THE NURSING CARE PLAN FOR Ms.

L WITH PROBLEM OF INEFFECTIVE AIRWAY CLEARANCE MEDICAL DIAGNOSIS ACUTE BRONCHITIS IN HEALTH WORLD HOSPITAL

A. ASSESSMENT I. THE IDENTITY OF PATIENT Nick Name Full name : Lily : Lilian Elizabeth Harrow

Date, Place of Birth : Herthfordshire, November 18th 1991 Sex Address : Female : 5 Fleur Drive, Wisteria Walk, Edensor,

Herthfordshire, 828 United Kingdom Religion Education Job Citizen Ward Admission date : Islam : 1st Degree : Student of Arts in Cambridge University : England : Magnolia number 8 : May 12th, 2011

Medical Diagnosis : Acute Bronchitis

II.

THE IDENTITY OF RESPONSIBLE PERSON Full name Age Address : Evelyne Harrow : 45 years old : 5 Fleur Drive, Wisteria Walk, Edensor,

Herthfordshire, 581328 United Kingdom Education Job Relationships : Double Degree : Lecturer : Mother

B. HEALTH HISTORY a) The Chief Complaint Patient said, I was difficult to breath and cough. I had bleeding cough.... b) The Additional Complaints Patient said, pain when trying to breath. P : because of the disease process Q : like pressure of heavy thing R : middle chest S:5 T : when trying to breath Patient said, I got fever. c) The Current Health History Patient admitted to Health World Hospital in 12th May 2011 with complaints of short breathing, ineffective cough, inability to remove airway secretions, chest pain, fever, anorexia and weakness. The medical diagnosis is acute bronchitis. In assessment, patient complained breathless, chest pain and high temperature (37,70 C). d) The Past Health History Patient said, I ever suffered the same illness when I was still 19 years old. But, it was not too bad. e) The Family Health History Patient said, There is no my family who suffered the same illness.

C. GORDONS FUNCTIONAL HEALTH PATTERNS I. The Health Perception and Management S : Patient said, I aware that health is very important, without health everything is nothing. O: Patient was admitted to the Health Word Hospital in May 12 th 2011 to cure his disease and get a better treatments.

II.

Nutrition and Metabolism S : Patient said, I could eat every food. But after getting sick I have anorexia. O: Patient didnt spend her food that supplied by the hospital.

III.

Elimination S : Patient said, I had bowel twice a day, and pass stool once a day. O: Patient had bowel twice a day, and pass stool once a day. Like usual.

IV.

Activity and Exercise S : Patient said, I couldnt run as far as before I got this sick. Now, I cant ride my bicycle to go to my campus. O: Patient couldnt do heavy activities such as walk fast, run, singing, and so on.

V.

Sleep and Rest S : Patient said, I couldnt sleep, because Im difficult to breath if I sleep. O: Patient had 3-5 hours for sleep.

VI.

Cognition and Perception S : Patient said, My senses are good, I just cant taste and smell well. O: Patients senses are normal. She cant taste and smell well because her illness.

VII.

Self-perception and Self-concept S : Patient said, I wish that I could be better after getting the best treatments. O: Patient can accept all medical and nursing treatment.

VIII.

Sexuality and Reproduction S : Patient said, I dont have boy friend. O: Patient wasnt visited by a boy, just her friends and her mother.

IX.

Coping and Stress Management

S : Patient said, When I have a problem, Im used to share it with my mother and my friends, and singing. O: Patient always share her problem with her mother, friends and nurses. X. Value and Beliefs S : Patient said, Im proud to be moslem. O: Patient always pray on time.

D. PHYSICAL EXAMINATION 1. General Examination a. General Condition b. Awareness c. Vital Signs : quiet well : compos mentis : BP 95/55 mmHg P 60 beats/min RR 25 times/min BT 37,7 0C. 2. Head to Toe Examination a. Head Eyes Ears Nose Mouth and teeth : symmetric, conjunctiva anemis : no cerumen, hearing function is good : little extension, smell function is disturbed : there is no caries

b. Neck Tyroid glands : there is no expansion

c. Chest Lung Heart Chest wall : breath sound is vesicular and creckles : normal : symmetric

d. Abdomen Stomach wall Liver : flat : normal

Intestines

: normal : normal : skin turgor is quiet good

e. Back f. Skin g. Extremities Superior Inferior

: there is no oedema, and infous : there is no oedema

E. ANALIZING OF DATA NO FOCUS DATA (Symptom and Sign) 1. Subjective Data (SD): Patient said, I was difficult to breath and cough. I had bleeding cough.... Objective Data (OD): Patient was seem breathless. She had bleeding cough. Subjective Data (SD): Patient said, pain when trying to breath. P : because of the disease process Q : like pressure of heavy thing R : middle chest S:5 T : when trying to breath Objective Data (OD): Patient was seem painfull when was breathing and she always hold her chest. Subjective Data (SD): Patient said, I got fever. Objective Data (OD): The body temperature is 37,70 C ETIOLOGY Increasing of mucus or secretions PROBLEM Ineffective airway clearance

Agent of biological injuries

Acute pain

Process of infection

Hyperthermia

F. NURSING DIAGNOSIS 1. Ineffective airway clearance related to Increasing of mucus or secretions as manifested by: Subjective Data (SD): Patient said, I was difficult to breath and cough. I had bleeding cough.... Objective Data (OD): Patient was seem breathless. She had bleeding cough. 2. Acute pain related to Agent of biological injuries as manifested by: Subjective Data (SD): Patient said, pain when trying to breath. P : because of the disease process Q : like pressure of heavy thing R : middle chest S:5 T : when trying to breath Objective Data (OD): Patient was seem painfull when was breathing and she always hold her chest. 3. Hyperthermia related to Process of infection as manifested by Subjective Data (SD): Patient said, I got fever. Objective Data (OD): The body temperature is 37,70 C.