GRUP 3 :

1. NITA KHIKMATUL AENI (170103061)

2. NOVI PURWATI (170103062)
3. RIZKI HANDAYANI (170103076)

CHASE 3
Mrs. D complained of abdominal pain with scale 7. It was kind of squeezing pain that circled
in her entire abdomen. She also vomited once, had bloody stool, constipation, and there was a
lump in the lower abdomen. The patient was in Compos Mentis state. BP: 120/80 mmHg; P:
68 bpm ; RR: 24 breath / minute ; T: 37.50 C, bowel peristaltic (+) 14x/minute, abdomen
palpation showed that there was a pressure pain and lump in the lower abdomen. The result of
blood test : HGB: 11.3 g/dl, Orem: 50 mg/dl, Creatinine: 1.2 mg/dl

OUTLINE OF NURSING CARE PLAN 2020

TITLE : Nursing Care Plan of Mrs.D

A Patient with hernia

A. IDENTITY
Patient’s Identity
Name : Mrs. D
B. CASE REVIEW
1. Chief Complaint
- complained of abdominal pain with scale 7
2. History of Present Illness
- abdominal pain with scale 7
- She also vomited once,
- had bloody stool,
- constipation,
- and there was a lump in the lower abdomen
3. Past Medical History
-
 4. Family History
-
5. Physical Examination
- BP: 120/80 mmHg
- P: 68 bpm
- RR: 24 breath / minute
- T: 37.50 C
- peristaltik usus (+)
- abdomen palpation showed that there was a pressure pain and lump in the lower
abdomen
6. Additional Data
- The patient was in Compos Mentis state
- HGB: 11.3 g/dl
- Orem: 50 mg/dl
- Creatinine: 1.2 mg/dl
-

C. DATA ANALYSIS
1. Data Clustering
No. Date Focus Data Problem Etiology
1. SD: Acute pain Biological injury agent
- Patients say pain
in the abdominal
area

OD:
- Pain
P:-
Q: squeezing
R : pain that circled
in her entire
abdomen
S:7
T:-
2. SD : Constipation Abdominal muscle
 - Patients say weakness
vomiting, bloody
stools and
constipation

OD :
- bowel peristaltic
(+)
- HGB: 11.3 g/dl,
- Orem: 50 mg/dl,
- Creatinine: 1.2
mg/dl

3. SD : Discomfort Discomfort associated

- abdomen palpation with pain in a lump
showed that there under the stomach
was a pressure pain
and lump in the
lower abdomen

OD :
- abdomen palpation
showed that there
was a lump in the
lower abdomen

2. Nursing Diagnosis and Problems Priority

a. Acute pain related to Biological injury agent
b. Constipation related to Abdominal muscle weakness
c. Discomfort related to Illnes : a lump in the stomach
D. NURSING OUTCOME
No. Nursing Expected Outcome Rationale
Diagnosis
1. Acute pain related to After taking nursing action for 3 x 1. not reporting
Biological injury 24 hours, it is expected that the pain pain occurs
agent will disappear with the following 2. do not feel pain
criteria: in the near future
Pain level (2102) 3. facial
Indikator Al Ar expressions show
1. Reporting 3 5 a scale of 1-2
pain 4. normal pulse 60-
2. The 3 5
100x / minute
frequency of
pain
3. Expression of 3 5
pain in the
face
4. Change in 4 5
pulse
Information :
1. Weight
2. Quite heavy
3. Medium
4. Light weight
5. Nothing

2. Constipation rel After taking nursing action for 3 x 1. normal

ated to Abdominal 24 hours, it is expected that the pain elimination
muscle weakness will disappear with the following pattern 2-3x a
criteria: day
Intestine Elimination (0501) 2. no intestinal
Indikator Al Ar peristalsis
1. pattern of 3 5 3. the amount of
elimination stool for a
2. control bowel 3 5
normal diet
movements
4. normal stool,
 3. feces color 3 5 soft not hard
4. the amount of 4 5 5. Normal bowel
stool for the movements
diet are not
5. soft stool 4 5
6. CHAPTER 4 5 constipated
PRESS 6. no blood in
7. direction in the 4 5 the stool
stool
1. very disturbed
2. much disturbed
3. quite disturbed
4. a little disturbed
5. not disturbed

