.

ASSESSMENT

1.1 IDENTITY

1.1.1 IDENTITY OF PATIENTS

Name : Mr. R

Gender : Male

Age : 58 years

Address : Central MambulauAnjir

Education : MTsN

Occupation : Private

Marital Status : Married

Religion :Islam

Tribe / Nation : Banjar / Indonesia

Dates RS : January 25th , 2017

Medical Diagnosis : Pulmonary Tuberculosis

No. Medical Records : 33xxxx

Assessment Date : January 29th , 2017

1.1.2 IDENTITY OF RESPONSIBLE

Name : Mr. D

Gender : Male

Age : 26 Years

Occupation : Private

Address : Central MambulauAnjir

Relationships with client : Son

Genogram :

Note :
Death

Man

Woman

Patient

Married
1.2 HEALTH HISTORY

1.2.1 Main Complaint

When do the assessment on January 29th, 2017, the client says cough with secretion, shortness of
breathing, fever and tightness in the chest. The client says no appetite. The Client says can not
sleep because of coughing and shivering.

1.2.2 History of Current Disease

Before being treated in hospitals dr. H. Moch. Ansari Saleh of Banjarmasin client could go to the
hospital of Kapuas. Previous, client experiencing severe cough, shortness of breath and body feel
chills while performing Umrah and the pain is worse when he was in Jeddah on their way home to
Jakarta. when he got in Jakarta, the client can not deal with the condition that his wife reported to
his group supervisor that he was sick. At Jakarta airport client was invited to check in the clinic
who provided first aid. After the clinic at the airport, when they arrived in Banjarmasin he
returned to the Kapuas hospital check because he feels a cough and fever that does not heal.
Because client do not feel kindness also, the client asks to be referred to dr. H. Moch Ansari Saleh
of Banjarmasin through the Emergency Room, and then after the client referred to hospitals
examined in the Emergency Room and placed into Zambrud ward for further care.

1.2.3 History of Previous Disease

Clients say have a history of asthma and Maag

1.2.4 History of family health

Clients said the family had not had that suffer from hypertension and tuberculosis as clients, but
on Alh. Dad clients asthma.

1.3 PHYSICAL EXAMINATION

1.3.1 General condition

Awareness: comfos mentis

GCS: E4 V5 M6

Client looks weak

TTV: BP: 80 / 60mmHg T: 39 C R: 20x / min N: 97x / min

Height: 165cm Weight: 65kg

BBI (TB-100) 10% (TB-100) = (165-100) 10% (165-100) = (65) 10% (65) = 65 6.5

= 65 to 6.5 = 58.5
 = 65 + 6.5 = 71.5

BBI = 58.5 to 71.5 Kg

1.3.2 Skin

The client's skin tan, felt moist, there is no open wounds, no tumor or lump, turgor back in 2
seconds.

1.3.3 Head and neck

Head shape looks symmetrical, distribution hair sparse and gray, no lumps, state heads and neck
fairly clean, no injuries / lesions, there is no limitation of motion, nonexistent enlargement jugular
vein, thyroid gland and lymph nodes, palpation touching carotid artery pulsed balanced.

1.3.4 Vision and eye

Symmetrical structure of the eye, the conjunctiva looks anemic. Sclera not icteric. There is no
secret in the eye. No lesions or inflammation of the eye. Isokhor pupillary reflex.Pupillary
reactions quickly when given the light. Symmetrical pupil diameter of 2 mm. visual function less
well marked by the client is not clearly in view the article nurses ID Card and had to be helped
with glasses -250.

1.3.5 Smell and nose

Symmetrical structure of the nose. There are no respiratory nostril. There are no polyps in the
nostrils. Either olfactory function marked the client is able to distinguish the smell of food and
eucalyptus oil.

1.3.6 Hearing and ear

Symmetrically left and right ears. Do not look any excess wax in the ear. Good hearing is well
marked the client nurses can answer questions correctly.

1.3.7 Mouth and teeth

Structure symmetrical lips. Teeth looked clean. Lips looked dry. The function of chewing,
swallowing and taste good. There is no inflammation of the gums and inside the mouth.

