RESUME OF NURSING

Name : Noor Muhammad Pandu Wira Sena Isnantopo

NPM : 162440110055

Room : Poly Surgery

A. PATIENT IDENTITY
Name : Sn. SMZ
Age : 3 years 3 month
Address : Komp. Kelapa gading
Medical Diagnosis : Polydactyly Pareaxial Tipe V
Dates : February 5th, 2018
Assessment Date : February 5th, 2018

B. DATA FOCUS
Subjective data : Mrs. patients say sometimes children ask why the left hand fingers of her
is not the same with his right hand and with the other person's hand

Objective Data : polydactyly Parexial type V (metacarpal and thumb branched, and two
Phalanx distal and proximal Duplication

a) inspection : the patient fidgeted during examination. there are defects on the thumb of
the left

b) Palpation : there is no tenderness, no enlargement, palpable muscle tissue and

bone

c) Percussion :
 d) Auscultation :

C. ADDITIONAL DATA
a. TTV
● Blood Pressure :-
● Pulse :-
● Temperature :-
● Respiration :-
b. Results of other support (LAB, CT scan, X-ray)

 X-Ray Left Hand bone

D. DATA ANALYSIS
DATA Etiology PROBLEM

DS : patient’s Mother said related to changes in bodily Body image disorders

sometimes her children functions (for anomalies)
asking why his left hand
fingers are not the same
with his right hand and
with the other person's
hand

DO : There are abnormalities

pad a thumb to the left.
There is no tenderness, no
enlargement, palpable
muscle tissue and bone

DS: patient’s mother say Related to anomaly Anxiety

sometimes her children ask
why the left hand fingers his
 not the same with his right
hand and with the other
person's hand

DO: Patients were seen agitated

during examination

E. PLAN FOR NURSING

Nursing Diagnosis:
Body image disorders and Anxiety
Purpose : Reduction feeling body image disorders and anxiety
Criteria Results : positive body image (Patients do not complain of abnormalities in him again) and
posture, facial expressions, body language and level activity showed reduced anxiety
Intervention :
1. Assess verbally and nonverbally the client's response to her body
2. Encourage families to accompany and motivate children
3. Collaboration in Operational planning

Implementation :

1. Conduct verbal and nonverbal assessment of the body\

2. Instruct parents to accompany and motivate their children
3. Collaboration in operations planning

Evaluation :

S : patient’s mother says his enthusiasm for the omitted finger enhancements
O : the patient looks happy after the planned addition to the finger is removed but still looks
uneasy with the surgery will be done
A : The destination is partially fulfilled
P : Intervention continued
- Instructs parents to accompany and motivate their children
- wound fixation