askep utek anemia

7/29/2019 ASKEP UTEK anemia

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I. Client Identitiy

Name : Mr. S

Age : 68 years oldTrible/nation : Banjarise Indonesia

Religion : Muslim

Educatoin : Junior high school

Medical record number : 1062719

Address : Kelayan B

Occupation : Private goverment

Enterance date : Augustus 26 2013

Assessment date : Augustus 29 2013

Medical diagnose : Anemia

II. The next of kind

Name : Mr. R

Sex : Male

Age : 36 year old

Addres : Kelayan B

Relationship with client : Children

III. Health History

A. Main Complaint:When assessment client said that he feel weakness and breathing shorrness and can.tsleep and disturbance for swallowing

B. Health History Of Current DiseaseWhen assessment client said that before he enter the ulin general hospital he feelfatigue and weakness and sometimes breathing shortness that condition make he

disturbance for do activity. Remember that condition he after a few days he feel that


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of body condition is not recovery client finally decided to check herself in the hospital

after getting the results of the examination client said that he suffered of anemia andget suggested from docter for hospitalization for get a treatment and recover from he

disease

C.

Health History Of Previous

Client said that saince 3 year ago he was when do devicate sometime that feces

mixced with blood the colour feces is black and after do devicate he feel that bodyweaknees

D. Family Health HistoryClient said that in the family never was suffered like he disease like he suffered right

now

IV. 1. Phyisical Examination

A. General Condition And ConciousnessClient looked weaknees and just lie down and sit down on the bad cient conciousnessis was composmenthis with gcs 4, 5, 5

Information:

Eyes : 4 eyes open response spontaneous

Verbal : 5 verbal response good can introduce / Orientation

Morotic response : 5 motor response can follow order but no to have energy

B. Vital signs:Blood Pressure :110/80mmHg Respiration : 28x/minutePulse : 68X/minute Temperature : 36,8.C

C. Antropometrik DataBody Weight : 48.kg Ideal Body Weight : 43.kg

Body Hight : 160.cm Body Maximum Ideal : 45.kg

2. Skin

Client skin white texture is a bit abrosive but there looked cynosis of the skin nolooked lesions on the skins. Skin turgor no looked edema while in the press back (-) 2

second there looked little dirt on the skin. Body temerature is 36,8c whilemeasurement using digital thermometer and when do palapation the client skin feel

warm


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3. Head And NeckStructure of the head and neack are symmetric. In the head there is no trauma, lession,

and lumps. The color hair white and blac, distribution hair is good. In the neck there isno enlargement of the thyroid gland and lymph nodes, normal neck movement

4. vision And EyeStructure of the eye is symmectric between left and right. The eyeball could be movedin any direction, there is looked dark circles around the eyes, amd conjunctiva anemis,

and client did not use glasses. Client can not see name tag 2 meter, visus client can see

2 meter.

5. Olfactory and nose

Structure of the nose is symmectric. There is no use nasal canula in the nose, no blood

out of the nose. Client can distinguish a either the smell of perfume and alcohol, client

had no complaint about olfactory problem

6. Hearing and ear

Structure of the ear is symmectric between right and lift. Client does not use hering aid,

client can be heard talking around client, and client can heard what nurse instruction.

Client had no complaint about hearing, in the ear ther is no lession, trauma, massa, and

blood.

7. Mouth and theeth

Structure of the mouth and theeth are symmectric. teeth client looked clean, there is

no inflammation. Lip mokus is good, in lip is no stomatitis, palatum is redness, and

client do not use dentures.

8. Chest, breathing, and circulation

Structure of the chest is symmectric. Client is 24 times/minute, tactil premetus is

normal when palpation, the sound sonor when percussion, when auscultation is sound

visikuler. Client do not use oxygen, in the chest there is no inflammation, edema,

lession, and trauma


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9. Heart and ciculation

Inspection : heart spead is normal

Palpation : The heart sound dim

Auscultatio : The heart sound is S1, S2, and S3 is no

addional heart. Circulation priphal blood perfussion to the fast.

10. Abdomen

Inspection : General state abdomen looked clean no lession and trauma,

shape normal breathing movement

Auscultatio : Perictaltic intestine 6/ minute

Palpation : Skin turgur back in 2 second, there is no tendress in hepar

Percussion : The sound is timpany

11. Genetalia and reproduction

Client is male. 60 years old was marreid and have 1 children, client looked no use

cateter and pempres to elimination. Client there is no complaint about genetalia and

reproduction.

