NURSING CARE B5 (BOWEL) DIGESTIVE SYSTEM GASTRITIS

Lecturer : Dessy Natalia, M.Pd

Arranged by :

Groups 5

1. Antoni Fandefitson ( 2017.C.09a.0875)

2. Halimatussyadiah (2017.C.09a.0889)
3. Hendri Frasetiawan (2017.C.09a.0000)
4. Istiyani Lotina Lilit (2017.C.09a.0892)
5. Lafa Nolla (2017.C.09a.0896)
6. Wenie (2017.C.09a.0913)
7. Winda Aprilia (2017.C.09a.0915)
8. Nola Cristina (2017.C.09a.0902)

FOUNDATION EKA HARAP PALANGKARAYA

SCHOOL OF HEALTH SCIENCES
PROGRAM S1 STUDY OF NURSING
ACADEMIC YEAR 201
Case

Mr. S 35 years old with high school education, an entrepreneur. A family head of Tlogomas
RT / RW 05/01 city of Malang, entered RSSA on April 19, 2016, No. RM 8680, Gastritis
medical diagnosis. Responsible person: Mrs. N 33 years old, Tlogomas RT / RW 05/01
Malang city, wife, housewife.
The patient complains of pain in the stomach (stomach ulcers) feels sore and hot, the patient
also says weakness and no appetite, often nausea and vomiting. pain feels like squeezing,
scale of pain 7, pain relief. The patient and family said that they had previously been treated
at the puskesmas but for 3 days taking the medication given, the patient did not feel any
changes in the condition. Then doctors refer patients to Saiful Anwar Hospital Malang.
Patient came to IGiful Hospital, Aniful Anwar Malang on Wednesday, April 19 2016 at
08.00, after being examined he got: Awareness: compos mentis E: 4 V: 5 M: 6. Looks pale
and weak, When checked the signs vital TD: 110/60 mmHg, N: 97 x / minute, RR: 24 x /
minute, S: 37,2ᵒ C. Body weight before illness: 60 kg, after BB pain: 55 kg and height: 173
cm. and pain during epigastric pressure. Given an infusion of RL 20 tpm (drops per minute),
Injection: Cefotaxime (1gr), Ranitidine (2x1 mg), Oral: Antacids (3x500 mg). Patients also
said they did not have any history of any allergies.
 NURSING PROCESS FORM : MEDICAL SURGICAL

FACULITY OF NURSING

1. ASSESSMENT
Admission Date : 19 April 2018 Time : 08.00
No. Reg : 8680 Medical Dx : 1234xxx
Date of Assessment :

I. PATIENT IDENTITY

1. Name : Tn.S
2. Age : 35
3. Race : Dayak
4. Religion : Christian
5. Education : High school
6. Occupation : Private
7. address : Jln. Yosudarso 4

II. HISTORY OF PRESENT ILNESS

1. Chief complain:
The patient complains of pain in the stomach (stomach ulcers) feels sore and hot, the
patient says no appetite, often nausea and vomiting.
P: The client is seen grimacing when the epigastrium is pressed
Q: Pain like squeezing
R: in the pit of the stomach / epigastrium
S: scale 7 (scale of pain 0 - 10)
Q: Pain relief arises when the epigastrium is pressed.

2. Present illness history:

The patient feels pain in the abdomen (solar plexus) since 1 week ago on the morning
after waking up. Then the patient came to the hospital at 8:00 to get himself checked
by getting a TD examination: 110/60 mmHg, N: 97 x / minute, RR: 24 x / minute, S:
37,2ᵒ C. and pain at the epigastric pressure.
III. PAST NURSING HISTORY

1. History of related diseases

2. History of contagious diseases:  None Yes

Mentioned:

3. Hereditary Diseases:  None Yes

Mentioned:

4. Allergic history: Medicine Food

Mentioned:

IV. FAMILY HEALTH HISTORY (GENOGRAM)

OBSERVATION AND PHYSICAL EXAMNATION

VS: T: 37,2ᵒ C P: 97 x/min R: 24 x/min BP: 110/60 mmHg

B1 : BREATHING (RESPIRATORY SYSTEM)

1. Complain : SOB paint, breathing

Cough others

Mentioned :

