LP Askep Hernia Inguinal Dextra

THEORITICAL BACKGROUND OF HERNIA INGUINAL AND NURSING
CARE REPORT OF MR. B WITH HERNIA INGUINAL DEXTRA IN

AL-MUIZZ (SURGERY) WARD AT RATU ZALECHA
GENERAL HOSPITAL
BY
ROY AHMAD SEPTIADI
NISRINA NADYA WAHDA
SRI ASTUTI
MUHAMMAD RIDHO PRADHANA
MUHAMMAD FAUZAN RIZALDIE
UNIVERSITY OF MUHAMMADIYAH BANJARMASIN
FACULTY OF NURSING AND HEALTH SCIENCE
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
ACADEMIC YEAR 2016/2017

1. ANATOMY AND PHYSIOLOGY OF HERNIA
https://upload.wikimedia.org/wikipedia/commons/thumb/3/3b/Blausen_0560_InguinalHernia
.png/600px-Blausen_0560_InguinalHernia.png
Physiology
The function of small intestine:

- Exertion of Small Intestine
The intestine produces mucus and salivary digestion that serves to protect the
duodenum from stomach acid.
- Digestion of Small Intestine
- Digestion is the physical and chemical change of food by the aid of enzymes and
coenzymes that are secreted by hormones and nerves, so that food becomes molecules
that can be absorb into the bloodstream. Intestinal enzymes and how they work
include: Enter kinase, Amino peptidase, Tetra peptidase, Tripeptidase, Dipeptides,
Amylase, Maltase, Is maltase, Lactase, Sucrose and Lipase
- Absorption of Small Bowel All carbohydrate, protein and fat digestion products as
well as most of the electrolytes, vitamins and water in the normal state are absorbed
by the small intestine. Most of the absorption takes place in the duodenum and
jejunum, and very little goes on the ileum. Other things are absorbed in the small
intestine Salt and Water, Carbohydrates, Proteins, Vitamins and Fats
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The main function of the colon is to absorb water, store waste, and absorb some vitamins
(such as vitamin K), thickening and discharge from the stool. Large intestine houses about
700 species of bacteria, which helps in the fermentation of fiber in foodstuffs. These bacteria
also produce large amounts of vitamins, such as vitamin K and biotin (vitamin B), which are
absorbed into the blood. (www.sridianti.com/anatomi-dan-fisiologi-usus-besar)
2. DEFINITION OF HERNIA
Hernia is a prosthesis or protrusion of the contents of a cavity through a defect or a weak
portion of the cavity wall. In the abdominal hernia, the contents of the abdomen protrude
through a defect or weak part of the abdominal musculo-aponeurotic layer. The hernia
consists of a ring, a pouch, and a herniated contents. Hernia can occur by default / congenital
and acquired / acquired. (Huda and Kusuma, 2015)
A hernia is the protrusion of tissue or part of an organ through the bone, muscular tissue, or
the membrane by which it is normally contained. Hernias can be classified as internal or
external and as abdominal or thoracic. (Medscape,2016)
The inguinal hernia is the prominence of the contents of a cavity through the inguinal ring
located in the lateral vaso epigastica inferior down the inguinal canal and out into the
abdominal cavity via the external inguinal annulus (Mansjoer, 2000)
The conclusion of the 3 definitions above is Hernia is a protrusion of the internal organs
through the weak portion of the cavity wall consisting of a ring, a pouch, and the contents of
a hernia. Hernia can occur by default and acquired
Here are some types of hernia according to its location:
https://www.epainassist.com/images/different-types-of-hernia.jpg
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a. Hiatal Hernia is a condition in which the clumps descend through the diagfragma through
a gap called hiatus so that some of the abdomen protrude into thorax.
b. Epigastric hernia occurs between the navel and the lower part of the rib cage in the
midline of the stomach. It usually occurs in weak and rare tissues containing the intestine.
Formed on the weak abdominal wall.
c. The Umbilikal Hernia develops in and around the umbilicus caused by openings in the
abdominal wall.
d. Inguinal hernia is the most common hernia and appears as a bulge in the groin or
scrotum. Inguinal hernia occurs when the abdominal wall develops so the intestines pass
through the gap.
e. Femoral hernia appears some bulge in the thigh pankal.
f. Incisional hernias can occur through postoperative abdominal injuries. It appears as a
bulge around the center that occurs when the muscles around the navel do not close
completely.
g. Pulmonary Nucleus Hernia (PNH) is a hernia involving spinal discs. Generally occurs in
the lower back on the three lower lumbar.
(Huda and Kusuma ,2015)
a. Reponibel / reducibel hernia, ie the contents of the hernia can go in and out. The
intestines will come out if standing or striking and entering again when lying down or
pushed in. In this reponibel hernia the patient does not complain of pain and there are no
symptoms of bowel obstruction.
b. Ireponibel hernia, the reciprocal of reponible hernia (hernias not reentered) is usually
caused by attachment of the sac bag to the peritoneum.
c. Inkaserata hernia, in this hernia the intestinal or intestinal contents entering into the
hernia sac can not be recovered with special flow disorders. Clinical features of intestinal
obstruction with an overview of electrolyte and acid-base fluid balance. This condition of
the hernia can be squeezed by the ring of the hernia. So that the contents of the bag can
be trapped and can not return to the abdominal cavity, consequently a passage disorder
and hernia is more intended irreponibel hernia.
d. Strangulata hernia, in this hernia blood vessels that affect the intestine into the hernia sac
is pinched so that the intestine loses its bleeding system resulting in necrosis of the
intestine. On the local examination of the intestine can not be re-entered in the presence
of tenderness.
(Huda and Kusuma 2015):
3. ETIOLOGY OF HERNIA
a. Congenital
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Congenital due to muscle weakness is one of the risk factors associated with increased
intra-abdominal pressure factor. Muscle weakness cannot be prevented by exercise or
exercise.
b. Obesity
Obesity is one of the causes of increased intra-abdominal pressure because of the amount
of fat clogged up and slowly pushing the peritoneum. This can be prevented by weight
control.
c. Pregnant mother
In pregnant women there is usually an increased intra-abdominal pressure especially in
the uterine region and surrounding areas.
d. Straining
Straining can also cause increased intra-abdominal pressure.
e. Lifting heavy loads
Lifting heavy weights can also cause increased intra-abdominal pressure.
4. CLINICAL MANAGEMENT OF HERNIA
a. In the form of a lump in and out and hard and often appears a lump in the groin.
b. The presence of pain in the area of the lump when the contents are pincphed with nausea.
c. There are symptoms of nausea and vomiting or distension when there are complications.
d. In case of inguinal hernia strangulate pain will grow great and the skin above it becomes
red and hot.
e. A small femoral hernia may contain a bladder wall causing symptoms of urinary pain.
(Dysuria) with hematuria (blood urine) in addition to a lump under the thigh.
f. Diaphragmatic hernia causes pain in the abdominal area with shortness of breath.
g. When straining or coughing the hernia lump will increase.
5. PATHOPHYSIOLOGY OF HERNIA INGUINALIS
The inguinal canal is a normal canal in the fetus of the next month of pregnancy. Densdensus
testiculorum through the canal. It will be interesting testicular descent peritoneum is called
peritoneal processus vaginalis.
When the baby is born generally this processus has obiters so that the contents of the stomach
cannot through the canal. But in some ways are often not close because of testicular turm
first from the right, then right inguinal canals more often open.
In the elderly canal 1 day has closed, but because the area is a minosy resistance lobe then
the circumstances that cause intra-abdominal pressure increased heavy objects, straining
during defecation and pushing at the time of miksi, become the result of hyper ration prostal.
(Mansjoer, 2004).
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Hernia can also occur because of the result of a defect (a hole, may occur due to congenital
abnormalities. Usually hernia is congenital and caused by failure of procesus vaginalis
(herniated pouch) .This hernia can also occur due to muscle weakness in the abdominal wall
and the increase intra- The abdomen is caused by a pregnancy of hard work pushing on
CHAPTER and micturition, chronic cough Hernia can occur if there is a defect and the
presence of intra-abdominal pressure. (dr. Jan. 2009)
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6. PATHWAY OF HERNIA
The trigger factors:
Severe activity, premature baby, abdominal wall Hernia
weakness, Intra-abdominal high, the presence of pressure
Congenital umbilical Para umbilical hernia Hernia Inguinal

hernia
The hernia bag passes The bag of hernia enters
through the abdominal wall the inguinal gap
The entry of the intestinal
organ omentum into the
umbilical pouch The posterior wall of the
Protrusion Disappears
weak inguinal canal
Impaired blood supply to
the intestinal Abdominal
discomfort Lump in the
inguinal region
Necrosis intestinal Surgical intervention
Relative / conservative Above the inguinal ligament
shrinks when lying down
Surgery
Anxiety
Surgical incision Nutrient intake is less Nausea
Bowel peristalsis Decreased Appetite

