PAPER ASSIGNMENT ENGLISH

“MEDICAL SURGICAL NURSING CASE”

Arranged By:

1. Faqihuddin ( 2020080025P)
2. Hardian Adi Sasongko (2020080026P)
3. Meli Candra Kinarti (2020080027P)
4. Wahyu Indah Rizki I (2020080028P)
5. Cicik Nurma Tristanti(2020080029P)
6. Reni Rahayu Yuspitasari (202080030P)
7. Novi Lestari S (2020080031P)
8. Syihabuddin Al Farosi (2020080032P)
9. Marlia Sinta (2020080033P)
10. Dian Purnomo (2020080034P)
11. Burhan Khanif Rafsanjani (2020080035P)
12. Fauziyah Ningsih (2020080036P)
13. Ismail Sulaiman (2020080037P)
14. Beliya Dini Yuliantika (2020080038P)
15. Nanang Widyatmoko (2020080039P)
16. Emi Indrawati (2020080041P)

Nursing Science Study Program

Faculty of Health Science
Gresik University
2021
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By:NURSALAM
NURSING PROCESS FORM: MEDICAL SURGICAL
SCHOOL OF NURSING, FACULTY OF NURSING
AIRLANGGA UNIVERSITY

1. ASSESSMENT

NURSING
HISTORY Admission Date : 24-02-2021
Time
: 08.00 WIB
No. Reg
: 2029
Medical Dx
: DM
Date of Assessment :
I. Patient Identity:
1. Name :Mrs.Jody
2. Age :78 Years old
3. Race :Asian
4. Religion :Moeslem
5. Education :Junior High School
6. Occupation :Housewife
7. Address : Kendung street 115, benowo

II. HISTORY OF PRESENT ILNESS

1. Chief Complain :The patient said that she has been urinating a lot
with nausea and just a little vomiting
2.Present illness history : When we doing home visit her said that she has
urinating a lot and felt like she has flu with nausea and vomiting for three days
.She has not been eating well but ads.she drank orange juice and turned out her
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blood sugar was high .her weight is 98 pounds which is 12 pounds less than she
weight last week.with frequent urination ( a lot).Her Finger Blood Glucose Stick
is 468 mg/dl
PAST NURSING HISTORY
2. History of Related Diseases
The patient having Diabetes and have used the NPH Insulin for 40 units at
07.30 in the morning
3. History of contagious diseases : None  Yes
Mentioned: -

4. Hereditary Diseases : None  Yes

Mentioned:-
5. Allergic history : medicine, food
Mentioned:-

IV. FAMILY HEALTH HISTORY

Biological her father has a history of DM disease,while there is no history of
hypertension.
OBSERVATION AND PHYSICAL EXAMINATION
General weakness
 VS: T: 37,3 oC P: 92x/mnt R: 22x/mnt BP:104/86 mmhg

1. B1 : BREATHING (RESPIRATORY SYSTEM)

1) complain :  SOB  pain, breathing
 Cough  other
mentioned :flue

2) RR pattern: Reguler Frequency :22 x/mnt

Rhythm:  regular  Irregular
Breathing :  Vesicular  Bronchovesiculr
Sounds  Ronchi  Wheezing
O2 adm :  Yes  None
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Others, mentioned :
2. B2 : BLEEDING (CARDIOVASCULAR SYSTEM)PROBLEM:
-

1) complain :  chest pain  dizziness

 headache  palpitation
2) Heart sounds
 Normal  Abnormal: S3  S4  Murmur

3) Edema  None  Yes

Others :
PROBLEM
-

3. B3: BRAIN (NERVOUS SYSTEM)

1) Orientation:  Person  Place  Time
2) Complain: none
3) Awareness :  Composmentis  Apathies 
Somnolent
 Sopor  Coma
GCS: E: 4 M : 5 V: 6 Total: 15
4) Eye
Pupil:  Isochors  An isochors
Sclera:  Icterik  bleeding
Others: sunken eyeball

Conjungtiva:  Pale  light red

5) Nerves disturbance :
Trismus:  Yes,  None
Paralyze:  Yes,  None
Sensory Perceptual  Yes,  None
Mentioned: -
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Others: Sclera is pale

PROBLEM:
4. B4: BLADDER (GENITOURINARY SYSTEM)
Fluid volume
) deficits/dehydration

1) Complain: Urinating often (a lot)


 Polyuria Oliguria  Anuria  Nocturia
2) Urine output: 2000 ml/day. Color: clear yellow
Smell: smells fruity
3) Fluid Intake : Oral 1000 cc/day, Parenteral :- cc/day
Others :

5. B5: BOWEL (GASTROINTESTINAL SYSTEM – GI TRACT)

1) Mouth:  pain-swallowed  trachea wound
 Others; dry tongue and furrowed

2) Abdomen:  Press pain  wound operation 

Colostomy
3) Alvi elimination: 2 x/day  Normal 
Abnormal
Consistency:  hard  soft  fluid 
blood
4) Diet: DM  hard  fluid  soft
Others :.she has not been eating well but ads and feelnausea and a little
vomiting.Her weight is 12 pounds less than she weight at our visited last week