3. Discomfort After taking nursing actions for 3 x 1. not reporting

associated with pain 24 hours, it is expected that pain occurs
in a lump under the discomfort due to pain can be 2. do not feel pain
stomach overcome with the expected results: in the near future
Pain level (2102) 3. facial
Indikator Al Ar expressions show
1. Reporting 3 5 a scale of 1-2
pain 4. normal pulse 60-
2. The 3 5
100x / minute
frequency of
pain
3. Expression of 3 5
pain in the
face
4. Change in 4 5
pulse
Information :
1. Weight
2. Quite heavy
3. Medium
4. Light weight
5. Nothing
E. NURSING INTERVENTION
No. Expected Outcome Nursing Rationale
Intervention
1. After taking nursing action for 3 Pain Management 1. to find out where
x 24 hours, it is expected that (1400) the pain is felt
the pain will disappear with the 1. Perform a 2. for the patient
following criteria: comprehensive knows the cause of
Pain level (2102) pain pain and how to
Indikator Al Ar assessment deal with it so that
1. Reporting 3 5 2. Provide pain can be
pain information overcome
2. The 3 5
about the pain 3. to practice
frequency of
that is felt relaxation
pain
3. Expression of 3 5 3. Teach non- techniques so that
pain in the pharmacologic pain can be
face al techniques overcome
4. Change in 4 5 4. Support the 4. To relieve pain
pulse patient's rest
Information :
5. Collaboration
1. Weight
of pain relief
2. Quite heavy
drugs
3. Medium
4. Light weight
5. Nothing

2. After taking nursing action for 3 Management of the 1. to assess normal

x 24 hours, it is expected that gastrointestinal tract bowel movements
the pain will disappear with the (0430) 2. monitor normal
following criteria: 1. note the date of bowel movements
Intestine Elimination (0501) last defecation concentration: soft
Indikator Al Ar 2. Monitors shape: solid
1. pattern of 3 5 defecate color: light yellow
elimination including to dark yellow and
2. control 3 5
frequency, the right way
bowel
consistency, 3. to facilitate
 movements shape, volume, defecation
3. feces color 3 5 and color in an 4. fibrous green food
4. the amount 4 5
appropriate in order to
of stool for
manner. facilitate intestinal
the diet
5. soft stool 4 5 3. Give warm activity
6. CHAPTER 4 5 liquids, in a fast 5. so that the family
PRESS way. 6. member can
7. direction in 4 5
4. encourage patient control related
the stool
1. very disturbed or family defecation of the

2. much disturbed members to patient when at

3. quite disturbed record volume, home ie

4. a little disturbed constipation and concentration: soft

5. not disturbed frequency of shape: solid

work. color: light yellow
5. get gualac for to dark yellow and
(stopping) faeces, the right way
in the right way.

3. After taking nursing actions for 1. not reporting 1. to find out where
3 x 24 hours, it is expected that pain occurs the pain is felt
discomfort due to pain can be 2. do not feel pain 2. for the patient
overcome with the expected in the near knows the cause of
results: future pain and how to
Pain level (2102) 3. facial deal with it so that
Indikator Al Ar expressions pain can be
1. Reporting 3 5 show a scale of overcome
pain 1-2 3. to practice
2. The 3 5
4. normal pulse relaxation
frequency of
60-100x / techniques so that
pain
3. Expression of 3 5 minute pain can be
pain in the overcome
face 4. To relieve pain
4. Change in 4 5
pulse
Information :
1. Weight
 2. Quite heavy
3. Medium
4. Light weight
5. Nothing