High Risk for Bleeding decreases
Resti infeksi Inadequate food intake

High Risk for Infection
Resti infeksi Nutrition less than
Disconnect of nerve body requirements
tissue
PAIN
The herniated bag

Incisional hernia enters the incision gap
The hernia bag enters

Hiatus hernia the thorax cavity
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7. MEDICAL MANAGEMENT OF HERNIA
a. Conservative (Townsend CM)
Conservative experiments are limited to the act of repositioning and wearing a
support or support to retain the contents of the repositioned hernia, not a definitive
action to recur, consisting of:
1) Reposition
Repositioning is an attempt to restore the contents of the hernia into
the peritonil or abdominal cavity. Repositioning is done bimanually.
Repositioning is performed in patients with reponibilis hernia by means of two
hands. Repositioning is not performed on strangulate inguinal hernia except in
children.
2) Injection
Conducted injection of sclerotic fluid in the form of alcohol around the hernia that
causes the hernia door to experience sclerosis or narrowing so that the contents of
the hernia out of the peritoneal cavity
3) Belt hernia
Given to patients whose hernia is small and refuse surgery
b. Operative
Hernia surgery can be done in three stages, namely:
1) Herniotomy
Open and cut the hernia pouch and restore the contents of the hernia to the
abdominal cavity
2) Hernioraphy
Starting from binding the neck of the hernia and hanging it on the conjoint tendon
(thickening between the free edge of intra-abdominal m.obliquus and the
m.Trans-versus abdomens in the tuberculum pubicum)
3) Hernioplasty
Stitch the conjoint tendon on the inguinal ligament so that the LMR is lost /
closed and the abdominal wall becomes stronger because it is covered in muscle.
8. DIAGNOSTIC EXAMINATION OF HERNIA

a. Physicals examination
b. Abdominal X-ray shows abnormal levels of gas in the intestine / bowel obstruction
c. Complete blood count and serum electrolyte may show hemoconcentration (increased
hematocrit), increase in white blood cells and electrolyte imbalances
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9. COMPLICATIONS OF HERNIA
Recurrent hernia,
Damage to the supply of blood, testes or nerves if male patient,
Excessive bleeding / surgical wound infections,
Bowel injury (if not careful),
After Herniography Hematoma can occur,
Fosters urine and feces
Residues,
Old complications are testicular atrophy due to lesions. (Giri, 2009)
10. THEORY OF NURSING ASSURANCE OF HERNIA
1. ASSESSMENT Nursing history
1) History of the disease now
Hernias can occur with symptoms of pain, nausea and vomiting.
2) Previous Disease History
Supportive assessment is to examine whether a previous client has suffered from
Hernia, a complaint in childhood, a hernia from another organ, and other diseases
that aggravate a hernia such as diabetes mellitus. Ask about medicines commonly
drunk by clients in the past relevant, these medications include OAT and
antitussive drugs. Note the side effects that occurred in the past. Assess more in
depth about how far weight loss (BB) in the last six months. The BB decrease in
clients with Hernia is closely related to the healing process of the disease as well
as the presence of anorexia and nausea which is often caused by drinking OAT.
3) Family Disease History
Hernia pathology is not inherited, but the nurse needs to ask whether the disease
has been experienced by other family members as a predisposing factor in the
home.
(www.currentnursing.com/nursing_theory)
2. Physical examination: focus data
a. Inspection of the regions Inguinal and femoral
Although the Hernia can be defined as any Viscos projection, or part of it,
through normal or abnormal holes, 90% of all Hernias are found in the
inguinal region. Usually, Hernia impulses are more clearly seen than to be
touched. Invite the patient to turn his head sideways and cough or strain.
Perform an inspection of the Inguinal and Femoral areas to see the onset of a
sudden lump during a cough, which may indicate a hernia. If a sudden lump
appears, ask the patient to cough again and compare this impulse to the
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impulse on the other side. If the patient complains of pain during coughing,
determine the location of the pain and reexamine the area.
b. Palpation of Inguinal Hernia
Palpation of the Inguinal Hernia is done by placing the right index finger in
the scrotum above the left testicle and pressing the scrotum skin inside. There
should be enough scrotal skin to reach the external inguinal ring. The finger
should be placed with the nail facing out and the finger pad into the inside.
The examiner's left hand can be placed on the patient's right hip for better
support. The right index finger should follow the dilenic spermatic cord into
the inguinal canal parallel to the inguinal ligament and move upwards toward
the external inguinal ring, which lies superior and lateral from the pubic
tubercle. The external ring can be widened and entered by the fingers. With
your index finger placed on the external ring or inside the inguinal canal, ask
the patient to turn his head sideways and cough or strain. Had there been a
Hernia, there would have been a sudden impulse touching the tip or pad of the
examiner's finger. If there is a Hernia, have the patient lie on his back and see
if the Hernia can be reduced by the gentle and continuous pressure of the day.
If the inspection carried out by the skin of the scrotum hernia which is quite a
lot and done slowly, this action does not cause pain (Tambayong, 2009).
Preoperative patient assessment (Doenges, 2008) includes:
4) Circulation
Symptoms: a history of heart problems, CHF, pulmonary edema,
peripheral vascular disease, or vascular stasis (increased risk of
thrombus formation).
5) Integrity of the ego
Symptoms: feelings of anxiety, fear, anger, apathy; Multiple stress
factors, such as financial, relationships, lifestyle.
Signs: unable to rest, tension / excitatory enhancement; Sympathetic
stimulation.
6) Food / liquid
Symptoms: pancreatic insufficiency / DM, (predisposition to
hypoglycemia / ketoacidosis); Malnutrition (including obesity); Dry
mucous membrane (restriction of preoperative fasting period).
7) Breathing
Symptoms: infection, chronic condition / cough, smoking.
8) Security
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Symptoms: allergy / sensitive to drugs, food, plaster, and solution;
Immune deficiency (increased risk of sitemic infection and delayed
healing); The emergence of the latest cancer / cancer therapy; Family
history of malignant hyperthermia / anesthetic reaction; History of
hepatic diseases (effects of drug detoxification and may alter
coagulation); History of blood transfusion / transfusion reaction
Signs: the emergence of a laborious infection process; fever.
9) Counseling / Learning
Symptoms: Using anticoagulation, steroids, antibiotics, antihypertensive,
cardio tonic glucose, antidisritmia, bronchodilator, diuretic,
decongestant, analgesic, anti-inflammatory, anticonvulsant drugs or
tranquilizers and well-counter, or recreational drugs. The use of alcohol
(risk of kidney damage, which affects the coagulation and choice of
anesthesia, and also the potential for postoperative with drawl).
a. NURSING DIAGNOSES
 Pre Operation
1. Pain r.t pinched intestine in the area crotch (NANDA NIC-NOC, 2015:306)
2. Anxiety r.t lack of knowledge about health conditions, inflammatory processes
(NANDA NIC-NOC, 2015:241)
 Post Operation
(NANDA NIC-NOC,
1. Acute pain r.t Network discontinuity due to operation action.
2015:306)
2. Imbalance nutrition less than body requirements r.t nausea and vomit. (NANDA NIC-
NOC, 2015:302)
3. A sense of comfort. (NANDA NIC-NOC, 2015:266)

