NURSING CARE of CA MAMMAE1. ASSESSMENT A. IDENTITY CLIENT IDENTITY Name Sex Age Address Education Occupation Marital status Religion Tribe / Nation RS Entry Date Medical Diagnosis RM Number
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Mrs. D.P Female. 21 years. Jl. Penghulu Senior High School Private. Married Islam. Banjar / Indonesia. July 7, 2010 Ca mammae (Malignant Neoplasma of Breast) 879987
RESPONSIBLE INSURER IDENTITY Name : Mr. D.R Sex : Male Age : 20 years Occupation : Private Address : Jl. Penghulu Relationship with client : Husband B. HEALTH HISTORY 1. The Main complaint At the time of assessment on 8 July 2010, at 9:00 pm, client said that her left breast feel a little pain and worry with the disease and the actions will be done. 2. The present illness history approximately one year ago, clients felt there was little tumor like marble the left side of her breast but did not feel pain, after some time in the last weeks before she was admitted to hospital, client done self breast care on the breasts and palpated there is the tumor on the left side of her breast like adults thumb and feel painful, because worried with the client condition , client and her husband went to check-up to the doctor. From the assessment found that medical diagnosis is ca mammae suffered by clients that caused by hormonal factors, from the emergency room clients were referred on 7 July 2010 to Nusa Indah to do long stay department and to do intensive care. 3. The Past Illness History Client says has never suffered a serious illness like she suffered now, just a cough and typhoid.
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4. The Family Disease History Clients say that none of her family members who experience such ca mammae diseases like suffered by clients now and none of client families have a infectious disease history but the client's mother has a history of hypertension. C. PHYSICAL EXAMINATION 1. General condition At the time of assessment dated 8 July 2010, client awareness is compos mentis (fully conscious, able to answer all questions with the co-operative) with GCS: 4-5 - 6 (E4: eyes open spontaneously, V5: good orientation and M6: follow orders) with vital signs : Blood pressure: 120/80 mmHg, Pulse: 84 beats / minute, Respiratory Rate: 28 times / minute and Temperature: 36,90 C, and anthropometric data are :Body Weight: 43 Kgs, Body height: 153 Cms and upper arm circumference : 23 Cms Ideal Body Weight = (153-100) - 10 % (153-100) Kgs = 53 5, 3 Kgs = 47, 7 Kgs 2. Skin skin is Brown color, skin condition is clean, there are no red spots, there is not inflammation or lesion, skin texture is moist, skin turgor is good (back before 2 seconds) and no other disorder form such as cyanosis or ikterik. 3. Head and Neck hair distribution is prevalent, there is no bump on the head, there is no lesion, clients hair is black and straight, the head cleanliness is clean and there is no headache or head trauma, no enlargement of the thyroid gland in the neck, no enlargement of lymph nodes, there is no pain when movement, there is no limitation of motion in the neck. 4. Eyes and eyesight eye structure is Symmetrical, the eyes look clean, no secretions in the eyes, conjunctiva is not anemic, sclera is no ikterik , no abnormalities in the eyeball and movable to all direction, client is not using visual aids such as glasses and contact lens and vision function well marked client can read the nurses shingle. 5. Nose and smell nose structure is Symmetrical, the nose look clean, it appears there is no dirt or obstruction on the nose and there was no bleeding, no inflammation or pain in the nostrils, there was no use of the nostrils during breathing, olfactory function is good was marked with a client can distinguish smells between cajuput oil and orange. 6. Ear and hearing both ears structure is Symmetrical, the client ears look clean, there is no secret that comes out, no pain, inflammation or bleeding, the client does not using hearing aids and hearing function is well marked by the client can answer all nurses questions well.
