CHAPTER I
INTRODUCTION
A. Background
Swedish national health insurance data from the statistical analysis reported 53% in populations with normal activities of daily experience lower back pain and 64% in population activities as heavy workers.
An estimated 60% to 80% of the adult population had experienced LBP, approximately 2% to 5% affected per year. People who are at work doing the repetitive bending or squatting, and sitting long had a higher frequency of LBP, psychosocial problems are also important as a trigger factor of lower back pain.
Meanwhile, in particular to the General Hospital of Islam Banjarmasin found the number of patients low back pain in January up to December 2003 as many as 17 people (Medical Record Data Islamic Hospital Banjarmasin).
In terms of disease treatment in general on LBP with other neurological diseases have similarities in the delivery of nursing care focuses on meeting basic human needs. The specificity of perawataan clients with LBP is due to problems that arise are complex and usually affects the body's system so that nursing care provided to prevent the occurrence of neurological deficits, deliver and restore function by increasing the activity gradually by doing a range of mation (ROM) active and passive .
There are several problems were found that nursing standards established hospitals can not be achieved to the maximum, of the reasons clients such as economic factors in which clients with LBP takes a long time to heal and thus require substantial funds if it should be treated in the hospital, while from the hospital for example is still a lack of health personnel compared to the amount by the number of clients who need care so that not every client can be served up by the standards of nursing at the hospital.
Based on the above phenomenon the authors are interested in raising health concerns, especially LBP and try to provide nursing care as a whole both in terms of biopsychosocial and spiritual to clients with LBP in the Ibn Sina Hospital Banjarmasin Islam.
B. General Purpose
Provide an overview of the implementation of nursing care clients with low back pain in the Ibn Sina Hospital Banjarmasin Islam.
C. Specific Objectives
The specific objectives of this paper is to perform the steps of the nursing process in stages, namely:
1. assess the health status of clients with low back pain, which includes aspects of the biopsychosocial spiritual Mr. H.T in space Banjarmasin Islam Ibn Sina Hospital.
2. Review and formulate nursing problems that arise in clients with low back pain in space Banjarmasin Islam Ibn Sina Hospital.
3. Determine a plan of action on the client with low back pain on Mr. H.T in space Banjarmasin Islam Ibn Sina Hospital.
4. Action / implementation of nursing to clients of low back pain due to interference on the client biopsychosocial spiritual Mr. H.T room Banjarmasin Islam Ibn Sina Hospital.
5. Evaluate the results of nursing care given to clients with low back pain on the client Mr. H.T room Banjarmasin Islam Ibn Sina Hospital.
D. Methods of care
Writing method used in the care of clients who reported this form of case studies that reported the results of nursing care directly implemented on the client with the approach of the nursing process which consists of assessment, nursing diagnosis, setting planning, implementing and evaluating the results of nursing care.
CHAPTER II
THEORETICAL REVIEW
LOW BACK PAIN AND CARE nursing
A. Theoretical Overview of Low Back Pain
1. Understanding
Lower back pain is a feeling of tenderness in the area and sakroiliakal lumbasakral, lower back pain is often accompanied by the propagation ketungkai to toe. (Harsono, 2000:265).
Disc herniation (carram) intervertebral (HNP) is a major cause of severe lower back pain, chronic and recurring (relapse), probably as a result of trauma or degenerative changes associated with aging. (Doenges, Marylinn, 1999:320).
Lower back pain is pain that is felt lower back area, can be a local or radicular pain or both, the pain is felt among the lowest point of the ribs (thoracic XII) and fold under the buttocks and lumbar area lumbasakral and often accompanied by pain spreading towards the legs and feet .
Low back pain, lower back pain is one of the most common pain in daily practice, is also a problem because society often lead to people unable to work in daily life.
Low back pain may be feeling a little stiff kemeng or until the pain completely, this pain may arise suddenly or gradually within a few hours to several days. The pain may be felt on the back of the body, from the last rib to the bottom of the buttocks and can also spread ketungkai. Often people worry if LBPnya derived from kidney disease or bladder stones that assumption is not always true.
If carefully considered the complaints of LBP vary widely, the quality of pain, intensity and distribution vary widely, a variety of posture such as standing, sitting or lying very influential on the emergence of pain.
2. Etiology
The division of etiology based on anatomical systems:
a. LBP Viserogenik (abdominal organs)
Abnormalities derived from kidney, pelvic viscera, the omentum minor, retroperitoneal tumors, fibroids retrouteri
b. LBP Verkulogenik (blood vessels)
Diabdomen aneurysm, vascular disease perifes, insufiensi of arterial glutea superior
c. LBP Neuvogenik
Tumors located Extradural and intradural extra medullar often causes LBP therefore also suppress radik.
d. LBP Spondilogenik
Derived from:
1) Bone koluma cord (trauma, inflammation, tumors, metabolic, and spondylolisthesis)
2) Joint-sendir sakroiliakan
3) The soft tissue (disc degeneration, disc aptur, clamping the nerve roots caused by spinal stenosis.
e. LBP Psychogenic
Can be caused by depression, anxiety and neurosis
Another division is based on etiology:
a. Traumatic LBP
1) LBP on the element miofasial
2) LBP caused by trauma to the hard component composition neuromuskuloskeletal
b. LBP due to the degenerative process that includes
1) Spondylosis
2) HNP
3) Spinal Stenosis
4) Oesteoartritis
c. LBP due to inflammatory disease that is
1) rheumatoid arthritis
2) spondylitis angkilopoetika
3) Spondylitis
d. LBP caused by metabolic disorders such as osteoporosis bone
e. LBP due to neoplasms
1) Tumor myelum
2) Retikulosis
f. LBP due to congenital abnormalities
g. LBP as pain refered
h. LBP due to interference sirkulatorik
i. LBP because psikoneurotik
3. Pathophysiology
Vertebral column can be considered as an elastic rod that is composed of many rigid unit (vertebrae) and flexible units (intervertebral disc) are tied to one another by a complex facet joints, ligaments and muscles paravertebralis variety.
Backs such unique construction allows flexibility while on the other hand can still provide maximum protection for the spinal cord. Curvature of the spine will absorb vertical shocks while running or jumping. Torso help stabilize the spine. Abdominal muscles and the piston is very important to the activity of lifting weights. If you have never used this will weaken the support structure. Obesity, posture problems, structural problems, and excessive stretching of supporting the spine can cause back pain.