4. Risk for bleeding. (NANDA NIC-NOC, 2015:334)
5. Risk for infection r.t incision wound after operation. (NANDA NIC-NOC, 2015:316)
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b. NURSING INTERVENTION
Preoperative nursing problems
1) Pre operation
Nursing Dx Intervention Rational
Pain r.t pinched 1. Assess the pain, note the 1.Benefits in the monitoring
intestine in the area location, characteristics, of the effectiveness of the
crotch scale (scale 1-10) drug, the progress of
healing
2.Pain not lost with flatus is
2. Determine the relationship
a sign of bowel
between flatus and pain
obstruction
subsided
3. Monitor bowel sounds, VS,
3.Information on the
note improvement / spasm
development of the
and pain
patient's condition
4. Give cold compresses to a
4.Cold compress adds blood
swollen hernia
vasoconstriction and
reduces pain
5. Collaboration with medical
5.Analgesic drugs for
team : analgesic drugs
decrease the pain
Anxiety r.t lack of 1. Take note of the behavioral 1. For anxiety degree
knowledge about behavior of unsteady indicator
health conditions, missal, rejected
inflammatory 2. Provide a calm and resting
2. calm and resting
processes environmen
environment improves
relaxation, helps decrease
anxiety
3. motivated from people
3. Motivated people closest to
closet increase relax and
show attention
confident
4. For helps reduce stress,
4. Help the patient learn new
improves disease control
coping mechanisms
5. Accurate basic
5. Review of disease
knowledge provides
processes, factors causing
patients with
opportunities to make
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choices about the future
and control of chronic
diseases.
2) Post operation
Nursing Dx Intervention Rational
Acute pain r.t 1.Assess the pain 1. Determine the

Network comprehensively including appropriate management
discontinuity due to location, characteristics, action of pain and
operation action. duration, frequency, monitoring of the
(NANDA NIC-NOC,
quality, and precipitation effectiveness of the drug,
2015:306)
factors (PQRST) the progress of healing
2.Monitor vital sign
3.Adjust the patient's 2. Knowing the patient's
comfortable position condition objectively
4.Teach pain management 3. Enhance the sense of
techniques comfort
5.Collaboration with medical 4. Reduce the pain
team 5. Accelerate patient
healing
Imbalance nutrition 1. Assess for food allergies, 1. To know the right diet
less than body favorite foods, and signs and avoid to another
requirements r.t of malnutrition. illness. Know sign and
nausea and vomit. 2. Assess patient's body symptoms malnutrition
(NANDA NIC-NOC,
weight before and after on client
2015:302)
illness 2. To know the weight
3. Monitor the patient's development of client
remaining food 3. To know the
4. Monitor patient's weight development of client’s
gain weight
5. Suggest eating a little but 4. To knows the client’s
often appetite in objective
6. Encourage food in warm 5. Avoid gastritis diagnose
food 6. Warm food can increase
7. Collaboration with appetite
nutritionists 7. To makes the right foot
for client’s diet.
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A sense of comfort. NIC label: Pain 1. Reduce the scale of pain
(NANDA NIC-NOC,
Management felt by the client
2015:266)
1. Ensure that patients get the 2. Prevent client pain
analgesic appropriately getting worse
2. Exploring factors that can 3. Provide techniques to
aggravate the client's pain deal with pain in the
3. Teach the principles of client
pain management 4. Provide a comfortable
temperature for the
NIC label: Enviromental patient more relaxed
Management Comfort 5. Prevent the emergence
1. Set the room temperature or worsen the bad
at a comfortable feeling of discomfort to
temperature for the client the client
2. Reduce the things that
can interfere with the
client's convenience
NIC Tags:
Pruritus Management
Determine the cause of
the itchiness
Use anti-pruritic creams
and lotions according to
medication
Instruct the client to
avoid sweat by avoiding hot
weather and excessive
activity
Use an antihistamine
cream
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NIC Labels >> Anxiety
Reduction:
• A convincing and
reassuring approach
• Describe all procedures,
including sensations that
may be experienced during
the procedure
• Assess client views
regarding stressful
situations
• Provide factual
information on diagnosis,
treatment, and prognosis
• Encourage families to be
with patients
• Encourages the
verbalization of feelings,
perceptions, and fears
• Identify when anxiety
level changes
• Provide diversion
activities directed at
reducing tension
• Helps patients identify
situations that trigger
anxiety
• Support the use of
appropriate defense
mechanisms
• Advise patients on the use
of relaxation techniques
• Assess verbal and
nonverbal signs of anxiety
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Risk for infection 1. Assess infection’s sign 1. Hb decrease and an
r.t incision wound and symptoms such blood increase in the number of
after operation. tests, such as Hb and leukocytes from normal
(NANDA NIC-NOC,
leukocytes. prove the presence of
2015:316)
2. Monitor vital signs. signs of infection.
3. Perform wound care with 2. If there is an increase in
aseptic techniques. vital signs of the
4. Perform maintenance of possibility of symptoms
impassive procedures of infection because the
such as infusions, body trying to intim
catheters, wound against foreign
drainage, etc. microorganisms that
5. Collaboration with the enter the increase in vital
medical team for signs.
administration of 3. Wound care with aseptic
antibiotics drugs techniques preventing the
risk of infection.
4. To reduce the risk of
nosocomial infection.
5. antibiotics prevent the
development of
pathogenic
microorganisms.
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NURSING CARE REPORT
A. Assessment
1. Client’s Identity
Name : Mr. B
Gender : Male
Age : 70 Years Old
Address : Astambul
Education : Elementary School
Marriage : Married
Occupation : Farmer
Religion : Moslem
Ethnic/Nation : Banjar / Indonesia
Date of Entry Hospital : August 07, 2017
Medical Diagnose : Hernia Inguinal
Medical Record Number : 30-55-XX
Date of Assessment : August 08, 2017
2. Responsible Person’s Identity
Name : Mrs. S
Gender : Female
Age : 68 Years Old
Occupation : Housewife
Client’s Relationship : Client’s Wife
B. Health History
1. Main Complain
At the first time client meet the nurse on August 08, 2017, client said that he felt
pain in his lower right part of stomach until his thigh and client said the pain appear
when he walk. Client also said he felt limp.
 P: Hernia
 Q: Sliced
 R: The right groin
 S: 4 (0-10) Moderate pain
 T: When walk
2. History of Current Disease
The client says that he initially stretches the body, and when stretching his right
leg then he feels pain in his right crotch and finds a lump there. The lump is in and
out, when lying, it goes in and as he sits or stands it’s out. Because, the pain is not too
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disturbing and the client has experienced it around 10 years ago, the client let alone
the lump in his crotch. Until, finally when the client checked his heart to the cardio
clinic. Doctors there saw the lump and suggested to perform surgery. Then, after
conferring with their children and wives, it is necessary to perform the hernia
operation. So, the client went to Ratu Zalecha General Hospital at Martapura to
perform hernia surgery on August 07, 2017 and got treatment in the surgery room
until now.
3. History of Previous Disease
Client said that he has history disease of hernia and get surgical process around
ten years ago and gastritis around 5 years ago. Client said he also has heart disease
around three years ago.
4. History of Family Disease
Client said nobody in his family who ever get the similar disease like him now or
ever suffer infectious disease. Client said there is no hereditary disease or infection
disease in his family one house.
C. Physical Examination
1. General Condition
- Client looks often to take a pee
- Acral palpable cool
- Client looks grimace and hold his lower right part of his abdomen
- Client’s skin looks pale
- Found a lump / hernia on his right groin that can go inside while lying down and
out while sitting or standing (Hernia Inguinal Dextral Reducible)
- Client attached infusion set of Ringer Lactate with 20 TPM on his left hand.
- Vital Signs : Blood Pressure : 110/70 mmHg
Temperature : 36, 4 ̊ C
Pulse : 75 x/Minutes
Respiration Rate : 28 x/Minutes
- GCS : E4 V5 M6
- Consciousness : Compos Mentis
- Anthropometric Data : Body Weight : 55 kg
Body Height : 166 cm
BMI : 55/(1.66x1.66)=19,96
Normal weight : 18.5 – 25.0
IBW : (166 – 100) ± 10% (166-100)
= 66 ± 10% (66)
= 59,4 – 72,6
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2. Skin
The general condition of client’s skin is pale, skin hygiene is less, skin integrity is
good, skin texture is normal, skin moisture is less, and no presence of ulcers/wound,
skin color is tan, no skin abnormalities on client’s skin. Fells cool when palpable
Turgor skin is normal.
3. Head and Neck
The general condition of client’s head is normal, hair color is white and oily,
client’s head is symmetric, no abnormalities on client’s head. The general condition
of client’s neck is normal, no limited motion, no jugular vein enlargement or thyroid
gland enlargement or lymph nodes enlargement, no other disorder or abnormalities on
client’s neck.
4. Sight and Eyes
The general condition of client’s eyes are normal, client’s visual function is quite
good, conjunctivas anemic, no abnormalities of the eyelid/eyeball, the power of eyes
accommodation is good, no eyes pressure, client didn’t use any visual aids and no
other disorder or abnormalities on client’s eyes.
5. Smelling and Nose
The general condition of client’s nose is normal, no airway blockage, no polyps or
inflammation or thick secretions on client’s nose, no cupping nose and other disorder
or abnormalities on client’s nose.
6. Hearing and Ears
The general condition of client’s ears are normal, client’s hearing function is
normal, client didn’t use any hearing aids, no ears shape abnormalities and other
disorder on client’s ears.
7. Mouth and Teeth
The general condition of client’s mouth and teeth are normal, oral hygiene is less,
client’s upper digestive function is good, no swallowing disorder, lip mucosa dry, no
inflammation on client’s mouth and no other disorder or abnormalities on client’s
mouth and teeth.
8. Thorax
a. Cardiovascular
Circulation: Blood perfusion to poor peripheral tissue, pale fingertips, dry lips
mucosa, dry skin moisture.
I: ictus cordis is visible
P: PMI is palpable, HR: 75 x/m
P: not found heart enlargement
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A: S1 and S2 Single sound lop dup
b. Respiratory
Inspection : The general condition of client’s chest is normal, client’s chest is
Symmetric, client’s chest expansion is normal. RR: 28 x/m
Palpation : Lung: Balance tactile fremitus.
Percussion : Lung: Resonant (Air).
Auscultation : Vesicular breath sound. BP: 110/70 mmHg
9. Abdomen
 Inspection : The general condition of client’s abdomen is normal, no lump,
No respiratory abnormal muscles, skin color is brown. Found a
lump / hernia on his right groin that can go inside while lying
down and out while sitting or standing (Hernia Inguinal Dextral
Reducible)
 Auscultation : Bowel peristaltic per minute is 8 x/Minutes.
 Palpation : Abdominal mass touched, Tenderness exists, skin turgor is
normal, no presence of ascites.
 Percussion : Tympanic sound.
10. Genitalia and Reproduction

