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CHAPTER III

CASE OVERVIEW

A. Assesment
The assesment was done on Monday, 21th April 2010 at 09.30 am in

Bougenville Room of Ambarawa Regional Hospital with autoanamnesa and

allowanamnesa.
1. Patient Identity
a. Patient
Name : Mrs. N
Age : 45 years old
Education : Senior High School
Address : Kopeng, Salatiga
Religion : Islam
Reg. No : 622331
Nationality : Javanese
Job : Labour
Medical Diagnose : uterine myoma
b. Responsible Person
Name : Mr.S
Religion : Islam
Nationality : Javanese
Job : Laborer
Address : Kopeng, Salatiga
Relation with patient : Husband

B. Health History
1. Main Complaint
Patient was anxious because there was lump at the bottom of stomach at

the top of sympisis


2. Present Health History
The patient said that more than 1 month she felt pain at the bottom of

stomach at the top of sympisis . She also realized there was lump in that

area. The lump ossified, patient checked it at the public health service.
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Doctor suggested the patient to get USG. Patient got USG at Lungs

Hospital. The result of USG refence the patient to get more action at

Hospital. Hospital planned to operate patient on Saturday, 24 April 2010.

Patient was very anxious with her disease now. She was getting anaemic.

Hb 6,6 and has been tranfusted with PRC Gol A 2 kolf, although patient

did not feel confuse or weak.


3. Past Health History
The patient said that she never got the disease before, patient did not get

oburtus, there was no allegy or contaminate diseases


4. Family Health History
The patient said that her family never got the disease before, there was no

hypertension , DM, they never got oburtus, caesar operation, distosia, etc.
5. Psychosocial History
Patient was very anxious with the disease and the procedure of operation.
6. Obsetry Status
The patient obsetry status was G2 P2 AO, patient menarche at 18 years

old, menstruation cycle ( patient overdue of menstruation for a week ).

There was no greivance during menstruation. Patient said that she used

contraception device MOW for 11 years. Before used MOW she uses

hypodermic contraception, She had been married and had 2 children

spontaneously.

C. PHYSICAL CHECKING
a. General Condition
Awareness : Composmentis
Condition : Weak
b. Vital signs
Blood presure : 120/70 mmHg
Artery rate : 91 times/minutes
c. Body Tall : 148 cm
Body Weight : 45,5 cm
d. Head
Mesochepal
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e. Hair
Dissemination apportionment, have gray hair, there was dandruff, hair

drop off
f. Eye
Sight function good, palpebra, there was no puffy, pupil issokor,

conjungtiva anemis.
g. Nose
There is no agonies,there was no epitacsis, there was no puffy polip,

there was no secret, smelling function was good.


h. Mouth
There was caries dentist, the tounge fright, the gums wasn’t bleeding,

the lip dries.


i. Ears
Ear clean, there was no infection, there was no lesi todak, earing

function good.
j. Neck
There was no stiff on the nape of the neck, there was no dilation of

tiroid, there was no pressed pain.

k. Chest

a. Lungs

I : balance between right and left (symmetrical), there was no

intercosta drought

Pal : tactil fremiitus balance between right and left, there was no

press pain

Per : resonant

A : vesiculer, there was no ronchi and wezhing

b. Heart
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I : there was no ictus cordis appear

P : ictus cordis was touched in costa 4 – 5, there was no pain

pressur

P : overcast, there was no cardio megali

A : Regular, there was no other sound

c. Abdomen

I : Stomach chubby, there was lump at the top of simpisis

pubis

A : intentines peristaltic 16 times/minutes

Pal : there was mass at the top of simpisis and 4 finger under

umbilikus

Per : tympani

l. Genetalia
Clean, there was no kateter
m. Dubur
Clean without hemoroid
n. Extremitas
Muscle strenght at the top of dextra 5555 5555
5555 5555
There was no lesion
Muscle strenght at the top of sinistra 5555 5555
5555 5555
Muscle strenght under dextra 5555 5555
5555 5555
There was no lesion
Muscle strenght under sinistra 5555 5555
5555 5555
There was no lesion
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o. Nail

There was no taboo nail, CRT 4 second.