Intervertebral discs will change the nature of old when you get older. In young people, especially the discus with a matrix composed of fibrocartilage gelatinus. In the elderly will become fibrocartilage dense and irregular. Disc degeneration is a common cause of back pain lower lumbar discs, L4-L5 and L5-S1, suffered the most severe mechanical stress and changes in the heaviest degeneration. Disc protrusion (herniation of nucleus pulposus) or facet joint damage can result when the emphasis on the nerve roots exit the spinal canal resulting in pain that spreads along the nerve. Approximately 12% of people with lower back pain hernia nucleus pulposus (Brunner & Suddarth, 2002: 2321).
4. Clinical Manifestations
In practical clinical manifestations drawn from the distribution system based on anatomy:
a. LBP Viscerogenik
This type is often severe pain is not increased in the presence of activity and rest. Generally accompanied by specific symptoms of organ viseralnya. More often caused by gynecologic factors, sometimes obtained paravertebralis muscle spasm and Ferguson angle changes on radiological examination, pain is also called flank pain due to Referred pain.
b. LBP vasculogenic
Early stages pain is only just back pain that is felt, the pain is back pain, pain often radiating kebokong, rear thigh, and both legs, pain often radiating kebokong, rear thigh, and both legs. Pain does not arise because of a specific stress on the spine (bending, coughing, etc.). Diagnosis is established when a lump is found that berpulpasi.
c. Neurogenic LBP
Pain is very severe, is persistent, slightly reduced during quiet stand up, especially felt at the time of night. Pain can be generated by the activity, and pain is reduced when the patient is lying down, often derived nerve root compression, muscle spasm was also found paravertebralis.
d. LBP Spondilogenik
What is often found are:
1) HNP: Pain is accompanied iskialgia, perceived as low back pain, radiating kebokong, hamstrings telapan heel until the foot.
2) Miofasial: Pain due to trauma to the muscle fascia or ligaments, complaints of pain lumbar region, less can be located to the right, suddenly arise when conducting a movement beyond the limits of his muscles.
3) Malignancy: Malignant tumors in the vertebrae may be primary or secondary. In X-rays seen any destruction, laboratory tests alkalifostase visible increase.
4) osteoporotic: Occurs in the elderly, especially women, pain is aching or radicular pain due to compression fractures as a complication of spinal osterporosis.
e. LBP Psychogenic
Complaints of severe pain is not balanced with organic abnormalities are found, the patient chose a defense mechanism against the threat of feeling safe with if not avoid doing certain things. This situation will cause the muscles in a state of tension thereby increasing muscle spasm and pain arise.
5. Examination Support
Physical examination:
a. Observation: observe the patient at the time how to walk into the examination room, also a favorite way to sit. When the lame, dragged, stiff (an indication for neurologic examination). Observe also whether the patient's behavior is consistent with complaints of pain (the possibility of excess psychiatric).
b. Inspection: to the vertebral column (thoroko-lumbar and lumbopsakral) follows deformitasnya, as well as the movement of the spine, such as forward flexion, backward extension, flexion kelateral right and left.
c. Pain that arises in almost every movement of the lumbar region, so people walking very carefully (the possibility of infection, inflammation, tumors and fractures)
d. Palpation: whether there is tenderness in the spine or the muscles beside the spine? Does the pressure of between two spinous prosessus cause pain (Spurling sign)
e. Percussion: note whether there is pain if the processus spinosus diketok
Neurologic examination of the legs
a. Sensibility (dermatome), motor (strength), muscle tone, reflexes, tropic.
b. Provocation test (sensory)
1) Laseque
2) Dry
3) Bragard and sicard
4) Patrick (lesion coxae)
5) Cons Patrik (lesion Sakroiliakal)
c. Are there micturition and defecation disorders
d. Are there signs of upper motor neuron lesion (UMN) and lower motor neuron (LMN)
Diagnostic Examination
a. Lumbar function: Knowing the color of cerebrospinal fluid (water clear, yellowish / xantokram, cloudy), the appearance of blockages / barriers to the flow of cerebrospinal fluid total or partial, the number of cells, the levels of protein, NaCl and glucose.
b. X-rays: Identifying a fracture vertebral bodies, arch or spinous processes, as well as the dislocation of the vertebrae, spionfilolistesis, bamboo spine vertebral destruction, HNP
c. Electroneuromiografi: Seeing the fibrillation, and can also be calculated speed and letensi distal nerve conductivity.
d. Tomography scan of: Can view pictures vetebra and surrounding tissues including the intervertebral discs
(Harsono, 2000:281)
6. Medical management
a. Bed rest:
Bed with a hard, flat tool to loosen muscle spasm, resulting in maximum muscle relaxation. Fouled off below the knee to reduce lumbar hiperlordosis, long bed rest is not more than 1 week.
b. Medical mentosa:
Using a single drug or in combination with a dose semiminimal possible, be given non-steroidal analgesic, muscle relaxant, tranguilizer, anti-depressant medication or sometimes neuratik blockade.
c. Physiotherapy:
In the form of heat therapy, peripheral electrical stimulation, pelvic traction, exercise therapy and ortesa (kovset)
d. Psychotherapy:
Given to people who on examination found the role of psychopathology in the onset of pain perception, providing psychotherapy may be combined with relaxation, and biofeedback training hyprosis.
e. Acupuncture:
The possibility of working with the way the establishment of neurohumoral substances as neurotras Mitter and worked as an activator intibitor descending fibers which then closes the pain gate.
f. Therapy operatic:
If conservative measures do not provide tangible results, or cases of fracture which directly resulted in neurologic deficits, or any disturbance spinger
g. Exercise:
Exercise needs to be done carefully and directed so as not to aggravate the situation, can be started on day 2 and 3 except if the cause is a disc herniation.
B. Overview of Theoretical Nursing Care Low Back Pain
1. Assessment
a. Activity and rest
1) Symptoms: a history of work that needs to lift heavy objects, sitting, driving in a long time, require the board / mat sleep time, decreased range of motion of ekstrimiter on one part of the body, unable to perform activities that are usually performed.
2) Signs: muscle atrophy in the affected body part, disturbances in walking.
b. Elimination
Symptoms: Contribution, have difficulty in defecation, the inkontenensia / retention of urine
c. Ego Integrity
1) Symptom: Fear of onset of paralysis, anxiety about work, family financially.
2) Signs: Looks worried, defresi, away from family / significant others
d. Neurosensori
1) Symptoms: Tingling, stiffness, weakness of the hands / feet
2) Signs: The reduction in deep tendon reflexes, muscle weakness, hipotania, tenderness / spasm pavavertebralis, persesi decrease pain (sensory)
e. Pain / comfort
1) Symptoms: Pain like a knife wound that would worsen in the presence of cough, sneeze, bend the body, lifting defecation, lifting legs, or flexion of the neck, pain that there is no ending or the presence of more severe episodes of pain in interminten; pain radiating to legs, buttocks (lumbar) or shoulder / arm; stiffness in the neck (cervical). There was the sound of "crick" when the pain starts / when trauma or feeling "broken backs", limited to mobilization / bending forward
2) Signs: Attitude: the way back from the affected body part, changes in gait: walk with a limp, waist up on the affected body part, pain on palpation.
f. Security
Symptoms: A history of back problems that just happened
g. Guidance and learning
1) Symptoms: Lifestyle; monotonous or hyperactive
2) Consideration: DRG showed an average treatment: 10.8 days
3) Plan of repatriation: It might take a rock transportation, personal care and completion of tasks.