The general condition of client’s genitalia organ isn’t normal, reproduction set
function isn’t normal, Client said pain when take a pee, and can’t do sexuality activity
since gets hernia.
11. Upper and Lower Extremities

Range of motion of client’s upper and lower extremities are normal, no limited
motion, no trauma or abnormalities on client’s upper and lower extremities,
intravenous insertion on left hand, client said he felt pain on his lower right part of his
stomach until his thigh when he try to walk. Found a lump on his right groin that can
go inside while lying down and out while sitting or standing (Hernia Inguinal Dextral
Reducible).
 Muscle Scales : 5555 5555
5554 5555
Muscle
Category
Scale
Level 0 Perfect paralysis
Level 1 No movement, muscle contraction can be palpated or seen
36
Level 2 Full muscle movement against gravity with support
Level 3 Normal movement against gravity
A normal full movement against gravity and against minimal
Level 4
resistance
Normal strength, normal full movement against gravity and
Level 5
full resistance.
 Activity Scales : Level 0 (Able to fully take themselves)

Activity
Category
Scale
Level 0 Able to fully take care themselves.
Level 1 Requires use of the tool.
Level 2 Requires help or supervision of others.
Level 3 Needs help, surveillance of others, and equipment.
Level 4 Highly dependent and unable to perform or participate in care.
D. Physical, Psychology, Social, And Spiritual Needs

1. Activity and Exercise
At Home : Client said before getting hospitalization he usually spend his time
with his wife at home and sometime go to his neighbor ‘s house.
At Hospital : Client said at hospital mostly he spend his time to lying on his bed,
go to toilet when need to take a pee and sometimes walk outside his
room.
2. Rest and Sleep
At Home : Client said before getting hospitalization he usually sleeps around 8
hours a day, client said sometime he take a nap at home.
At Hospital : Client said at hospital he could sleep as well as at his home, client
said sometime he take a nap at hospital about 5 hours a day.
3. Personal Hygiene
At Home : Client said before getting hospitalization he usually bathing three
times a day, shampooing and brushing his teeth once a day.
At Hospital : Client said at hospital he didn’t bathing yet since the first day of his
hospitalization. Client said he felt afraid to bathing because he
attached infusion set. The client perceives that if hospitalized then it
should not take a bath. Client said he only wash his face in the
morning.
37
4. Nutrition
At Home : Client said before getting hospitalization he usually eats twice a day
with Rice, fish and vegetable. Client said he usually drink water
almost 1 Liter a day. Client hasn’t any allergies.
At Hospital : Client said at hospital he eat three times a day with full portion of
food given by hospital. Client’s appetite is good and client get food
with high carbohydrate and high protein diet.
5. Elimination
At Home : Client said before getting hospitalization he usually urinates 3 until 4
times a day and defecates once a day. Client hasn’t any complaint
with elimination process.
At Hospital : Client said at hospital he urinates 8-9 or more a day and the urine 5-
10 cc/pee. Client said he hasn’t defecated anymore since the first day
of hospitalization.
6. Sexuality
Client is male, he has married, he has 2 sons and a daughter and he said can’t do
sexual activity like usual with her wife since got hernia.
7. Psychology
Client’s psychological condition is good, client is quite known about his disease
because three years ago he ever suffers the similar disease.
8. Social
Client said his relationship with his family or other patients are good.
9. Spiritual
Client said he can’t pray five times as usual because of his current condition but
he still prays on his bed hoping for his better condition.
E. Data Focus
Data Subjective :
- Client said he is 70 years old.
- Client said that he felt pain in his stomach until his thigh.
- Client said the pain appear when he walk.
- P: Hernia
Q: Sliced
R: The right groin
S: 4 (0-10) Moderate pain
T: When walk
- Client said he felt limp.
- Client said at hospital he didn’t bathing yet since the first day of his hospitalization.
38
- Client said he felt afraid to bathing because he attached infusion set.
- The client perceives that if hospitalized then it should not take a bath
- Client said he only wash his face in the morning.
- Client said at hospital he urinates 8-9 or more a day and the urine 5-10 cc/pee.
- Client said than drinks water 8-9 glass a day.
- Client said he hasn’t defecated anymore since the first day of hospitalization.
Data Objective
1. Inspection :
- Client looked often to take a pee.
- Client’s skin looks pale.
- Conjunctivas anemic
- Fingertip pale
- Lip mucosa dry
- Laboratory result on August 07, 2017 Hb: 8, 5 g/dl.
- Client gets the 1st and 2nd transfusion bags of Packed Red Cell transfusion with
blood type O+ on August 08, 2017.
- Found a lump on his right groin that can go inside while lying down and out
while sitting or standing (Hernia Inguinal Dextral Reducible).
- Client’s looks grimace and hold his lower right part of his abdomen.
- Client attached infusion set of Ringer Lactate with 20 TPM on his left hand.
- Client’s skin hygiene is less.
- Oral hygiene is less.
- Client’s hair color is white and oily
- GCS : E4 V5 M6
- Consciousness : Compos Mentis
- Muscle Scale : 5555 5555
5554 5555
Muscle
Category
Scale
Level 0 Perfect paralysis
Level 1 No movement, muscle contraction can be palpated or seen
Level 2 Full muscle movement against gravity with support
Level 3 Normal movement against gravity
A normal full movement against gravity and against minimal
Level 4
resistance
Level 5 Normal strength, normal full movement against gravity and
39
full resistance.
- Activity Scale : Level 0 (Able to fully take care themselves.)
Activity
Category
Scale
Level 0 Able to fully take care themselves.
Level 1 Requires use of the tool.
Level 2 Requires help or supervision of others.
Level 3 Needs help, surveillance of others, and equipment.
Level 4 Highly dependent and unable to perform or participate in care.
2. Palpation :
- CRT 5 seconds.
- Acral palpable cool.
- Skin moisture is less.
- Feels cool when palpable
- Abdominal mass touched, Tenderness exists,
- Vital Signs : Blood Pressure : 110/70 mmHg
Temperature : 36, 4 ̊ C
- Anthropometric Data : Body Weight : 55 kg
Body Height : 166 cm
BMI : 55/(1.66x1.66)=19,96
Normal weight : 18.5 – 25.0
IBW : (166 – 100) ± 10% (166-100)
= 66 ± 10% (66)
= 59,4 – 72,6 kg
3. Percussion :
- Lung: Resonant (Air).
- Tympanic sound.
4. Auscultation :
- Vesicular breath sound.
- Bowel peristaltic per minute 8 x/Minutes.
40
F. Examination Support
1. Laboratory result on Ratu Zalecha General Hospital Laboratory
REFERENCE
DAY/DATE ASSESSMENT RESULT
VALUE
August 07, 2017 Hemoglobin 8,5 13,8-17,2 g/dl
Blood Type O+
Leukocyte 9.400 5000-10.000/mm3
Hematocrit 36,2 40-48%
Thrombocyte 260.000 150.000-440.000 /mm3
Erytrosit 4,25 4,6-6,2 million
GDS 94 70-115 mg/dl
2. Transfusion Blood Data

