NURSING IN PATIENTS MR.

CR
WITH SNH + WITH SUSPECTED DVT IN THE
QUEEN AB BALI ROYAL HOSPITAL
DATED 7 MAY - 10 MAY 2019

BY:
GROUP A

MINISTRY OF HEALTH RI
POLYTECHNIC OF HEALTH MINISTRY OF HEALTH DENPASAR
NURSING MAJOR
YEAR 2019
 ASSESSME
NT
1. Patient Identity
• Name :Tn. CR
• Dates RS : Saturday, May 4th 2019
• Date of birth : Netherland, October 24th 1956
• Resources : Patient, family and medical records of patients
• Age : 63 years old Religion : Christian
• Gender : Male Status : Divorced
• Education: High School
• Work : Retired yacht
• Length of work :-
• Address : Netherland / Jl Prapat Beris, Gang Kubu Meranggi II C.
• complaints Uall : The patient said pain and swelling in the left leg.
• Historical PEW : Patient is on vacation in Bali, currently in the villa area of Denpasar, the patient feels dizzy and fainted. Patients were immediately
rushed to the hospital emergency room Bali Royal by friends. Arriving in the ER, patients complained of weak and dizzy with decreased consciousness.
Patients had a history of high blood pressure. Once observed, the patient was treated at the HCU for 1 day and after his condition improved, the
patient is then moved in the inpatient unit Queen AB Bali Royal Hospital with a medical diagnosis of DVT SNH + Suspect on May 5 th, 2019.
•
2. Next of kin can be informed (kids)
• Work : Private (yacht)
• Education : S1 hospitality education
• Address : Netherland
3. Allergy : -
4. Habits : Patients usually smoke discharged half a pack a day, drinking coffee 1 regular meals a day and drinking
alcohol.
5. Drugs
• duration : ± 2 years
• Own: - Valsartan
- Lorazepam
- Blood Thinner
• Others (recipe) :-
6. nutritional patterns : 8. Patterns of sleep and rest:
• Frequency / eating : 3 times a day • Sleep time (hours) : 21:00 pm - 05. 00 pm
• Weight : 95 Kg Height : 190 cm • Old bed / day : 8 hours
• type of food : Soft rice and side dishes low in salt, low in fat. • Bedtime habits :-
• Favorite food : Cheese Burger
• Sleep habits: -
• The food is not favored : There is no
• Difficulty in sleeping: -
• Food restrictions : There is no
• Appetite : Good (no nausea, vomiting and ulcers)
• Changes in the last 3 months BB: No change B (fixed) 9. Activity and exercise patterns:
7. patterns of elimination : • Activity in the work : Business
a. Defecate • Sports : Jogging
• Frequency :1 times a day Time: Morning • Leisure activities : Vacation
• Color : Yellow-brown Consistency: soft • Difficulty / complaint in this regard:
• Use of Laxatives: -
• [√] body movement [] Preen
b. Urination
• [√] shower, intend [] easy to feel fatigue
• Frequency: 4-6 times a day Color : Yellow
• [√] wear [] shortness of breath after holding
• Smell : typical ammonia
activities
II. FAMILY HISTORY (GENOGRAM)

Explanation genogram:

When the assessment Tn.CR said no

family history of inherited diseases such
as hypertension. Tn.CR said the
grandfather, grandmother and her
parents died of old age. Tn.CR said've
been divorced since 30 years ago. Tn.CR
is currently living with her daughter. Kids
- Tn.CR no children who have a history of
high blood pressure such as Tn.CR
III. Environmental History 3. Mood: Patients feel less comfortable with the pain in his legs.
• Environmental Hygiene : The environment around the patient looks 4. Relationship / communication:
clean
• speak
• Danger : There is no danger that threatens environment
• Pollution : No pollution of the environment surrounding the
[√] clear The main languages: Dutch
patient [] Relevan Area Language: Nederlands
IV. Psychosocial aspects [√] able to express
1. Mindset and perception
[√] able to understand others
• Tools used: while reading a book.
• Residence
[√] glasses [-] hearing aids
[ ] own
• Difficulties experienced:
[√] with others, namely with her children
[√] dizziness
• family life
[] Decrease in sensitivity to hot and cold
Adat customs adopted :-
[] Read / write
Producing a decision in the family : Mr. CR
2. self-perception
• Things to think about when this : Patients report pain in the left leg
Pola communication : The patient was cooperative when talk