2. Nursing Diagnosis
a. Acute / chronic relate to:
1) Trauma and reflex spasm of the muscle tissue
2) Inflammation
3) Compression of nerve
b. Damage to physical mobility related to
1) Pain and discomfort
2) Muscle Spasms
3) Therapy testriktif
4) Neuromuscular Kerusanan
c. Anxiety / ineffective individual coping related to
1) Crisis situations
2) Overcome / change in health status, socioeconomic status, role function
3) recurrent disorder with continuous pain
4) Ketidakadekuatan methods of coping
d. Lack of knowledge (learning needs) about the condition, pragnosis, and actions related to:
1) Errors of information / lack of knowledge
2) Errors of interpretation of information about mengungat
3) Not knowing the sources of information
Priority nursing
1. Reduce stress on the spine, muscle spasm, and pain
2. Improve functioning optimally
3. Provide support to patient / family / significant others in the process of rehabilitation
4. Provide information related to disease / prignosis and needs treatment.
3. Intervention Nursing
Diagnosis I
a. Assess complaints of pain, record the location, duration of the attack, trigger factors that aggravate, ask the patient to determine on a scale of 0-10
b. Maintain bed rest during the acute phase, laying the patient in semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position with or without elevating the head of 10-30 degrees or in lateral position
c. Use logirdi (board) during a change of position
d. Auxiliary mounting brace / corset
e. Limit activity during as needed
f. Put all needs, including call bell within easy reach / reached by the patient.
Diagnosis II
a. Provide security measures as indicated by the specific situation
b. Note the emotional responses / behaviors in immobilization provide activities tailored to the client
c. Follow the activity / procedure with a rest period, instruct the patient to continue to participate in daily activities
d. Give / aids patients to perform passive range of motion exercises and active
e. Assist patients in ambulation activity progressively
f. Demonstrate the use of auxiliary equipment such as a walker, cane
Diagnosis III
a. Assess the client's anxiety level, determine how patients deal with the problem in the past and how patients make coping with the problem now.
b. Provide accurate information and answer honestly
c. Provide an opportunity for patients to disclose the problem
d. Review of secondary problems that may impede the desire to heal and may impede the healing process
e. Note the behavior of the nearest person / family that increased "sick role" patient.
IV Diagnosis
a. Explain the process of disease and prognisis and restriction of activities
b. Provide information about various things and instruct the patient to make changes in "body mechanics" without the help and also do exercises
c. Discuss about the treatment and its side effects, as well as some drugs that cause drowsiness are very heavy (analgesic, muscle relaxant)
d. Discuss about dietary needs
e. Avoid the use of heaters in a long time
f. Refer back to the use of a soft neck kakolar
4. Evaluation
Diagnosis I
a. Eliminating pain is gone / controlled
b. Disclose a method that provides removal
c. Demonstrate the use of interventions (eg relaxation skills) to relieve pain.
Diagnosis II
a. Expressing understanding of the situation / risk factors and individualized treatment rules
b. Demonstrate techniques / behaviors that may
c. Maintain or improve strength and function of diseased body parts and / or compensation
Diagnosis III
a. Looks relaxed and reported anisetas reduced in level can be overcome
b. Identify inefficiencies coping behavior and its consequences
c. Accurately assess the latest situation
d. Demonstrate problem solving skills
e. Develop a plan for lifestyle changes that need to be
IV Diagnosis
a. Expressing understanding of the condition, prognosis and action
b. Doing back lifestyle changes
c. Participate in the rule action
CHAPTER III
CARE PRODUCTS
A. Case illustration
Mr. HT age of 60 years, male gender, past junior high school education, private employment, address Jl. Prince Gang Rahman, married marital status, religion, ethnicity Banjar, Banjarmasin Islamic hospitalized on June 4, 2004 with a medical diagnosis of low back pain (lower back pain).
Over at the hospital who was in charge of the client is Mr. R. age 34 years, addresses the complex Full Sakti Banjarmasin.
The main complaint when admitted to hospital on June 4, 2004: hip pain behind the left side of a half months ago and the pain in right shoulder blade (scapula). Time of assessment (dated June 9, 2004) The client is still complaining of low back pain behind the left side to right manjalar.
History of present illness ± 1 month ago a client fell from the vehicle but the client is not to be taken to the hospital just brought ketukang massage and drinking store-bought medications to relieve pain. Half months later the client complains of low back pain behind the left side. On 03-06-2004 the client brought his family kepraktek dr. Djohan S, then the client is getting worse because of illness on 05-06-2004 client brought his family to the Islamic Hospital and treated dikamar Banjarmasin 35B in the Ibn Sina.
Past history of disease ± 5 years ago a client had experienced hypertension, diabetes and high cholesterol, but not to the hospital only outpatient treatment.
Family history of disease according to the client's family no family clients who have suffered from diseases such as client or DM disease, hypertension and tuberculosis.
From a physical examination on June 9, 2004 obtained the results of the general state of awareness the client is compos mentis. GCS 4-5-6, the results of measurements of vital signs: BP: 140/80 mmHg, T: 37.2 ° C, N: 100 x / min, R: 24 m / min, weight: 70 kg. Client's circumstances seem weak and lethargic.
The results of examination of the skin, skin success obtained clean (no dirt), brown skin color, smooth skin texture, no odema.
Head of the neck, head structure appears symmetrical, there is no pain or trauma to the head, no lesions, graying black hair color, hair distribution evenly, there is no enlargement of the neck or thyroid gland lugularis vein.
Sight and eyes, the eyes of the client looks symmetrical, there is no dirt or secret, the client can see with both eyes can be driven kesegala direction. Clients do not use visual aids, not jaundiced eye sclera, conjunctiva anemis not, the client looks listless eyes, blackish color around the eyes.
Smell and nose, nasal structure is symmetrical, it seems clear there is no secret, or dirt, no bleeding or epistaxis, no inflammation or pain in the nose, olfactory function either can distinguish the smell of alcohol and eucalyptus oil, there is no mass (polyp).
Hearing and ear, symmetrical structure of the ear, looks clean does ada secret or fluid, no bleeding or inflammation, either auditory function, do not use hearing aids.
