NURSING CARE

ON Ms. M WITH ASMA BRONCHIALE

AT INPATIET INSTALATION KANDOU GCH, MANADO

I.ASSESSMENT
The assessment was conducted on August 2, 2019 at 10:45 a.m.
a. Patient identity
Name : Ms. M
Age : 16 years old
Job : Student
Status : Not Married
Address : Malalayang, manado
Register No : 381478
Medical Diagnosis: Asthma Bronchiale
b. Person in charge
Name : Mrs. S
Age : 45 years old
Relationship with patients: Mother
Job : Entrepreneur
Address : Malalayang, manado

II.PRIMARY ASSESSMENT
a.Airway
Unproductive cough, sticky thick discharge is difficult to come out, wheezing, the
sound of bronchial base expiration is extended, ronkhi wet lung area.
b. Breathing
Shortness of breath, RR 30 x / minute, shallow and fast breathing regular rhythm,
inspiration shortens, elongated expiration, intercostal muscle pull, nasal lobe
breath
c. Circulation
Blood pressure 90/50 mmHg, pulse 112 x / minute, temperature 36.8 0 C, cold
akral, restlessness, cyanosis, diaphoresis
III.SECONDARY ASSESSMENT
1. Main complaint
Clients complain of continuous shortness of breath and the taste of ampeg.
2. Current medical history
Clients complain of shortness of breath since the day before. Cough
accompanied by thick secretions that are difficult to get out. During the last three weeks
the client has had an asthma attack three times. If there is an attack the client is
accustomed to drinking amoxilin 500 mg and salbutamol. Because the tightness that is
felt is not reduced then the client is taken to Kandou General Center Hospital.
3. Past medical history
Clients have a shortness of breath since childhood. Lately, shortness of breath
attacks often recur and families only find out if the client has asthma. Shortness of
relapse, especially if the client experiences stress, a lot of thoughts and problems,
especially the problem of assignments in school and family.
4. Family history
The client's mother has a history of shortness of breath since childhood but now
has never relapsed.
5. Habit pattern
Clients everyday help their mothers sell food at home after returning from
school.
6. Physical examination
Head : a mesochepal shape, straight black hair is not easily removed
Eyes : The conjunctiva is not anemic, the sclera is not jaundiced
Nose : clear secretions / snot
Ears : there are a few ears, hearing functions normally
Mouth : slightly dry lip mucosa, clean teeth, cyanotic lips
Neck : there is no enlarged limpha and thyroid gland
 Lungs
I : symmetrical shape, symmetrical chest movement, intercostal muscle
pull
Pa : Fremitus right = left
Pe : Sonor all lung fields
Au : Wet Ronchi and Whezing the entire lung field, the sound of the bronchial base
expiration is extended

Heart
I : Ictus cordis is not visible
Pa : Ictus cordis palpable at SIC V, 2 cm mid LMCS
Pe : Pekak
Au : Bj S1-S2 is pure

Abdomen
I : flat
Au : bowel sounds (+), 32x / minute
Pa : liver and spleen are not palpable
Pe : timpani
Genetalia: clean
Extremeity:
Above: cold akral, cyanosis, edema (-)
Below: cold akral, edema (-), varicose veins (-)

7. Supporting data
Hb : 10, 65 gr%
Ht : 43%
Leukocytes: 8500 / ul
Platelets: 253,000 / ul
GDS : 110 mg / dl

8. Therapy
- Nebulezer: (Atrovent 1cc + berry 1cc + bisolvon 1cc) and nacl 0.9% 6 cc
- Aminophilin drip 1 ampoule
- infuse RL 20 drops / men
 DATA ANALYSIS

No. Focus Data Etiology Problem

1 Ds: Clients say continuous Thick bronchospasm and The ineffectiveness of
shortness of breath secretions cleaning the airway
Do:
- shortness of breath, shallow
and fast breathing
- pulling the intercostal
muscle
- Auscultation: wheezing in
the bronchi and lung area
- unproductive cough, sticky
thick discharge is difficult
to get out
- RR = 30 times per minute
2. Ds: The client says his chest Hyperinflation of the alveoli, Gas exchange
feels heavy ventilation-perfusion changes damage
Do:
- Auscultation of wet ronkhi
both basal lung
- Shortness of breath, rapid
shallow breath
- Dyspnea with long
expiration of short
inspiration
- RR 30 x / minute
- SaO2 95%, cold akral
3. Ds: The client said his body Hypoxia, lack of oxygen Changes in tissue
felt weak supply to tissues perfusion
Do: n
- TD 90/50 mmHg, pulse 112
x / minute, temperature
36.8 degrees
- Cyanosis, diaphoresis, cold
akral, restlessness
- SaO2 95%
4. Ds: clients often ask when the Difficulty breathing, fear of Anxious
tightness will decrease repeated attacks
DO:
- The patient looks
nervous, tensed
- Continuous shortness of
breath
- Pulse: 112x / minute,
RR: 30 x / minute,
TD: 90/50 mmHg

Nursing diagnoses that appear;

1. Ineffective cleaning of the airway for bronchospasm, thick secretions
2. Gas exchange damage for hyperinflation of the alveoli, ventilation-perfusion changes
3. Changes in tissue perfusion in hypoxia, lack of oxygen supply to tissues
4. Anxious about difficulty breathing, fear of repeated attacks
 NURSING CARE PLAN