D. Functional Pattern Assestment


a. Breathing Pattern
Before being sick : there was no breathing disorder , there was

no asthma.
During being sick : Patient said she did not get asthma,

breathing sound normal, there was no renchi

and weezhing.
b. Nutrition Pattern
Before being sick : Patient ate 3 times a day, meal composition:

rice, vegetable soup, in one portion. Drank

average 5 glasses a day 1000 cc


During being sick : Patient ate 3 times a day with hospital meal

composition in half portion, Drank average

5 glasses a day 1000 cc


c. Ellimination Pattern
Before being sick : Patient said bowel eleminated once a day

with soft consintence, urinated eleminated

3- 4 times a day, yellow pure


During being sick : Patient said bowel eleminated once a day

with soft consintence, urinated eleminatied

4 - 5 times a day, yellow pure


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d. Rest & Seep Pattern


Before being sick : Patient slept without annoyance for 6 -8

hours a day.
During being sick : Patient slept for 6 -7 hours at night and 1

hour at noon
e. Balance Movement Pattern
Before being sick : Patient was able to do daily activities.
During being sick : activity done by herself such as took a bath

and went to the toilet.


f. Temperature Defense Pattern
Before being sick : Patient wore thick clothes and blanket while

cold, wore thin clothes while hot.


During being sick : Patient wore t-shirt, while cold blanket.
g. Personal Hygine Pattern
Before being sick : Patient took a bath and cleaned the teeth 2

times a day, clean the hair 3 times a day,

changed clothes once a day.


During being sick : Patient took a bath once a day, clean the

teeth 2 times a day, while in the hospital has

not cleaned the hair yet.

h. Communication Need Pattern


Before and during being sick patient used Indonesian and Javanese in

communication, there was no miss communication.


i. Spiritual Relationship Pattern
Before being sick : Patient was Islam, she used to solat 5 times

a day
During being sick : Patient never solat and only prayed for his

healing.
j. Recreation Need
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Before being sick : Patient did not have enough time to went

recreation but sometimes she goes to her

family.
During being sick : Patient was happy while she visited by her

family.
k. Study Need
Before being sick : Patient watched tv to add her knowledge
During being sick : Patient did not know about her disease and

often asked to the nurse.

E. SUPPORTING EXAMINATION
1. Routine blood checking, April, 19th 2010
Hemoglobin : 6.6 L g/dl 12-16
Leukosit : 5,5 L thousand 6.0-12.0
Eritrocit : 3.60 million 4.0-5.0
Hematokrit : 23,1 % 36-46
Trombosit : 225 thousand 150-400
Mc.v : 62,8 mikrom3 80-100
Mc. H : 17.9 Pg 26-34
MCHC :28,6 g/dl 31-35,5
MPV : 81,1 % 5-11
Limfosit : 2,2 10^mikro L 1-5
Monosit : 0,8 10^mikro L 0,1 - 1
Granulosit : 2,6 10^mikro L 2-8
PCT : 0, 182 %
2. 20 April 2010
Leukosit : 8,9 L Thousand 6.0 – 12.00
Elloting time : 3:00
Bleeding Time : 1:00

3. April, 20th 2010


Routine blood checking, April, 19th 2010
Hemoglobin : 7.6 L g/dl 12-16
Leukosit : 7,7 L thousand 6.0-12.0
Eritrocit : 3.79 million 4.0-5.0
Hematokrit : 25,4 % 36-46
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Trombosit : 231 thousand 150-400


Mc.v : 67,0 mikrom3 80-100
Mc. H : 20,1 Pg 26-34
MCHC : 29,9 g/dl 31-35,5
RDW : 19,2 % 5-11
Limfosit : 2,6 10^mikro L 1-5
Monosit : 0,8 10^mikro L 0,1 - 1
Granulosit : 4,3 10^mikro L 2-8
Limfosit % : 33,6 % 1-5
Monosit % : 10,8 % 0,1 - 1
Granulosit% : 55,6 % 2-8
PCT : 0, 182 %

4. Therapy (April, 19th 2010)


PRC Gol A 2 Kolf
Infus NaCl
DATA ANALYSIS
Name : Mrs. N Dx. Medis : Uterine myoma
No reg : 622331