12. Upper and lower extremitiesStructure of the upper and lower extremities are good. In lower extremities in right use

infuse Nacl, join movement in upper and lower extremities are abnormal because guot,

the client said there is limition of motion because gout, client said that pain in lower

right and lift because gout since 1 year ago. Still weak, client do its own mobility whit

muscle scale :

4444 4444 0 : Paralysis total

1 : Movement palpable or visible muscle contraction

4444 4444 2 : Full muscle movement against gravity and endorsement

3 : Normal movement against gravity and endorsement

4 : Normal movement against gravity whit little resistance

5 : Full normal movement against gravity whit full eustady


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V. Need physical, psychological, scocial, and spiritual

1. Activity and rest

At home : Activity at home is not heavy. Client can sleep 7 until hours. Client

said that sometimes help by his family do activity

At hospital : Clien said that just laying on the bed for rest, activity not to heavy

and client said that activity help by clients family. And said he cant sleep because

light to brighter, client said that he sleep 2-3 hour at night client scale activity is 3

0 : Unable to care for them selves in full

1 : Require tools

2 : Require assistance, or supervision of another person

3 : Require assistance, monitor and supervision of another

4 : Very dependent and unableto perfrom or practipaeta intreatment

2. Personal Hygine

At home : Client said that he took a bath two times / day at home, used shampoo

once every two days, brushed her teeth after a meal, client said that the nail food

and hand are restong since 1 years ago

At hospital : Client said that just swabbed by her son twice a day.

3. Nutrition

At home : Client said that eat 3 a day, client said that have food allergies like

beans, abbage, belinjo, and water spinach because have gout. Drink water 8

glasses a day

At hospital : Client said that cant eat because any stomatitis in the tongue client

just eat of spood


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4. Elimination

At home : Client said that defecation 1 a day, and urinate 46 a day

At hospital : Client said that to day defecation is never 1 a day, and urinate 3 a

day

5. Sexuality

Client is male 60 years old. Client was marreid and have 2 children

6. Psychosocial

Client relationship is harmonious, many families that come to visit. Relationship

whit nurse, doctor and medical team looked good

7. Spiritual

Client is a moslem, client and family alwasy pray to Allah SWT hope fully speady

recovery from disease.


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VI. Focus data

Subjective date

Client said that he feel weakness

Client said that he cant sleep because light to brighter

Client said tat e cant swallowing te food

Client said that he just eat spood of food

Client said that he cant do personal hygiene idependenly

Client said that e activity helped by famly

client said that he sleep 2-3 hour at night

Objective data

inspection

Client HB 2,9

Client lekosit 93,2

Looked client cant do activity independenly

Looked client just lie down on te bad

Looked client breathing sortness

Looked stomatitis on the client tongue

Additional data

BP: 110/80mmHg RR: 26X/Minute

P: 68x/minute T : 36,8c

Looked black cycle under client eyes and anemis


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looked cynosis of the client skin

looked client sleeply wen morning

looked stomatitis on te client tongue

looked client just can eat slightly

looked there is dirt on the client body

looked client just lie down on te bad

VII. Diagnostic examination

Laboratorium examination on august 26 2013

Parameter Result Limit

Hemoglobin 2,9 14,0018,00

Leucosit 93,2 4,010,5

Eritrosit 2,95 4,506,00

Hematokrit 21,9 42,0052,00

Trombosit 358 150450

RdwRcv 13,6 11,514,7

Mcv 74,3 80,097,0

Mch 26,4 27,032,0

Mchc 34,3 32,038,0

Gran % 83,7 50,070,0

Limfosit % 4,9 25,040,0

Mid % 6,7 4,011,0

Gran # 11,87 2,507,00

Limfosit # 4,9 1,254,0

Mid # 0,9

SI 55 55175

TIBC 350 300400STI 35 20 - 45


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VIIII. Therapy farmokology

Nam

e

Medicine Type Dose Time

M E N

Mr. s LasixCefriaxone

Infuse Nacl

Blood transfustion

DiureticAntibiotic

elektrolite

1x1 amp1x1 amp

20 minute

08.0008.00

08.00

11.00

12.0012.00

12.00

21.0021.00

21.00

IX . Analysis data

No Data Problem Etiology

1.

2.

3.

-Subjective data:-Client said that he feel weakness

Objective date:

-Client HB 2,9

-Client lekosit 93,2

l-ooked cynosis of the client skin

Subjective data:

-Client said that e activity helped by

famly-Client said that he feel weakness

Objective data:

-looked client just lie down on te bad-Looked client cant do activityindependenly

subjective data-Client said tat e cant swallowing te

food

-Client said that he just eat spoodof food

IneffectiveTissue

perfussion

Activity

Intolerance

Inbalence

nutrition lees

than bodyrequement

In adequate oxygenRequement body

need

General weakness

Swallowing disoder


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4.

5.