The mouth and teeth, the color pink lips mokusa, mouth and tongue besih, no bleeding and lesions, there is a single tooth, chewing function properly, do not use dentures.
Chest, breathing and circulation, symmetrical movement of the chest cavity, chest cavity shape is symmetrical between left and right, the frequency of 24 breaths / min, and in regular rhythm, sometimes cough, no shortness of breath, no pain, breathing through the nose, not using the muscles of respiration, no additional audible breath sounds, chest resonant to percussion.
Abdomen, abdominal shape is symmetrical between left and right, there was no abdominal distension, bowel sounds audible 6 x / minute, the client is experiencing lower back pain radiating from the left goto the right side, pain scale 4 (heavy) 0 1 2 3 4 5 Frequency of pain continues continuous and more severe when the motion, the quantity of prickling pain, no tenderness in the left hip.
Genitalia and reproduction, there is no inflammation of the genetalia inside and out, there is no difficulty when erect and ejakuasi, there is no pain when urinating, there is no net genetalian hygiene lesions, lice, redness and ekskoriasi.
Upper and lower extremities, the structure of the left and right extremities and symmetric, the structure of the left and right lower extremities symmetrically, in the right lower extremity is attached infusion RL 20 tts / min drif toradol an ampoule, low back pain worse when the lower extremity motion, muscle strength scale.
Description:
4 = Can be moved against gravity with some resistance
of examiner
3 = Can be driven against gravity but can not withstand
custody of the examiner
Activity and rest, daily client home just rest and not work anymore, nap 1-2 hours / day and night sleep 6-8 hours / day. At the hospital, the client just lying in bed, and the scale of activity 2 (physical mobility is assisted by someone else entirely). The client complained of can not sleep because of low back pain sleep eating only ± 2 hours, clients often wake up during sleep.
Personal hygiene in the client's home bath 2 x 3 x daily, brush your teeth 2 times a day, wash it 1 -2 times a week, cut the nails when the length, change clothes when dirty. At the hospital, the client swabbed 1 x daily by his family, occasionally brushing teeth, nails short, change clothes when dirty.
Nutrition, at the client's home to eat 3 times a day, regular diet of rice and other clients according to taste, good appetite, drinking 6-8 glasses of water a day. At the hospital, clients eat 3 times a day sometimes up sometimes not a single serving, there is appetite but lost when the pain worse, drinking 3-4 glasses of water a day, diet TKTP BB.
Elimination in the client's home said the current Chapter 1-2 times daily, the consistency of soft, yellowish color, foul odor. CHAPTER smooth 3-4 x daily, clear yellow color of urine odor. At the hospital, SECTION 1 x daily, soft consistency, odor, BAK 2-3 times daily, clear, yellowish color, the smell of urine.
Sexuality clients are married have a wife and 4 children, a client relationship with the wife and children well
Psychosocial, good client relationships with nurses. Clients want to communicate with the nurse, client relationship with the family well, it looks from the wife and children to accompany and assist the client always a client's activities, the client looks stoic face of illness
Spiritual, a Muslim client, the client is always a regular home prayer 5 times, while in the hospital clients also pray if only for the client is always in bed and prayed for his recovery.
Supporting Data
Therapy / treatment (June 4, 2004)
- Injection Acran 2 x 1 amp
- Myonal 3 x 1 tab
- Lytadex 3 x 1 tab
- Trolip 300 2 x 1
- 3 x CI Dulcolaxtol
- Pronalges 100 1-0-1
- Esilgan 2 mg 0-0-1
Additional therapy (June 9, 2004)
- Inj stesolid / diazepam ½ amp night
- MST 10 mg 1-0-1
- Fundamine 3 x 1
The results of radiological examinations on June 5, 2004
Shoulder joint AP Ext (24 x 30)
Results: The suspect fibro sarcoma
Clinical laboratory dated June 4, 2004
a. Blood chemistry
- Fasting Blood Sugar: 114.5 mg / dl Normal: 75-115 mg / dl
- Blood sugar 2 hours pp: 149 mg / dl Normal: 125 mg / dl
b. Test liver physiology
- ALT: 18.2 U / L Normal: up to 12 mg / dl
c. Test renal physiology
- Creatinine: 0.8 mm / dl Normal: 0.6 to 1.1 mg / dl
- Uric acid: 4.9 mg / dl Normal: 3.4 to 7.0 mg / dl
d. Blood fat
- Choksterol: 178.6 mg / dl Normal: up to 200 mg / dl
- Triglycerides: 256m5 mg / dl Normal: 60-15 mg / dl
Data Focus
1) Data inspection:
a. Clients seemed to grimace in pain scale 4 (heavy) 0 1 2 3 4 5
b. Clients sometimes cough
c. Black line appears around the eyes
d. The client was restless
e. Frequency of breath 24x/menit
2) Palpation:
a. There is tenderness in the left hip
b. Pulse rate 100 times / minute
3) Percussion: -
4) Auscultation: -
B. Analysis and Nursing Diagnosis
No Data Problem Etiology
1 2 3 4
A DO:
- Medical Diagnosis of low back pain status
- The client looks grimacing in pain
- Client was restless
- Vital signs:
BP: 140/80 mmHg
T: 37.2 ° C
N: 100 x / minute
R: 24 x / minute
DS:
- The client complained of radiating pain in the left dish gets right to the pain scale 4 (heavy)
0 1 2 3 4 5
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
Impaired sense of comfort (acute pain) Reflection muscle spasm secondary to pressure nervous edge of the waist area
A
2 3 4
2 DO:
- Clients appear weak and lethargic
- Looks blackish color around the eyes.
- Vital signs:
BP: 140/80 mmHg
T: 37.2 ° C
N: 100 x / minute
R: 24 x / minute
DS:
- The client complained of can not sleep because of low back pain radiating to the left to right with the pain scale 4 (heavy)
0 1 2 3 4 5
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
- The client said that the longest night sleep ± 2 hours the client is often awakened during sleep
Patterns of rest and sleep disorders Pain in left waist
A
2 3 4
3 DO:
- The client seemed to just lay in bed
- The client looks winced in pain when doing the client can only move in bed with the Bantu family with the scale of activity 2 (fully assisted by others)
DS:
- The client said he was very sore when doing the movement with a pain scale of 4 (very severe)
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
- Damage to physical mobility secondary to pain muscle spasm
Priority issues:
1. Impaired sense of comfort (acute pain) are associated with reflex muscle spasm secondary to pressure syaraftapi arrangement of the lumbar region.
2. Patterns of rest and sleep disorders associated with pain in left hip
3. Damage to physical mobility related to pain secondary to muscle spasm
INTRODUCTION
A. Background
Swedish national health insurance data from the statistical analysis reported 53% in populations with normal activities of daily experience lower back pain and 64% in population activities as heavy workers.