1.3.8 Chest, breathing

At the time of the inspection performed on the client, the chest looks symmetrical, shape and
posture of normal breast, skin color chest together with other skin color. Not visible cyanosis. No
edema and chest movement symmetrical. No tenderness on palpation chest, tactilpremitus not
balanced in the upper left lobe.when percussion time sounded dull on the upper left lobe and
auscultation sound Ronchi on the upper left lobe.

1.3.9 Chest and Circulation

At the time of inspection ictus cordis does not appear, fingertip pink, lip mucosa dry. no
tenderness on palpation. On examination of the percussion is not visible enlargement of the heart.
Auscultation of S1 and S2 single.

1.3.10 abdomen

At the time of the inspection there was no tension, inflammation, lesions, or sores. auskultation to
the gut, intestine peristaltis 10 times per minute. On examination of percussion, tympani sound in
+ +
the abdomen ( )
+ +
At the time of palpation, no palpable lump and tenderness.Skin turgor back in 2 seconds.

1.3.11 Genitalia and reproductive

Clients sex is male. Clients do not use diapers and catheters.

1.3.12 Upper and lower extremities

Upper and lower extremity structure looks symmetrical. Acral palpable warm.Installed IVFD RL
12dpm on the right upper extremity.The movement of upper and lower extremities no interference.

Muscle strength scale: 5555 5555

5555 5555

Muscles scale Description:

0: parilisis total

1: no movement, palpable / visible muscle contraction.

2: full muscle movement against gravity with support.

3: the full normal movement against gravity but can not resist arrest examiner muscle.

4: the full normal gravity-defying moves with little containment

5: the full normal movement, defying gravity with full containment.

1.4 NEED FOR PHYSICAL, PSYCHOLOGICAL, SOCIAL AND SPIRITUAL

1.4.1 Activities and exercises

At home: the client and the wife said client activity usually at home every morning to go to the
rubber plantation.

In the Hospital: clients do not do strenuous activity, client just sat up in bed or lying down.

The scale of activity: 2

Description scale of activity:

0: able to care for themselves in full

1: requires the use of tools

2: need help and supervision of others

3: need assistance, supervision of others, and equipment

4: very dependent and may not conduct or participate in treatment

1.4.2 Rest and sleep

At home: a break from the gardens client after about 3 hours later into the garden again until Asr
prayer time. Clients usually going to bed at 09:30 pm and woke up at 05.00 a.m

In the Hospital: clients can not sleep because coughing shivering. During the day, clients sleep
one or two hours. While at night, 5-6 hours and did not sleep well, because often woke
up because of the heat and cough.

1.4.3 Personal hygiene

In the house: 3 time daily bath client. Wash every day. Brush your teeth twice a day. Cut the nail
if necessary.

In the Hospital: client shower twice a day. Wash every day. Brush your teeth twice a day. Cut the
nail if necessary with the assistance of his wife.

1.4.4 Nutrition

At home: client eat time / day with a side dish of fish, vegetables and rice. Client are allergic to
fish, chicken, eggs, chicken and catfish
In the hospital: follow a diet in the hospital, client say no appetite, can finish 3 table of spoon of
diet

1.4.5 Elimination

At home: bowel 2-3 times / day and bladder 7 times / day

In the hospital: bowel twice / day and bladder 6 times / day

1.4.6 Sexuality

Clients gender is male, has a wife and has three children.

1.4.7 Psychosocial

Client relationship with the family was nice and friendly to the people around, and medical
personnel.

