I. HEALTH HISTORY A.

DEMOGRAPHIC DATA
FULL NAME GENDER AGE BIRTHDATE CIVIL STATUS RACE/NATIONALITY RELIGION
MUSLIM

: J.P

: MALE

FEMALE

:46 tahun :sonder,12/01/1966 :

MARRIED SINGLE DIVORCED INDONESIA CHATOLIC OTHER PROTESTANT WIDOWED / WIDOWER

: :

BORN AGAIN CHRISTIAN OTHER

FULL ADDRESS CONTACT NUMBER E-MAIL ADDRESS EDUCATIONAL BACKGROUND

:Sonder, Kauneran Jaga III :::

ELEM. GRAD ELEM. UNDERGRAD H.S. UNDERGRAD COLLEGE UNDERGRAD H.S. GRAD COLLEGE GRAD

OTHER SIGNIFICANT TRAINING OCCUPATION SIGNIFICANT TRAINING OCUPATION (PRESENT/USUAL) USUAL SOURCE OF MED. CARE

:-

:: FARMER : (Check all that applies.)

HILOT ALBULARYO HEALTH CENTER SELF-MEDICATION OTHER FAMILY DOCTOR

DATE OF ADMISSION ADMISSION DIAGNOSIS

: 20 Juni 2012 : GOUT ARTHRITIS

B. SOURCE & RELIABILITY OF INFO.

PATIENT PATIENTS SISTER OTHER :

C. REASONS FOR SEEKING CARE : Patient come with joint pain, pale, and feel nausea.

D. HX OF PRESENT ILLNESS/HEALTH :
The painhas beengoing on sinceoneyearago. Clientsalsosaid thepainfeltlike stabbing, pain scale6 (moderate), pain in thejoints ofthe feet andhands andapain2 to3 hours.

ONSET FREQUENCY DURATION LOCATION QUALITY/CHARACTER QUANTITY/SEVERITY

: since a year ago : moderate : a pain in the joints two up to three hours : joints of the feet and hands :the pain feel like stabbing : on the scale 0-10 with 10 the worst. Patient feel the pain in scale 6

ASSOCIATED PHENOMENA/FACTORS: life style AGGRAVATING FACTORS :consume the foods with high purines and smoking ALLEVIATING FACTORS CLIENTS PERCEPTION ADMITTED BY : reduced the activity, consume the food with low purines and consume the medicine from doctors : patient hope to get the health condition :SELF ADMIITED
RELATIVE OTHER

ADMITTED VIA

:AMBULATORY
STRETCHER AMBULANCE

E. PAST MEDICAL HX
CHILDHOOD ILLNESS ADULT ILLNESS INJURIES/ACCIDENTS :::-

PRIOR HOSPITALIZATIONS : At Gunung maria Hospital PAST SURGICAL OPS. IMMUNIZATIONS :: COMPLETE
INCOMPLETE

FOOD ALLERGIES MEDICATION ALLERGIES

::-

MEDICATIONS BEING TAKEN BEFORE HOSPITALIZATION : medicine just from shop LAST MEDICAL CHECK-UP : May 2012 MENSTRUAL HISTORY FOR FEMALE CLIENT : -

AGE OF ONSET REGULARITY

:-

USUAL # OF DAYS : REGULAR :-

:-

IRREGULAR

AGE OF MENOPAUSAL ONSET

OBSTETRIC HISTORY FOR FEMALE CLIENT : IF PREGNANT : GRAVIDA : PARA :

IF NON PREGNANT :

F. FAMILY HISTORY :

Tn. JP

Legend :