An estimated 60% to 80% of the adult population had experienced LBP, approximately 2% to 5% affected per year. People who are at work doing the repetitive bending or squatting, and sitting long had a higher frequency of LBP, psychosocial problems are also important as a trigger factor of lower back pain.
Meanwhile, in particular to the General Hospital of Islam Banjarmasin found the number of patients low back pain in January up to December 2003 as many as 17 people (Medical Record Data Islamic Hospital Banjarmasin).
In terms of disease treatment in general on LBP with other neurological diseases have similarities in the delivery of nursing care focuses on meeting basic human needs. The specificity of perawataan clients with LBP is due to problems that arise are complex and usually affects the body's system so that nursing care provided to prevent the occurrence of neurological deficits, deliver and restore function by increasing the activity gradually by doing a range of mation (ROM) active and passive .
There are several problems were found that nursing standards established hospitals can not be achieved to the maximum, of the reasons clients such as economic factors in which clients with LBP takes a long time to heal and thus require substantial funds if it should be treated in the hospital, while from the hospital for example is still a lack of health personnel compared to the amount by the number of clients who need care so that not every client can be served up by the standards of nursing at the hospital.
Based on the above phenomenon the authors are interested in raising health concerns, especially LBP and try to provide nursing care as a whole both in terms of biopsychosocial and spiritual to clients with LBP in the Ibn Sina Hospital Banjarmasin Islam.
B. General Purpose
Provide an overview of the implementation of nursing care clients with low back pain in the Ibn Sina Hospital Banjarmasin Islam.
C. Specific Objectives
The specific objectives of this paper is to perform the steps of the nursing process in stages, namely:
1. assess the health status of clients with low back pain, which includes aspects of the biopsychosocial spiritual Mr. H.T in space Banjarmasin Islam Ibn Sina Hospital.
2. Review and formulate nursing problems that arise in clients with low back pain in space Banjarmasin Islam Ibn Sina Hospital.
3. Determine a plan of action on the client with low back pain on Mr. H.T in space Banjarmasin Islam Ibn Sina Hospital.
4. Action / implementation of nursing to clients of low back pain due to interference on the client biopsychosocial spiritual Mr. H.T room Banjarmasin Islam Ibn Sina Hospital.
5. Evaluate the results of nursing care given to clients with low back pain on the client Mr. H.T room Banjarmasin Islam Ibn Sina Hospital.
D. Methods of care
Writing method used in the care of clients who reported this form of case studies that reported the results of nursing care directly implemented on the client with the approach of the nursing process which consists of assessment, nursing diagnosis, setting planning, implementing and evaluating the results of nursing care.
CHAPTER II
THEORETICAL REVIEW
LOW BACK PAIN AND CARE nursing
A. Theoretical Overview of Low Back Pain
1. Understanding
Lower back pain is a feeling of tenderness in the area and sakroiliakal lumbasakral, lower back pain is often accompanied by the propagation ketungkai to toe. (Harsono, 2000:265).
Disc herniation (carram) intervertebral (HNP) is a major cause of severe lower back pain, chronic and recurring (relapse), probably as a result of trauma or degenerative changes associated with aging. (Doenges, Marylinn, 1999:320).
Lower back pain is pain that is felt lower back area, can be a local or radicular pain or both, the pain is felt among the lowest point of the ribs (thoracic XII) and fold under the buttocks and lumbar area lumbasakral and often accompanied by pain spreading towards the legs and feet .
Low back pain, lower back pain is one of the most common pain in daily practice, is also a problem because society often lead to people unable to work in daily life.
Low back pain may be feeling a little stiff kemeng or until the pain completely, this pain may arise suddenly or gradually within a few hours to several days. The pain may be felt on the back of the body, from the last rib to the bottom of the buttocks and can also spread ketungkai. Often people worry if LBPnya derived from kidney disease or bladder stones that assumption is not always true.
If carefully considered the complaints of LBP vary widely, the quality of pain, intensity and distribution vary widely, a variety of posture such as standing, sitting or lying very influential on the emergence of pain.
2. Etiology
The division of etiology based on anatomical systems:
a. LBP Viserogenik (abdominal organs)
Abnormalities derived from kidney, pelvic viscera, the omentum minor, retroperitoneal tumors, fibroids retrouteri
b. LBP Verkulogenik (blood vessels)
Diabdomen aneurysm, vascular disease perifes, insufiensi of arterial glutea superior
c. LBP Neuvogenik
Tumors located Extradural and intradural extra medullar often causes LBP therefore also suppress radik.
d. LBP Spondilogenik
Derived from:
1) Bone koluma cord (trauma, inflammation, tumors, metabolic, and spondylolisthesis)
2) Joint-sendir sakroiliakan
3) The soft tissue (disc degeneration, disc aptur, clamping the nerve roots caused by spinal stenosis.
e. LBP Psychogenic
Can be caused by depression, anxiety and neurosis
Another division is based on etiology:
a. Traumatic LBP
1) LBP on the element miofasial
2) LBP caused by trauma to the hard component composition neuromuskuloskeletal
b. LBP due to the degenerative process that includes
1) Spondylosis
2) HNP
3) Spinal Stenosis
4) Oesteoartritis
c. LBP due to inflammatory disease that is
1) rheumatoid arthritis
2) spondylitis angkilopoetika
3) Spondylitis
d. LBP caused by metabolic disorders such as osteoporosis bone
e. LBP due to neoplasms
1) Tumor myelum
2) Retikulosis
f. LBP due to congenital abnormalities
g. LBP as pain refered
h. LBP due to interference sirkulatorik
i. LBP because psikoneurotik
3. Pathophysiology
Vertebral column can be considered as an elastic rod that is composed of many rigid unit (vertebrae) and flexible units (intervertebral disc) are tied to one another by a complex facet joints, ligaments and muscles paravertebralis variety.
Backs such unique construction allows flexibility while on the other hand can still provide maximum protection for the spinal cord. Curvature of the spine will absorb vertical shocks while running or jumping. Torso help stabilize the spine. Abdominal muscles and the piston is very important to the activity of lifting weights. If you have never used this will weaken the support structure. Obesity, posture problems, structural problems, and excessive stretching of supporting the spine can cause back pain.
Intervertebral discs will change the nature of old when you get older. In young people, especially the discus with a matrix composed of fibrocartilage gelatinus. In the elderly will become fibrocartilage dense and irregular. Disc degeneration is a common cause of back pain lower lumbar discs, L4-L5 and L5-S1, suffered the most severe mechanical stress and changes in the heaviest degeneration. Disc protrusion (herniation of nucleus pulposus) or facet joint damage can result when the emphasis on the nerve roots exit the spinal canal resulting in pain that spreads along the nerve. Approximately 12% of people with lower back pain hernia nucleus pulposus (Brunner & Suddarth, 2002: 2321).
