CHAPTER I INTRODUCTION

A. Background homeostasis means the resistance or the regulatory mechanism of dynamic equilibrium in the body (organism) which is constant, both psychologically, and mentally. Briefly, homeostasis means balance. homeostasis in the human body is needed to keep all aspects of the body. God has given humans the unique ways in maintaining homeostasis of the body, such as by removing the urine to maintain fluid balance in the body, and sweating to keep the body temperature remained normal. these methods carried after being given a stimulus by the brain to maintain body homeostasis. if there is one aspect that disturbed, there will be problems in the process of homeostasis, the body will require extra effort to maintain the balance of the body, such as excessive sweating, or excessive urine output. B. Purpose 1. provides an overview of the nursing process 2. discuss the nursing process in self hygiene and urinary elimination 3. gives an overview by role-play simulation in self hygiene and urinary elimination 4. inform discussion focuses on all chapters

C. The Scope The scope of the discussion in this paper is anything that have part with a review of the theory, which is nursing assessment, nursing diagnosis, planning, implementation, and evaluation, as well as nursing care with urinary elimination problems and personal hygiene. D. Writing method The method used in this paper are:

1. Literature method the methods used by studying and collecting data from the literature relating to the paper, either a book or information from the Internet 2. Discussion the data obtained by asking questions directly to the mentors and friends who know about the information required in making this paper 3. Study case with fiction case learning by making appropriate nursing care fictional case E. Writing Systematic systematic writing of this paper consists of preface, table of contents consists of six chapters. in Chapter I there are introduction that consists of background, the purpose of writing, scope, method of writing, and writing systematic. then Chapter II there is theoretical background. In Chapter III there are a review of cases such as the nursing process with its sub-chapters. and Chapter IV the screenplay. and in Chapter V, contains discussion. Chapter VI contains conclusions and finally bibliography