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7. Mouth and teeth Oral hygiene is clean, there is no inflammation of the mouth, client's dental hygiene is clean, there is no inflammation of the gums and no chewing and swallowing disorders. 8. Chest, breathing and circulation Chest form is Normal with a ratio between the anterior posterior diameter and transverse diameter is 1:2, the movement left and right chest looks symmetrical, clients respiratory is eupnea (normal breathing rhythm and speed), when in percussion is resonant sound and there is no buildup of fluid in the lungs, when auscultation is vesicular breath sounds (low and soft), there is extra heart sound (single-S1 and S2), a normal CRT ( Capillary Refill Time ) back less than two seconds, when inspection, breast is normal and symmetrical and can be described is medium form, breast skin color is olive, there is no lesion and no edema in the breasts, there are no retraction in the breasts and there is no swelling of the nipples, when palpated with self care techniques of the breasts aware there is a tumor like adults finger at the left side breast, the client says little pain with a pain scale is one ( middle pain) when held or sometimes just appears like an ant bite but rarely. 9. Abdomen Abdominal structure is symmetrical, there is no lesion and there is no lump, no ascites. When auscultation, bowel sounds is 10 times / minute. When percussion is tympani sound and when palpated there is no mass in the abdomen, there was no enlargement of liver and lymph. 10.Genital and Reproduction client is Female, the client does not use the catheter, there is no pain during bowel and bladder, the client is the first child of three brothers, married approximately 1 years ago, client does not has children yet, there is no using contraception drugs either pills or injections. Clients menstrual cycle is irregular, slow, and when menstruation is eight days, clients say sometimes until the second moon periods the menstruation begin comes and are not checked. 11. Extremities on top and bottom The structure of right and left extremities are symmetrical, infusion is not installed on the extremities, no pain, inflammation or bleeding on extremities, no limitation of motion, muscle strength scale 5555 5555 (normal movement, full of challenging gravity) 5555 5555
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D. PHYSICAL, PSYCHOLOGICAL, SOCIAL AND SPIRITUAL NEEDS 1. Activity and rest Home : Client is a housewife and employer at PT. JAMSOSTEK (Persero) of branch office South Kalimantan, client sleep in the night around 7-8 hours and sleep in the afternoon around 1 hour. In the Hospital : During in hospital client sleep in the night around 7 to 8 hours and in the afternoon two hours, clients can conduct their own activities without help from others with the activity scale is 0 (independent) 2. Personal Hygiene Home : client takes a bath two times a day, brush her teeth four times a day, washed her hair three times a week and cut the nails when the length In the Hospital : client takes bath 2 times a day, brush her teeth two times a day, washed her hair if necessary, and no cutting nails 3. Nutrition Home : client eats three times a day, ordinary rice foods + side dish + vegetables, clients have food restrictions such as shrimp, client has a good appetite, client drinks around 7 cups per day and there is no difficulty in swallowing In the Hospital : clients eat three times a day with diet NB (normal rice), and the client drinks five glasses a day and clients appetite is not disturbed, normal rice with high calories and high proteins. 4. Elimination Home : the frequency of defecate is normal one time a day, the time is in the morning, consistent is soft, yellow and do not use laxatives, urinate 3-4 times per day, no pain during defecate and urinate. In the Hospital : frequency of defecate is normal one time a day, the time is in the morning with a consistent is soft, yellow and not using laxatives, urinate around 5 times a day, no pain during defecate and urinate. 5. Sexual A client was married and has not children, no complaints in sexual relations. 6. Psychosocial Clients be able to communicate well and there is no mental disorder, the client looked anxiety when she discovered her illness and when in hospital, Client can establish good relationships with family, doctors, nurses who cared for her, client looking anxious, the client can easily adapt to the environment, anxiety scale is 3 (level of concern is increases) 7. Spiritual Clients Moslems, on the hospital client sometimes remembrance and always pray for a speedy recovery illness.
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E. SUPPORTING DATA Examination Hematological Hemoglobin leukocytes Erythrocytes Hematocrite Platelet RDW-CV MCV, MCH, MCHC MCV MCH MCHC differential count Basofil % Eosinophils % Neutrophils % Lymphocytes % Monocytes % Basofil # Eosinophils # Neutrophils # Lymphocytes # Monocytes # Prothrombin time PT results INR Control normal PT APTT APTT result Control normal APTT
Result 11,8 * 9,3 3,81 * 32 * 209 12,7 83,2 31,0 37,2 0,2 3,6 * 67,7 21,9 * 6,6 0,02 0,33 * 6,26 2,03 0,61 13,4 0,96 13,80 32,8 32,20
Reference value 12,0 16,0 4,0 10,5 3,90 - 5,50 35 45 150 450 11,5 - 14,7 80,0 97,0 27,0 32,0 32,0 38,0 0,0 1,0 1,0 3,0 50,0 70,0 25,0 40,0 3,0 9,0