4. Clinical Manifestations
In practical clinical manifestations drawn from the distribution system based on anatomy:
a. LBP Viscerogenik
This type is often severe pain is not increased in the presence of activity and rest. Generally accompanied by specific symptoms of organ viseralnya. More often caused by gynecologic factors, sometimes obtained paravertebralis muscle spasm and Ferguson angle changes on radiological examination, pain is also called flank pain due to Referred pain.
b. LBP vasculogenic
Early stages pain is only just back pain that is felt, the pain is back pain, pain often radiating kebokong, rear thigh, and both legs, pain often radiating kebokong, rear thigh, and both legs. Pain does not arise because of a specific stress on the spine (bending, coughing, etc.). Diagnosis is established when a lump is found that berpulpasi.
c. Neurogenic LBP
Pain is very severe, is persistent, slightly reduced during quiet stand up, especially felt at the time of night. Pain can be generated by the activity, and pain is reduced when the patient is lying down, often derived nerve root compression, muscle spasm was also found paravertebralis.
d. LBP Spondilogenik
What is often found are:
1) HNP: Pain is accompanied iskialgia, perceived as low back pain, radiating kebokong, hamstrings telapan heel until the foot.
2) Miofasial: Pain due to trauma to the muscle fascia or ligaments, complaints of pain lumbar region, less can be located to the right, suddenly arise when conducting a movement beyond the limits of his muscles.
3) Malignancy: Malignant tumors in the vertebrae may be primary or secondary. In X-rays seen any destruction, laboratory tests alkalifostase visible increase.
4) osteoporotic: Occurs in the elderly, especially women, pain is aching or radicular pain due to compression fractures as a complication of spinal osterporosis.
e. LBP Psychogenic
Complaints of severe pain is not balanced with organic abnormalities are found, the patient chose a defense mechanism against the threat of feeling safe with if not avoid doing certain things. This situation will cause the muscles in a state of tension thereby increasing muscle spasm and pain arise.
5. Examination Support
Physical examination:
a. Observation: observe the patient at the time how to walk into the examination room, also a favorite way to sit. When the lame, dragged, stiff (an indication for neurologic examination). Observe also whether the patient's behavior is consistent with complaints of pain (the possibility of excess psychiatric).
b. Inspection: to the vertebral column (thoroko-lumbar and lumbopsakral) follows deformitasnya, as well as the movement of the spine, such as forward flexion, backward extension, flexion kelateral right and left.
c. Pain that arises in almost every movement of the lumbar region, so people walking very carefully (the possibility of infection, inflammation, tumors and fractures)
d. Palpation: whether there is tenderness in the spine or the muscles beside the spine? Does the pressure of between two spinous prosessus cause pain (Spurling sign)
e. Percussion: note whether there is pain if the processus spinosus diketok
Neurologic examination of the legs
a. Sensibility (dermatome), motor (strength), muscle tone, reflexes, tropic.
b. Provocation test (sensory)
1) Laseque
2) Dry
3) Bragard and sicard
4) Patrick (lesion coxae)
5) Cons Patrik (lesion Sakroiliakal)
c. Are there micturition and defecation disorders
d. Are there signs of upper motor neuron lesion (UMN) and lower motor neuron (LMN)
Diagnostic Examination
a. Lumbar function: Knowing the color of cerebrospinal fluid (water clear, yellowish / xantokram, cloudy), the appearance of blockages / barriers to the flow of cerebrospinal fluid total or partial, the number of cells, the levels of protein, NaCl and glucose.
b. X-rays: Identifying a fracture vertebral bodies, arch or spinous processes, as well as the dislocation of the vertebrae, spionfilolistesis, bamboo spine vertebral destruction, HNP
c. Electroneuromiografi: Seeing the fibrillation, and can also be calculated speed and letensi distal nerve conductivity.
d. Tomography scan of: Can view pictures vetebra and surrounding tissues including the intervertebral discs
(Harsono, 2000:281)
6. Medical management
a. Bed rest:
Bed with a hard, flat tool to loosen muscle spasm, resulting in maximum muscle relaxation. Fouled off below the knee to reduce lumbar hiperlordosis, long bed rest is not more than 1 week.
b. Medical mentosa:
Using a single drug or in combination with a dose semiminimal possible, be given non-steroidal analgesic, muscle relaxant, tranguilizer, anti-depressant medication or sometimes neuratik blockade.
c. Physiotherapy:
In the form of heat therapy, peripheral electrical stimulation, pelvic traction, exercise therapy and ortesa (kovset)
d. Psychotherapy:
Given to people who on examination found the role of psychopathology in the onset of pain perception, providing psychotherapy may be combined with relaxation, and biofeedback training hyprosis.
e. Acupuncture:
The possibility of working with the way the establishment of neurohumoral substances as neurotras Mitter and worked as an activator intibitor descending fibers which then closes the pain gate.
f. Therapy operatic:
If conservative measures do not provide tangible results, or cases of fracture which directly resulted in neurologic deficits, or any disturbance spinger
g. Exercise:
Exercise needs to be done carefully and directed so as not to aggravate the situation, can be started on day 2 and 3 except if the cause is a disc herniation.
B. Overview of Theoretical Nursing Care Low Back Pain
1. Assessment
a. Activity and rest
1) Symptoms: a history of work that needs to lift heavy objects, sitting, driving in a long time, require the board / mat sleep time, decreased range of motion of ekstrimiter on one part of the body, unable to perform activities that are usually performed.
2) Signs: muscle atrophy in the affected body part, disturbances in walking.
b. Elimination
Symptoms: Contribution, have difficulty in defecation, the inkontenensia / retention of urine
c. Ego Integrity
1) Symptom: Fear of onset of paralysis, anxiety about work, family financially.
2) Signs: Looks worried, defresi, away from family / significant others
d. Neurosensori
1) Symptoms: Tingling, stiffness, weakness of the hands / feet
2) Signs: The reduction in deep tendon reflexes, muscle weakness, hipotania, tenderness / spasm pavavertebralis, persesi decrease pain (sensory)
e. Pain / comfort
1) Symptoms: Pain like a knife wound that would worsen in the presence of cough, sneeze, bend the body, lifting defecation, lifting legs, or flexion of the neck, pain that there is no ending or the presence of more severe episodes of pain in interminten; pain radiating to legs, buttocks (lumbar) or shoulder / arm; stiffness in the neck (cervical). There was the sound of "crick" when the pain starts / when trauma or feeling "broken backs", limited to mobilization / bending forward
2) Signs: Attitude: the way back from the affected body part, changes in gait: walk with a limp, waist up on the affected body part, pain on palpation.
f. Security
Symptoms: A history of back problems that just happened
g. Guidance and learning
1) Symptoms: Lifestyle; monotonous or hyperactive
2) Consideration: DRG showed an average treatment: 10.8 days
3) Plan of repatriation: It might take a rock transportation, personal care and completion of tasks.