1.4.8 Spiritual

A Muslim client, the client pray at times when lying on a mattress or semi-Fowler. Client always
prayed that the disease is cured

1.5 DATA FOCUS

1.5.1 Subjective data

- Client say cough with secretion

- Client says fever
- Client says tightness in the chest
- Client says no appetite
- Client says can not sleep because of coughing and shivering

1.5.2 Objective data

inspection:

- Client seen coughing

- Client looks sitting against the wall
- Client looks weak
- Client often looks set deep breath
- TTV: BP: 80/60 mmHg
 N: 97 x / m

R: 20 x / m

T: 39 C

- Height: 165 cm Weight: 65 kg BBI: 58.5 to 71.5 Kg (Ideal)

- Muscles Scale: Scale 5555 5555 activities scale: 2

5555 5555

Palpation : Tactile fremitus not balance

Percussion : Sound dull on the upper left lobe

Auscultation : Sound ronchi on the left upper lobe

In Abdomen: Intestine Peristalsis 10 time / minute

1.1 Supporting Examination

Serology Immunology Examination: January 29, 2017

- HBsAg Card: negative

Sputum examination: January 28, 2017

Sputum Specimen Result

A (In time) Negative
B (Morning) Negative
C (In time) Negative
Conclusion: inactive TB

Laboratory examination: January 26, 2017

Parameter Result Reference value

WBC 17.5 x 10^3/uL 4.0 10.0
HGB 9.2 g/dL 13.0 16.0
MCV 89.1 fL 82.0 95.0
MCH 29.2 pg 27.0 31.0
PLT 331 x 10^3/uL 150 450
Examination of Clinical Chemistry: January 26, 2017

Parameter Metode Result NilaiRujukan

Blood Glucose Random GOD-PAP Test 104 mg/dl Dws 76 120.0
Blood Urea Kinetics UV Test 13.3 mg/dl 10.0 50.0 mg/dl
Creatinine Jaffe Reaction 1.2 mg/dl Lk 0.7 1.2 mg/dl
Aspartat Transaminase IFCC Opt. 37C 91 U/L Lk 10 37 U/L
(GOT)
Alanine Transaminase IFCC Opt. 37C 87 U/L Lk 12 40 U/L
(GPT)
Bilirubin Total Jendrassik Groff 1.2 mg/dl Up to 1.00 mg/dl
Bilirubin Direct SchellongWene 0.2 mg/dl Up to 0.25 mg/dl
Bilirubin Indirect Jend-Schellong 1.0 mg/dl Up to 0.75 mg/dl

1.2 Therapy pharmacology

Inf. RL500 15tpm

Inf. AminofusinHepar 20tpm

Lesichole 3x1

PCT 500 mg 3x1

HE (300/750) 1x1

Hepa-Q 3x1

Ranitidine inj 2x1 amp (06.00 & 18.00)

Cefixime 2x1 tab (06.00, 12.00, 18.00)

Codein 3x1 tab (06.00, 12.00, 18.00)

Rifampisin 1x3 tab (06.00)

INH 1x3 tab (06.00)

PZA 1x3 tab (06.00)

Etambutol 1x3 tab (06.00)

2. ANALISA DATA
Data Masalah Etiologi
DS: Ineffective airway clearence Secret accumalation in the
- Client complain of shortness of (Nurarif, 2015) airway
breathing
- The client complained of cough
with secretion

DO:
- Client looks weak
- The sound of breath ronkhi
- The existence of a mass in the
chest or deaf
- Awareness: Compos mentis.
GCS: E4 V5 M6
- TTV:
BP: 80/60 mmHg
Q: 39oC
R: 20x / min
N: 97 x / minute
- HB: 9.2 g / Dl
DS: The client complained of Hypertermi infection process of
fever (Nurarif, 2015) Mycobacterium Tuberculosis
DO:
- Client seen shivering
- Client looks using warm
compresses
- Client looks sweaty
- When touched, the client's skin
felt hot, wet heat palpable akral
- Temperature client: 39C
- WBC = 17.5 x 10^3/uL
DS: Sleep Pattern disorder Disease Process
Client complain can not sleep (Nurarif, 2015)
nights because of chills and
cough
DO:
- Client looks weak
- Face the client looks wistful
- - Client sleep one or two
hours, By afternoon. at
night, sleep for 5-6 hours
and did not sleep well,
because often woke up
because of the heat and
cough.
DS: The risk of nutrition less than Anorexia
Clients say only eat 3 body requirements
tablespoons of porridge after the (Nurarif, 2015)
client has no appetite
DO:
- Client look weak
- Client look thin