Transfusion Blood
No Day/Date Unit Total
Type Type
Tuesday/August 08, Packed Red
1 O+ 500cc 2 Bags
2017 Cell
G. Pharmacology Therapy on August 8, 2017

No Name composition Rute Dosage Indication
natrium
1 Antrain IV 3x 1000 mg / 1ampul Analgesic
metamizole
2 Ranitidine Ranitidin HCl IV 2x 50 mg / 1ampul Antihistamine
3 Cefixime Cefixime O 2 x 100 mg/ 1 tablet Antibiotic
Natrium laktat
Ringer 3,1 gr, NaCl 6 Full fillment of fluids
4 IVFD 500ml x 20 dpm
Lactate gr, KCl 0,3 gr, and electrolytes
CaCl2 0,2 gr
41
H. Data Analysis
No Data Problem Etiology
1. Subjective data : Ineffective Decreased Hb

- Client said he is 70 years old peripheral and blood
- Client said he felt limp. tissue concentrations.
Objective data : perfusion
- Client’s skin looks pale
- Skin feels cool when palpable
- CRT 5 seconds
- Fingertip pale
- Dry lip mucosa
- Laboratory result on August 07, 2017 of
Hb: 8, 5.
- Client gets the 1st at morning and 2ndat
evening transfusion bags of Packed Red
Cell transfusion with blood type O+ on
August 08, 2017.
- Vital Signs
Blood Pressure : 110/70 mmHg
Temperature : 36,4 ̊ C
2. Subjective data : Acute Pain Biological
- Client said that he felt pain in his lower Injury
right of his stomach until his thigh. Agent(Hernia
- Client said the pain appear when he walk. inguinal on the
- P: Hernia right groin)
Q: Sliced
R: The right groin
T: When walk
Objective data :
- Client looks grimace and hold his lower
right of his abdomen when the pain
42
appears.
- Found a lump on his right groin that can go
inside while lying down and out while
sitting or standing (Hernia Inguinal Dextral
Reducible)
5554 5555
- Activity Scale : Level 0 (Able to fully take
care themselves.)
- Vital Signs
Blood Pressure : 110/70 mmHg
Temperature : 36,4 ̊ C
3. Subjective data : Self-care Lack of
- Client said at hospital he didn’t bathing yet deficit: knowledge
since the first day of his hospitalization. personal
- Client said he felt afraid to bathing because and oral
he attached infusion set. hygiene
- The client perceives that if hospitalized
then it should not take a bath
- Client said he only wash his face in the
morning.
Objective data :
- Client’s skin hygiene is less.
- Oral hygiene is less.
5554 5555
- Activity Scale : Level 0 (Able to fully take
care themselves.)
4. Subjective:. Disturbance Constipation
of alvi
- Client said he hasn’t defecated anymore
elimination
since the first day of hospitalization.
pattern
- Client said before getting hospitalization he
43
usually defecates once a day
Objective data:
- Abdominal mass touched, Tenderness

exists,
- Bowel Sound 8x/m
5. Subjective Data: Impaired Pain

- Client said that he felt pain in his lower Physical
right of his stomach until his thigh. mobility
- Client said the pain appear when he walk.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
Objective Data:
- Activity Scale: Level 0 (Able to fully take
care themselves.)
5554 5555
I. Nursing Diagnosis
Problem priorities:
1. Ineffective peripheral tissue perfusion related to decreased Hb and blood
concentrations.
2. Acute pain related to Biological Injury Agent(Hernia inguinal on the right groin).
3. Self-care deficit: personal and oral hygiene related to lack of knowledge
4. Disturbance of alvi elimination pattern r.t Constipation.
5. Impaired physical mobility r.t pain.
44
J. Intervention
Nursing Rational
No Goals Intervention
Diagnosis
1 Ineffective After doing the 1.Examination skin 1. To know the
peripheral nursing intervention color, peripheral basic information
tissue in 1x8 hours expected pulse, and CRT/ of peripheral
perfusion to ineffective cyanosis sign tissue perfusion.
related to peripheral perfusion
decreased Hb solved. 2.Observe client’s 2. To know the
and blood Criteria result : general condition basic information
concentrations 1.Vital signs are in and vital signs. of client’s general
normal range. condition.
2.Conjunctivas not
anemic. 3.Observe input and 3. To measure the
3.No cyanosis found. output fluids. incoming and
4.Client doesn’t look outgoing fluids.
pale.
5.CRT < 2 seconds 4.Increase adequate 4. Full fill the fluids
6.Client verbally said fluids intake. and electrolytes
that he doesn’t felt needs.
lump anymore.
7.Hb in normal range 5.Collaboration with 5. Increase
(13,8-17,2 g/dl) Medical team in hemoglobin in
giving blood the body and
transfusion. improve
peripheral tissue
perfusion.
2 Acute pain After doing the 1. Examination the 1. To know the
related to nursing intervention pain with PQRST basic
Biological in 1 x 15 minutes method. information of
Injury expected to acute pain the pain.
Agent(Hernia solved.
inguinal on the Criteria result : 2. Observe client’s 2. To know the
right groin) 1.Vital signs are in vital signs. basic information
normal range. of client’s general
2.Client verbally said condition.
the pain is
decreased. 3. Teach client Pain 3. Pain management
45
3.Pain scale in level 0- management (deep for decrease the
2 (mild pain). breath relaxation pain.
technic)
4. Give comfortable 4. Comfortable

position (semi position such as
fowler position) semi fowler
position useful to
decrease the pain
5. Ask client to do 5. Help to decrease

deep breath the pain
relaxation technic
and distraction
technic when the
pain appear.
6. Collaboration with 6. Analgesic

medical team in medicine is
giving analgesic useful for reduce
medicine. the pain
Inj antrain 3 x
1000gr/ I ampule
3 Self-care After doing the 1. Examination 1. To know the
deficit : nursing intervention client’s capability basic
personal and in 1x30 minutes in doing personal information of
oral hygiene expected to self-care hygiene. client’s
related to lack deficit solved. problem.
of knowledge Criteria result : 2. Examination 2. To know how
1. Client’s personal muscle and worse is client’s
and oral hygiene activity scale of personal
are in optimal client. hygiene
status. problem.
2. Client’s family
involve in 3. Monitor client’s 3. To know
helping client full hygiene. development of
fill his personal client hygiene
46
hygiene.
3. Client looks 4. Motivate client to 4. Motivate client
fresher. bathing as usual. to full fill his
personal
hygiene with
bathing.
5. Wipe client on 5. Give