• Hope after treatment : Patients expect to get back healthy as before Finance: [√] adequate [] Less
• Changes considered after illness : Patients feel bored because they • Difficulties in the family: The patient no problems with her
could not beraktivias as usual. children and was divorced by his wife's patients.
5. sexual habits
• The value system - trust
• Disorders of sexual intercourse due to the following • Who or what is the source of power : God,
conditions: - themselves and the children.
• An understanding of the sexual function: the patient does • Does God, Religion, Faith is important to you:
not want to answer about it.
6. Defense coping
[√ ] Yes No
• Decision-making • Activities conducted on Religion or Belief (type
[√] own
and frequency) Mention: Prayer, a frequency of 1
times a day or 2 times a day
[] Helped by other people; mentioned
• Religion or Belief activities to do while in hospital,
• Preferably about yourself : Patients said they were delighted
when on holiday abroad Mention: Patients just pray in my heart.
• Who want to change from life :-
• What to do if're stressed:
[√] Troubleshooting [] looking for help
[] Eat [] eat medicine
[√] sleep
[] Other (eg, anger, silence, etc.) mentioned
V. PHYSICAL ASSESSMENT

• A. Vital Sign • C. general state :

Blood pressure : 130/80 mmHg • Pain / tenderness: Medium
Temperature : 36,8ºC • pain scale: 6 (0-10) (Patient looks grimacing,
restlessness)
Pulse : 90 x / minute
• Pain in the area : Left Foot
breathing : 20 x / min
• Nutritional status: 1. fat 2. normal3. thin
• B. Awareness : Compos mentis GCS: 15
• BB : 95 Kg Height: 190 cm
Eye :4
• Attitude : agitated
motor : 6
• Personal hygiene: Clean
verbal : 5
• Orientation time / place / person: Good.
•
D. Physical Examination Head To Toe • Nose
• Head of smell : Normal
Shape: Normochepale Secretions / blood / polyps : No secretions / blood /
Lesions / wounds: No lesions / wounds polyp
• Hair Caping pull the nose : -
Color : Blonde whitish, louse(-), dandruff(-) • Ear
Abnormalities : No abnormalities in the hair Hearing: Normal
• Eye Secret / fluid / blood: No secretions / fluid / blood
Vision: 1. normal 2. goggles / lensa3. etc ........ • Mouth and Teeth
Sclera: Jaundice (-) Lip : Moist
Conjunctiva: Anemis (-) Mouth and throat : Normal
Pupil: Isokor Tooth: 1. Full / normal 2. ompong 3.
abnormalities: No abnormalities Other.....

Additional data: -
• Neck • abdomen
Enlargement of the thyroid : No thyroid enlargement Intestinal peristalsis: There are 5 x / min
Lesions : No lesions bloating: -
Carotid pulse : Palpable Tenderness: -
Enlargement lymphoid : No enlargement of lymphoid
ascites: no ascites
• thorax
• genitalia
Heart: 1. Nadi 84x / min, 2. strength: Strong
Pimosis: not reviewed
3. rhythm: Regular
Aids: do not use tools
• Lung: 1. frequency breath: 20 x / min (regular)
Abnormalities: patients said there was no problem
2. quality: normal
regarding the genitalia
3. breath sounds : vesicular
• Skin
4. cough : No cough
5. airway obstruction : There is no blockage of the turgor: elastic
airway lacerations: no laceration
6. chest retraction : No chest retractions Skin color: normal (white)
• Ekstremities
Muscle strenght: 555 555
555 444
ROM: Limited
Hemiplegi / parese : A little pain for the
movement of the left leg.
akral : Warm
Capillary refill time : <3 seconds
edema : Looked swollen left leg.
Etc : There is a fracture in the scar under
the left knee area.
• Data neurological examination: None
 SUPPORTING DATA
1. Investigations Laboratories
• Date of May 4th, 2019 (CBC)
PARAMETER REFERENCE RANGE

WBC 17:33 + 10 ^ 3 / uL 4:00 to 11:00

RBC 4.14 - 10 ^ 6 / uL 4:50 to 6:50

HGB 12.8- g / dL 13.0-18.0

HCT 37.0 - % 40.0-54.0

MCV 89.4 fL 77.0-93.0

MCH 30.9 pg 27.0-32.0
MCHC 34.6 g / dL 31.0-35.0
PLT 207 10 ^ 3 / uL 150-400

RDW-SD 43.1 fL 37.0-54.0

RDW-CV 13.2 % 11.0-14.5
PDW 12.6 fL 9.0-17.0
MPV 10.6 fL 9.0-13.0
CONTINUE
P-LCR 29.7 % 13.0-43.0
PCT 0:22 % 0:17 to 0:35