Problem Priority

1. Ineffective airway clearence Related to Secret accumalation in the airway

2. Hypertermi Related to infection process of mycobakterium tuberculosis
3. Sleep Pattern disorder Related to Disease process
 4. The risk of nutrition less than body requirements Related to Anorexia

Nursing Intervention

No Diagnosis Purpose and result Intervention Rational

criteria
1 Ineffectiveness airway Airway clearance 1. Assess respiratory 1. Decreased function
clearance related to back effectively after functions such as of breath may indicate
airway obstruction a given act of nursing sound, speed and an inability to clear
for 3 days with rhythm every day the airway.
expected outcomes:
- Cough slimy 2. Observation of vital 2. Deviations normal
reduced or lost signs every day vital signs indicate a
- Watery secretions change in patient
- Vital signs within status.
normal breaking 3. Adjust the position 3. Position help lung
- Ronchi - / - of the client with semi- expansion and lower
Fowler position every respiratory effort.
time the client was
blown
4. Teach the 4. Maximizing
techniques of breath ventilation and
and cough effectively improve the
at the first meeting movement of
secretions in the
airway big as easily
removed
5. Instruct the patient 5. Train the patient to
to use the technique be able to learn to
effectively every wish cope with a cough
cough cough that happened.
6. Encourage clients to 6. Entry of a lot of
increase fluid intake at fluids to help thin
least 2,500 ml / day secretions.

7. Collaborate give 7. Give medication

medication according regularly speed up the
to doctor's instructions healing process
Inf. RL 500 15 Dpm
Inf. The liver
Aminofusin 20 Dpm
Lesichole 3x1
PCT 500 mg 3x1
HE (300/750) 1x1
Hepa-Q 3x1
Ranitidine inj 2x1 amp
(06:00 & 18:00)
Cefixime 2x1 tab
(06:00, 12:00, 18:00)
3x1 codeine tabs
 (06:00, 12:00, 18:00)
Rifampicin 1x3 tab
(6:00)
INH 1x3 tab (6:00)
PZA 1x3 tab (6:00)
Ethambutol 1x3 tab
(6:00)
Hypertermi Related to After being given a a. Assess the patient's a. Knowing Increased
infection process of 1X7 hour nursing temperature body temperature,
mycobakterium actions expected ease intervention.
tuberculosis body temperature b. Reduce heat with
returned to normal b. Give warm water heat transfer by
with KH: compresses conduction. Warm
The body water control
temperature of 36 Gradually heat
C-37 C transfer without
causing hypothermia
or shivering.
c. Give / instruct the c. To replace fluids
patient to drink plenty lost through
of 1500-2000 cc / day evaporation
(as tolerated)

d. Instruct the patient d. Providing a sense

to wear clothing that is of comfort and Easier
thin and easy to absorb thin clothes that
sweat absorb sweat and does
not stimulate
Increased body
temperature.

e. Observation intake e. Early detection of

and output, vital signs lack of fluids and to
(temperature, pulse, know the fluid and
blood pressure) every electrolyte balance in
three hours or as the body. Vital Signs
indicated is a reference to
Determine the
patient's general
condition.

f. Collaboration: f. Giving fluids is

intravenous fluids and very important for
medication as ordered. Patients with a high
body temperature.
Drugs in particular to
lower the patient's
body heat.
Sleep Pattern disorder After the act of 1. examine the sleep 1. To determine the
Related to Disease nursing for 2 x 24 habits of patients extent of sleep
hours expected of before the illness and disorder sufferers
process patients can rest during illness
optimal night's sleep 2. Observe the effect 2. psychological
with KH = abot - drugs that can disturbances can
1. Reporting rest be suffered by the occur when it can use
optimal night's sleep. client kartifosteroid
2. Not showing including the change
anxious behavior. of mood and uisomnia
3. The face is pale 3. Keep an eye on the 3. To find out what is
and anemic activity of the patient causing a sleep
conjunctiva eye not habits disorder sufferers
because of lack of 4. Encourage clients to 4. Make it easy for
sleep. night. relax at bedtime. clients to be able to
4. maintain (or sleep
establish) sleep 5. Create an 5. Environment and
patterns that provide atmosphere and a comfortable siasana
enough energy to comfortable will facilitate the
undergo daily environment patient to sleep.
activities.
The risk of nutrition less After the act of 1. Record nutrients 1. Useful in defining
than body requirements nursing for 1X7 client at the reception, the degree of the
Related to Anorexia hours Shows clients weight, skin turgor, a problem and the
with improved history of nausea, selection of
nutrition outcomes: vomiting or not appropriate
- Increased BB interventions
- No sign of 2. Supervise the input 2. Handy measuring
malnutrition of food and fluids. the effectiveness of
Keep an eye on nutritional and fluid
expenditures urine, support
sweat Weigh every
day
3. Encourage clients to 3. Maximizing the
eat in small portions nutritional input as
but frequently with energy needs
food