2. RR pattern : Frequency x/min

Rhythm :  regular irregular
Breathing : Vesicular Bronchovesicular
Sound : Ronchi Wheezing
O2 adm : Yes  None
Others, mentioned :
B2 : BLEEDING (CARDIOVASKULAR SYSTEM)

1. Complain : Chest paint dizzines

Headache palpitatio
2. Heart sounds
 Normal Abnormal S4 Murmur
3. Edema  None Yes
Others :

B3: BRAIN (NERVOUS SYSTEM)

1) Orientation : Person Place Time

2) Complain :
3) Awareness :  Composmentis Apathies Somnolent
Sopor Coma

GCS : E =4 M =6 V=5 Total:15

4) Eye
Pupil :  Isochors Anisochors
Sclera : Icteric Bleeding
Others :
Conjungtiva :  Pale Light red
5) Nerves disturbance :
Trismus: Yes  None
Paralyze: Yes  None
Sensory Perceptual: Yes  None
Mentioned :
Others :
B4 : BLADDER (GENITOURINARY SYSTEM)
1) Complain :
Polyuria Oliguria Anuria Nocturia
2) Urine Output : ml/day Color : Smell :
3) Fluid Intake : Oral cc/day Parenteral : cc/day
Others :

B5: BOWEL ( GASTROINTESTINAL SYSTEM – GI TRANCT )

1) Mouth : Pain-swallowed Trachea wound Others

2) Abdomen  Press pain Operation Wound Colostomy
3) Alvi Elimination : X/Day Normal Abnormal
Consistency :
Hard Soft Fluid Blood
4) Diet : Hard Fluid Soft
Others :
The patient complains of pain in the stomach (stomach ulcers) feels
sore and hot, the patient also says weakness and no appetite, often
nausea and vomiting. pain feels like squeezing, scale of pain 7

B6 : BONE (BONE-MUSCLE-INTEGUMENT)

1) Joint Activity : Free Limited

Reason :
2) Extr3mities complain : Yes None
3) Back Injury : Yes None
4) Integuments : Icteric Cyanosis
Redness Hyperpigmentation
Acral : Warm Dry Redness
Turgor : Excellent Good Poor
Others :
ENDOCRINE SYSTEM

Complain : Yes None

Polydipsia Polyphagia Polyuria

Others :

IV. PSYCHOSOCIAL ASSESSMENT

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 disturbance
Yes : self ideal, identity, role, self-esteem, and body image
Not
Others, explain :
Others :
DIAGNOSTIC TEST AND MEDICAL TREATMENT

1. Laboratory:
2. Radiology: X-Ray, CT-Scan
3. ECG
4. USG,ect
5. Therapy:

6. Others:
V. ADDITIONAL DATA

Name : Tn.S

Room : Bougenvile A

No.reg : 8680

No Data Focus Etiology Problem

1 DS : Inflammation of the Acute pain
- The patient says that the area of his gastric mucous wall
stomach feels hot and burning (gastric)
- The patient says that the pain is
absent if the epigastrium is pressed

DO :
The patient appears to be in pain when
the epigastrium is pressed.
P: The client is seen grimacing when
the epigastrium is pressed
Q: Pain like squeezing
R: in the pit of the stomach /
epigastrium
S: scale 7 (scale of pain 0 - 10)
Q: Pain relief arises when the
epigastrium is pressed.
 2 DS : Fulfillment of Nutritional
- Mr. S often feels nauseous and nutrition is imbalance is less
vomiting inadequate than the body's
-Tn.S said they didn't eat needs

DO :
-Tn. S looks weak and pale
-Sc Composmentis Awareness
TTV:
TD: 110/60 mmHg
N: 97 x / minute
RR: 24 x / minute
S: 37,2ᵒ C.