PROBLEM Imbalanced
nutrition, less than body
requirements
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6. B6: BONE (BONE-MUSCLE-INTEGUMENT

1) Joint Activity :  free  limited,
Reason;
2) Extremities complain:  Yes  None
3) Back Injury :  Yes  None
4) Integuments:  Icterik  cyanosis
 Redness  Hyper pigmentation
Acral :  Warm  dry  redness
Turgor:  Excellent  Good  Poor
Others

PROBLEM: Fluid
deficits/dehydration

7. ENDOCRINE SYSTEM
Complain:  Yes  None
 Polydepsia  Polyphagia  Polyuria
Others : Patients complain of frequent urination and alot

PROBLEM:
Fluid
deficits/dehydration

III. PSYCHOOSOCIAL ASSEMENT

1. Client perception about her disease
 God-struggle  Penalty  Other
2. Client expression toward his/her disease
 Quit  restlessness  Anxiety  Angry / crying
3. Year reaction
 Cooperatif Not Cooperatif  prejudice
4. Self concept disturbane
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 Yes; self ideal, identity, role, self-esteem, and body image

 Not,
 Others, Explain,
Others: The patient said that the disease was not serious because does not have
high temperature
The patient refuses to be checked for blood sugar on her own device
The patient does not call the nurse or the doctor when she become ill

PROBLEM:K
nowledge
deficit

DIAGNOSTIC TEST AND MEDICAL TREATMENT

1. Laboratory: Date Februari ,24 2021
HGB:11,6 g/dl (N:11,7-15,5)
HCT :31,6% (N:35.0-47.0)
PLT : 200 10^3/ul ( N: 150-400)
WBC: 11,72 10^3/ul (N: 3,60-11,00)
BUN: 8.0mg/dl ( N: 8-18)
Creatinin : 1.00 ( N < 0.9)
Sodium : 133 mmol/L ( N :136-146)
Potassium : 3,3 mmol/L ( N :3,5-5,0)
Stick blood glucose : 468 mg/dl ( N < 200)

2. Radiology: X Ray: Cor and pulmo normal

3. ECG synus rhythm 92 x/mnt

4. USG, etc

5. Therapy:
-Infuse Nacl 0,9 % 1000 ml/day
-RCI 3x4 unit
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-Insulin maintenance 3x4 unit(sc)

-Ondancentron inj 3x4 mg (iv)
-Ranitidin inj 2x1 vial (iv)
-Diamicron MR 1-0-0 (po)

6. Others :
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………

Additional Data
………………………………………………………………………………………
………………………………………………………………………………………
………………………………
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DATA ANALYSIS

DATA ETIOLOGY PROBLEMS

Subjective Data: Unhealthy life style Fluid volume

The patient says deficits related to
often urinating and osmotic diuresis
alot,nausea and a beta cells are
little vomiting damaged

insulin resistance

Objective Data: impaired insulin

Sunken eyeball, secretion
dry tongue and
furrowed glucose transport into
BP : 104/86 cells is lacking
T : 37,3
C hyperglycemia
P : 92x/mnt
Sodium : 133 hyperosmolarity
Potassium : 3,3
Creatinin : 1.00 glucosuria

osmotic diuresis

polyuria

Fluid and electrolyte

loss
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Lack of fluid volume

Subjective Data: decreased cell Imbalanced

The patient said glucose use Nutrition, less than
she didn’t eat well body requirements
but ads. there was
nausea and a little proteolysis
vomiting
She drink orange
juice to keep her amino acids increase
blood sugar up

gluconeugenesis

Objective Data: ketogenesis

-Weight before ketonemia
being sick : 110
pounds
-Weight when sick weight loss
: 98 pounds
-The weight loss
12 pounds
- She eats only 1-3
table spoons
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B. Nursing Diagnosis
1. Fluid volume deficits related to osmotic diuresis.
2. Imbalanced Nutrition, less than the body requirements related to poor nutrition
intake.
3. Knowledge deficit about the disease process, diet and treatment is releated to
lack of information.
4. Risk of instability of blood glucose levels is related to uncontrolled blood
glucose

Surabaya,24 february 2021

Nurses,
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C. INTERVENTION (POR – PROBLEM ORIENTED RECORDS)

NURSING NOC NIC

DIAGNOSIS (Nursing Outcome (Nursing Intervention
Criteria) Classification)

1. Fluid GOAL : - Maintain accurate intake

volume - Fluid balance and output records
deficits - Hydration - Monitor hydration status
related to - Nutritional (mucous membrance
osmotic status: food and moisture adequate pulse,
diuresis. fluid intake orthostatic blood pressure) if
necessary
- Monitor vital sign every 15
minutes to 1 hour
- Collaboration of
NOC : intravenous fluids
After taking nursing - Monitor nutrisional status
actions for 1x8 hours - Give oral fluids
the deficit of fluid - Encourage the family to
volume is resolved by help patients eat
criteria : - Collaboration with docter if
1. Maintain urin output sign of excess fluid appear to
according to age and worsen
body weight, normal - Install the catheter if
urin specific gravity necessary
2. BP, P, T and - Monitor intake and urine
laboratorium output every 8 hours
examination
( Creatinin and
Electrolit)within
normal limits
3. There are no signs
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of dehydration, good
skin, turgor elasticity,
moist mucous
membranes, no
excessive thirst.