male

female

G. SOCIO-ECONOMIC DATA
HOUSE OWNERSHIP : OWNED
RENTED SHARED

HOUSES NUMBER OF STOREYS HOUSEMATES

:: parents : WARM & FRIENDLY

FAIRLY WELL HOSTILE

RELATIONSHIP WITH HOUSEMATES

SOURCE OF INCOME MONTHLY INCOME

: garden :-

RECEIVES FINANCIAL CONTRIBUTION FROM ANYONE ? WATER SOURCE : WATER DISCRIT

COMMUNAL

WATER REFILLING STATION DEEP WELL OTHER

METHOD OF GARBAGE DISPOSAL : OPEN PIT

BURNING GARBAGE COLLECTOR OTHER

FACILITIES & INSTITUTIONS NEARBY HOME :HEALTH CENTER

POLICE STATION CHURCH SCHOOL

BARANGGAY HALL

FIRE STATION HOSPITAL WET MARKET

MALL/COMMERCIAL CENTER OTHER

MODE OF TRANSPORTATION USUALLY USED

:TRICYCLE
SIDE CAR JEEPNEY MINI BUS OWNED VEHICLE

RELATIONSHIP WITH NEIGHBORS IN GENERAL : WARM & FRIENDLY

FAIRLY WELL HOSTILE

INVOLVEMENT IN COMMUNITY SERVICES

: UNINVOLVED
INVOLVED

H. DEVELOPMENTAL HISTORY

I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE ROS (includes history of illness or complaints) - all subjective Patient said that he felt pain since a year ago,the pain like stabbing in the foot and hands. b. Integument Patient said there were no injuries but the skin feel dry. c. Head Patient said there is no lesion. PE (includes assessment via IPPA) - all objective the patient seemed to withstand the pain. the scale of pain is 6(moderate). the skin seemed dry, there no wound and the skin is good The head looks symmetrical, no lessions, no lumps,the scalp

System

a. General/overall health

clean, and the hair slightly oil. d. Eyes Patient said never had eye disease before and not use glasses. The eyes looks symmetrical, sklera icterus, conjunctiva anemis. e. Ears f. Nose and Sinuses Patient said never had ear disease. the ears looks symmetrical. Mouth looks clean and there is no swelling. h. Neck There is no swelling in lymph nodes. i. Breast and Axially j. Respiratory breast and axially looks symmetrical. Frequency of respiratory is 22X/m, regular rhythm, and kind of respiratory is chest. k. Cardiovascular Ictus cordis cant be seen but can palpated with gentle vibration, patient doesnt use a pacemaker. l. Urinary Patient said he always consume the water about 2.000cc and have a pee about 4 time a day. m. Genitalia There is no hemoroid or inflamation. n. Musculoskeletal o. Neurologic p. Hematologic q. Endocrine Palpated suprapubica the bladder is empty.

g. Mouth and Throat -

2. LABORATORY STUDIES/DIAGNOSTICS Procedure Date 20 June 2012 Indication Normal Values / Findings Actual - Findings Nursing Responsibillities/Implications (PRE, INTRA, POST)

Urine Check up : 1. Leukosit 2. Eritrosit 3. Sel e.p 4. Kristal 5. Silinder 6. Bacterium 7. Dll 1. 0-2 2. 0-1 3. + 4. Amoniumurat + 5. 6. 7.

20 June 2012

Blood Check up : 1. Urea-UV 2. Creatinine 3. Uric-acid 1. 1050m g/dl 2. 01,3m g/dl 3. 3,47mg/ dl. 1. 219mg/dl 2. 8,5mg/dl 3. 10,4mg/dl

3. OTHER ASSESMENT TOOLS Date (s) taken Comprehensive Actual Content / Legend Actual Result

J. FUNCTIONAL ASSESMENT
A. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
CLIENTS PERCEPTION OF HEALTH :patient

thinks that health is the most important

thing and must keep health.

HEALTH BEFORE HOSPITALIZATION :when

sick patient just a buy the medicine of

shop and use without doctor instruction.

MOST IMPORTANT THINGS DONE TO MAINTAIN HEALTH :

to keep the diet

especially do not consume the foot with high purine

CLIENTS PERCEPTION OF WHAT MIGHT HAVE CAUSED CURRENT ILLNESS :because bad

life style.

CLIENTS UNDERSTANDING / AWARENESS OF HIS / HER MEDICAL DIAGNOSIS: client

understand about her medical diagnosis.

COMPLIANCE WITH DOCTORS ORDERS, DRUG REGIMEN, & MEDICAL TREATMENTS :there is

no complaint about doctors orders, drug regimen and

medical.
B. SELF PERCEPTION / SELF CONCEPT PATTERN
CLIENTS PERCEPTION OF SELF (FEELS GOOD / BAD ABOUT SELF?) : feels LEVEL OF COMFORT WITH SELF :

good

good

PERCEPTION ON BODY IMAGE :good CHANGES IN FEELINGS ABOUT SELF SINCE ILLNESS BEGAN :he felt

slightly inferior

with him self.

ANY CURRENT EMOTIONS (ANXIETY, FEAR? WHAT HELPS TO RELIEVE THESE FEELINGS?) : sometimes he feels

anxiety about his condition.