VI. NURSING DIAGNOSES

Name : Tn.S
Room : Bougenvile A
No. Reg : 8680
No Nursing Diagnoses
1 Acute pain is associated with inflammation of the gastric mucosa (gastric) wall
2 Nutritional imbalances less than body requirements are associated with inadequate
nutrition fulfillment
VII. INTERVENTION

Name : Tn.S
Room : Bougenvile A
No. Reg : 8680
Tanggal No Nursing Diagnosis NOC NIC
Dx
19 1 Acute pain  Pain Level Pain
April Definition : An unpleasant sensory  Pain Control Management:
2016 and emotional experience arising  Comfort - Perform a
from actual or potential tissue Level comprehensive
damage or described in terms of Criteria for pain assessment
damage in such a way results: including
(International Association for the • Able to control location,
study of pain): sudden or slow pain (know the characteristics,
onset of mild to severe intensity cause of pain, duration,
with the end that can anticipated or be able to use frequency,
predicted and lasts <6 months. non- quality, and
Limitation of characteristics: pharmacological precipitation
• Changes in appetite techniques to factors
• Changes in blood pressure reduce pain, - Observai non
• Expressing behavior (grimacing, seek help) verbal reactions
restlessness) • Report that of discomfort
• Change of position to avoid pain pain is reduced - Select and do
• Report pain verbally by using pain pain
Related factors : management management
• Injury agents (eg biological, • Able to (pharmacology,
chemical, physical, psychological) recognize pain non-
(scale, intensity, pharmacology
frequency and and inter
signs of pain) personal)
• Express - Assess the
comfort after type and source
the pain has of pain to
diminished determine
intervention
- Give
analgesics to
reduce pain
- Increase rest
- Collaborate
with doctors if
complaints and
actions of pain
are not
Succeeded

Analgesic
 administration:
- Determine the
location,
characteristics,
quality, and
degree of pain
before
administration
of the drug
- Choose an
analgesic choice
depending on
the type and
severity of the
pain
- Vital sign
monitor before
and after the
first analgesic
administration
- Evaluate the
effectiveness of
analgesics, signs
and symptoms

19 2 Nutritional imbalance is less  Nutritional Nutrition

April than the body's needs Status: management:
2016 Definition : Nutritional intake is  Nutritional - Collaboration
not enough to meet metabolic Status: food with
needs and fluid nutritionists to
Limitation of characteristics: intake determine the
• Abdominal pain  Nutritional number of
• Lack of food Status: calories and
• Inability to eat food nutrient nutrients needed
Related factors: intake by patients
• Biological factors  Weight - Encourage
• Inability to swallow food control patients to
Criteria for increase Fe
results: intake
• There is an - Give selected
increase in food (already
body weight consulted with a
according to nutritionist)
the goal - Monitor the
• Ideal body amount of
weight nutrients and
according to calorie content
height - Assess
• Able patient's ability
identify to get the
nutritional nutrients needed
needs Nutrition
• There are no Monitoring:
signs of - BB reaches
malnutrition within normal
• Shows an limits
increase in taste - Schedule
fungi from treatment and
swallowing actions not
• No significant during mealtime
weight loss - Monitor
nausea and
vomiting
 VIII. IMPLEMENTATION

Name: Tn.S
Room: Bougenvile A
No. Reg: 8680
Date No. hour Implementation
Dx
19 April 1. 08.00 - Conduct comprehensive pain assessment including location,
2016 characteristics, duration, frequency, quality, and precipitation
factors
- Provides analgesics to reduce pain
Monitor vital signs before and after the first analgesic administration
19 April 2. 10.00 - Collaborate with nutritionists to determine the number of calories
2016 and nutrients needed by patients
- Provide selected food (already consulted with a nutritionist)
Monitor the amount of nutrients and calorie content

IX. EVALUATION
Name: Tn.S
Room: Bougenvile A
No. reg: 8680
Date No. Dx Evaluation
19 April 1. S: The patient says the pain is reduced
2016
O: The patient appears not to grimace in pain again when
the epigastrium is pressed
P: the client looks grimacing when the epigastrium is
pressed,
Q: pain like wringing,
R: in the pit of the stomach / epigastrium,
S: scale 3 (pain scale 0 - 10),
Q: Pain relief arises when the epigastrium is pressed.

A: Acute pain resolves in part

P: intervention continued

19 April 2. S: the patient says that he does not have appetite and often
2016 nausea vomiting

O: the patient looks fresh not weak and pale

TTV:
TD: 110/80 mmHg
N: 90 x / minute
RR: 28 x / minute
BB: 56 Kg (up 1 minute)
S: 37,2ᵒ C.

A: Nutritional imbalances less than body requirements are

partially overcome

P: intervention continued