Data Social, Psychology And Economics

1. Patient Can Interact With Either One Room To Friend, Family, And Nurse Or Other
Health Workers
2. Patient Say Receive a Condition That He Felt At This Time.
3. Patient Using Health Insurance In The Form Of Jamkesda

Data Spiritual
Patient Say Always Pray To Allah And Submit Or Surrender To Allah. Including Her Pain
Related Disease, as well as consider her illness as a trial

Supporting Investigation
Date of inspection : 4 January 2014
1)
2)
3)
4)
5)
6)
7)

Hemoglobin
Total of white blood cells
Segment
Lymphoycyte
Monocytes
Platelet
Hematokrit

Date of inspection : 5 January 2014

HbsAg

: Non Reaktif

HIV

: Non Reaktif

Normal : ( 12 14 ) g%
: ( 5.000 10.000 ) mm3
: ( 50 70 ) %
: ( 20 40 ) %
:(28)%
: ( 37 43 ) %

= 11,2
= 6.000
= 72
= 20
=8
= 231.000
= 34

Blood Chemistry
Type
SGOT
SGPT
Alkali Phospatase
Gama GT
Total Bilirubin
Direct Bilirubin
Indirect Bilirubin
Total Protein
Albumin
Globulin
Cholesterol
Trigiserida
HDL Cholesterol
LDL Cholesterol
Creatinin
Ureum

Result
28
38
101
79
0,7
0,2
0,5
7,7
3,8
3,9
134
109
36
76
0,5
20

Unit
UI
UI
UI
UI
Mg/dl
Mg/dl
Mg/dl
Mg/dl
g/dl
g/dl
Mg/dl
Mg/dl
Mg/dl
Mg/dl
Mg/dl
Mg/dl

Normal Limits
P < 25 / W < 31
P < 4 / W < 32
74 311
P < 38 / W < 25
0, 1 , 0
0, 0, 5
0 0,75
6,6 8,7
3,2 4,5
2,3 3,5
150 220
< 200
P > 35 / W > 45
< 190
0,5 1,5
18

Management / Therapy / Diet

Therapi :
RL + Tramadol

1 Amp

15 Tpm

Ranitidine

2x1

IV

Diet
BDL

Data Focus
A. Data Subjektif
1) Patient Say Pain Heartburn, Scale Pain 6, Pulse 78 x/m
2) Patient Say Nausea, Dizziness, Loss Of Appetite
3) Patient Say it is difficult to sleep, because of the heat and the atmosphere of the
rooms were noisy
B. Data Objectif
1) There is a epigastric tenderness, scale pain 6
2) Patient only spend servings of food at Hospital

3) Patient only sleep 2 3 hours / day, there are eye poke, drums konjungtifa
anemic. Blood pressure : 100 / 60 Mmhg
4) Seen patient vomit when finished

Data Analysis
No
1.

2.

3.

Grouping Data
Problem
Ds : Patient Say Pain at the epigastric with
pain scale is 6
Pain
Do : there tenderness in epigastric with pain
scale is 6 and pulse : 78
Ds : Patient say nausea, dizziness, no
appetite
Nutrition less than
Do : Patient only spends a quarter of eating body requirements
in hospital
Ds : Patient say difficult to sleep because of
the heat and the atmosphere noisier
Disruption of
Do : Patient only sleep 2 3 hours per day sleep patterns
there are poke under the eyes conjungtival
pallor

Causes
Agent Injury

Less intake

Ambient temperature
and noise

Diagnose Nurse
1. Pain Acute associated with agent injury marked by patient say pain heartburn, pain scale
6 there is pain press in epigastric. Pulse 78 x/m
2. Deficient nutrition than the body needs associated with less intake of food symptoms by
said patient said patient nausea, dizziness, patient say no appetite only spend portion of
food in the hospital.
3. Trouble Of patterns sleep associated with room temperature and noisy by patient say
wakeful, because hot and noisy, atmosphere, patient only sleep 2 3 hours everyday,
under the eyes conjungtiva unanemis, blood pressure : 100/60 Mmhg.

