MEDICAL SURGICAL NURSING Tn.

W
IN THE NEW BOUGENVILLE ROOM

Prepared by :

Fira Mawaddah (16013)

AKADEMI KEPERAWATAN PELNI

JAKARTA
Jl. Aipda KS Tubun 92-94 Jakarta Barat
Telp. 021.5484809 Fax. 5485709

TAHUN AJARAN 2018/2019

 Patient Assessment Form

A. NURSING ASSESSMENT

1. Client Identy
My client’s name is Mr.W and He is 51 years old. He is Moslem and married. His
etnic is Javanese and his last education is senior high school. His addres is
Nongkomangsi Rt 010/004 Jatisobo, Karang Anyar. He speaks Indonesian and Javanese.
He does not work.
He entered Pelni Hospital Jakarta on 2nd January 2018 in New Bougenville Room.
His register number is 646894 and his medical diagnose is Gastritis. His financial source
is BPJS and the information source is from family.

2. Resume
Mr.W is Admitted to hospital 1th January 2018. The client admitted to hospital
with complaints of nausea and vomiting, cough, and dizzy. This complaint occurs when
the client is nausea and vomiting when waking up in the morning and increasing when
the move.
Clients look anxious. Clients claim to has no desire to eat. Clients also said to
have a history of asthma since childhood and the client said that there is one family
member who has a history of gastritis, namely his mother.
From result of observation got result: awareness level: compost mentis, and result
of vital signs : Blood pressure = 105/72 mmHg, RR = 20 x/min, Pulse = 88 x/min,
Temperature = 36,9oC. Clients are currently receiving therapy: Ranitidine 50 mg by
injection, Primperan 10 mg by injection and asering infusion for 8 hours. On chest X-ray/
thorax investigation, the lung results are obtained within normal limits. On USG
Examination the result abdomen within normal limits. On ECG Examination the result
ECG within normal limits.

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3. History of Nursing :
a. Current of medical history
The main complaint was nausea and vomiting, cough, and dizzy, Clients claim
to has no desire to eat, Clients claim to can not sleep, and upper right abdominal pain.
has happened since 2 days ago. The problem solving was going to hospital

b. Past medical history

His medical history Kidney Stones and Gall Stones but has been opration. He has no
allergy. He has taken medicine gastritis drug.

c. Family health history (Genogram and description of three generations of clients)

Note
Died : Female :
Male : Living together :
Line of Married : Line of Generation :

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 d. Disease experienced by a family member who becomes a risk factor
The client's mother is also suffering from the same illness as the client

e. Psychosocial and Spiritual History

The patient’s communication pattern and decision within the family is dialogue and
discussion. The effect of the patient’s illness to the family is anxity. The patient
expecting rapid recovery and get home earlier

4. Physical Assessment:
a. General Physical Examination
The physical examination was conducted on January 2nd, 2018. The client
weight was 72 kg and decreased 2 kg after. His height is 160 cm. The general
circumstances of the client was not bad. He didn't have enlarged lymph nodes.

b. Vision System
The client had position symmetry eyes. The eyelid and eyeball movement
was normal. Corneas was normal. His conjunctivas was anemis. The client had an
isokor pupil. The client had good visual function. He didn't signs of inflammation,
didn’t use glasses or no contact lens. He had a good reaction to light.

c. Hearing System
His middle ear condition was normal. There was no fluid, feeling full, tinitus
or otalgia. He had normal hearing. His hearing function was good. He didn’t have
balance disorder. He didn’t use tools.

d. Speech System
Speech system was normal. There was no problem with Aphaisa, Aphonia,
Dysartria, Dysphasia or Anarthia.

e. Respiration System
The airway was blocked because there was sputum. He had a breathing frequency
of 20 x / min. His rhythm was irregular. The type of breathing was spontaneous. He
had shallow breathing. He had a productive cough with sputum and thick
consistency. There wasn’t blood. He didn't have symmetrical chest. His chest
percussion was resonant. He had a vesicular breathing sound, and no pain when