4. Collaboration 4. Provide assistance

nutritionist diet in planning diet with
composition adequate nutrition
Morning: porridge and
eggs,
Lunch: rice, eggs /
fish, vegetables, soup,
fruit,
Afternoon: extra egg,
Tonight: rice, eggs /
fish, vegetables
3. IMPLEMENTATION
No Day/Date Time Diagnosis Implementation
1 Selasa, 31 1 12.00 1. Assess respiratory functions such as
sound, speed and rhythm every day
2017 2. Observation of vital signs every day
3. Adjust the position of the client with
semi-Fowler position every time the
client was blown

I
4. Teach the techniques of breath and
cough effectively at the first meeting
5. Instruct the patient to use the
technique effectively every wish
cough cough
6. Encourage clients to increase fluid
intake at least 2,500 ml / day
7. Collaborate give medication
according to doctor's instructions
Inf. RL 500 15 dpms
Inf. The liver Aminofusin 20 Dpm
Lesichole 3x1
PCT 500 mg 3x1
HE (300/750) 1x1
Hepa-Q 3x1
Ranitidine inj 2x1 amp (06:00 &
18:00)
Cefixime 2x1 tab (06:00, 12:00,
18:00)
3x1 codeine tabs (06:00, 12:00, 18:00)
Rifampicin 1x3 tab (6:00)
INH 1x3 tab (6:00)
PZA 1x3 tab (6:00)
Ethambutol 1x3 tab (6:00)
2 Selasa, 31 1 12.10 a. Assess the patient's temperature
b. Give warm water compresses
2017 c. Give / instruct the patient to drink
plenty of 1500-2000 cc / day (as
tolerated)

II d. Instruct the patient to wear clothing

that is thin and easy to absorb sweat

e. Observation intake and output, vital

signs (temperature, pulse, blood
pressure) every three hours or as
indicated

f. Collaboration: intravenous fluids

and medication as ordered.
3 Selasa, 31 1 12.20 1. Examine the sleep habits of patients
before the illness and during illness
2017

III 2. Observe the effect about - drugs that

can be suffered by the client
3. Keep an eye on the activity of the
patient habits
4. Encourage clients to relax at
bedtime.
5. Create an atmosphere and a
comfortable environment
4 Selasa, 31 1 12.30 1. Record nutrients client at the
reception, weight, skin turgor, a
2017 history of nausea, vomiting or not
2. Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
3. Encourage clients to eat in small
portions but frequently with food

IV
4. Collaboration nutritionist diet
composition
Morning: porridge and eggs,
Lunch: rice, eggs / fish, vegetables,
soup, fruit,
Afternoon: extra egg,
Tonight: rice, eggs / fish, vegetables

4. EVALUATION
No Hari/tanggal Waktu Diagnosa Evaluasi
1 Selasa, 31 1 12.00 S:
- Clients complain of shortness of breath
2017
- The client complained of cough with
secretion

O:

