Asyifa Nuranzani

P17320317006
III A
REPORT TEXT
DYING PATIENT WITH LUNG CANCER

1. Opening one liner

Mr. R age of 55 years, Client entered the hospital on November 5, 2015 due to
experiencing Ca. Lungs The client came to Pelamonia Hospital delivered by
his family through the emergency room, on November 5, 2015, with
complaints of shortness of breath, chest pain, coughing, no appetite, weight
loss, and fatigue.
2. Event of the past 24 hours
The patient says shortness of breath and feel uncomfortable especially when
lying down. The patient looks weak and pale. Dry lip mucosa. Moderate
general state, compositional awareness.
3. PE Remarkable for
The patient looks short of breath and is uncomfortable when lying down. Vital
sign :
Blood pressure: 110/70 mmHg Pulse: 94x / minute
Respiration: 30x / minute Temperature: 37,4oC
Head to toe
Breathing: breathing 28x / minute, no chest retraction, using 1 lpm nasal canul
breathing apparatus
Blood: regular heart rhythm, pulse 88x / minute
Bladder: urinate smoothly and regularly, the amount of urine is approximately
1500cc / day, bowel movements 1x / day, soft consistency
Bowel: no bloating, normal bowel sounds 10x / minute, normal appetite, eat 3
times / day, porridge diet.
Bone: normal muscle strength, legs and hands no paralysis
Patients continue to worship diligently and beg that their illness can be cured.
4. Labs and imaging remarkable for
Laboratory examination :
Hb : 12.6 gr%
Ht : 34.7%
Leulocytes : 4400 / ml
Platelets : 191000 / ml
Creatinine : 2.40 mg / dl
Treatment:
Infusion of RL 12 tts / min
Aminophilin 3 x 500 mg
Asyifa Nuranzani
P17320317006
III A
Injection of Dexamethason 3 x 2 ampoules.
Management : Planned surgery with general Anesthesiologist.
Supporting investigation :
pH : 7.25
TCO2 : 23 mmol / L
PCO2 : 30mmHg
BE : 1 mEq / L
PO2 : 85mmHg
saturation O2 : 95%
HCO3 : 23
5. Assessment and plan
From the case above, the problem of nursing is :
a. Damage to the gas exchange
b. Airway clearance is not effective
The intervention is :
a. Damage to the gas exchange is related to Hypoventilation
Outcome criteria : Indicates adequate ventilation and oxygenation
improvement with GDA in the normal range and symptom-free breathing
distress.
Nursing intervention :
1) Assess respiratory status frequently, note increasing frequency or
effort breathing or changes in breathing pattern.
2) Note the presence or absence of additional sounds and the presence of
additional sounds, for example krekels, wheezing.
3) Assess for cyanosis
4) Collaboration of moist oxygen as indicated
5) Monitor or draw the GDA series.
b. Ineffective airway clearance is associated with loss of ciliary function,
increased amount / pulmonary secret viscosity, increased airway
resistance.
Outcome criteria : Declare / show loss of dyspnea. Maintain a patent
airway with a clean breath. Remove secretions without difficulty.
Demonstrating behavior to improve / maintain airway clearance.
Nursing intervention :
1) Record changes in effort and breathing pattern.
2) Observation of decreased chest wall expansion and presence.
3) Note the characteristics of cough (for example, permanent, effective,
ineffective), also production and sputum characteristics.
4) Maintain proper body / head position and use the airway as needed.
Asyifa Nuranzani
P17320317006
III A
5) Collaborative administration of bronchodilators, for example
aminophylline, albuterol etc. Watch for adverse side effects from
drugs, for example tachycardia, hypertension, tremor, insomnia.