Objective data:-Looked stomatitis on the client

tongue

-looked client just can eat slightly

Subjective data:-Client said that he cant sleepbecause light to brighter

-client said that he sleep 2-3 hour at

night

Objective data :

-Looked black cycle under client eyes

and anemis

-looked client sleeply wen morning

Subjective data:

-Client said that he cant do personalhygiene idependenly

-Client said that e activity helped by

famly

Objective data-looked there is dirt on the clientbody

Insomia

Deficit ofpersonal

hygiene self

care bating

Hospitalization

weakness

X. Problem Periorty

1) Ineffective tissue perfussion related to inaequat oxygen requement body need2) Activity intolerance relate to general weakness3)

Inbalance nutrition less than body requement related to swallowing disoder4) Insomnia related to hospitalization

5) Deficit personal hygeiene self care bating related to weakness


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XI. Intervention

No Nursing diagnose Goal Intervention Rasional

1.

2.

Ineffective tissueperfussion relatedto inaequat oxygen

requement body

need

Subjective data:

-Client said that he

feel weakness

Objective date:

-Client HB 2,9-Client lekosit 93,2

l-ooked cynosis of

the client skin

looked clientsometimes breating

shortness

Activity intolerancerelated to general

weakness

Subjective data:-Client said that e

activity helped by

famly

-Client said that hefeel weakness

Objective data:-looked client just

lie down on te bad

-Looked client cantdo activity

After donusing action1x24 hour

expected

ineffectivetissue

perfusion can

be resoved

with outcome:

-Client saidthat e not feel

weakness

agains

-Client HB

14,0018,00

Client lekosit4,010,5

No looked

cynosis in te

client skin

After doNusing action

1x24 hour

expected

activityintolerance

can be

resloved

without come:

-client said he

cant doactivity witout

helped

by family

1).examine ofcause ineffectivetissue perfussion

on the client

2 set client

position semi

fowler

3).pullpilled

oxygen on theclient body need

4).set thepetilizaton of air

on te client room

5).Set fluid intake

the body needs

1).Examine causeof activity

intolerance

2).provide clienteat food that many

carbohydrate

3).Encourageclient rest more

4).Provide clientfood high iron

substance

5).give blood

1). for easydetermine nextintervention

2).smooth the the

entry of oxygen in

to the body

3).for comply

oxygen body need

4).to maximun of02 in air on the

client room

5).optimize the

balance of O2

status in the client

body

1).for easydetermine next

intervention

2).for make clienthave energy do

Activity

3).for collect client

energy

4).fullpiled client

evenue base

material ofhemoglobin


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.

3.

4.

Independently

inbalance nutrition

less than body

requement related

to swallowing

disoder

subjective data-Client said tat he

cant swallowing te

food-Client said that he

just eat spood of

food

Objective data:

-Looked stomatitison the client tongue-looked client just

can eat slightly

Insomnia related to

hospitalization

Subjective data:-Client said that he

cant sleep because

light to brighter-client said that he

sleep 2-3 hour at

night

-clint said he

feel energyfor do

activity

looked clientcan walking

looked clientcan do activty

independently

After do

Nusing action

1x24 hour

expected

inbalancenutrition

can beresolved with

out come:

-client said

that he can

swallowing

food

-client said hecan eat allfood portion

-no looked

stomatitis onthe client

tongue

After do

Nusing action

1 x shift

expectedinsomnia

can be

resolved without come

client said that

transfusion

1).examine cause

of inbalance

nutrition

2)ecorage clienteat slightly but

often

3).give client foodwarm

4).help client on

oral ygiene

5).give client foodhigh nutrition andvitamin

1).Examine cause

of insomenia on

the client

2).explaint to the

client inportance

sleep for heality

3).position client

5).increase of

hemoglobin on theclient bloodfor

binds nutrition in

the blood

1).for easy

determine nex

intervention

2).maxsimalizefulpiled nutrition on

the client body needin slowlly

3).to improve clienttest

4). Give frest felling

On the clint mouth

5).For increaseclient imunesystem

1).For easy

determine next

intervention

2).for client

understand about

very infortancesleep for heality

3).for provide client


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5.