his bed if needed. comfortable
sensation and
increase his
personal
hygiene.
6. Help client in 6. Give

giving oral comfortable
hygiene if sensation and
needed. increase his oral
hygiene.
7. Help client in 7. Give

shampooing in comfortable
his bed if needed. sensation and
increase his
personal
hygiene.
8. Collaboration 8. Engage client’s

with client’s family for also
family to help motivate and
client dong help client to
personal and oral full fll his
hygiene. personal
hygiene.
3 Fecal After doing the nursing 1. Define the pattern 1. To restore

elimination intervention in 1x8 of defecation for regularity of
disorder r.t hours expected to the client and client defect
47
Constipation. Fecal elimination train the client to pattern
disorder solved. run it
2. Set the right time 2. To facilitate the
Criteria result :
for the client's reflex.
1) Defecation can be
defect like after a
done once a day.
meal
2) The consistency of
3. Provide coverage 3. High fiber
soft feces
of fibrous nutrients to
3) Elimination of
nutrients as facilitate fecal
feces without
indicated elimination
excessive straining
4. Give fluids if not 4. To soften the
contraindicated 2- elimination of
3 liters per day feces
5. Giving laxatives 5. To soften the
or enema as elimination of
indicated feces
5. Impaired After doing the nursing Pain management:

physical intervention in 1x8 1. Examination the 1. To know the
mobility r.t hours Impaired pain with basic
inconvenience physical mobility PQRST method. information of
solved. the pain.
Criteria result :
2. Observe client’s 2. To know the
1) Client can move
vital signs. basic information
easily and
of client’s general
comfortable
condition.
2) Pain can be
decrease
3. Teach client Pain 3. Pain management
3) Client said feels
management (deep for decrease the
comfortable when
breath relaxation pain.
walking
technic)
4. Give comfortable 4. Comfortable

position (semi position such as
fowler position) semi fowler
position useful to
decrease the pain
48
5. Ask client to do 5. Help to decrease
deep breath the pain
relaxation technic
and distraction
technic when the
pain appear.
6. Collaboration with Analgesic medicine

medical team in is useful for reduce
giving analgesic the pain
medicine.
Inj antrain 3 x
1000gr/ I ampule
K. Implementation
Nursing
No Day/Date Time Implementation
Diagnosis
1 Tuesday/ 09.00 Ineffective 1. Examining cyanosis sign:
August 08, AM peripheral - Conjunctiva anemic
2017 tissue - Skin color pale
perfusion - CRT 5 second
Morning related to 2. Observing client’s general condition and
Shift decreased Hb vital signs.
and blood - GC good
concentrations - BP: 110/70 mmHg
HR: 75 x/m
RR: 28 x/m
T: 36,4oC
3. Observing input and output fluids.
- Input : RL 500ml 20 dpm
Drinks 8-9 glass a day
- Output : urinate 8-9x or more 5-10cc
4. Increasing adequate fluids intake.
- Drinks 8-9 glass a day
5. Collaborating with Medical Team:
- Packed Red Cell transfusion with
49
type O+
- Food with high carbohydrate and
high protein diet.
- RL 500ml 20 dpm
09.20 Acute pain 1. Examining the pain with PQRST method
AM related to - P: Hernia
Biological Q: Sliced
Injury R: The right groin
Agent(Hernia S: 4 (0-10) Moderate Pain
inguinal on T: When walk
the right 2. Observing client’s vital signs.
groin) - BP: 110/70 mmHg
HR: 75 x/m
RR: 28 x/m
T: 36,4oC
3. Teaching client pain management:
- Deep breathe relaxation technic.
4. Giving comfortable position:
- semi fowler position
5. Asking client to do deep breath relaxation
technic when the pain appear.
- Client said he will do it when the the
pain appear.
6. Collaborating with medical team:
- IVFD: RL 500ml 20 dpm
IV : Antrain 3 x 1000
mg/1ampule
- Ranitidin 2 x 50 mg / 1 ampule
09.50 Self-care 1. Exanimating client’s capability in doing
AM deficit: personal hygiene.
personal and - Client can do personal hygiene by
oral hygiene himself.
related to lack - Client said he only wash his face every
of knowledge morning.
2. Examining muscle and activity scale of
client.
- Muscle Scales: 5555 5555
5554 5555
50
- Activity scale 0
3. Monitoring client’s hygiene.
- Client’s skin and oral hygiene is less
4. Motivating client to bathing as usual.
- Client nodded his head means
understand and said will be cleaner
5. Wiping client on his bed if needed.
- Client refuses to accept nurse offer
6. Helping client in giving oral hygiene if
needed.
7. Helping client in shampooing in his bed
if needed.
8. Asking with client’s family to help client
doing personal and oral hygiene.
- Client’s family said will help and
motivated client to do personal
hygiene.
Evening 02.30 Ineffective 1. Examining cyanosis sign:
Shift PM peripheral - Conjunctiva anemic
tissue - Skin color pale
perfusion - Peripheral pulse
related to - CRT 5 second
decreased Hb 2. Observing client’s general condition and
and blood vital signs.
concentrations - GC good
- BP: 110/70 mmHg
HR: 75 x/m
RR: 26 x/m
T: 36,3oC
3. Observing input and output fluids every 8
hours.
51
- 2nd bag of Packed Red Cell
transfusion with type O+
high protein diet.
RL 500ml 20 dpm
PM related to - P: Hernia
HR: 75 x/m
RR: 26 x/m
T: 36,3oC
3. Evaluating client pain management:
- Client said he do deep breathe
relaxation technic and the pain
decrease a bit.
4. Keeping comfortable position:
- Client said he will do it when the pain
appears.
mg/1ampule
- Ranitidin 2 x 50 mg /
1ampule
PM deficit: personal hygiene.
52
related to lack - Client said wash his face every
of knowledge morning
client.
5554 5555
- Activity scale 0
- Client’s skin and oral hygiene is quite
good
4. Motivating client to bathing as usual.
- Client nodded his head means
understand and said will be cleaner
hygiene.
Night Shift 20.30 Ineffective 1. Examining cyanosis sign:
PM peripheral - Conjunctiva anemic
perfusion - CRT 5 second
related to 2. Observing client’s general condition and
decreased Hb vital signs.
and blood - GC good
concentrations - BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
53
- Check Hb
high protein diet.
- RL 500ml 20 dpm

HR: 76 x/m
RR: 28 x/m
T: 36,4oC
3. Evaluating client pain management:
- Client said he does deep breathe
relaxation technic and the pain
decrease a bit.
4. Keeping comfortable position:
- Client said he will do it when the pain
appears.
mg/1ampule
Ranitidin 2 x 50 mg / 1ampule
related to lack - Client said wash his face every
of knowledge morning.
54
client.
5554 5555
- Activity scale 0
- Client’s skin and oral hygiene is quite
good
hygiene.
2 Wednesday 09.00 Ineffective 1. Examining cyanosis sign:
Augustus AM peripheral - Conjunctiva anemic
09, 2017 tissue - Skin color pale
Morning perfusion - CRT 4 second
Shift related to 2. Observing client’s general condition, Hb
decreased Hb and vital signs.
and blood - GC good
concentrations - Hb : 10,2 g/dl
- BP: 120/80 mmHg
HR: 78 x/m
RR: 28 x/m
T: 36,3oC
high protein diet.
- RL 500ml 20 dpm
55
HR: 78 x/m
RR: 28 x/m
T: 36,3oC
pain appear.
mg/1ampule
Ranitidin 2 x 50 mg / 1 ampule
09.50 Self-care 1. Exanimating client’s capability in
AM deficit: doing personal hygiene.
related to lack - Client said this morning he is wash his
of knowledge face and brush his teeth.
client.
5554 5555
- Activity scale 0
- Client’s skin and oral hygiene is good
56
- Client’s family said will wipe client
this morning.
shift PM peripheral - Conjunctiva anemic
decreased Hb 2. Observing client’s general condition, Hb
and blood and vital signs.
- Hb : 10,2 g/dl
- BP: 120/90 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
- A bag of Packed Red Cell transfusion
with type O+
high protein diet.
- RL 500ml 20 dpm
HR: 76 x/m
57
RR: 28 x/m
T: 36,3oC
pain appear.
mg/1ampule
related to lack - Client said this morning he is wash his
of knowledge face and brush his teeth.
- Client said gets wipe by his family this
morning.
client.
5554 5555
- Activity scale 0
- Client’s skin and oral hygiene is good
- Client’s family said will keep
client’s hygiene
Night Shift 21.00 Ineffective 1. Examining cyanosis sign:
58
- Hb : 8, 5 g/dl (august 07, 2017)
- BP: 120/90 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
- Check Hb
high protein diet.
- RL 500ml 20 dpm
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
3. Evaluating pain management:
- Client can control his pain with Deep
breathe relaxation technic.
59
- IV : Antrain 3 x 1000
mg/1ampule
3 Thursday/ 09.00 Ineffective 6. Examining cyanosis sign:
Morning perfusion - Peripheral pulse
Shift related to - CRT 4 second
- Hb : 10,2 g/dl
- BP: 120/90 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
with type O+
high protein diet.
- RL 500ml 20 dpm
60
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
mg/1ampule

