Case Study

Mrs. Tina is 45 years old. Her weight is 58 kg. The height is 158 cm. She had
complained shortness of breath.
The patient was coughing that last three or more week .She was often awake at
night, either coughing or having drenching night sweats.
Her temperatures was 37,5 C . She also loss of appetite. She had lost 4 kg in
weight. The vital signs showed that HR: 110 bpm, RR: 26 bpm, BP: 130/70
mmHg,

DIALOGUE

N1

: Rifka Amalina

N2

: Ega Silvia Roza

N3

: Raudhatin Jinan

N4

: Melly Elya Yeriza

N5

: Tria Wulandari

Ns. Ega, Roza, and Rifka are discussing the result of physical examination of the
patient.
N1

: Good Morning Ns. Ega.

Ns Roza and I just came from Mrs. Tina s room to do physical examination.

N2

: Morning.
How is the patients condition right now?

N1

: She complained shortness of breath, loss appetite, pain, and cough.

N2

: How is the result of the vital signs?

N1

: The vital signs showed that:

BP: 130/70 mmHg, RR: 26 bpm, HR: 110 bpm, T: 37,5 C.

N2

: So, the temperature and blood pressure of the patient is still normal. The
respiratory rate and pulse of the patiient is abnormal.

N1

: Lets make the nursing diagnosis.

N2

: Ok
10 minutes later....

N2

: Hi Ns. Roza.
As the result of physical examination, the patient complained shortness of breath
and cough which the nursing diagnosis is ineffective airway clearance. Because
the RR is 26 bpm and the pulse is 110 bpm. What do you think?

N3

: Yeah. I agree with you about the diagnose of the patient is ineffective airway
clearance. How about you ns. Rifka?

N1

: Yes, I agree. According to the characteristics of the ineffective airway clearance

such as shortness of breath, coughing, and it all happened to patient

N3

: How about the other diagnosis?

N1

: I think the other diagnose is imbalance nutrition less than body requirements.

N2

: No. In my opinion,the diagnose is activity intolerance based on the data of Mrs.

Tina, she cant do activities normally, then she got shortness of breath.

N1

: No. But the patients complained loss of appetite. Then, she got weight loss of
4 kg. Because of that, I put the nursing diagnosis is imbalance nutrition: less
than body requirements.

N3

: Hmm. The main nursing diagnosis is ineffective airway clearance. The patient
cant do activities normally. The patient complained shortness of breath. So, it
makes the patient s loss appetite. The second diagnose is imbalance nutrition:
less than body requirement. The third diagnose is activity intolerance.

N1

: Yeah. I agree with you.. if the ineffective airway be handled, indirectly

intolerance activities can be completed, it happened because of shortness of
breath.

N3

: What do you think ns. Ega?

N2

: Thats right. I agree with you.

Ns Melly come to the nurses room...

N4

: Hy nurses. What are you doing here? Are there any problems?

N3

: We just discussed the nursing diagnosis of the patient

N5

: Can you tell me the diagnose?

N3

: We get the main diagnose is ineffective airway clearance. The second diagnose
is imbalance nutrition: less than body requirements and activity intolerance.

N4

: So, what are the outcomes that will we take to the patient?

N5

: Not yet. I think Ns. Roza & Ns. Melly have to try take the outcomes.

N3

:Ns. Rifka and I will do physical examination that just arrived in Emergency
room. Its better for you to take the outcomes of the patient now.

Ns. Rifka & Ns. Ega left the room to check the other patients condition. Then, Ns.
Tria& Ns. Melly are discussing the nursing outcomes.
N5

: The main diagnosis is ineffective airway clearance. I think the respiratory

status will take is effective airway clearance.

N4

: Of course. Then, we should make the criteria that will take to Mrs. Tina

N5

: After 24 hours, the criteria that should take to Mrs. Tina are the normal
respiratory rate, ability to take our secretion, breathing pattern normally. How
about you?

N4

: Ok. In my opinion its better to take dyspnea and normal activity.

N5

: I agree with you. How about the outcomes for the second diagnose?

N4

: The nursing outcomes for the second diagnose is nutrition status: food intake
and electrolyte. How about the indicator?

N6

: The indicator for nutrition status that should be achieve are nutrient intake,
food intake, electrolyte, protein, carbohydrates, and mineral.

N4

: Okay nurse. We have done discusssed the nursing outcomes for the patient.
Now, its time to give the other patient injection.

N5

: Yeah... Thats right. Come on nurse.