Nursing care with atrial septal defect (ASD) Part 1

I. ASSESSMENT

Assessment Date : January 2, 2011

Space : UPJ Dr dr . Kariadi Semarang

How to study : interviews , physical assessment

Date Added : December 26, 2011

A. Demographic Data

1 . Name : Br . W

2 . Age : 19 years

3 . Gender: Female

4 . Religions : Islam

5 . Education : High School

6 . Occupation : Self Employed

7 . Address : Jalan Randu Bukateja RT 3/XI Bukateja Alas , Purbalingga

8 . Ethnicity : Java , Indonesia

9 . Languages ​​: Java , Indonesia

10 . Responsible Person : Mr. . K

11 . Relations : Father client

Main complaints

shortness of breath

Disease History Now

Since about 2 months ago a client complaining of shortness of breath severe enough than usual . Clients feel tired easily , especially when cycling to the workplace, as well as a rather strenuous activity . Then the client check to Nirmala Hospital , Purbalingga near his home . Abdominal ultrasound performed on 18/10/2011 , the results of the examination showed no abnormalities impression , does not seem the tumor mass , and no ascites . Doctors concluded that there is a disturbance in the abdomen . Clients were given the drug and got advice for outpatient .

Perceived tightness of the ever growing client last up to 3 weeks was admitted to the hospital for 9 days with Nirmala oxygenation therapy . Clients are referred to Prof. RS . Dr. . Margono Soekarjo Purwokerto , then was diagnosed heart defects . Due to the limitations of the tools to perform surgery , the client referred to the department Dr . Kariadi Semarang on December 26, 2011 . Sixth day care . Thoracic images has been carried out on December 26, 2011 ( image : Cardiomegaly in LV and RA ; Preview bronchopneumonia ) , an EKG on December 26, 2011 ( image : sinus tachycardia , biatrial enlargement , right bundle branch block , LV hypertrophy with repolarization abnormality , anteroseptal infarct age undermined , abnormal ECG ) , laboratory tests on December 27, 2011 ( uric acid which exceed the normal limit of 7.57 g / dl ) and bacteriological examination . Clients are still complaining a little shortness of breath , cold enough akral , conjunctival pallor , and cyanotic . BP = 90/70 mmHg , HR = 76x/menit , RR = 22x/menit , there is a fixed wide S2 spilled . The client looked weak and pale . Programmed ASD Closure on December 5, 2012 .

Past history of disease

Clients say fatigue when doing daily activities .

Family history of disease

The family said no family history of tumors or cancer , heart disease, hypertension , diabetes , and other genetic diseases .

A. Assessment of Physical

Head	Mesochepal, straight hair, not easy to fall off, a little dry scalp, no dandruff or other debris on the scalp
eye	Symmetrical right and left eye, the pupil diameter 3mm isokor, conjunctival pallor, no jaundice sclera
nose	There is no discharge, clean, no sinus pain, no injuries
Ear	Symmetrical right and left ear, there is little wax, no injuries
mouth	Clean, teeth are still complete, fairly moist lip mucosa
neck	No injuries, no enlargement of the lymph glands and thyroid, no tenderness, abnormal movements, JVP R +4 cm H2O
Thorax	Lungs: I: symmetric, normal posture, maximum expansion, all costa can be seen, there is no use of accessory muscles of breath Pa: tactile fremitus left = right. Pe: left = right resonant Au: right = left = vesicular, no Ronchi, no wheezing heart: I: apical pulsation apparent Pa: pulsation of the aorta and pulmonary palpable Pe: dim, 2nd base ICS, ICS apex 5th mid clavicle Au: normal S1, S2 fixed wide spilled, no gallop, no murmurs, ESM LSB (+) 3/6
Abdomen	I: Flat Au: bowel sounds (+) 15 BPM Pe: Timpani Pa: There is no abdominal distension, no bowel distension and blader, palpable soft, no tenderness
Genitalia	-
Ektremitas	above: Right: no injury, is quite moist skin, brown skin color tends to be pale Left: no injury, the skin tends to be dry, brown skin color tends to center below: Right: no injury, is quite moist skin, brown skin color tends to center Left: no injury, is quite moist skin, brown skin color tends to center

To be continued