition and he
clients coping
hope he will do
mechanism.
early surgery.
Giving positive
O : Clients coping
57
reinforcement if
mechanism was
client can accept
adaptive.
his condition.
Client looked he
had spirit to do
surgery.
A : Body image
disturbance
problem had
been solved.
P : Intervention
stopped.
3.
Post Op
11.35
1.
Right
pterygium.
Monday
11.40
2.
29/04/2013
11.00
12.00
3.
11.30 pm
(first day)
13.10
11.35
4.
5.
Assessing verbal
and non verbal
he felt no pain in
of pain.
his right eye.
Observing vital
P : Pain because
signs.
of eye surgery..
Arranging
Q : sores pain
comfortable
R : right eye.
position to
S : 0 (no pain)
client.
T : 30 seconds
Teaching
when opened eye
relaxation and
and looked
distraction
above, pain
technique.
reduced when
Collaborating in
client closed the
giving analgesic
eye and drank
medicine.
mefenamat acid
drug.
O : - Client did not
look pain
58
BP: 140/90
mmHg.
N: 84x/minute.
R: 20x/minute
T: 36,0o C.
A : Acute pain
problem had
been solved.
P : Intervention
stopped.
11.50
12.40
1.
2.
Assessing visual
sharpness of
he couldnt see
client.
because his right
Orientating
eye was
client with the
operated.
environment.
13.35
14.00
13.50
3.
4.
5.
O : - Installed
Putting the thing
bandage on right
nearest from
eye.
client side.
- VOD could not
Involving
be assessed
clients family
because of wore
to help client
bandage.
activities.
- VOS was 6/60.
Observing
BP: 140/90
disorientation of
mmHg.
client with
N: 84x/minute.
environment.
R: 20x/minute
T: 36,0o C.
A : Sensory
perception
disturbances
problem had
59
been half solved.

P : Intervention
continued :
1.
Asses visual
sharpness of
client.
2.
Orient client
with the
environment.
3.
Put the thing

nearest from
client side.
4.
Involve clients
family to help
client activities.
5.
Observe
disorientation
of client with
environment.
14.05
14.05
14.10
14.30
1.
2.
3.
4.
Giving
S:-
understanding to
O : Installed
client about the
bandage on right
important thing
eye .
to do hand
- VOD could
washing before
not be assessed
and after
because client
treatment.
wore bandage.
Teaching aseptic
- Client was
technique.
did right eye
Suggest client to
surgery on
do not touch
first day.
surgery area.
-there was no
Doing eye
infection signs
60
11.40
5.
dressing.
such as redness,
Observing signs
pain/itching,
and symptoms
watery eyes,
of infection.
swelling eye etc.

A : Infection had not
been happened.
P : Intervention
stopped
4.
Post Op
12.30
1.
Left
pterygium.
Tuesday
14.00
2.
Assessing verbal
and non verbal
he felt no pain in
of pain.
his left eye.
Observing vital
P : Pain because of
signs.
eye surgery.
Arranging
Q : sores pain
12.20 am
comfortable
R : left eye.
(second
position to
S : 0 (no pain)
client.
T : 10 seconds
Teaching
when opened
relaxation and
eye and looked
distraction
above, pain
technique.
reduced when
Collaborating in
client closed the
giving analgesic
eye and drank
medicine.
mefenamat acid
30/04/2013
12.00
day)
12.35
3.
12.40
4.
12.30
5.
drug.
O : - Client did not
look pain
BP: 120/80
mmHg.
N: 90x/minute.
R: 21x/minute
T: 36,5o C.
A : Acute pain had
61
been solved.
P : Intervention
stopped
13.00
12.45
1.
2.
Assessing visual
sharpness of
he couldnt see
client.
because his left
Orientating
eye was
client with the
operated
environment.
12.45
12.50
14.00
3.
4.
5.
O : - VOS could not
Put ting the
asses because
thing nearest
wore bandage
from client side.
- VOD was 6/60
Involving
- Installed
clients family
bandage on left
to help client
eye.
activities.
BP: 120/80
Observing
mmHg.
disorientation of
N: 90x/minute.
client with
R: 21x/minute
environment.
T: 36,5o C.
A : Sensory
perception
disturbances
problem had
been half solved.
P : Intervention
continued :
1.
Asses visual
sharpness of
client.
2.
Observe
disorientation
of client with
62
environment.
13.10
13.15
13.20
14.05
14.10
1.
2.
3.
4.
5.
Giving
S:-
understanding to
O : - VOS could not
client about the
asses because
important thing
wore bandage
to do hand
- VOD was 6/60
washing before
- Installed
and after
bandage on left
treatment.
eye.
Teaching aseptic
- The surgery
technique.
for clients left
Suggest client to
eye was done
do not touch
-there was no
surgery area.
infection signs
Doing eye
such as redness,
dressing.
pain/itching,
Observing signs
watery eyes,
and symptoms
swelling eye etc.
of infection.