CHAPTER II THEORITICAL BACKGROUND

In the nursing process, there are four stages: 1. Assessment The first step is the assessment of the nursing process; the nurse began to apply the knowledge and experience to collect patient data. Nurse applies nursing knowledge and scientific disciplines to explore and discover the unique and personal patient health care issues. Assessment is an early stage, and the main basis of the nursing process. Assessment phase consists of collecting data and formulating the client's needs or problems. Data collected includes data biological, psychological, social, and spiritual. The ability of nurses who are expected to carry out the assessment is to have awareness / self-teller, the ability to observe accurately, therapeutic communication skills and always be able to respond effectively. Basically the purpose of the assessment is to collect objective data and the opinion of the client. The data collected includes the client, family, community, environment, or culture. As for the things that need to be considered during the assessment include: Understanding the overall situation being faced by the client by looking at the physical, psychological, emotional, socialcultural, and spiritual which can affect health status. Gather all the information related to the past, present and even something that could potentially be a problem for the client to create a complete database. Data collected from the nurse-client for interacting and other sources. Secondary sources of information include family members, people who play an important role and the client's health record. Data collection methods include: Conducting interviews / interview. Medical history / nursing Physical examination Collecting data supporting the results of laboratory and other diagnostic and health records (medical records)
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2. Nursing Diagnosis Nursing diagnosis is subjective and objectively analyzes data to make nursing diagnoses. Nursing Diagnosis involves a complex process of thinking about the data gathered from the client, family, medical records and other health care providers. Nursing diagnosis is a diagnosis made by a professional nurse who describes the signs and symptoms that indicate a problem in which the client's perceived health nurses based on education and experience is able to help clients. The North American Nursing Diagnosis Association (NANDA, 1992) defines the kind of nursing diagnoses that include clinical decision the client, family, and community response to something which potential health problems in the process of life. In making nursing diagnoses needed a good clinical skill, including the formulation of nursing diagnoses and nursing in making a statement. The process of nursing diagnoses was divided into groups and ensures the accuracy of the diagnostic interpretation of the nursing process itself. Formulation of nursing diagnoses statements have some requirements that have the knowledge to distinguish between something that is actual, risks, and potential nursing diagnoses. Type of Nursing Diagnosis there are three types according to the NANDA nursing diagnoses are: Actual nursing diagnoses, ie manusian response to kindisi health or life processes are supported by a group including the defining characteristics and related factors (etiology) that have contributed to the development or maintenance of health. Nursing diagnosis risk, namely human shows that response can arise in person or vulnerable groups and supported by risk factors that contributes to the increased susceptibility. Nursing Diagnosis welfare, which outlines human response to the health of the individual or group that has the potential for improving health status is higher. Formulation of the problem. After the nurse completed the assessment, the nurse then selects outcome using identifiers rating scale measurement and desired to be achieved through intervention. The goal in criteria results will provide guidance for nurses to determine the nursing actions and to improve the evaluation of the nurse. Goals should be
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written in terms of behavior. This means that the verb used to indicate the purpose of describing the behavior may be observed and should have a bit of interpretation. Goals should be realistic describing what nurses want to finish up with a specific time. Intervention Nursing plan of action is a series of actions to achieve each specific goal. Planning nursing covers the formulation of objectives, actions, and judgments series of nursing care to clients based on analysis of assessment so that health problems can be addressed and nursing clients. Plans of action tailored to the standards of nursing care mental Indonesia or American standard of nursing care that divides the characteristic form of the action: action counseling, health education, self-care and activities of daily living, nursing modality treatment, ongoing care, collaborative action (somatic therapy and psychopharmacy) . Basically nursing actions consist of action observation and monitoring, therapeutic care, health education and collaborative action. 3. Implementation Implementation is the realization of the plan of treatment and nursing that were prepared in the planning stage (Effendi, 1995). Type of action on the implementation consists of independent action, interdependence / collaboration, and action referral / dependence. Implementation of action plan of action tailored to nursing. In the real situation is often far different from the plan implementation. This happens because the nurse not accustomed to using a written plan to implement nursing actions yet. The usual plan is not written what he/she thinks, feels, was conducted. It is very harmful to the client and the nurse if crucial, and also does not meet the legal aspect. Before determine actions planned, nurses need to validate briefly whether the plan is still appropriate and necessary action in accordance with the client's current condition. Nurses also assess yourself, would have interpersonal skills, intellect, technique according to the measures to be implemented Evaluation refers to the assessment, stages, and repair. At this stage the nurses find the cause of why the nursing process can succeed or fail. Nurses found the client's reaction to nursing interventions that have been given and determine what is the target of the plan is the basis of nursing can given. Nursing plan to support an evaluation. Reassign new information provided to the client to change or delete a nursing diagnosis, goals, or nursing
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interventions. Determining the target of an outcome to be achieved is a joint decision between the nurse and patient. 4. Evaluation Evaluation focused on individual clients and groups of clients themselves. The evaluation process requires some skill in determining the nursing care plan., Including knowledge of the standards of nursing care, the client's normal response to nursing actions and knowledge of the concept model of nursing.

Chapter III CASE STUDY

Case
Ms SY, 19 Years old, hospitalized since 2 days ago at the surgery with lumbar spine fracture IIIIV and tibia fracture on the right leg. compos mentis awareness, attached drip on his right hand, and looks in pain, especially when moving the body. all activities must be helped by nurse and his wife. patients often cannot resist the desire to urinate causing the patient wetting, much sweating, sticky hair, and had unpleasant smells. checking vital signs was performed 4 hours ago with the results: blood pressure 130/70 mmHg, pulse: 88 x / min, respiration: 28 x / minute, and temperature 37.4 C

Assessment
1. Patient identity: Name: Ms. SY Age : 19 years old Sex : Female 2. Subjective data: Patients often cannot resist the desire to urinate causing the patient wetting, much sweating, sticky hair, and had unpleasant smells. 3. Objective data: performed installation of gypsum in the emergency room Compos mentis awareness, attached drip on his right hand, looks in pain, especially when moving the body, Blood pressure 130/70 mmHg Pulse: 88 x/Minute Respiratory: 28 x/Minute Temperature: 37,4OC

Data Analysis
The incapability to fulfill basic needs: Elimination of urine and self hygiene related to the patient's disease; fracture No
1.

Data SD:

Problems Inability to implement

Ethiology Patient had a fracture in

Patients often cannot urinary elimination resist the desire to procedures and personal urinate causing the hygiene procedures. patient wetting, much sweating, sticky hair, and had unpleasant smells. Performed installation of gypsum in the emergency room Compos mentis awareness, attached drip on his right hand, looks in pain, especially when moving the body, Blood pressure 130/70 mmHg Pulse: 88 x/Minute Respiratory: 28 x/Minute Temperature: 37,4OC

his right leg, and can not perform mobility

DO:

Nursing Diagnosis
1. Inability to perform urinary elimination procedure due to the patient's right leg fracture. 2. Inability to perform Self Hygiene procedure due to the patient's right leg fracture.