C. ACTIVITY / EXERCISE PATTERN

TYPICAL ACTIVITIES OF DAILY LIVING :work SUFFICIENCY OF ENERGY FOR A.D.L : EXERCISE PATTERN, REGULARITY, & TYPE(S) : LEISURE / RECREATIONAL ACTIVITIES : FUNCTIONAL LEVEL CLASSIFICATION :
FEEDING BATHING TOILING/WORKING BED MOBILITY DRESSING :2 :2 :2 :1 :2 GROOMING GEN. MOBILITY COOKING HOME MAIN SHOPPING :2 :2 :5 :5 :5

at garden

Legend 0 1 2 Full self-care

Functional Level Code

Requires use of equipments or device Requires assistance or supervision from another person

3 4

Requires assistance or supervision from anotherperson or device Is dependent and does not participate

D. SLEEP REST PATTERN

TYPICAL HOURS OF SLEEP AT NIGHT, TIME USUALLY ASLEEP & TIME USUALLY AWOKEN:6

hours. wake up at night because the pain.

SLEEPING PATTERN, STRAIGHT SLEEP OR THERE TIMES WHEN SLEEP IS DISTURBED? : Sometimes patient

FEELS GOOD UPON WAKING UP? : No USE OF SLEEPING AIDS :DAYTIME NAPS; DAILY? FROM WHAT TIME & UNTIL WHAT TIME? : yes.

E. NUTRITION / ELIMINATION PATTERN

CLIENTS HEIGHT : 166 cm CLIENTS WEIGHT : 54 kg USUAL EATING PATTERN, TYPICAL DAILY FOOD INTAKE : patient usual eating 30gr protein with carbohidrat. FOOD INTAKE: portion. USE OF SUPPLEMENTS : RECENT WEIGHT LOSS OR WEIGHT GAIN : APPETITE :moderate FOOD ALLERGIES : EATING DISCOMFORTS : DIET RESTRICTIONS : high purine DENTAL PROBLEMS : CONDITION OF INTEGUMENT; SPEED OF HEALING WHEN () WOUNDS:BOWEL ELIMINATION PATTERN : 2 times a day URINARY ELIMINATION PATTERN : 4 times a day EXCESS PESPIRATION; PRESENCE OF ODOR PROBLEMS : -

F. SEXUALITY / REPRODUCTIVE PATTERN

ORIENTATION TO OWN SEXUALITY (IF APPROPRIATE) : STATUS OF SEXUAL RELATIONS; CHANGES OR PROBLEMS; SATISFICATION/ DISSATISFICATION : USE OF CONTRACEPTIVES : REPRODUCTIVE PATTERN : -

G. INTERPERSONAL RELATIONSHIPS PATTERN

FAMILIAL ROLE : GOOD SOCIAL ROLE : GOOD GETS ALONG WELL WITH FRIENDS, CO-WORKERS, PEERS, NEW ACQUAINTANCES?

H. COPING / STRESS TOLERANCE PATTERN

CURRENT CONCERNS : YES STRESS IN LIFE; CHANGES IN LIFESTYLE : YES METHOD USED TO RELIEVE STRESS; STRESS-RELIEF METHODS EFFECTIVENESS: WALK OUT AND ACT ACCORDINGLY. METHOD OF HANDLING BIG PROBLEMS; EFFECTIVENESS; PERSON APPROACHED FOR HELP : DISSCUS WITH HIS FAMILY

I. PERSONAL HABITS
P.P.D. (PACK PER DAY) :1 P.P.D.X ALCOHOL : SOMETIMES STREET DRUGS : YR. (S) OF SMOKING TOBACCO :

J. ENVIRONMENTAL HAZARDS
NEIGHBORHOOD AIR POLLUTION : NEIGHBORHOOD WATER POLLUTION : NEIGHBORHOOD SOIL POLLUTION : NEIGHBORHOOD NOISE POLLUTION : OVERALL SAFETY OF NEIGHBORHOOD : WORK ENVIRONMENT; PRESENCE OF WORK ENVIRONMENT HAZARDS : -

II. PROBLEM LIST A. ACTUAL or Active Problem Problem No. 1. Pain associated with inflammatory processes. Data Identified DS : patient said the pain has been going on since 1 year ago. DO : the pain felt like stabbing and scale is 6. The patient seen grimacing. 2. physical mobility impaired associated with pain. DS : patient said the activity has stop and the daily activity should need the help of others. 22 june 2012 Date Resolved / Remarks 22 june 2012

DO : the daily activity like eat, bath, dressing, grooming, defecation, urination, and mobilization in bad need help by the others.