NO DP PURPOSE INTERVENTION TTD

1. Ineffective cleaning After nursing action - Assess the frequency and depth
of the airway for for 1 hour, the airway of breathing
bronchospasm, cleaning becomes - Auscultation of additional
thick secretions more effective with breath sounds
the results criteria: - Assess the type of cough and
- shortness of breath / cough production
loss of breath - Collaboration on giving beta 2
- RR 16-24 x / agonist to reduce
minute bronchospasm (nebulizer)
- There is no - Chest physiotherapy if
wheezing and indicated
secretions are - Teach coughing and breathing
runny in effective after treatment and
suctioning secretions
- Give warm fluids
- Maintain patency of the
airway

2. Gas exchange After nursing action - Assess respiratory

damage for for 1 hour, damage to function; auscultation of
hyperinflation of the gas exchange is breath sounds, examine the
the alveoli, reduced, with the skin every minute to 4 hours
ventilation- resulting criteria: - Provide ventilation support
perfusion changes - Breath in a regular - Give oxygen according to the
rhythm of 16-24 program and monitor pulse
x / min oximetry
- Wet Ronkhi - Give a comfortable semi fowler
decreases position
- BGA is within - Monitor the side effects of
normal limits giving treatment
- Check BGA levels
3. Changes in tissue After nursing action - Assess for signs and symptoms
perfusion in for 1 hour, tissue of hypoxia; anxiety, fatigue,
hypoxia, lack of perfusion increases, irritability, tachycardia,
oxygen supply to with the results tachypnea
 tissues criteria: - Give physical comfort; support
- There is no hypoxia, with pillows and position
irritability settings
- Akral is warm - Give oxygen with
- SaO2 100% humidification
- Monitor the effect of giving
nebulizer; then monitor breath
sounds and effort breathing
after therapy
4 Anxious about After nursing action - Assess patient anxiety level
difficulty breathing, for 1 hour, worry the - Describe each procedure
repeated attacks patient is reduced / performed
lost with the results - Explain about patient care and
criteria: treatment
- Patients look more - Teach relaxation techniques
relaxed with deep breath
- Turn 60-100 x / - Encourage the family to
minute accompany the client during
- Patients understand the attack
and are
cooperative for
each nursing
action performed

NURSING NOTE

DATE / NO. DP IMPLEMENTATION EVALUATION TTD

CLOCK
2-8-04 1 - Assess the frequency and depth of 12:00 p.m.
10.45 breathing S: the patient says the
R: RR 30 x / minute, shallow breath fast, tightness has diminished
expiration is longer than inspiration O:
 - Treat breath sounds - RR 24 x / minute
R: There is Whezing in the lung field and- There is still wheezing in
bronchi part of the lung
11.00 - Give nebulezer (atrovent 1 cc, bisolvon- Expiration is still a little
1 cc, berecec 1 cc and Nacl 0.9% 6 lengthy
cc) - The cough client expels
R: The patient says the airway becomes phlegm
more loose and tight, the client coughs,A: the problem is partially
snot out in the nose resolved
- Teaches patient deep breathing andQ: continue to administer
effective coughing after being given a Aminophilin 1 ampul
nebulizer drip through infusion of
R: secretions can come out, runny RL in the room if the
cystole blood pressure is
above 100 mmHg
2-8-2004 2 - Give the patient a fowler position 12:00 p.m.
10.50 R: patients say comfortable with a sittingS: the patient says the
position tightness has diminished
- Give O2 3 liters / minute O:
R: binasal kanul, tightness does not - RR 24 x / minute
decrease - There's still wet ronkhi
- Assess the frequency and depth of- Expiration is still a little
breathing lengthy
R: RR 30 x / minute, shallow breath fast, - reduced dyspnea
10.55 expiration is longer than inspiration - SaO2 98%
- Treat breath sounds A: the problem is partially
R: There is a ronchi throughout the lung resolved
field with the sound of the bronchial Q: continue to monitor
expiratory base extending for acidic balance
- Monitor the effects of nebulizer disorders
administration on changes in
perfusion ventilation
R: reduced dyspnea

2-8-2004 3 - Assessing signs and symptoms of 12:00 p.m.

11.05 hypoxia S: The client said his
R: Clients are nervous, pulse 110x / min, body was still rather
tachypnea, cold akral, diaphoresis weak
- Provides a comfortable position so as O:
 to facilitate peripheral perfusion - TD 95/60 mmHg
R: fowler position - Pulse 98x / minute
- Give oxygen with humidification - RR 24x / min
R: O2 3 lt / min, tightness is slightly - Temperature of 36.9
reduced degrees
- Provides RL loading fluid - Akral is rather cold,
11.30 R: entry fluid, TD 90/50 mmHg not cyanosis
- Monitor the effect of giving nebulizer A: the problem is
on the adequacy of peripheral partially resolved
circulation and its side effects Q: continue to monitor
R: pulse 98 x / min, SaO2 99%, akral is the level of tissue
still cold perfusion in the room

7-7-04 2 - Assess the patient's anxiety level 12:00 p.m.

11. 40 R: Patients say that anxiety when tight is not
reduced S: The patient said that
- Explain about treatment and treatment he was not so worried
R: The patient nods in understanding and O: The patient is more
pays attention to the nurse's explanation relaxed
- Teach relaxation techniques with deep The patient appears
breath lying down
11.45 R: Patients follow what is taught and say Nd = 98x / minute
more comfortable A = problem partially
- Encourage patients to lie down and resolved
rest P = advise the family to
R: cooperative patient always accompany the
- accompany the patient when anxious client especially during
R: the patient feels more calm the attack
- Monitor TTV
R = TD 95/60 mmHg
11.50 RR = 24x / minute
S = 36.9 0 C
Nd = 96x / minute