Nursing Plan
Nursing Diagnosis 1. Inability to perform urinary elimination procedure due to the patient's right leg fracture. Goals and Outcomes Goals: - incapability of Urinary elimination problem resolved in 1 x 24 hours Outcomes: - Patient stop doing - the urine elimination on the bed Goals: - Incapability to fullfil the self hygiene procedure resolved in 1 x 24 hours Actions Implement the settling Urine catheter procedures to the patient

2. Inability to perform Self Hygiene procedure due to the patient's right leg fracture.

Implement the Bathing procedure to the patient Implement the hair washing procedure to the patient

Outcomes: - Patients body no longer feels sticky - Patients body becomes fresh and sweet - Patients hair feel refreshed and no longer sticky

Implementation
Day/date/time
Nursing diagnosis number

Action

Result the patient Urine Elimination controlled The patient stopped doing urine elimination directly on the mattress Patients hair feel refreshed and no longer sticky Patients body no longer feels sticky Patients body becomes fresh and sweet

Sign

- pairing the settling

Wednesday, December 12nd ,2012, 09.00 WIB 1 Urine catheter to the patient using settling urine procedure

13.00 WIB 2 13.00 WIB 2

Washing patient hair

Bathing the patient

Evaluation
Day/date/time Nursing diagnosis number Development Sign

Thursday, December rd 13 ,2012, 09.00 WIB

S: The patient said that his bed is no longer wet and no longer do the urine elimination on the bed. O: patient urinates regularly and collected into the urine bag. A: the problem in the inability in doing the urine elimination resolved. Q: action checked regularly, keep monitoring the patient's condition. S: Patient's says her hair feels fresh and sweet O: Patient's cleaned hair once in 2 days A: Problem solved P: Actions performed regularly
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S: Patient's says that his body feels fresh and comfortable O: help patient bathing 1 times per day minimum. A: Problem solved Q: actions performed regularly

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CHAPTER IV SCENARIO

In a international hospital in Jakarta, there is a patient, her name is Ms. SY (initial), 19 years, hospitalized since 2 days ago at the surgery with lumbar spine fracture III-IV and tibia fracture on the right leg so she cannot fulfill her urinary elimination and self hygiene, she is in the observation by three nurses who also deal with patients' families, and theres also her mother who faithfully accompanies her children all day.

In the morning, at the patient room, come nurse 1 and start talking with Ms. SY. Nurse 1 Patient Nurse 1 Patient Nurse 1 : Good morning, Maam? My name is nurse umi, and i here to check your health status. : Yes, Nurse, please. : how do you feel now? :after the surgery, i cant hold my pee, so i just peeing on bed. An that causing the bed wet. That also make my body feel sticky and uncomfortable. : Okay, before we go on, I will check your vital sign first, that contains checking the blood pressure, the respiration, the temperature and the pulse. Are you ready? : Yes, Nurse. : Okay, I will go out now and prepare the tools. (Nurses preparing the tools)

Patient Nurse 1

A few moments later, the nurse brings the tools needed for the vital sign. Nurse 1 : Okay maam. I will start checking your temperature measurement first , then checking the other vital signs. ---------------------------------------------------------------------------------------------------Nurse 1 Patient Nurse 1 : Well, it's done. (Explains this examination) : okay, thank you nurse. : You're welcome. (Directly speak to patient's family). At the next time, the examination will be continued by my friend. (back to the patient) if you need any help. Just press the bell on the left of you, okay?

Patient's mom : Well okay. Thank you Nurse. After that the nurse 1 out from the room, nurse 1 is explaining to the nurse 2 about the results from the test that already done and make nursing plans for Ms. SY at the office on 14.00 pm.

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Nurse 2 Nurse 1

: Good afternoon Nurse Umi, so? What will we do now? : Good Afternoon Nurse, i need your help to check the Ms. SY condition. Lets discuss it now. nurse, around 08.00 I have made observations to Ms. SY and this is the results,the patient hospitalized since 2 days ago at the surgery with lumbar spine fracture III-IV and tibia fracture on the right leg, the patient also had a urinary incontinence, and patient has some self hygiene problem. When i check the patient vital signs. The results are: blood pressure about 130/70 mmHg, the pulse about 88 x / minutes, the respiration about 28 x/ minute and the axillary temperature is 37.4 degrees Celsius. : so? What intervention shall i do to miss SY? : The intervention are put the settled catether to the patient and help her to fullfill her self hygiene, such as bathing and washing hairs. : All right, then. Ill do it now.