N0 DATE DATA FOCUS CAUSED PROBLEM SIGNATU


POSSIBILITY RE

1. Wednesd Subjective data : Less Anxiety


ay, 21 - Patient said that she was worried information
April because of the operation about the
2010 - Patient said that she did not know disease and
the procedure of the operation operation
- Patient said that she did not know procedure
about her disease
Objective data :
- Patient seemed worried
- Patient asked when the operation
done
- Patient asks about her disease
2. Wednesd Subjective data: Inadequate Less
ay, 21 - Patient said that she was lose intake nutrition nutrition is
April not enough
appetite
2010, for body
Objective data:
need
A: Weight before sick 45 kg,
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while sick 45,5 kg, Height 148


cm
B:-
C : The hair drop off
D : Patient eats 3 times a day in
half portion

3. Wednesd Subjective data:


ay, 21 - Patient said that she was not Less of O2 Ineffective
April weak and headache transport tissue
2010 Objective data: perfusion
- Hb 6,6 g/dl
- Conjungtiva Anemi
- Patient seem pale
- CRT 4 second
- Vital sign
Blood preasure : 120/70 mm
Hg
Pulse :91 times/minutes
Temperature : 36,8 degree
celcious
1. Respiratory rate : 22 times /
minutes

NURSING DIAGNOSIS BASED ON PRIORITY


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1. Ineffective tissue perfusion related to less of O2 transport


2. Nutrition change less than body requirement related to inadequate

nutrition intake
3. Anxiety related to less information about the disease and operation

procedure.

NURSING CARE PLAN

NAME : Mrs. N MEDICAL DIAGNOSE :Mioma Uteri


NO. RM : 622331

N0 DATE NO. PURPOSE AND RESULT INTERVENTION SIG


37

DX. CRITERIA NAT


URE
1. Wednesday, I After doing nursing action for 2 1. Observation skin colour
21 April 24 hours, it was expected perifer and temperature
2010 circulation was good which the 2. Check capilary refil
result below: 3. Keep warm patient
- Hb :10-13 g/dl temperature
- Ht : 36-46 % 4. Monitored Hb and Ht
- There is no conjungtiva of 5. Monitored Vital signs
anemis 6. Maintenanced in giving
- Patient does not pale blood transfusion

2. Wednesday, II After doing nursing action for 2 1. Gave information about


21 April 24 hours, it was expected patient nutrition need
2010 fulfill her nutrition which the 2. Investigated food
result below: consumption
- Appetite increase 3. Served patient with high
A: There was no loss of body calory high protein
weight 4. Gave sugar substance
B: - 5. Gave her favorite meal and
C: Hair could not drop off variated
D: Patient eats 3 times a day
in portion
3. Wednesday, III After doing nursing action 1 X 1. Gave patient psycology
28 April 30 minutes, it is expected patient respon and supporting
2010, 11.30 is not worried again which result needed
am below: 2. Attended to the procedure
- Patient was not worried planned
- Patient understod about her 3. Accompany the patient
2. disease and give emphaty
4. Gave accurate information
- Patient more relax
with simple terminology
5. Describe procedure clearly
IMPLEMENTATION
NAME : Mrs. N MEDICAL DIAGNOSE :Mioma Uteri
NO. RM :622331

N0 DATE NO. IMPLEMENTATION RESPON SIGNA


DX. TURE
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1. Wednesday,
28 April
2010,
10.30 am. I - Keep warm patient by O:
giving her blanket Patient was cooperative
and will to use blanket

10.30 am II - Investigated patient S:


supporting system Patient said that her
husband is the first person
who support her

10.20 am II - Gave rose apple juice 250 O:


cc Patient will to drink rose
apple juice
11.45 am
II O:
- Motivated patient to diet Patient will ate ¾ in
based on hospital schedule portion
12.00 am
I S:
- Took sampling of the blood Patient agree being taken
her blood
O:
Sampling of the blood is 3
cc
12.35 am
III - Collaborated with medical O:Operation plan wait
team and nurse about the reparation of KU
room will be used for
operation
05.00 pm
II - Motivated patient to diet O:Patient will ate ¾ in
based on hospital schedule portion

05.00 pm
I Blood preasure : 110/80
- Measured vital sign and CRT
mmHg
Pulse : 88 times /minutes
temperature :36,7 degree
. celcious
RR: 22 times /minutes
CRT : 3 second
06.50 pm
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V - Investigated checked result Hb: 7,6 gd/dl


of Hb and Ht Ht: 25,4 %
07.00 pm
I - Gave the patient knowledge O:
about the importance of Patient was able to
nutrition absorb mention again about the
importance of nutrition
Thursday absorb
22 April
3. 2010
06.30 am - Measured vital sign and CRT
III
Blood preasure: 110/70
mmHg
Pulse : 88 times /minutes
Temperature :36 degree
celcious
RR: 22 times /minutes
09.30 am - Gave health education about CRT : 3 second
III mioma uteri, such as:
1. Signification - Patient was able to
2. Etiology mention etiology and
3. Sign and Sympton device implementation
4. Device implementation of mioma uteri