Intervention Nurse
Date /
Hours
6 / 1 / 2014
3 pm

Diagnose
Nurse
Pain Acute
associated
with agent
injury

6 / 1 / 2014
4 pm

Deficient
nutrition than
the body
needs
associated
with less
intake of food
symptoms

Pourpose
After the act of nursing for
2 x 24 hours. expected
outcomes with reduced
pain :
1. Patient is able to
control pain
2. Pain can be receive
by pain scale 2.
3. Patient
say
comfortable.
Feeling after pain is
reduced
4. Report that pain is
reduced by using
pain management

After the act of nursing for

2 x 24 expected nutrient
can be resolved with
outcomes :
1. An increase in body
weight
in
accordancing with
purpose.
2. Able to identify
nutritional needs
3. No signs of mal
nutrition
4. There
is
no

Intervention
1. Perform
a
comprehensive
pain
assessment,
including
location, characteristics,
duration,
frequency,
quality
factor
and
precipitation.
2. Observation of non
verbal
reactions
of
discomfort
3. Teach
non

pharmacological
techniques
(
deep
breathing )
4. Give
analgesics
to
reduce pain
5. Evaluation
of
the
effectiveness of pain
control
6. Collaboration
with
doctor if there is a
complaint and the action
was not successful pain
1. Assess for food allergies
2. Make sure to eat a diet
containing high fiber to
prevent constipation
3. Provide
information
about nutritional needs
4. Assess patient ability to
obtain needed nutrients

6 / 1 / 2014
5 pm

Trouble Of
patterns sleep
associated
with room
temperature
and noisy

significant weight
loss
After nursing care for 1x24
hours, expected trouble of
sleep patterns can be
resolved with outcomes :
1. Patient can be a
normal sleep 6 8
hours / day
2. Diminish eye poke
3. Conjungtiva back
pink.
4. Face look and fresh
feeling
while
sleeping.

1. Observation of vital sign

2. Create a calm and
comfortable
environment
3. Provide as comfortable a
position as possible
4. Next time patient
minimum number of
hours of sleep 6 8
hours / day

Implementation
No
1.

Date / Hours
7 / 1 / 2014
8 am

Action
1.1 Comprehensively Acsess Pain
1.2 Observing Nonverbal reactions of
discomfort
1.3 Teaches non pharmacological
techniques, deep breathing
1.5 Evaluating the effectiveness of pain
control
2.1 Assess for food allergies
2.2 Convincing diet hight in
fibercontaining meal to prevent
constipation
2.3 Proding information about the
needed nutrition
2.4 Assess the patient ability to obtain
needed nutrition
3.1 Monitor the signs and symptoms of
constipation

Evaluation
DS: client say pain in heartburn
as a puncture puncture,the
pain scale 6
DO: there tenderness epigastric,
paim scale 6, pulse 78 x/m
Ds : patient say pain in
heartburn as in puncture, with
scale 6
Do : patient looks agitated and
grimace
Ds : patient say school
Do : patient looks follow the
instructions of nurse and nod
Ds : patient say reduced pain
scale 4
Do : Patient looks calm. Pain
scale
Ds : patient say can not eat
acidic food and drinking tea
Do : Ds : patient say school

8 / 1 / 2014
11 am

12 am

12 am

3.3 monitor stool : the frequency

and volume consistency
3.4 provide dulkolax

Do : Patient nod
Ds : Patient say school
Do : Patient looks nod
Ds : Patient say buy papaya to
increase the nutritional
Do : Ds : Patient say he can not
defecate defecation only one
time during in patient at the
hospital.
Do : Patient looks nervous hand
stools and brown.
Ds : Do : Bowel 10 x/m
Ds : Patient Say only slept in
the room during the illness,
always in aid of her husband
Do : patient seen lying
DS: Patient say not defecate
DO: Patient fidgeled
DS: Patient say will soon be in
use
DO: Patient are seen in the
auxiliary nurses use dulkolax

4.1 observed vital sign

DS: patient say dizziness

DO: Blood pressure :100/70
mmHg. Respiratory : 20 x/I.
pulse : 85 x/i. temperature ;
36,2 C

3.5 reviewing the minimum number

of hours of sleep patient 6 8
hours every day
3.2 creating a quiet environment
reduces the number of visitors
3.3 provide right sim position to sleep

Ds : patient say no noisier room

anymore
Do : Patient looks relaxed

Ds : Patient say cozy

Do : Patient looks relaxed