2. Imbalanced GOAL : - Assess for food allergies

Nutrition less - Nutritional - Collaboration with a
than the body status : nutritionist to determine the
requirement Adequacy of number of calories and
related to nutrient nutrients the patient needs
poor nutrition - Nutritional -Teach patients how to make
intake. status : Food daily food records
and fluid -Monitor for weight loss and
intake blood sugar
- Weight -Monitor of skin turgor
control -Monitor nausea and
vomiting
-Pale monitors,redness,and
dryness of the conjungtival
NOC : tissue.
After taking nursing -Monitor for nutrition intake
action for 2x 24 jam -Inform the client and family
nutrition is not about the benefits of
overcome with nutrition.
indication: -Collaboration with doctors
1.Serum albumin about the need for food
2.Pre albumin serum supplements such as
3.Hematocrit NGT/PTN nutrition ,So that
4.Hemoglobin adequate fluid intake can be
5.Total iron binding maintened
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capacity -Manage anti emetic

6.Lymphocyte count delivery.

B. INTERVENTION (PIE APPROACHES)

PROBLE IMPLEMENTATIO EVALUATION

M N
(NOC & NIC)

MORNING NOON NIGHT

1. Fluid 24 February 2021 08.00 AM 16.00 PM 21.00 PM
volume
deficits - Maintain accurate S: The S: The S: The
related to intake and output patient says patient said patient said
osmotic records often that she still the
diuresis. -Monitor hydration urinating , often frequency
status (mucous the body urinated and of
membrance moisture feels limp the body was urination
adequate pulse, still rather began to
orthostatic blood O: General limp decrease
pressure) if necessary weakness, and the
- Monitor vital sign sunken O: General body isn’t
every 15 minutes to 1 eyeball, dry weakness, limp
hour tongue and eyes not
- Collaboration of furrowed sunken,
intravenous fluids BP : 104/86 moist lips O:
- Collaboration with mmhg BP: 110/80 Conditions
docter if sign of T : 37,3 C mmhg in general
excess fluid appear to P: 92x/mnt T: 37 C were
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worsen Sodium : 133 P: 88x/mnt sufficient,

- Monitor intake and Potassium : eyes not
urine output every 8 3,2 A: The sunken,
hours problem is moist lips
A: The resolved in BP:130/80
problem has part mmhg
not been T: 36,8 C
resolved P:Interventio P:80x/mnt
n continued :
P:Interventio - Maintain
n continued : accurate A: The
- Maintain intake and problem is
accurate output resolved
intake and records
output -Monitor
records hydration P:
-Monitor status Interventio
hydration (mucous n stopped
status membrance
(mucous moisture
membrance adequate
moisture pulse,
adequate orthostatic
pulse, blood
orthostatic pressure) if
blood necessary
pressure) if - Monitor
necessary vital sign
- Monitor every 4 hour
vital sign -
every 15 Collaboratio
minutes to 1 n of
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hour intravenous
- fluids
Collaboratio -
n of Collaboratio
intravenous n with docter
fluids if sign of
- excess fluid
Collaboratio appear to
n with docter worsen
if sign of - Monitor
excess fluid intake and
appear to urine output
worsen every 8 hours
- Monitor - Encourage
intake and the family to
urine output help patients
every 8 hours eat

5. EVALUATION

NURSING EVALUATION
DIAGNOSIS
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1. 1. Fluid volume S: The patient said the frequency of

deficits related to urination began to normal
O: Conditions in general were sufficient,
osmotic diuresis
eyes not sunken, moist lips
BP:130/80 mmhg
T: 36,8 C
P:80x/mnt
Creatinin : 0.8 ( N < 0.9)
Sodium : 136 mmol/L ( N :136-146)
Potassium : 3,5 mmol/L ( N :3,5-5,0)

A: The problem is resolved

P: Intervention stopped

2. Nutritional S: The patient say that she want to eating

imbalances less than there wasn’t nausea nor vomit
the body’s needs are
related to poor food
O: :- Conditions in general were sufficient
intake.
-Weight before being sick : 110 pounds
-Weight when sick : 98 pounds
-The weight loss 5 12 pounds
- She eats half a portion

A: The problem is resolved

P: Intervention stopped