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 breathing. He not use respiratory muscles with chest retraction . He does not use
oxygen.

f. Cardiovascular System
1) Peripheral Circulation
The pulse was 82 times/minute. His rhythm was regular and the pulse was
strong, Blood pressure was 100/60 mmhg.There wasn’t jugular venous
distention in left and right. His skin temperature was warm and the color was
pale. It took 2 seconds to feel capillary. There wasn’t edema.
2) Heart Circulation
The apical pulse rate was 82 x/minute. The rhythm was regular. There
wasn’t heart sound abnormalities. He didn’t chest pain.

g. Hematological System
The color was normal. There wasn’t bleeding found.

h. Central Nervous System

He not complained of vertigo or migrain. The awareness level was compos mentis.
The glasgow coma scale (GCS) was E ( eye): 4, M (motorik) : 6, and V ( verbal ) : 5.
There wasn’t improvement of intracranial pressure. He didn’t have disturbance of
nervous system. The physiologic reflex was normal and there wasn’t phatologic
reflex.

i. Digestive System
Nutrition
He didn,t have caries. He didn’t use of dentures. There wasn’t sprue. His tongue
was dirty. He had a saliva was normal. The appetite was less. He couldn't eat spicy.
He had vomiting, once a day and the amount was 200 ml.
He had pain in stomach area, in scale was 4, and the location has in abdomen.
There wasn't hepar enlargment and bloated abdomen. He was not installed NGT and
the pattern of eating habits at home was five times a day.
Elimination
His noise intestines was 5 x/min. He didn't have diarrhea. His feces color was
brown and its consistency was solid half, He didn’t have constipation and he didn’t
use laxative. His pattern of defecation habit at home has once a day.
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j. Endokrin System
There wasn't thyroid gland increase. The breath didn't smell like ketones. He
didn’t have polyuria, polydipsia, or polyphagia. He didn't have gangrene wound.

k. Urogenital System
His amount intake was 800 ml. It consisted of oral 500 ml and parentral 300 ml.
His amount output was 800 ml. It consisted of urine 600 ml, vomit 200 ml, and IWL
720 ml. His urinary pattern was normal and the color was clear yellow. He didn't have
bladder distension. There wasn't back pain complaints. He didn't use catheter.

l. Integumen System
The skin turgor was elastic. He had skin temperature was warm and the color was
pale. His skin condition was good. He didn't have decubitus. He didn’t abnormalities
of the skin. The condition of the area of the skin was good and not swollen. The hair
had good texture and cleanliness. The patterns of personal hygyne at home was he
takes a bath three times in a day.

m. The Musculoskeletal System

He didn't have difficulty in his movement. He didn't pain in his bones, joints and
skin. He didn’t have fracture and bone joint difference. He didn’t have vertebra
structure difference. His muscles strength was good.
The muscles strength was

5 5 5 5 5 5 5 5

5 5 5 5 5 5 5 5

Additional data ( comprehension of the illness ), client said that he knew obout
this illness. He knew that he couldn’t eat spicy.

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5. Supporting Data ( Diagnostic test that support problem : Laboratory, Radiology ,
Endoscopy. Etc.)
X-Ray Throrax is normal .

USG Examination is normal .

ECG Examination is normal .

6. Management ( Therapy/Medicine diet including )

Ranitidine 25mg/ml .

Primperan 10mg/2ml .

NACL 500mg Caps (Natrium Clorida) .