Objective data :

-Looked black cycleunder client eyes and

anemis

-looked client

sleeply wenmorning

Deficit personal

hygeiene self care

bating related to

weakness

Subjective data:-Client said that he

cant do personal

hygiene idependenly-Client said that e

activity helped by

famly

Objective data-looked there is dirton the client body

he can sleep

at night clientsaid he

can sleep 6-7

hour

no looked

black cycleunder client

eyes and

anemis

After do

Nusing action

1 x shift

Expecteddeficit

personalhygiene can

be resloved

with outcome:

client said that

he can dopersonal

hygieneindependenlyclient said that

he can do

activity

withouthelped with

he family

no looked

there is dirt

on the client

body

as a comfortable

when try to sleep

4). Set ambiance a

quet environtment

5).set client roomtemperature

1).Examine te

cause of deficit of

personal hygiene

2).helped client on

the body personalygiene her self

3).do secking onthe client 1-2

times a day

4).Encourageclient

family for helpclient on clientpersonal hygiene

5).change the

client shirt andblacked 1 time a

day

comfotable wen

sleep

4)for give client

quetness when

sleep

5).for make clientnot dhydration

when sleep

1).for easy

determine

next intervention

3).to easy client on

do body personalygiene

3).for maintainclient body of

hygiene

4).maximilizefullpiled personal

hygiene on theclient body

5).give comfortabe

end fiiled clean on

theclient


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XIII. Implementation and evaluation

No Time No Diagnose Implementation

with nursing actionevaluation

Evaluation

1. 08.00

08.10

08.15

09.00

09.00

I 1).assessing ofcause ineffective

tissue perfussion

on the client

E because

Client HB 2,9

-Client lekosit 93,2

2).setting client

position semifowler

E: Client said that e feel

comfortable with thisposttion because easy for

brearthing

3).pullpiling oxygen on

The client body need

E: looked client no use

asesory muscle for

brething

4).setting the

petilizaton of airon te client room

E:loeeked client feel

comfort when brthing

5).Setting fluid intake

the body

S: Client said that e feelcomfortable with this

posttion because easy for

brearthing

O: looked client no use

asesory muscle for

brething

A: ineffective tissue

Perfussion has beenresolved

P: Stop intervention


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2. 09.10

09.33

09.35

09.37

09.40

II 1).assessing cause of

activity intolerance

E: bcause supply

nutrition no maximalize

on the client body

2).providing client eatfood that manycarbohydrate and

nutrition

E looked client eat

carbohydrate food

3)suggesting client rest

more

E: client said that he justlie down and shit down

one te band

4).Providing client food

high iron substance

E;looked client eat foodhight iron sbstance

5).giving bloodtransfusion

E:Client HB begin

increase Client HB 10,9Client lekosit 93,6

S: client said that he just

lie down and shit downone te band because still

feel weakness for o

activity independenly

O: looked client just liedown and shit down one

te band

A : activity intoleranceHas been not resoved

P: countinue intervetion

by nurse ward

-providing client eat food

that manycarbohydrateand nutrition

-Providing client foodhigh iron substance

-giving blood transfusion

acrding doctor instrution


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3. 09.45

10.00

10.12

10.18

10.20

III 1).asessing cause of

inbalance nutrition

E:because on the client

tongue any stomatitis

2)suggesting client

eat slightly butoften

E: looked client eat

slightly butoften

3).giving client food

Warm

E:client said he have

Appetae for eating warmfood

4).helping client onoral ygiene

E: Client said he feel

Frest after get oralHygiene

5).giving client food highnutrition and vitamin

E: client said he feel have

little energy for doactivity

S: client said he have

appetae for eat warmfood

O: looked client

eat slightly butoften after give warm

food

A: inbalance nutrition

problem part has

been resolved

P: countinue intervetion

by nurse ward

-giving client food

Warm

-helping client on

oral ygiene

-giving client food high

nutrition and vitamin


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4. 10.21

10.23

10.25

10.30

10.32

IV. 1).Assessing cause of

insomenia on the client

E: Client said that he

cant sleep because

light to brighter

2).explaint to the client

inportance sleep for

heality

E: client said he

understand with nurse

explain

3).positioning client as a

comfortable when try tosleep

E: looke client cmfortwhen try to sleep

4). Setting ambiance a

quet environtment

E:Client said e feel calmwhen try to sleep

5).setting client room

temperature

E: Client said he not feel

hot when sleep

S: Client said he can

sleep comfortble andcalm

O:looked client comfort

when sleep

A: InsomeniaHas been resolved

P: Stop intervention


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5 10.35

10.37

10.40

10.50

11.00

V. 1).Assessing the

cause of deficit ofpersonal hygiene

E:because client feel

weakness for do activty

2).helpeing client on thebody personal ygiene her

self

E: client said he feel frestafter get personal

hygiene rom nurse

3).do secking on

the client 1-2times a day

E: looked client bod

y clean

4).suggesting client

family for help

client on client

personal hygiene

E: looked client familiyCollaborative in helpclient on personal

hygiene

5).changing theclient shirt and

blacked 1 time a

day

E: looked client shirt is

clean

S: Client said he feel

frest after get personalhygiene from nurse

O: looked client body is

ClientLooked client family

collabortive in helpclient on do personal

hygiene

A: problem has beenresolved

p: stop intervention


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askep utek anemia

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