NURSING PROCESS RISK FOR INFECTION IN MM PATIENTS WITH VULNUS APERTUM AND NAIL AVULSION IN AMBULATORY EMERGENCY ROOM

INSTALLATION BADUNG REGION GENERAL HOSPITAL

Member : Ayu Aditya Willy Agustini Antari, I Gusti Ayu Dewi Rakasiwi Wahyu Mas Utari Udara Istri Ratna Charlina Ari Irayati Agus Hendrawan (10C10403) (10C10387) (10C10394) (10C10419) (10C10504) (10C10501) (10C10411) (10C10399) (10C10381) Rahayuni Dian Shanti Nita Wahyundari Dian Ardana De Indra Oktalida Yulli Endrayanti Yanti Yuliawati (10C10475) (10C10423) (10C10466) (10C10422) (10C10518) (10C10469) (10C10515) (10C10512)

PROGRAM STUDY BACHELOR OF NURSING SEKOLAH TINGGI ILMU KESEHATAN (STIKES) BALI DENPASAR 2012

1.

Assessment Assessment done on 11 March 2012 at 07.00 am in the room with the method of observation, interviews, physical examinations and medical records. A. Data collection a. Identity Patient Name Age Sex Tribe Religion Civil status Employment Address no. register : Mr. Daniel : 45 years old : male : Indonesian : Hindu : married : farmer : Gn Lumut St. no. 34 Denpasar : 104RS21 Hindu married Teacher Gn Lumut Johnson 25 years old male Indonesian

Date of Admission :11 march 2012

Medical history

A. The main complaint was hospitalized patients come to realize, with a wound on the right ring finger and the left leg.

B Recent history on 11 March 2012, patients present with her child delivered had an accident while going to the field. Patient appears frightened and anxious when brought to the IRD. In the IRD space Ro.manus radiological examination (D) and Ro.engkel(S). and wound care. of the examination of patients diagnosed vulnus appertumand nail avulsion.

C.

Previous history disease The patient's family said the patient had never had an accident before

D.

Family history of disease the patient's family said that about six months ago had an accident.

2.

Patterns of patients 1. Motion and activity Before and during the assessment, the patient said that since the accident the patient cant indulge as usual. 2. Recreation Patients say often into the fields to take care of their fields, and because of ill patients cant take care of their fields for a while. 3. Sense Of Comfort Before and during the assessment, patient said she felt uncomfortable because of his injuries 4. Sense of Security Before and during the assessment, patient said she felt afraid when the wound is cleaned

3.

Physic Examination
-

Extremity Above: no edema, no clubbing, no cyanosis is not installed infusion. bottom: no edema, no wound on his left foot, there is no finger clubbing

Data Analysis Data Analysis in Patient MM with Impaired Risk of Infection in Ambulatory Emergency Room Installation Badung Regional General Hospital On March 11, 2012 No 1. Subjective Data Objective Data Conclusion

The patient said, There is an open wound on the heel, Risk of infection there are wounds on and the wound on the right-ring finger. the rightring finger Vital signs: and left foot injury. Blood Pressure = 130/90 mmHg Pulse rate = 64x / minute Respiration rate = 24x / minute Temperature = 36.10C

Problem Formulation : Risk of Infection

Problem Analysis : P = Risk of infection. E = Inadequate primary defenses (broken skin, traumatized tissue). The occurrence of the process : Inadequate primary defenses (broken skin, traumatized tissue) that cause of open wound will create the microorganism proliferate and finally it cause infection turn up.

Result if not addressed : The infection will spread into other areas, and can be more chronic.

1. Nursing Diagnosis : 4

Risk of infection related to inadequate primary defenses (tissue trauma, damage to the skin).
2.Nursing Care Plan

Nursing Care Plans in MM patients with Vulnus Apertum and nail avulsion In Ambulatory Emergency room Installation Badung Region General Hospital On March 11, 2012 Day/ date/ hour Sunday, March 11, 2012 08.15 AM Dx. Risk of infecti on related to inadeq uate primar y defens es (tissue trauma , damag e to the skin) Goal and Criteria outcomes After doing nursing care for 1x24 hour is expected to the risk of infection can be resolved with the criteria outcomes:
1. Patients do not feel

Intervention Independent
1. Observation of

Rational

patients general condition and vital signs for fever, increase respiratory rate.
2. Give complete

1. To find out the vital

signs and patient's general condition that will use for the next treatment
2. Lowers the risk of

pain in the right ring finger and left foot.

2. Wounds on the

treatment by performing correct hand washing and aseptic wound care.

spreading infection

rightring finger and left foot wont 3. See incision and 3. Provide early spread. dressing. Record the detection of the characteristics of infection process, and 3. Vital signs: wound drainage / monitoring of wound T = 36.8 to 37.40C drain (if included), the healing. P = 60-100 x presence of erythema. /minute BP = 110/70-120/80 4. Provide appropriate mmHg information, be honest 4. Provide the R = 16-24 x / with patients or care information about minute with patients next of wound care. kin about the wound. Collaborative 5. Give the antibiotics metronidazole 500 mg 3x1, 3x1 mefenamic acid 500 mg orally. 5. Antibiotics metronidazole 500 mg 3x1, 3x1 mefenamic acid 500 mg orally go
5

6. Take for example the

drainage when indicated.

through without any allergic symptoms.

6. Gram staining and

culture sensitivity is useful to identify the causative organism and treatment options.

4.Nursing Implementation

Nursing implementation in MM patients with Vulnus Apertum and nail avulsion In Ambulatory Emergency room Installation Badung Region General Hospital On March 11, 2012 Day/ date/ hour Sunday, March 11, 2012 08.15 AM Dx. 1 Implementation Independent
1. Observing the vital signs

Evaluation

Sign Stud

and patients general condition.

1. Patients seem like in pain

T = 370 C BD = 130/ 90 mmHg P = 64 x/ minute R = 24 x/ minute

2. wound has been cleaned

2. Giving complete

08.40 AM

treatment by performing good hand washing and aseptic wound care.

3. Providing appropriate

and covered with hass +antiseptic

09.10 AM

information, be honest with patients or care with patients next of kin about the wound. Collaborative
4. Giving the antibiotics

3. the patient has been said

it was understood

10.00 AM

metronidazole 500 mg 3x1, 3x1 mefenamic acid 500 mg orally.

4. the antibiotic metronidazole 500mg and mefenamic acid 500 mg have been taken orally.

5. Evaluation ( done in accordance with goal plans)

Nursing Evaluation in MM patients with Vulnus Apertum and nail avulsion in Ambulatory Emergency room Installation Badung Region General Hospital On March 11, 2012 No 1 Day/Date/time Saturday, March 12, 2012 time 08.00 wita 1 Nursing Diagnose Evaluation S: Patients said that there is pain in the wound on his right-ring finger and left foot is reduced. O : The patient was calm, wounds on the feet and hands of patients has been dried frequently A: The objective 1,2,3 fully achieved. The risk of infection attained matter ent irely. P: Maintain the condition patient Sign Stud