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 7. Data Focus

Subjective Data (SD) Objective Data (OD)

1. The patient said nausea 1. The patient appears weak
2. The patient said vomiting 2. The patient appears sunken in the eye
3. The patient said limp and cough continues 3. Moist mucous membranes
4. The patient said his head is dizzy 4. Vital signs :
5. The patient said can not sleep Blood pressure = 100/60 mmHg
6. The patient said the right upper abdominal RR = 20 x/min
pain Pulse = 82 x/min
7. The patient complained that she has no Temperature = 36,3 oC
desire to eat 5. The patient appear to be holding the upper
8. The patient has been sick kidney stones and right abdomen
gall stones but has been operated 6. P = lack of rest
9. The patient no allergy Q = sharp
10. The patient use gastritis drug R = upper right abdomen
S=4
T = long intermitten pain
7. The patient emotions seem stable
8. BAB, BAK normal
9. The patient ate only ¼ portion, visible
nausea while eating

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8. Data Analysis
No. Data Problem Etiology
1 SD : Risk of lack of fluid Excessive
1. The patient said limp and cough volume vomiting/output
continues
2. The patient said his head is dizzy

OD :
1. The patient appears weak
2. The patient appears sunken in the eye
3. Moist mucous membranes
4. Vital signs :
Blood pressure = 100/60 mmHg
RR = 20 x/min
Pulse = 82 x/min
Temperature = 36,3 oC

2. SD : Nutrition imbalance is inadequate food input

1. The patient said nausea
less than necessity
2. The patient said vomiting
3. The patient complained that she has
no desire to eat

OD :
1. The patient ate only ¼ portion, visible
nausea while eating
3. Comfort disorder Biological injury
SD : (gastric irritation)
(acute pain)
1. The patient said can not sleep
2. The patient said the right upper
abdominal pain

OD :
1. The patient appear to be holding the
upper right abdomen
2. P = lack of rest
Q = sharp
R = upper right abdomen
S=4
T = long intermitten pain

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B. Nursing Diagnoses (According to Priority)

The Date is
No. Nursing Diagnoses (P & E) Date Found Clear Name
Resolved
1 Risk of lack of fluid volume 2nd January 2018 rd
3 January 2018 Fira Mawaddah
Excessive by vomiting/output

2 Nutrition imbalance is less 2nd January 2018 3rd January 2018 Fira Mawaddah
than necessity by Inadequate
food input

3 Comfort disorder (acute pain) 2nd January 2018 3rd January 2018 Fira Mawaddah
by Biological injury (gastric
irritation)

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C. Nursing Plan

(Includes independent and interdependent nursing actions)

Patient Name/Age : Tn. W/51 years old
Class Number/Room : 321/New Bougenville lt.3
Objectives and yield criteria Autograph &
Date No. Nursing Diagnoses (PES) Action Plan
Clear Name
3rd 1 Risk of lack of fluid volume Excessive by Purpose : Plan :
January vomiting/output after 3 x 24 hours of nursing 1. Keep the intake and output accurate Fira Mawaddah
2018 SD : action is expected there is no R : to meet the needs of fluids
sign of lack of fluid volume
1. The patient said limp and cough
2. Monitor hydration status (mucous Fira Mawaddah
continues with the results criteria: membrane)
2. The patient said his head is dizzy S = The patient said his head R : to know the current condition
is not dizzy, his body is
OD : not weak 3. Observation of vital signs Fira Mawaddah
1. The patient appears weak M = The patient eye R : to know thegeneral situation
2. The patient appears sunken in the eye expression is not
concave 4. Encourage food inputs Fira Mawaddah
3. Moist mucous membranes
A = Balance of intake and R : to increase fluid requirements
4. Vital signs : output
Blood pressure = 100/60 mmHg R = Mucosal membrane 5. Administer ranitidine 25 mg/ml by Fira Mawaddah
RR = 20 x/min patient are damp injection
Pulse = 82 x/min T = The patient general R : to reduce nausea
Temperature = 36,3 oC condition improved for
3x4 hours
3rd 2 Nutrition imbalance is less than necessity Purpose : Plan :
January by Inadequate food input after 3 x 24 hours of nursing 1. Give the selected food Fira Mawaddah
2018 SD : action is expected to meet the R : to control nutritional intake
1. The patient said nausea nutritional needs
2. The patient said vomiting 2. Encourge patient to choose soft Fira Mawaddah
3. The patient complained that she has with the results criteria: foods
no desire to eat S = The patient said no R : to prevent stomach irritation
OD : nausea
1. The patient ate only ¼ portion, visible M = The patient is not weak 3. Encourage patient to increase Fira Mawaddah
nausea while eating A = Increased appetite protein and vitamin c
R = The patient want to eat R : to increase nutritional intake
T = The patient general
condition improved for 4. Avoid spicy and sour foods Fira Mawaddah
3x4 hours R : to prevent stomach irritation