2. Nursing Diagnosis
a. Acute / chronic relate to:
1) Trauma and reflex spasm of the muscle tissue
2) Inflammation
3) Compression of nerve
b. Damage to physical mobility related to
1) Pain and discomfort
2) Muscle Spasms
3) Therapy testriktif
4) Neuromuscular Kerusanan
c. Anxiety / ineffective individual coping related to
1) Crisis situations
2) Overcome / change in health status, socioeconomic status, role function
3) recurrent disorder with continuous pain
4) Ketidakadekuatan methods of coping
d. Lack of knowledge (learning needs) about the condition, pragnosis, and actions related to:
1) Errors of information / lack of knowledge
2) Errors of interpretation of information about mengungat
3) Not knowing the sources of information
Priority nursing
1. Reduce stress on the spine, muscle spasm, and pain
2. Improve functioning optimally
3. Provide support to patient / family / significant others in the process of rehabilitation
4. Provide information related to disease / prignosis and needs treatment.
3. Intervention Nursing
Diagnosis I
a. Assess complaints of pain, record the location, duration of the attack, trigger factors that aggravate, ask the patient to determine on a scale of 0-10
b. Maintain bed rest during the acute phase, laying the patient in semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position with or without elevating the head of 10-30 degrees or in lateral position
c. Use logirdi (board) during a change of position
d. Auxiliary mounting brace / corset
e. Limit activity during as needed
f. Put all needs, including call bell within easy reach / reached by the patient.
Diagnosis II
a. Provide security measures as indicated by the specific situation
b. Note the emotional responses / behaviors in immobilization provide activities tailored to the client
c. Follow the activity / procedure with a rest period, instruct the patient to continue to participate in daily activities
d. Give / aids patients to perform passive range of motion exercises and active
e. Assist patients in ambulation activity progressively
f. Demonstrate the use of auxiliary equipment such as a walker, cane
Diagnosis III
a. Assess the client's anxiety level, determine how patients deal with the problem in the past and how patients make coping with the problem now.
b. Provide accurate information and answer honestly
c. Provide an opportunity for patients to disclose the problem
d. Review of secondary problems that may impede the desire to heal and may impede the healing process
e. Note the behavior of the nearest person / family that increased "sick role" patient.
IV Diagnosis
a. Explain the process of disease and prognisis and restriction of activities
b. Provide information about various things and instruct the patient to make changes in "body mechanics" without the help and also do exercises
c. Discuss about the treatment and its side effects, as well as some drugs that cause drowsiness are very heavy (analgesic, muscle relaxant)
d. Discuss about dietary needs
e. Avoid the use of heaters in a long time
f. Refer back to the use of a soft neck kakolar
4. Evaluation
Diagnosis I
a. Eliminating pain is gone / controlled
b. Disclose a method that provides removal
c. Demonstrate the use of interventions (eg relaxation skills) to relieve pain.
Diagnosis II
a. Expressing understanding of the situation / risk factors and individualized treatment rules
b. Demonstrate techniques / behaviors that may
c. Maintain or improve strength and function of diseased body parts and / or compensation
Diagnosis III
a. Looks relaxed and reported anisetas reduced in level can be overcome
b. Identify inefficiencies coping behavior and its consequences
c. Accurately assess the latest situation
d. Demonstrate problem solving skills
e. Develop a plan for lifestyle changes that need to be
IV Diagnosis
a. Expressing understanding of the condition, prognosis and action
b. Doing back lifestyle changes
c. Participate in the rule action
CHAPTER III
CARE PRODUCTS
A. Case illustration
Mr. HT age of 60 years, male gender, past junior high school education, private employment, address Jl. Prince Gang Rahman, married marital status, religion, ethnicity Banjar, Banjarmasin Islamic hospitalized on June 4, 2004 with a medical diagnosis of low back pain (lower back pain).
Over at the hospital who was in charge of the client is Mr. R. age 34 years, addresses the complex Full Sakti Banjarmasin.
The main complaint when admitted to hospital on June 4, 2004: hip pain behind the left side of a half months ago and the pain in right shoulder blade (scapula). Time of assessment (dated June 9, 2004) The client is still complaining of low back pain behind the left side to right manjalar.
History of present illness ± 1 month ago a client fell from the vehicle but the client is not to be taken to the hospital just brought ketukang massage and drinking store-bought medications to relieve pain. Half months later the client complains of low back pain behind the left side. On 03-06-2004 the client brought his family kepraktek dr. Djohan S, then the client is getting worse because of illness on 05-06-2004 client brought his family to the Islamic Hospital and treated dikamar Banjarmasin 35B in the Ibn Sina.
Past history of disease ± 5 years ago a client had experienced hypertension, diabetes and high cholesterol, but not to the hospital only outpatient treatment.
Family history of disease according to the client's family no family clients who have suffered from diseases such as client or DM disease, hypertension and tuberculosis.
From a physical examination on June 9, 2004 obtained the results of the general state of awareness the client is compos mentis. GCS 4-5-6, the results of measurements of vital signs: BP: 140/80 mmHg, T: 37.2 ° C, N: 100 x / min, R: 24 m / min, weight: 70 kg. Client's circumstances seem weak and lethargic.
The results of examination of the skin, skin success obtained clean (no dirt), brown skin color, smooth skin texture, no odema.
Head of the neck, head structure appears symmetrical, there is no pain or trauma to the head, no lesions, graying black hair color, hair distribution evenly, there is no enlargement of the neck or thyroid gland lugularis vein.
Sight and eyes, the eyes of the client looks symmetrical, there is no dirt or secret, the client can see with both eyes can be driven kesegala direction. Clients do not use visual aids, not jaundiced eye sclera, conjunctiva anemis not, the client looks listless eyes, blackish color around the eyes.
Smell and nose, nasal structure is symmetrical, it seems clear there is no secret, or dirt, no bleeding or epistaxis, no inflammation or pain in the nose, olfactory function either can distinguish the smell of alcohol and eucalyptus oil, there is no mass (polyp).
Hearing and ear, symmetrical structure of the ear, looks clean does ada secret or fluid, no bleeding or inflammation, either auditory function, do not use hearing aids.