been happened.
P : Intervention
continued :
1.
Give
understanding
to client about
the important
thing to do
hand washing
before and
after treatment.
2.
Suggest client
to do not touch
surgery area.
63
3.
Do eye
dressing.
4.
Observe signs
and symptoms
of infection.
5.
Post Op
08.30
1.
Left
Assessing
visual
he couldnt see
Pterygium
sharpness of
because his left
Wednesday
client.
eye was covered
Observing
by bandage.
01/05/2013
08.35
2.
disorientation of
(third day)
O : - VOS could not
client with
be assessed
environment.
because client
wore bandage.
- VOD was 6/60
- Installed
bandage on left
eye.
BP: 130/80
mmHg.
N: 86x/minute.
R: 22x/minute
S: 36,3o C.
A : Sensory
perception
disturbances
problem had
been solved.
P : Intervention
stopped.
09.00
1.
Give
understanding to
S:O : - VOS could not
client about the
asses because
important thing
wore bandage
64
09.10
to do hand
- VOD was 6/60
washing before
- Installed
and after
bandage on left
treatment.
eye.
Suggest client to
- The surgery
do not touch
for clients eye
surgery area.
was done
2.
09.15
3.
Do eye dressing.
-there was no
09.20
4.
Observe signs
infection signs
and symptoms
such as redness,
of infection.
pain/itching,
watery eyes,
swelling eye etc.
been happened.
P : Intervention
stopped
3.11
Evaluation
Table 3.8
Evaluation.
o.
1.
Day/date
Time
Post Op
14.40
Left
Pterygium
Wednesday
Diagnosis no.
Evaluation
S : Client said that he couldnt see
because his left eye was covered by
bandage.
O : - VOS could not be assessed
01/05/2013
because client wore bandage
(third day)
- VOD was 6/60

- Installed bandage on left eye.
BP: 130/80
mmHg.
65
N: 86x/minute.
R: 22x/minute
S: 36,3o C.
A : Sensory perception disturbances
problem had been solved.
P : Intervention stopped.
14.45
S:O : - VOS could not be assessed

because client wore bandage
- VOD was 6/60
- Installed bandage on left eye.
- The surgery for clients left eye
was done.
-there was no infection signs such as
redness, pain/icthing, watery eyes,
swelling eye etc.
-Left eye bandage was take off on
13.50 pm.
A : Infection had not been happened.
P : Intervention stopped

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CHAPTER 3

URSI G CARE REPORT

80x/minute, respiration was 25x/minute, and clients body temperature was

Physical, Psychological, Social and Spiritual eeds

:Client is a worker in palm oil company, he did his

:Client usually took a bath two times a day. Client often

: Client urinate 4-5 times a day and defecate once

14,00 18,00 g/dL

4,0 10,5 thousand/ul

4,50 6,00 million/ul

42,00 52,00 vol %

150 450 thousand/ul

2,5 7,0 thousand/ul

1,25 4,0 thousand/ul

MCH, MCV, MCHC

2 x 1 tab (200 mg)

2x1 tab (1000mg)

1 tab (10 mg)

3.5.2 Objective data

There was fibrovascular growth on the right eye nasal

There was fibrovascular growth on the left eye nasal

Visus orbital dextra (VOD) was 6/60.

Visus orbital sinistra (VOS) was 6/60.

Client looked he avoided to see his eyes.

Client looked as if he felt shy with his eyes with said

Client looked anxious and fear something.

Client often asked about his disease and operation

Respiration was 25x/minute.

(NANDA 2012 2013)

Body image disturbance

SD : Client said that there

disturbing his appearance.

Post operative right

Injury agent : post op pterygium

(NANDA 2012 2013)

SD : Client said that he

couldnt see because his

interference : Post operative

right eye was operated.

Risk for infection

Post operative left

Injury agent : post op pterygium

(NANDA 2012 2013)

pain in his left eye.

SD : Client said that he

couldnt see because his

interference : Post operative

left eye was operated.

Risk for infection

(NANDA 2012 - 2013)

Body image disturbance related to appearance change

3.7.2.3 Risk for infection.

Pre op, April 26th, 2013.

situational crisis: operative

felt afraid with surgery

resulting in blind eyes.

1. Asses the cause

anxiety and fear

2. Client often asked about

his disease and operation

3. BP: 130/90 mmHg.

4. Anxiety level was 2

Body image disturbance

done in 4 days the