shift PM peripheral - Conjunctiva anemic
- Hb : 10,2 g/dl
- BP: 120/90 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
61
with type O+
high protein diet.
- RL 500ml 20 dpm
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
mg/1ampule
Night Shift 09,00 Ineffective 1. Examining cyanosis sign:

- Hb : 10,2 g/dl
- BP: 120/90 mmHg
HR: 76 x/m
62
RR: 28 x/m
T: 36,3oC
- Check Hb
high protein diet.
- RL 500ml 20 dpm
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
mg/1ampule
4 Friday/ 09.00 Ineffective 1. Examining cyanosis sign:
63
- Hb : 10,5 g/dl
- BP: 120/90 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
high protein diet.
- RL 500ml 20 dpm
HR: 76 x/m
RR: 28 x/m
T: 36,3oC
64
mg/1ampule
L. Evaluations
Nursing Evaluation
No Day/Date Time
Diagnosis
1 Tuesday/ 09.30 AM Ineffective S:
August 08, Morning peripheral - Client said he still felt limp.
2017 Shift tissue - Client he said urinate 8-9x or
perfusion more a day 5-10cc
related to
decreased Hb O:.
and blood - General Condition is good
concentrations - Conjunctivas anemic
- CRT 5 seconds.
- Laboratory result on August 07,
2017 of Hb: 8, 5.
- Client gets the 1st transfusion
bags of Packed Red Cell
transfusion 350 cc with blood
type O+ on August 08, 2017. At
09.05 AM
- Client attached infusion set of
Ringer Lactate with 20 TPM on
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 28 x/Minutes
T : 36,6 ̊ C
A: Ineffective peripheral tissue

perfusion has not been resolved.
65
P: Continue the intervention.
1. Examine cyanosis sign:
Skin color, peripheral pulse, and
CRT.
2. Observe client’s general
condition and vital signs.
3. Observation input and output
fluids.
4. Increase adequate fluids intake.
team:
- 2 bags of Packed Red Cell
with blood type O+.
- Food with high carbohydrate
and high protein diet
- RL 500ml 20dp
09.50 AM Acute pain S:
Morning related to - Client said that he still felt
Shift Biological pain in his stomach until his
Injury thigh.
Agent(Hernia - Client said the pain still
inguinal on the appears when he walks.
right groin) - Client said do deep breathe
and said the pain a bit
decreased.
- Pain examination :
- P: Hernia
Q: Sliced
R: The right groin
S: 4 (0-10) Moderate Pain
T: When walk
O:
- Client still looks grimace and
holds his hernia when the pain
appears.
- Client can do deep breathe
66
technic
- Found a lump on his right
groin that can go inside while
lying down and out while
sitting or standing (Hernia
Inguinal Dextral Reducible)
- Client in Semi fowler
position.
- Vital Signs :
BP: 110/70 mmHg
HR: 75 x/m
RR: 28 x/m
T: 36,4oC
- Muscle Scales : 5555 5555
5554 5555
- Activity Scales : Level 0
Ringer Lactate with 20 TPM
on his left hand.
- Client gets injection of:
Antrain 3 x 1000 mg/1ampule
Ranitidine 2 x 50 gr/1ampule
A: Acute pain has been not resolve.

- Examination the pain with
PQRST method.
- Observation client’s vital
signs.
- Keep comfortable position:
Semi fowler position.
- Ask client to do deep breath
relaxation technic when the
pain appear.
- Collaborating with medical
team :
RL 500ml 20 dpm
67
inj: Antrain 3 x 1000
mg/1ampule
Ranitidine 2 x 50 gr/1
ampule
10.55 AM Self-care S:
Morning deficit: - Client said at hospital he didn’t
Shift personal and bathing yet since the first day of
oral hygiene his hospitalization.
related to lack - Client said he only wash his face
of knowledge in the morning.
- Client said today he will wipe
his body and brush his teeth
O:
- Client’s skin hygiene is still less.
- Oral hygiene is still less.
5554 5555
A: Self-care deficit has been not

resolved.

1. Examination client’s capability
in doing personal hygiene.
2. Examination muscle and activity
scale of client.
3. Motivate client to bathing as
usual.
4. Monitor client’s hygiene.
5. Ask with client’s family to help
client doing personal and oral
hygiene.
Evening 03.00 PM Ineffective S:
Shift peripheral - Client said he is 70 years old
tissue - Client said he still felt limp.
68
perfusion - Client said urinate 8-9x or more
related to a day 5-10cc
decreased Hb - Client said drinks 8-9 glass a day
and blood
concentrations O:.
- General Condition is good
- CRT 5 seconds.
2017 of Hb: 8, 5.
- Client gets the 2st transfusion
bags of Packed Red Cell
transfusion 350 cc with blood
type O+ on August 08, 2017. At
05.05 PM
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 26 x/Minutes
T : 36,3 ̊ C


- Examination cyanosis sign:
CRT.
- Observation client’s general
- Observation input and output
fluids.
69
- Increase adequate fluids intake.
- Collaboration with medical
team:
- A bags of Packed Red Cell
with blood type O+.
- RL 500ml 20dp
03.20 PM Acute pain S:
related to - Client said that he still felt
Biological pain in his stomach until his
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
70
BP: 110/70 mmHg
HR: 75 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
inj: Antrain 3 x 1000
mg/1ampule
Ranitidine 2 x 50 gr/1 ampule
15.35 PM Self-care S:
deficit: - Client said at hospital he didn’t
personal and bathing yet since the first day of
71
- Client said to day will wipe his
body and brush his teeth
O:
- Client looks weak.
- Client’s skin hygiene is quite
good.
5554 5555

resolved.

scale of client.
8. Motivate client to bathing as
usual.
Ask with client’s family to help client
Night Shift 09.30 Ineffective S:

PM peripheral - Client said he is 70 years old
and blood
concentrations O:.
72
- CRT 5 seconds.
2017 of Hb: 8, 5.
Ringer Lactate with 20 dpm on
his left hand.
- Vital Signs :
BP : 110/80 mmHg
HR : 76 x/Minutes
RR : 28 x/Minutes
T : 36,4 ̊ C


1. Examination cyanosis sign:
CRT.
2. Observation client’s general
condition, Hb and vital signs.
fluids.
team:
- Check Hb.
- RL 500ml 20dp
09.50 PM Acute pain S:
Injury thigh.
73
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule
74