The mouth and teeth, the color pink lips mokusa, mouth and tongue besih, no bleeding and lesions, there is a single tooth, chewing function properly, do not use dentures.
Chest, breathing and circulation, symmetrical movement of the chest cavity, chest cavity shape is symmetrical between left and right, the frequency of 24 breaths / min, and in regular rhythm, sometimes cough, no shortness of breath, no pain, breathing through the nose, not using the muscles of respiration, no additional audible breath sounds, chest resonant to percussion.
Abdomen, abdominal shape is symmetrical between left and right, there was no abdominal distension, bowel sounds audible 6 x / minute, the client is experiencing lower back pain radiating from the left goto the right side, pain scale 4 (heavy) 0 1 2 3 4 5 Frequency of pain continues continuous and more severe when the motion, the quantity of prickling pain, no tenderness in the left hip.
Genitalia and reproduction, there is no inflammation of the genetalia inside and out, there is no difficulty when erect and ejakuasi, there is no pain when urinating, there is no net genetalian hygiene lesions, lice, redness and ekskoriasi.
Upper and lower extremities, the structure of the left and right extremities and symmetric, the structure of the left and right lower extremities symmetrically, in the right lower extremity is attached infusion RL 20 tts / min drif toradol an ampoule, low back pain worse when the lower extremity motion, muscle strength scale.
Description:
4 = Can be moved against gravity with some resistance
of examiner
3 = Can be driven against gravity but can not withstand
custody of the examiner
Activity and rest, daily client home just rest and not work anymore, nap 1-2 hours / day and night sleep 6-8 hours / day. At the hospital, the client just lying in bed, and the scale of activity 2 (physical mobility is assisted by someone else entirely). The client complained of can not sleep because of low back pain sleep eating only ± 2 hours, clients often wake up during sleep.
Personal hygiene in the client's home bath 2 x 3 x daily, brush your teeth 2 times a day, wash it 1 -2 times a week, cut the nails when the length, change clothes when dirty. At the hospital, the client swabbed 1 x daily by his family, occasionally brushing teeth, nails short, change clothes when dirty.
Nutrition, at the client's home to eat 3 times a day, regular diet of rice and other clients according to taste, good appetite, drinking 6-8 glasses of water a day. At the hospital, clients eat 3 times a day sometimes up sometimes not a single serving, there is appetite but lost when the pain worse, drinking 3-4 glasses of water a day, diet TKTP BB.
Elimination in the client's home said the current Chapter 1-2 times daily, the consistency of soft, yellowish color, foul odor. CHAPTER smooth 3-4 x daily, clear yellow color of urine odor. At the hospital, SECTION 1 x daily, soft consistency, odor, BAK 2-3 times daily, clear, yellowish color, the smell of urine.
Sexuality clients are married have a wife and 4 children, a client relationship with the wife and children well
Psychosocial, good client relationships with nurses. Clients want to communicate with the nurse, client relationship with the family well, it looks from the wife and children to accompany and assist the client always a client's activities, the client looks stoic face of illness
Spiritual, a Muslim client, the client is always a regular home prayer 5 times, while in the hospital clients also pray if only for the client is always in bed and prayed for his recovery.
Supporting Data
Therapy / treatment (June 4, 2004)
- Injection Acran 2 x 1 amp
- Myonal 3 x 1 tab
- Lytadex 3 x 1 tab
- Trolip 300 2 x 1
- 3 x CI Dulcolaxtol
- Pronalges 100 1-0-1
- Esilgan 2 mg 0-0-1
Additional therapy (June 9, 2004)
- Inj stesolid / diazepam ½ amp night
- MST 10 mg 1-0-1
- Fundamine 3 x 1
The results of radiological examinations on June 5, 2004
Shoulder joint AP Ext (24 x 30)
Results: The suspect fibro sarcoma
Clinical laboratory dated June 4, 2004
a. Blood chemistry
- Fasting Blood Sugar: 114.5 mg / dl Normal: 75-115 mg / dl
- Blood sugar 2 hours pp: 149 mg / dl Normal: 125 mg / dl
b. Test liver physiology
- ALT: 18.2 U / L Normal: up to 12 mg / dl
c. Test renal physiology
- Creatinine: 0.8 mm / dl Normal: 0.6 to 1.1 mg / dl
- Uric acid: 4.9 mg / dl Normal: 3.4 to 7.0 mg / dl
d. Blood fat
- Choksterol: 178.6 mg / dl Normal: up to 200 mg / dl
- Triglycerides: 256m5 mg / dl Normal: 60-15 mg / dl
Data Focus
1) Data inspection:
a. Clients seemed to grimace in pain scale 4 (heavy) 0 1 2 3 4 5
b. Clients sometimes cough
c. Black line appears around the eyes
d. The client was restless
e. Frequency of breath 24x/menit
2) Palpation:
a. There is tenderness in the left hip
b. Pulse rate 100 times / minute
3) Percussion: -
4) Auscultation: -
B. Analysis and Nursing Diagnosis
No Data Problem Etiology
1 2 3 4
A DO:
- Medical Diagnosis of low back pain status
- The client looks grimacing in pain
- Client was restless
- Vital signs:
BP: 140/80 mmHg
T: 37.2 ° C
N: 100 x / minute
R: 24 x / minute
DS:
- The client complained of radiating pain in the left dish gets right to the pain scale 4 (heavy)
0 1 2 3 4 5
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
Impaired sense of comfort (acute pain) Reflection muscle spasm secondary to pressure nervous edge of the waist area
A
2 3 4
2 DO:
- Clients appear weak and lethargic
- Looks blackish color around the eyes.
- Vital signs:
BP: 140/80 mmHg
T: 37.2 ° C
N: 100 x / minute
R: 24 x / minute
DS:
- The client complained of can not sleep because of low back pain radiating to the left to right with the pain scale 4 (heavy)
0 1 2 3 4 5
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
- The client said that the longest night sleep ± 2 hours the client is often awakened during sleep
Patterns of rest and sleep disorders Pain in left waist
A
2 3 4
3 DO:
- The client seemed to just lay in bed
- The client looks winced in pain when doing the client can only move in bed with the Bantu family with the scale of activity 2 (fully assisted by others)
DS:
- The client said he was very sore when doing the movement with a pain scale of 4 (very severe)
- Quality of pain such as tingling
- Frequency of continuous pain and more severe when the motion
- Damage to physical mobility secondary to pain muscle spasm
Priority issues:
1. Impaired sense of comfort (acute pain) are associated with reflex muscle spasm secondary to pressure syaraftapi arrangement of the lumbar region.
2. Patterns of rest and sleep disorders associated with pain in left hip
3. Damage to physical mobility related to pain secondary to muscle spasm
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