Nurse 2 Nurse 1 Nurse 2

Nurse 1 left the office room, and the nurse 2 set the tools that will be used for further action to Nn.SY. after that, Nurses 2 go to the patient's room. Nurse 2 : Good afternoon, madame.

Patients mom : oh yes, good afternoon, Nurse. Nurse 2 : My name is nurse ifa. I will be nursing your daughter for now. now i will do the catheter procedure to help your daughter urinate constantly and make sure your daughter wont urinate in the bed. Do you agree?

Patients mom : yes. I am agree, nurse. Nurse 2 : okay then, i will go out for a moment to set up the equipment, and then, go back to here again in a few minutes. (the nurse left the patient and preparing the equipment needed)

Nurse 2 go back to the patient room with the equipment needed and tell the patient the condition. After that, nurse 2 begin to installing the curtain, washing hand, putting the sterile handscoon, and start the urine catheter procedure. Nurse 2 Patients : well, i will begin to put you a catheter urine. Please just be relax. It will help make you more comfortabe. (do the procedure) : okay nurse, thank you. im ready.

(The nurse Start applying the condom catheter to the patient) Nurse 2 : okay maam, the catheter already installed. So you dont need to go back to the bathroom and stop peeing in bed. now, i will bath you and also wash your hair so you will become more relax and comfy. : yes nurse. But can i use my own soap and shampoo? : of course, you can. (start bathing and washing hair procedure)

Patients Nurse 2

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(After completion) Nurse 2 Patient Nurse 2 : how do feel now, maam? : I feel great! My body isnt sticky and smelly anymore, and my hair isnt tangled again, so light and fresh. : so maam, im done putting the catheter on you and done shampooing. Now i will out, but if you need help, you can call me by pressing the button on the left side of you. Okay? : okay nurse. Thank you very much. : Youre welcome. (out from the patient room)

Patient nurse 2

Nurses 2 back into the office and immediately made plans for further action. Nurse 2 in the office discussing with bruder 1 to continue the implementation and evaluation. Nurse 2 Bruder 1 : Good evening bruder Cahyo, please continue the condition development of Ms.SY, here is the data. : (read the data) oh, okay. Ill do it now.

At patient room Bruder 1 Patient Bruder 1 : Good evening Miss. My name is bruder cahyo and im here to continue the check your vital sign tonight. Are you willing? : yes, I willing. : well, please wait a second. Ill prepare all equipment first. Okay? (leave the patient)

A few moments later the nurse returned with the equipment for patients vital examination. Bruder 1 : well, I'll start checking the condition of you. (Inspection action)

A few minutes later the bruder had done doing the physical examination. Patient Bruder 1 : Bruder, how is my condition? : well, its better than yesterday. Now you just need to take a rest. I will go out now. but if you need me, you can call me just by pressing the button on your left side. : yes bruder, thank you. : its nothing. (Leaves the room)

Patient Bruder 3

Bruder 1 out from the room and go back to the office to make implementation and evaluation. Later on in the morning, the nurse 1 meet bruder 1 to submit the result of the implementation and the evaluation Nurse 1 : Good morning bruder cahyo, how is the patient? Is the evaluation done?

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Bruder 1

: good morning too nurse, Ms. SY is keep improving, the evaluation has also completed (while handing the evaluation)

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CHAPTER V

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CHAPTER VI CONCLUSION

Nurse 1 diagnosed the patients. Ms. SY were hospitalized since 2 days ago at the surgery with lumbar spine fracture III-IV and tibia fracture on the right leg, so she cannot fulfill the urinary elimination and personal hygiene especially in giving the patient bath and washing the patient hair. After that Nurse 2 action will be associated with urinary incontinence Ms. SY overcome with the catheter in order not to urinate on mattresses uncontrollably, then the action of bathing the patient and do the personal hair hygiene with hair combing and washing patient hair. After that, Bruder 1 checking vital sign during the night to find Ms. SY development. Ms. SY is being checked by 3 nurses to see the patient's progress to determine intervent to be done again until the patient fully recovered.

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