5. Monitor the amount of nutrition Fira Mawaddah

and calorie intake
R : to control nutrional needs
3rd 3 Comfort disorder (acute pain) by Plan :
January Biological injury (gastric irritation) Purpose : 1. Do pain assessment Fira Mawaddah
2018 SD : after 3 x 24 hours of nursing R : to know the development of
1. The patient said can not sleep action is expected to reduce pain
2. The patient said the right upper pain/loss
abdominal pain 2. Teach relaxation techniques
with the results criteria:
OD : R : to help reduce pain Fira Mawaddah
S = The patient said the pain is
1. The patient appear to be holding the decreased
upper right abdomen M = Patient facial expression 3. Collaboration of analgesic
2. P = lack of rest calm administration as indicated Fira Mawaddah
Q = sharp A = Pain scale 0 R : to reduce pain
R = upper right abdomen R = The patient can control pain
S=4 T = The patient general 4. Observation of vital signs
T = long intermitten pain condition improved for 3x4 R : to know thegeneral situation Fira Mawaddah
hours
D. Implementation of Nursing (Nursing Note)
No.Nursing Autograph & Clear
Date/Time Nursing Actions and Outcomes
Diagnoses Name
3rd January
2018

10 : 00 1 1. Maintaining intake and output Fira Mawaddah

Results : Balance + intake

10 : 30 2. Monitoring hydration status Fira Mawaddah

Results : moist mucous membranes

11 : 00 3. Observing of vital signs Fira Mawaddah

Results :
Vital signs :
Blood pressure = 110/70 mmHg
RR = 20 x/min
Pulse = 88 x/min
Temperature = 37,1 oC

11 : 30 4. Giving ranitidine 25 mg/mlby injection Fira Mawaddah

Results : patient willing. Pattient love to
be noticed

3rd January
2018

10 : 00 2 1. Giving the selected food Fira Mawaddah

Results : Patient ate ½ portion

10 : 30 2. Encourgeing patient to choose soft foods Fira Mawaddah

Results : patient want to eat soft foods

11 : 00 3. Avoiding spicy and sour foods Fira Mawaddah

Results : patient want to do it

3rd January
2018

10 : 00 3 1. Doing pain assessment Fira Mawaddah

Results : Sudden pain, pain on top right,
scale 2
10 : 30
2. Observing nonverbal discomfort Fira Mawaddah
Results : patient is getting comfortable
11 : 00
3. Teaching relaxation techniques Fira Mawaddah
Results : patient can do alone
E. Evaluation (Progress Notes)
No.
Evaluation of Results (SOAP) Autograpgh &
Nursing Day/Date/Time
(Refers to the purpose) Clear Name
Diagnoses
1 Wednesday/3rd S = The patient said “my body is not Fira Mawaddah
January 2018/12:00 weak and no dizzy sus”

O = Blood pressure = 141/99 mmHg

RR = 20 x/min
Pulse = 72 x/min
Temperature = 36,9 oC

A = destination is resolved

P = The plan stopped, patient

returning home

2 Wednesday/3rd S = The patient said “no nausea and Fira Mawaddah

January/12:00 vomiting sus”

O = patient want to eat foods thar

are soft, not spicy and sour.
Patient eat 1 portion

A = destination is resolved

P = The plan stopped, patient

returning home

3 Wednesday/3rd S = The patient said “the pain is Fira Mawaddah

January/12:00 gone sus”

O = patient is already comfortable.

Pain scale 0

A = destination is resolved

P = The plan stopped, patient

returning home