09.30 am - Explained procedure of


III operation which done to the
patient - Patient seemed
understand about what
10.00 am - Asked patient about her has been explained
III preparation for operation
- Patient said ready to be
operated
12.50 am - Motivated patient to eat
II
- Patient ate ¾ in portion
EVALUATION
NAME : Mrs. N Medical Diagnose :Uterine myoma
NO. RM : 622331

N0 DATE NO. EVALUATION SIGNAT


DX. URE
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1. Wednesday,
21 April I S: Patient said that she was not headache
2010, O:
01.00 pm. - Hb 6,6 g/dl
- Ht 23,1 g/dl
- Conjungtiva Anemi
- Lip mukose pale
- CRT 3 second
A: The problem wasn’t overcomed yet
P: Continue to intervention
- Monitor CRT and Vital sings
- Monitor Hb and Ht
- Monitor trombosit
2. Wednesday, II
S: Patient said that she lost of appetite
21 April
O : beforesick 45 kg, whlie sick 45,5 kg, body tall 148
2010,
kg, 3 times a day ¾ in portion
01.00 Pm.
A: the problem wasn’t overcomed yet.
P: continue to intervention
- Investigate nutrition absorb
- Give patient with high calory high meal protein
- Give meal or drink with sugar substance
3. Wednesday, III
21 April S:
2010, - Patient said that she still worried with the operation
01.00 Pm. - Patient said that she still does not know with her
disease
O:
- Patient seem worried
- Patient ask when she will be operated
A: the problem couldn’t overcomed yet.
P: continue to intervention
- Give health education and procedeure of the
operation
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N0 DATE NO. EVALUATION SIGNAT


DX. URE
1. Thursday, 22 S: Patient said that she did not get headache
April 2010,
07.00 am. O:
I - Hb 7,6 g/dl
- Ht 25,5 g/dl
- Conjungtiva does not Anemi
- Lip mucose is pink
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- CRT 3 second

A: The problem was not overcomed yet


P: Continue to intervention
- Monitor CRT and Vital signs
- Monitor Hb and Ht
- Collaborate the blood tranfusion given

2. Thursday, 22 II
April 2010, S: Patient said that she lose of appetite
07.00 am.
O:
- A : BB before sick 45 kg, whlie sick 45,5 kg, body
tall 148 cm
- B:-
- C: Patient hair drop off
- D : patient eat 3 times a day ¾ in portion
A: the problem was not overcomed yet.
P: continue to intervention
- Investigate nutrition absorb
- Give patient with high calory high protein meal
- Give meal or drink with sugar substance
3. Thursday, 22 III
April 2010,
07.00 am. S:
- Patient said that she still worried with the operation
- Patient said that she still does not know with her
disease
O:
- Patient seem worried
- Patient ask when she will be operated
A: the problem does not overcomed yet.
P: continue to intervention
- Give health education and procedeure of the oper

N0 DATE NO. EVALUATION SIGNAT


DX. URE
KEP
1. Thursday, 22 S: Patient said that she did not get headache
April 2010, I O:
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12.00 am. - Hb 7,6 g/dl


- Ht 25,4 g/dl
- Conjungtiva was not Anemi
- CRT 3 second
A: The problem was not overcomed yet
P: Continue to intervention
- Monitor CRT and TTV
- Monitoring Hb and Ht
- Collaborate the blood tranfusion given

2. Thursday, 22 II S : Patient said that she still lose of appetite


April 2010, O: Before being sick 45 kg, during being sick 45,5 kg, TB
12.00 am. 148 cm, air drop off, ate 3 times a day ¾ in portion
A: the problem was not overcomed yet.
P: continue to intervention
- Investigate nutrition absorb
- Give patient with TKTP meal
- Give meal or drink with sugar substance

3. Thursday, 22 III
April 2010, S:
12.00 am. - Patient said that she has not worried with the operation
again
O:
- Patient seem relax
A: the problem has overcomed .
P: keep the intervention