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
10.10 PM Self-care S:
- Client said today will wipe his
O:
- Client looks weak.
good.
5554 5555

resolved.
75
scale of client.
4. Ask with client’s family to help
client doing personal and oral
hygiene.
2 Wednesday/ 09.30 AM Ineffective S:
August 09 peripheral - Client said he is 70 years old
2017 tissue - Client said he still felt limp.
Morning perfusion - Client said urinate 8-9x or more
Shift related to a day 5-10cc
and blood
concentrations O:.
- CRT 5 seconds.
2017 of Hb: 10, 2.
his left hand.
- Vital Signs :
BP : 110/80 mmHg
HR : 76 x/Minutes
RR : 28 x/Minutes
T : 36,4 ̊ C

76
CRT.
fluids.
team:
- Check Hb.
- RL 500ml 20dp
Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
77
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
78
Self-care S:
related to lack - Client said he wash his face in
of knowledge the morning.
- Client said to day will wipe his
O:
good.
5554 5555

resolved.

scale of client.
Ask with client’s family to help client
Evening 03.00 PM Ineffective S:
and blood
concentrations O:.
79
- CRT 5 seconds.
2017 of Hb: 10, 2.
- Client gets the transfusion bags
of Packed Red Cell transfusion
350 cc with blood type O+ on
August 09, 2017. At 05.05 PM
- Client attached transfusion blood
set on his left hand.
- Vital Signs :
BP : 110/80 mmHg
HR : 76 x/Minutes
RR : 28 x/Minutes
T : 36,4 ̊ C


CRT.
fluids.
team:
- Check Hb.
RL 500ml 20dp
80
Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
81
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
Self-care S:
related to lack - Client said he wash his face in
of knowledge the morning.
- Client said to day just wipe his
body by his wife and brush his
teeth
O:
- Client’s skin hygiene is good
- Oral hygiene is good
5554 5555
82
A: Self-care deficit has been

resolved.
P: Stop Intervention
Night Shift 09.30 pm Ineffective S:

peripheral - Client said he is 70 years old
and blood
concentrations O:.
- CRT 5 seconds.
2017 of Hb: 10, 2.
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 26 x/Minutes
T : 36,3 ̊ C


CRT.
83
fluids.
team:
- Check Hb
RL 500ml 20dp
Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
84
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
3 Thursday / Ineffective S:
85
August 10, peripheral - Client said he is 70 years old
2017 tissue - Client said he still felt limp.
and blood
concentrations O:.
- CRT 5 seconds.
2017 of Hb: 10,4.
Client attached infusion set of
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 26 x/Minutes
T : 36,3 ̊ C


CRT.
fluids.
team:
86
with blood type O+.
RL 500ml 20dp
Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
87
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
Evening Ineffective S:
88
and blood
concentrations O:.
- CRT 5 seconds.
2017 of Hb: 10,4.
- Client gets the transfusion bags
of Packed Red Cell transfusion
350 cc with blood type O+ on
August 08, 2017. At 05.05 PM
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 26 x/Minutes
T : 36,3 ̊ C


CRT.
fluids.
team:
89
with blood type O+.
- RL 500ml 20dp
Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
90
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
Night Shift Ineffective S:

peripheral - Client said he is 70 years old
91
and blood
concentrations O:.
- CRT 5 seconds.
2017 of Hb: 10,4.
his left hand.
- Vital Signs :
BP : 110/70 mmHg
HR : 75 x/Minutes
RR : 26 x/Minutes
T : 36,3 ̊ C


CRT.
fluids.
team:
- Check Hb
- RL 500ml 20dp
Acute pain S:
92
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
93
Antrain 3 x 1000
mg/1ampule

PQRST method.
signs.
pain appear.
team :
RL 500ml 20 dpm
4 Friday/ 09.30 AM Ineffective S:
Augustus peripheral - Client said he is 70 years old
11,2017 tissue - Client said he still felt limp.
and blood
concentrations O:.
- CRT 4 seconds.
2017 of Hb: 10, 5.
94
his left hand.
- Vital Signs :
BP : 110/80 mmHg
HR : 76 x/Minutes
RR : 28 x/Minutes
T : 36,4 ̊ C

- The client is discharged
- Hb is not within normal limits
- Internist is not there
- Surgical process canceled
- At his own request
09.50 AM Acute pain S:
Injury thigh.
decreased.
- P: Hernia
Q: Sliced
R: The right groin
T: When walk
O:
95
appears.
technic
position.
- Vital Signs :
BP: 110/80 mmHg
HR: 76 x/m
RR: 28 x/m
T: 36,4oC
5554 5555
on his left hand.
Antrain 3 x 1000
mg/1ampule

- The client is discharged
- Hb is not within normal limits
- Internist is not there
- Surgical process canceled
- At his own request
96
REFERENCES
Huda, A. dan Kusuma, H. 2015. Asuhan Keperawatan Praktis Volume 1. Jogjakarta: MediAction
Buranda, Theopilus Dkk. 2008. Anatomi Umum. Makassar: Bagian Anatomi, Fakultas
Kedokteran, Universitas Hasanuddin
Doenges, Marilynn E. 2008. Rencana Asuhan Keperawatan pedoman untuk perencanaan dan
pendokumentasian pasien, ed.3. EGC, Jakarta
Tambayong, dr. Jan. 2009. Patofisiologi untuk Keperawatan. Jakarta : EGC
Giri Made Kusala, 2009. Kumpulan Penyakit Dalam. Jakarta : EGC
Amin Kesuma Nurarif, S.Kep.,Ns 2015. North American Nursing Diagnosis Associantion: Jilid
3,
http://www.sridianti.com/anatomi-dan-fisiologi-usus-besar.html
http://currentnursing.com/nursing_theory/application_goal_attainment_theory.html
http://www.perawatina.com/2015/12/laporan-pendahuluan-hernia-inguinal.html
97

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THEORITICAL BACKGROUND OF HERNIA INGUINAL AND NURSING

CARE REPORT OF MR. B WITH HERNIA INGUINAL DEXTRA IN

ROY AHMAD SEPTIADI

NISRINA NADYA WAHDA

MUHAMMAD RIDHO PRADHANA

MUHAMMAD FAUZAN RIZALDIE

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

FACULTY OF NURSING AND HEALTH SCIENCE

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

ACADEMIC YEAR 2016/2017

The function of small intestine:

Here are some types of hernia according to its location:

Congenital umbilical Para umbilical hernia Hernia Inguinal

Surgical incision Nutrient intake is less Nausea

Bowel peristalsis Decreased Appetite

Resti infeksi Inadequate food intake

The herniated bag

The hernia bag enters

8. DIAGNOSTIC EXAMINATION OF HERNIA

Preoperative patient assessment (Doenges, 2008) includes:

3. A sense of comfort. (NANDA NIC-NOC, 2015:266)

Acute pain r.t 1.Assess the pain 1. Determine the

10. Genitalia and Reproduction

11. Upper and Lower Extremities

 Activity Scales : Level 0 (Able to fully take themselves)

D. Physical, Psychology, Social, And Spiritual Needs

- Activity Scale : Level 0 (Able to fully take care themselves.)

2. Transfusion Blood Data

G. Pharmacology Therapy on August 8, 2017

1. Subjective data : Ineffective Decreased Hb

- Abdominal mass touched, Tenderness

5. Subjective Data: Impaired Pain

giving blood the body and

4. Give comfortable 4. Comfortable

5. Ask client to do 5. Help to decrease

6. Collaboration with 6. Analgesic

5. Wipe client on 5. Give

6. Help client in 6. Give

7. Help client in 7. Give

8. Collaboration 8. Engage client’s

3 Fecal After doing the nursing 1. Define the pattern 1. To restore

5. Impaired After doing the nursing Pain management:

4. Give comfortable 4. Comfortable

6. Collaboration with Analgesic medicine

21.00 Acute pain 1. Examining the pain with PQRST method

Evening 02.30 Ineffective 1. Examining cyanosis sign:

Night Shift 09,00 Ineffective 1. Examining cyanosis sign:

A: Ineffective peripheral tissue

A: Acute pain has been not resolve.

P: Continue the intervention.

A: Self-care deficit has been not

P: Continue the intervention.

A: Ineffective peripheral tissue

P: Continue the intervention.

A: Acute pain has been not resolve.

P: Continue the intervention.

A: Self-care deficit has been not