I - Client looks weak

- The sound of breath ronkhi
- The existence of a mass in the chest or
deaf
- Awareness: Compos mentis. GCS: E4
V5 M6
- TTV:
BP: 80/60 mmHg
T : 39C
R: 20x / min
N: 97 x / minute
 - HB: 9.2 g / Dl
A: The problem is not resolved
P: continue intervention
- Assess respiratory functions such as
sound, speed and rhythm every day
- Observation of vital signs every day
- Adjust the position of the client with
semi-Fowler position every time the
client was blown
- Collaborate give medication
according to doctor's instructions
a. Inf. RL 500 15 dpm
b. Inf. The liver Aminofusin 20 Dpm
c. Lesichole 3x1
d. PCT 500 mg 3x1
e. HE (300/750) 1x1
f. Hepa-Q 3x1
g. Ranitidine inj 2x1 amp (06:00 &
18:00)
h. Cefixime 2x1 tab (06:00, 12:00,
18:00)
i. Codeine tabs 3x1 (06:00, 12:00,
18:00)
j. Rifampicin 1x3 tab (6:00)
k. INH 1x3 tab (6:00)
l. PZA 1x3 tab (6:00)
m. Ethambutol 1x3 tab (6:00)
Selasa, 31 1 12.10 S: Clients complaining of fever
O:
2017
- Client seen shivering
- Clients look using warm compresses
- Client looks sweaty

II
- When touched, the client's skin felt hot,
wet heat palpable akral
- Temperature client: 39C
A: The problem is not the majority
P: Continue interventions
- Assess the patient's temperature
- Give warm water compresses
- Give / instruct the patient to drink
plenty of 1500-2000 cc / day (as
tolerated)
- Instruct the patient to wear clothing
that is thin and easy to absorb sweat
 - Observation intake and output, vital
signs (temperature, pulse, blood
pressure) every three hours or as
indicated

- Collaboration: intravenous fluids

and medication as ordered.
Selasa, 31 1 12.20 S:
- The client says it can not sleep nights
2017

III because of coughing and shivering

O:
- Clients look weak
- Face the client looks wistful
- Napping: 1-2 hours
- Sleepless nights: 5-6 hours
- Client awakened by coughing and shivering
A: The problem is not resolved
P: Continue interventions
- Examine the sleep habits of patients
before the illness and during illness
- Observe the effect about - drugs that
can be suffered by the client
- Keep an eye on the activity of the
patient habits
Selasa, 31 1 12.30 S:
- Client say they eat with 3 tablespoons of
2017

IV porridge, after the client has no appetite

O:
- Client look weak
- Client look thin
A: The problem is not resolved
P: continue intervention
- Record nutrients client at the
reception, weight, skin turgor, a
history of nausea, vomiting or not
- Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
- Encourage clients to eat in small
 portions but frequently with food
- Collaboration nutritionist diet
composition

5. NOTES PROGRESS
No Hari/tanggal Waktu Diagnosa Evaluasi
1 Rabu, 1 2 - 12.00 I S:
- The client still complain of shortness of
2017
breath
- The client still complain cough with
secretion