NRBC 0:00 10 ^ 3 / uL

NRBC% 0.0 %
Neut 14.71 + 10 ^ 3 / uL 2:00 to 7:50

Lymph 1:23 - 10 ^ 3 / uL 1:50 to 4:00

MONO 1:17 + 10 ^ 3 / uL 0.20-0.80

EO 0:18 10 ^ 3 / uL 0:00 to 0:40

MEATBALL 0:04 10 ^ 3 / uL 0:00 to 0:10

neut% 84.9 + % 40.0-70.0

lymph% 7.1 - % 20.0-45.0

MONO% 6.8 % 2.0-10.0
EO% 1.0 % 1.0-6.0
MEATBALL% 0.2 % 0.0-1.0
IG 0:07 10 ^ 3 / uL 0:00 to 7:00

IG% 0.4 % 0.0-72.0

Date of May 5 th, 2019

TEST RESU REFEREN UNIT TEST RESUL RE UNIT

NAME LT CE NAME T FERE
NCE

LIVER
FUNCTION
TEST LIPID
PROFILE
SGOT 26 0-50 U/L
total 157 14 mg /
SGPT 15 0-50 U/L Cholesterol 0- 199 dL

RENAL
HDL - 23 40- mg /
FUNCTION
Cholesterol 65 dL
TEST
LDL - 111 <1 mg /
urea N 23 8-23 mg / Cholesterol 00 dL
Dl
creatinin 0.9 0.7 to 1.2 mg /
e dL triglycerid 128 <1 mg /
es 50 dL
DATE OF MAY 9 TH, 2019 (URINE
EXAMINATION)
PARAMETER RESULT UNIT
REFERENCE
Urinalisa
Color Yellow

Turbidity Cloudy

specific Gravity 1,005 1003-1035

pH 7.0 4.5 - 8.0

leukocytes negative negative / mL

nitrite negative negative

protein negative negative Mg / dL

glucose Normal Normal Mg / dL

ketone 50 negative Mg / dL

urobilinogen 1 Normal ≤ 1 Mg / dL

Bilirubine negative negative

Blood negative negative / mL

CONTINUE
sedimentation

Leukocytes 1-3 0-5 / LPB

Nitrocytes 0-1 0-2 / LPB

squamous epithelium 4-6 <10 / LPK

Cylinder negative negative / LPB

Crystal negative negative

yeast negative negative

bacteria Positive (+) negative

THERAPY PROGRAM
• Citicoline 2 x 500 gr (IV)
• Sanmol flash 3 x 1000 mg (IV)
• Lovenox 2 x 0,6 mg (SC)
• Vomizole 1 x 40 mg ( IV)
• Merosan 3 x 1 gr (IV)
• Nebul combivent + Pulmicort + bisolvon 12 tetes @6 hours (inhalasi)
• Forneuro 2 x 1 tablet (oral)
• Tramadol 2 x 100 mg (IV)
• Lyrica 75mg 2 x 1 tablet (oral)
• Lodomer 2 mg 1 x 1 tablet (oral)
• Valsartan 80 mg 1 x 1 tablet (oral)
• PCA 25 mg/50 cc
 DATA ANALYSIS
Data Focus analysis Problem

DS: Lack of exercise Acute pain

Patients report pain in the left leg
P: The patient said that the pain arises if the foot Slowing of blood flow in veins
is moved.
Q: The patient said that the pain such as tingling Hypercoagulable
R: Patients report pain in the left leg
S: Patients report pain scale 6 (0-10) Thrombus
Q: The pain is continuous.
Deep Vein Thrombosis
DO:
Patients seemed to grimace and restless. Acute pain
TD: 130/80 mmHg
Temperature: 36,8º C
Nadi: 90 x / minute
RR: 20 x / min
DS: Pencidera agent physiological (Deep Physical Mobility Disorders
Patients say the pain while moving, Vein Thrombosis)
reluctant to perform the movement.
Edema
DO:
Patient's muscle strength declines pain receptors
555 555
555 444 pain perception
Patients seemed limited in doing
movement acute pain

Impaired physical mobility

DS: History falls risk of Falling
Patients say require assistance in the
move. Hipertension

DO: Intracranial Increased

-Patients had fallen when dihotel
-Patients aged 62 years Lost of consciousness
-Patients are assisted in part in mobility
-Patients are fully assisted in ADL (Activity Deep Vein Thrombosis at left leg
Daily Living)
-Patients received antihypertensive Edema
treatment
-Patients having non hemorrhagic stroke Pain when moving (stad up and walk)

Body balance disorders

Risk of falling
NURSING DIAGNOSIS AND PRIORITY ISSUES

1. Acute pain associated with physiological pencidera agent (ischemia) is characterized by patients said
pain occur when the foot is moved, the pain such as tingling, pain is felt on the left leg, a pain scale 6
(0-10), pain is persistent, patients seem to wince and agitated, BP: 130/80 mmHg, temperature: 36.8
℃, Nadi: 84 x / min, RR: 20 x / min.
2. Physical mobility impairments associated with pain characterized by pain when moving the patient
says, reluctant to move, muscle strength decreased patient 5 5 5 5 5 5, the patient appears to be
limited in doing movemen 555 444
3. The risk of falling associated with a history of falls.
NURSING PLANNING
N Aim Intervention Rational
N
O

