fractur olecranon

NURSING ASSESSMENT
IN PATIENTS FRAKTUR OLECRANON

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Compiled By:

Windra bangun S

DIII NURSING PROGRAM STUDY
HEALTH SCIENCE HIGH SCHOOL (STIKES) MUHAMMADIYAH
GOMBONG
2011

NURSING ASSESSMENT

Assessment Date         : 2011-04-19

Review Name                         :  -

Room                          : Inayah

Time Assessment        : -

A.    Identity

1.         Client Identity

Name                                : Imam Arifin

Date of Birth                    : 16 may 1993

Age                                  : 18 years old

Gender                             : male

Weight                             : 52 kg

Height                              : 162 cm

Address                            : Sidoharum Rt 03/01

Religion                            : Moslem

Education                         : Wongsorejo vocational High School

Ethnicity                          : Indonesian

Medical Diagnosis           : Fraktur Olecranon sinistra

2.         The identity of responsible person

Name                                : Mrs. Lina

Gender                             : Female

Address                            : Sidoharum Rt 03 / 01

Religion                            : Moslem

Occupation                       : House wife

Education                         : Senior high school

Ethnicity                          : Indonesian

Relationships                    : Mother

B.     Nursing History

1.         Main complaint

Bone Fractures Elbow sinistra because traffic jam

2.         Disease History Now

Clients enter Kebumen Hospital on 18 April 2011 with complaints of pain in the left elbow and left hand parts, high fever.

3.         History Formerly Disease

Client's mother said the client had never been hospitalized, the Client had pain and diarrhea

4.         Family Disease History

Client and Client's mother said there was no hereditary disease in him family

C.    Systematic Assessment

1.         Health Overview

Clients complain of pain with pain once in the elbow and radiating on the left hand accompanied by swelling in the injured area.

2.         Pattern Nutrition

    Clients say eat three meals a day with a menu of rice, egg, drink water before illness.

    At the time of hospital clients eat two meals a day with a menu of porridge, with tofu stew

3.         Elimination Pattern

    Clients say defecate once a day in yellow

    Clients say urinate six times a day with the color yellow.

4.         Activity Pattern

    Clients say rarely exercise, leaving school at 07.00 to go home at 16.00 on a motorcycle.

    Clients say often sleepy during lectures before illness

5.         Pattern Perception

    Clients say there is no problem on the five senses before patient sick.

    At the time of illness, the client says is less clear vision

6.         Rest Pattern

    Before the ill client 21:00 hours sleep a night and wake up at 05.00

    At the time of illness, the client said was difficult to sleep at night.

7.         Social Interaction

    Clients say lazy to go play with friends - theme.

    Clients spend free time to play internet

8.         Patterns of sexual

Unmarried clients, and clients have no problem with sexual function.

9.         Pattern Confidence

Clients said the Islamic religion, always praying, fasting, and diligent

D.    Examination

1.         TTV
Blood Pressure                 : 100/70 mmhg

Respiratory rate                : 24 per minutes

Pulse                                 : 110 per minutes

Body Temperature           : 38,5 C

2.         Physical examination

Head
Neat hair, black hair and smooth, meshocepal head, head a little dizzy

Eye
Normal conjunctiva, is less clear eyesight

Nose
Blocked nose

Ears

There is no wax in ears

Lips and Mouth

Mucosa moist lips, lips slightly injured in an accident.

Chest
Symmetrical lung development, no tenderness, normal lung sounds

Abdomen
There is no bloating, no tenderness, no palpable liver

Extremity
Normal leg movement

Passive hand movement, severe pain in the hand, and swollen

Elimination
Normal elimination patterns were 1 times daily bowel movement, and six-time urination
Physical description

Pain and fever

3.         Examination Support

From the results rongsen, found a shift in the elbow due to severe pounding.

E.     Nursing Diagnosis

     pain associated with physical injury

    damage skin integrity related to pressure, changes in metabolic status, circulation damage and decreased sensation are evidenced by the injury or ulceration, weakness,

F.     Intervention

1.         Pain associated with physical injury

Objectives:
Once the action has been nursing for 7 days fell to expected pain disappear
Criteria Results:

    Client looked calm and comfortable

    client's body temperature is 37 C

    Clients can rest in peace even though there are still restrictions on movement

Intervension

    Do approach the client and family

    Set the client in a comfortable sleeping position

    Check the temperature periodically client

    Provide warm water compresses

    Do distraction relaxation

    Collaboration medical action to give fever-lowering drugs

    Collaborate with physician for infusion and pain-lowering Obet

Implementation

    To approach the client and family

    Setting the client in a comfortable sleeping position

    Check the temperature periodically client

    Provide warm water compresses to relieve pain

    Do distraction therapy for the client more quiet relaxation

    Provide hands buffer (gibs)

    collaborating medical action to give fever-lowering drugs

    collaborate-lowering action of pain, the infusion

Evaluation

    Client says more comfortable to rest

     The client said never again because of fever, chills

    Client feel pain gradually decreased until the pain disappeared after 7 days treatment

    Client successfully perform the action plan as expected.

2.         Damage to skin integrity related to pressure, changes in metabolic status, circulation damage and decreased sensation are evidenced by wounds / ulcerations, weakness,

Objectives:

    After nursing action immediately, it is expected to be overcome and the healing process can be faster

    Criteria Results

    Pain resolved sore on the skin

    Dry skin wounds faster

     Bleeding at the elbow and hand dry.

Intervention

    Assess the location, size and color wound

    Monitor the increase in body temperature.

    Provide wound care with aseptic technique

     Collaboration antibiotics as indicated.

Implementation

    Reviewing the location, size, and color wound

    Monitor the increase in body temperature

    Providing wound care with aseptic technique

     Mengkolaborasi with the doctor for antibiotics as indicated

Evaluation

    Clients say the bleeding stops

    The client says the wound dry

    Clients seem more comfortable and tenderness fade away

G.    Overview About Olecranon Fractures

            Fractures are the normal breakup of a bone or cartilage caused by violence. (E.

Oerswari, 1989: 144).

            Fractures or broken bones are the breakdown of continuity of bone or cartilage tissue

which is generally caused by involuntary (Mansjoer, 2000: 347).

            Olecranon fracture is a fracture that occurs in the elbow caused by direct violence,

usually accompanied by Comminuted and other fractures or anterior dislocation of these joints (FKUI, 1995:553).