O:
- Client looks weak
- The sound of breath ronkhi
- The existence of a mass in the chest or
deaf
- Awareness: Compos mentis. GCS: E4
V5 M6
- TTV:
BP: 110/70 mmHg
Q: 38oC
R: 20x / min
N: 97 x / minute
- HB: 9.2 g / Dl
A: The problem is not resolved
P: continue intervention
- Assess respiratory functions such as
sound, speed and rhythm every day
- Observation of vital signs every day
- Adjust the position of the client with
semi-Fowler position every time the
client was blown
- Collaborate give medication
according to doctor's instructions
a) Inf. RL 500 15 dpm
b) Inf. The liver Aminofusin 20 Dpm
c) Lesichole 3x1
d) PCT 500 mg 3x1
e) HE (300/750) 1x1
f) Hepa-Q 3x1
g) Ranitidine inj 2x1 amp (06:00 &
18:00)
 h) Cefixime 2x1 tab (06:00, 12:00,
18:00)
i) Codeine tabs 3x1 (06:00, 12:00,
18:00)
j) Rifampicin 1x3 tab (6:00)
k) INH 1x3 tab (6:00)
l) PZA 1x3 tab (6:00)
m) Ethambutol 1x3 tab (6:00)
12.10 II S: The client is still complaining of fever
O:
- The client is still visible shiver
- The client is still visible using warm
compresses
- The client is still visible sweat
- When touched, the client's skin felt hot,
wet heat palpable akral
- Temperature client: 38oC
A: The problem is not the majority
P: Continue interventions
- Assess the patient's temperature
- Give warm water compresses
- Give / instruct the patient to drink
plenty of 1500-2000 cc / day (as
tolerated)
- Instruct the patient to wear clothing
that is thin and easy to absorb sweat
- Observation intake and output, vital
signs (temperature, pulse, blood
pressure) every three hours or as
indicated
- Collaboration: intravenous fluids and
medication as ordered.
12.20 III S:
- Clients say they can not sleep nights
because of coughing and shivering
O:
 - Clients still look weak
- Face the client looks wistful
- Napping: 1-2 hours
- Sleepless nights: 5-6 hours
- The client was awakened by coughing and
shivering
A: The problem is not resolved
P: Continue interventions
- Examine the sleep habits of patients
before the illness and during illness
- Observe the effect about - drugs that
can be suffered by the client
- Keep an eye on the activity of the
patient habits
12.30 IV S:
- Clients say they eat with three spoons of
porridge, after the client has no appetite
O:
- The client still looks weak
- Clients look thin
A: The problem is not resolved
P: continue intervention
- Record nutrients client at the
reception, weight, skin turgor, a
history of nausea, vomiting or not
- Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
- Encourage clients to eat in small
portions but frequently with food
- Collaboration nutritionist diet
composition
2 Kamis, 02 08.00 I S:
- The client says it is still short of breath
02 - 2017
- Clients say they cough with secretion

O:
- The client still looks weak
- The sound of breath ronkhi
- The existence of a mass in the chest or
 deaf
- Awareness: Compos mentis. GCS: E4
V5 M6
- TTV:
BP: 100/60 mmHg
Q: 37,6oC
R: 20x / min
N: 97 x / minute
- HB: 9.2 g / Dl
A: The problem is not resolved
P: continue intervention
- Assess respiratory functions such as
sound, speed and rhythm every day
- Observation of vital signs every day
- Adjust the position of the client with
semi-Fowler position every time the
client was blown
- Collaborate give medication
according to doctor's instructions
a. Inf. RL 500 15 dpm
b. Inf. The liver Aminofusin 20 Dpm
c. Lesichole 3x1
d. PCT 500 mg 3x1
e. HE (300/750) 1x1
f. Hepa-Q 3x1
g. Ranitidine inj 2x1 amp (06:00 &
18:00)
h. Cefixime 2x1 tab (06:00, 12:00,
18:00)
i. Codeine tabs 3x1 (06:00, 12:00,
18:00)
j. Rifampicin 1x3 tab (6:00)
k. INH 1x3 tab (6:00)
l. PZA 1x3 tab (6:00)
m. Ethambutol 1x3 tab (6:00)
08.10 II S: The client complained of fever reduced
O:
- Clients are not visible shiver
- The client is still visible using warm
compresses
- The client is still visible sweat
- When touched, the client's skin feels
warm, wet feel warm akral
- Temperature client: 37,6oC
A: The issue is resolved in part
P: Continue interventions
- Assess the patient's temperature
 - Give warm water compresses
- Give / instruct the patient to drink
plenty of 1500-2000 cc / day (as
tolerated)
- Instruct the patient to wear clothing
that is thin and easy to absorb sweat
- Observation intake and output, vital
signs (temperature, pulse, blood
pressure) every three hours or as
indicated
- Collaboration: intravenous fluids and
medication as ordered.
08.20 III S:
- Clients say they can not sleep nights
because of coughing
O:
- Clients still look weak
- Face the client looks wistful
- Napping: 1-2 hours
- Sleepless nights: 5-6 hours
- The client was awakened by coughing
A: The problem is not resolved
P: Continue interventions
- Examine the sleep habits of patients
before the illness and during illness
- Observe the effect about - drugs that
can be suffered by the client
- Keep an eye on the activity of the
patient habits
08.30 IV S:
- Clients say they eat with half of the slurry is
provided, after the client has no appetite
O:
- The client does not look weak
- Clients look thin
A: The problem is resolved
P: continue intervention
- Record nutrients client at the
reception, weight, skin turgor, a
 history of nausea, vomiting or not
- Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
- Encourage clients to eat in small
portions but frequently with food
- Collaboration nutritionist diet
composition
3 Jumat, 03 09.00 I S:
- Clients say shortness of breath decrease
02 2017
- Clients say cough with secretion reduced