1 After nursing intervention for 4 x 24 pain management 1. To determine the quality of a patient's
hours, the level of pain decreased, with the Observation pain
criteria Results: 1. Identify the location, characteristics, duration, 2. To determine the patient's pain scale
1. Complaints of pain decreases frequency, quality, intensity of pain 3. To determine the non-verbal response
2. grimacing decline 2. Identify the pain scale perceived as pain arising
3. Decreased protective attitude 3. Identification of non-verbal response to pain 4. That families know the side effects of
4. agitated decline 4. Monitor side effects from use of analgesics the use of analgesic drugs
5. Improved pulse frequency: Education 5. Provide comfort and relieve pain
 Adults (60-100 beats / min) 5. Teach nonpharmacologic techniques to 6. Helps reduce pain
6. Improved breathing pattern: reduce pain
 Adults (12-20 breaths / min) Collaboration
7. Improved blood pressure: 6. Collaboration analgetik
 Systolic: 100-140 mmHg
 Diastolic <85 mmHg
 PLANING OF PHYSICAL MOBILITY DISORDERS

2 After nursing intervention for 4 x 24 hours, Mobilization Support 1. To determine the characteristics of the
then the Physical Mobility increased, with Observation patient's perceived pain
expected outcomes: 1. Identification of any pain or other physical 2. Mengatahui movement of patients
1. Increased limb movement complaints 3. Given the level of fatigue and the ability to
2. Increased muscle strength 2. Identification of physical tolerance-movement mobilize patients
3. Range of motion (ROM) increased 3. Monitor the general conditions for mobilizing 4. Keep patients from falling
4. pain decreased Therapeutic 5. To assist patients in performing the
5. anxiety decreased 4. Facilitating mobilization activities with the tool movement
6. Stiffness decreases (eg. Rail bed) 6. So that patients know how and
7. Limited movement decreases 5. Facilitation doing the movement, if necessary mobilization purposes
8. Decreased physical weakness Education 7. Coaching mobilization and independence
6. Explain the purpose and mobilization procedures of patients
7. Encourage early mobilization
 PLANNING OF RISK OF FALLING

3 After nursing intervention for 4 x 24 hours, prevention of falls 1. To prevent the incidence of falls in
then the rate of falls decreased with expected Observation patients
outcomes: 1. Identification of risk factors for falls at least 2. To determine the patient's environment
1. Falling out of bed decreases once every shift that can increase the risk of falls
2. Fall while sitting downhill 2. Identification of environmental factors that 3. So that the patient does not fall
3. Fall when moved downhill increase the risk of falls 4. So that the patient does not fall
Therapeutic 5. To speed up the action when it happens
3. Make sure the bed is always locked wheels to fall
4. Replace hand roll bed 6. Allowing the patient to call a nurse if
5. Place the patient at risk of falling close to the you need help
nurse nurses station 7. To help mobilize so as not to fall
6. Bring the patient call bell within reach 8. In order to know the patient and
Education allowing the patient to call a nurse
7. Instruct the nurse call if they needed help to
move
8. Teach how to use the call bell for the nurse
 IMPLEMENTATION

TOLONG DIHYPERLINK IN YA GAESS.. DI

LAPTOPKU GA MAU
EVALUATION
No Date / hour Responses Initials

1. May 10th, 2019 S:

13:00 pm - Patients report reduced pain
- P: Patients say the pain is reduced if the foot is moved
Q: Patients say prickling pain is reduced
R: Patients report decreased pain in the left leg
S: Patients report pain scale of 5 (0-10)
Q: Pain arises at any time
O:
- Patient looks comfortable not grimacing
- Patient calm not nervous
- TTV:
BP: 140/80 mmHg
N: 72 x / min
R: 24 x / min
S: 36.6ºC
A: Acute pain resolved in part
P: Keep the patient's condition
CONTINUE
2. May 10th, 2019 S:
13:00 pm - The patint said he was able to move independently
- The patient said he was able to move his legs because the pain he felt was not disturbing
- Patients said they understood the importance of mobilization
O
- Increased muscle strength 555 555
555 555
- Patients seem able to mobilize
- Active patient without restriction
- The patient is able to move his left leg
- Patient are able to move independently
- Patient are able to go to the bathroom independently
- The patient does not grimace while moving
A:
Impaired physical mobility resolved
P:
Keep the patient's condition
CONTINUE
3. May 10th, 2019 S:
13:00 pm - The patient said he never fell while being treated in the hospital
- The patient says feel safe

O:
- The patient did not fall from the bed
- The patient did not fall while sitting
- The patient did not fall while moving
- The patient bed handroll is always attached

A:
the risk of falling does not occur
the risk of falling resolved

P:
Keep the patient's condition