B. HIGH RISK or Potential Problem No. Problem Data Identified

III. NURSING CARE PLAN

CUES NURSING DIAGNOSIS BACKGROUND KNOWLEDGE LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

ndx 1

Pain associated with

DS : patient said the pain has been going

Patien patient t can cope the pain s showe dpainr esolve din time 3X24 hours

1.TTVobservati

1.Paincan affectTTV 2.assist indetermini ng the need forpain managemen t. 3.Bed restis necessaryto limit pain/joint injuries(up toobjective and subjectivei mprovemen

S: Patients say his legs are still aching joints O: patients seen still wince when the foot touched A: Pain is not resolved P: Intervention s continued 1. TTV observations 2. Investigate complaints of pain and

ons 2.Assesspain leveland recordthe location andintensity of pain(scale0-10) 3.Let thepatienttakea comfortable positiononabed orsittingin a chair, Boostbreaks atappropriatein dications

inflammato on since 1 year ry processes. ago. DO : the pain felt like stabbing and scale is 6. The patient seen grimacing.

4.Pushtofrequen tobtained) tlychange positions, 4.Preventin gthe

tomovein bed. 5.Encouragethe use ofstressmanage menttechniques eg.

occurrence ofgeneral fatigueand joint stiffness. 5.Increasere

record the location and intensity of pain (scale 0-10) 3. Let the patient take a comfortable position on a bed or sitting in a chair, Boost breaks at appropriate indications. 4.Pushtofreq uentlychang e positions, tomovein bed. 5.Encourage the use ofstressman agementtech niqueseg. relaxationte chniques 6.Collaborat iononanalge sicmedicatio n/therapyco ntinue.

relaxationtechni laxationand ques a sense

6.Engageinrecre ofcontrol ational activitiesapprop riatetothe whenpain 6.Focus attention

individualsituati andincrease on. 7.Collaboration ofanalgesicdrug s. the sense ofself andfeeling healthycele brants 7.As ananalgesict o relieve pain.

Ndx 2

physical mobility impaired associated with pain.

DS : patient said the activity has stop and the daily activity should need the help of others. DO : the daily activity like eat, bath, dressing, grooming, defecation, urination, and mobilization in bad need help by the others.

patien patient tis able to donor is able to dodail y

malda activiti ilyacti eswith vities again out thehel p of othersi n the 3X24 hours.

1. Maintain bed rest breaks if necessary. 2. Assist with range of motion active / passive if possible 3. Change the position of patients with frequent 4. Evaluation of monitoring the level of pain / inflammation in the joints.

1.Restis recommend edtoprevent

S:The patientsays it is

fatigueandm stillweak aintainpowe r 2.Mengingk atkanjoint function, muscle strength andgenerals tamina. 3.Relieving pressure on thetissueand increase circulation 4.Dependin g on theactivity levelofresol ution/progre ssionof inflammator yprocesses. tomovethem selves O: patientsstill can notperform daily activitiesthe mselves A: Activity intoleranceis not resolved P: Intervention scontinued 1.maintainb ed restbreaks 2.assistivera nge of motionactiv e /passivewith therequested moving thelegsandar msslowly 3.reposition thepatient

4.evaluation of monitoringl evelsof pain /inflammati onin the joints.

Subject Lecturer

: English in nursing 3 : Wahyuni Langelo BSN M.kes

NURSING CARE IN PATIENTS WITH GOUT ARTHRITIS

By group 5 Members of group : Renitha Pumadada Charly Londa Novilia P Tambajong Nelva Sagala Vica Safitri Ayu Indri H Solitan Ketut Swiranata

FACULTY OF NURSING DE LA SALLE CATHOLIC UNIVERSITY MANADO 2012

INTRODUCTION

Thank God we prayed to the Lord the Almighty's blessings and His grace so that we can complete the group of five papers "NURSING CARE IN PATIENTS WITH GOUT ARTHRITIS" well. We thank the subjects English lecturers in Nursing who has provided guidance and direction for us. In making this paper we realized is far from perfection, for that we are expecting criticism and constructive suggestions from readers for better preparation of the next paper to be useful for all of us. Hopefully, this paper can provide a benefit to us, especially for my friends in learning and increase student knowledge about gout arthritis.

Manado, Desember17th 2012

Group V