O:
- The client does not look weak
- The sound of breath ronkhi
- The existence of a mass in the chest or
deaf
- Awareness: Compos mentis. GCS: E4
V5 M6
- TTV:
BP: 110/80 mmHg
Q: 37,1oC
R: 20x / min
N: 97 x / minute
- HB: 9.2 g / Dl
A: The issue is resolved in part
P: continue intervention
- Assess respiratory functions such as
sound, speed and rhythm every day
- Observation of vital signs every day
- Adjust the position of the client with
semi-Fowler position every time the
client was blown
- Collaborate give medication
according to doctor's instructions
a) Inf. RL 500 15 dpm
b) Inf. The liver Aminofusin 20 Dpm
c) Lesichole 3x1
d) PCT 500 mg 3x1
e) HE (300/750) 1x1
f) Hepa-Q 3x1
g) Ranitidine inj 2x1 amp (06:00 &
18:00)
h) Cefixime 2x1 tab (06:00, 12:00,
18:00)
 i) Codeine tabs 3x1 (06:00, 12:00,
18:00)
j) Rifampicin 1x3 tab (6:00)
k) INH 1x3 tab (6:00)
l) PZA 1x3 tab (6:00)
m) Ethambutol 1x3 tab (6:00)
09.10 II S: Clients say fever is not there
O:
- Clients are not visible shiver
- Clients are not visible using warm
compresses
- The client does not look sweaty
- When touched, the client's skin feels
warm, akral palpable warmth
- Temperature client: 37, 1oC
A: The problem is resolved
P: stop intervention
09.20 III S:
- The client said it was able to sleep the night
because of coughing decreases
O:
- The client does not look weak
- Face the client does not look pale
- Napping: 1-2 hours
- Sleepless nights: 6-7 hours
- Client awakened by cough has been
reduced
A: The issue is resolved in part
P: Continue interventions
- Examine the sleep habits of patients
before the illness and during illness
- Observe the effect about - drugs that
can be suffered by the client
- Keep an eye on the activity of the
patient habits
09.30 IV S:
- Clients say they eat with half of the slurry is
provided, after the client has no appetite
O:
- The client does not look weak
- Clients look thin
A: The problem is resolved
P: continue intervention
- Record nutrients client at the
 reception, weight, skin turgor, a
history of nausea, vomiting or not
- Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
- Encourage clients to eat in small
portions but frequently with food
- Collaboration nutritionist diet
composition
4 Sabtu, 04 09.00 I S:
- The client said he had no shortness of
02 - 2017
breath
- The client said it was not coughing up
secretion

O:
- The client does not look weak
- Vesicular breath sounds
- No mass in the chest or resonant
- Awareness: Compos mentis. GCS: E4
V5 M6
- TTV:
BP: 10/80 mmHg
Q: 36,1oC
R: 20x / min
N: 97 x / minute
- HB: 9.2 g / Dl
A: The problem is resolved
P: Stop intervention

09.10 III S:
- The client said he had a good night's sleep
O:
- The client does not look weak
- Face the client does not look pale
- Napping: 2 hours
- Sleepless nights: 7-8 hours
- Clients are not awakened because the
cough is not there
A: The problem is resolved
P: Stop interventions
09.20 IV S:
- Clients say they eat with half of the slurry
supplied, after eating fruit or cake clients
who brought his wife or family
O:
- The client does not look weak
- Clients look thin
A: The problem is resolved
P: continue intervention
- Record nutrients client at the
reception, weight, skin turgor, a
history of nausea, vomiting or not
- Supervise the input of food and
fluids. Keep an eye on expenditures
urine, sweat Weigh every day
- Encourage clients to eat in small
portions but frequently with food
- Collaboration nutritionist diet
composition