NURSING DOCUMENTATION

A. ASSESSMENT
1. Data
a. Patient Record
Surname
First name
Gender
DOB
Place of birth
Address
Occupation
Marital status
Next of kin
Contact no.
Smoking intake
Alcohol intake
Reason for admission
Medical history
Family history
Allergies
Diagnosis

: Atmadiyanti
: Ayu Lita
: Female
: 28 08 1995
: Tangerang, Indonesia
:
: College student
: Single
:
:
: n/a
: n/a
: Abdominal pain and vomitting
:
: Her father had maag
: cassava leaves
: chronic gastritis

b. Medical history:
1) Keluhan utama saat dikaji : pain in the pit of stomach
2) Riwayat Kesehatan Sekarang : she complained that she had
pain in the pit of stomach in the last three days, loss
appetite, flutulance, nausea and anorexia
3) Riwayat Kesehatan Dahulu : 4) Riwayat kesehatan keluarga : her father had maag
5) Riwayat sosial : irregular eating habit, she often eat spicy
and sour foods, lack of sleep, stress, staying up until late
with a cup of coffee every night.
c. Data Biologis
1) Assessment
a) Keadaan Umum
(1) Kesadaran : composmentis
b) Vital signs
(1) Temperature
: 37,2
(2) Heart rate
: 120 x/minute
(3) Respiratory rate
: 25 x/minute
(4) Blood Pressure
: 90/60 mmHg
(5) Height
: 150 cm
(6) Weight
: 41 kg
c) Physical assessment
(1) Head
- Skin
: normal, there arent any lesion

- Face
: pale
- Eyes
: Konjungtiva anemis
- Mouth
: white patches on the tongue
(2) Neck
Normal
(3) Thorax and lungs
Respiratory rate : 25x/min (tachipnea)
(4) Heart
- Heart rate : 120x/min (takikardia)
- Blood pressure : 90/60 mmHg
(5) Abdomen
- Pain in the pit of stomach, flatulance, thympany
(6) Extremity
- normal
d. Data Psikologis
a. Emotional status
She felt stress
b. Pola Komunikasi
She can do communication well and cooperative
2. ANALISA DATA
N
o
1

Data

Etiologi

Masalah

Ds : she said pain

in the pit of
stomach
Do : she looks
pale.
BP: 90/60 mmHg
HR : 120x/menit
RR : 25 x/menit
T : 37,2

Precipitating factors

Pain related to
inflammation
of
gastric
mucosa layer.

Inflammation of gastric
mucosa layer
Gastritis
HCL increase
Irritation
Exfoliation
Erosion of mucosa layer

Ds : she said that

she had nausea.
Do : she looks
pale, there are
white patches on
the tongue.
BP: 90/60 mmHg
HR: 120x/menit
RR : 58 x/menit
T : 37,2

Pain
Precipitating factors
Inflammation of gastric
mucosa layer
Gastritis
HCL increase
Suppress the gag reflex

Deficit
fluid
volume related
to nausea.

Height : 150 cm
Weight : 41 kg

Nausea
Deficit fluid volume

Ds : she said that

she
had
loss
appetite,
flatulance
and
anorexia
Do : she looks
pale, there are
white patches on
the tongue.
BP: 90/60 mmHg
HR: 120x/menit
RR : 58 x/menit
T : 37,2
Height : 150 cm
Weight : 41 kg.

Precipitating factors
Inflammation of gastric
mucosa layer
Gastritis

Imbalance
nutrition: less
than body
requirements
related to
insufficient
interest in food.

HCL increase
Sensation of fullness
Anorexia
loss appetite
decrease nutritional
intake
imbalance nutrition:
less than body
requirements

NURSING CARE PLAN

N
O
1.

NURSING
AIM
PLANNING
DIAGNOSIS
INTERVENTION
RATIONAL
Pain related to Dalam 1x24 1. Adjust the
1. Proper and
jam,
position
that
is
comfortable position
inflammation
of
comfortable
for client can decrease
gastric
mucosa
for client.
risk of pain.
layer.

2. Assess pain
scale (0-10).

2. To compare with
previous pain scale to
prevent complication.

3. Assess the
aggravate
factors and
Kaji ulang
faktor yang
meningkatkan
atau
menurunkan
nyeri.

3. Assist in making
nursing diagnosis and
gives the right therapy

4. Gives little
portion of
foods but
often.

4. Foods have acid

neutralizing effects,
and also can destroy
gastric content. Eat
with a little portion
can prevent gastrin
distentsion.
5. It can make client feels
better and forget the
pain for a while.

5. Teach the
client
distraction
and relaxation
technique.
6. Collaboration
with other
health care
staffs to give
right
indication
medicine. For
example :
Antacid
2.

Deficit fluid
volume related to
nausea.

1. Take a note of
vomit criteria.

2. Look out for

6. Decrease acid gaster

with absorbtion or
chemical neutralizing.
It is given in the night
to decrease gastric
motility, suppress acid
production, decelerate
process emptying
gastric, and relieve
nocturnal pain.
1. Help to differ gastric
distress causes.
Yellow-greenish
gallblader contents
shows that pilorus is
opening. Fecal
contents shows
intestines obstruction.
Bright red blood
indicates that there is
arterial bleeding acute.
2. Alteration in blood

vital signs.

3. Look out fot

input and
output fluid
volume.

3. Gives an orientation
for replacement fluids.

4. Suggest the
client to drink
(adult: 40-60
cc/kg/hour).

4. Replace the loss fluids

and repair fluid
imbalance
immediately.

5. Collaboration
with other
health care
staffs to give
client fluids
with proper
indication.

3.

Imbalance
nutrition: less than
body requirements
related to
insufficient interest
in food.

pressure and heart rate

can be used for
presupposition of
blood loss

5. Strong fluid intake

will decrease risk of
dehydration.

6. Collaboration 6. Cimetidine dan

ranitidine can prevent
with other
gastric acid secretion.
health care
staffs to give
client
cimitidine and
ranitidine
1. Give the client 1. Gastric dilatation can
a little portion
be happen if foods are
of foods and
given too fast after
give a proper
fasting period.
portion for
snacks.
2. Make a list for 2. Client can be more
available
confident and feel she
menu and give
has more power to
the client
control her foods.
permition to
control the
choice of her
foods.
3. Consultation
with diet
specialist to

3. Intake nutritions
individual can be
calculated by different
methods.

plan about
calories and
nutrition
intake

1. Mengatur posisi yang nyaman bagi klien

2. Mengkaji keluhan nyeri: intensitas, karakteristik, lokasi, durasi, faktor
yang memperburuk dan meredakan
3. Mengawasi TTV
4. Mengkaji keluhan mual, muntah, sakit menelan
5. Mencatat kriteria muntah
6. Mengawasi keluaran dan masukan cairan
7. Menganjurkan pasien untuk minum (dewasa 40-60 cc/kg/jam)
8. Memberikan cairan sesuai indikasi
9. Memberikan makanan sedikit tapi sering, dan makanan kecil tambahan
yang tepat
10. Kolaborasi pemberian obat
11. Mengajarkan teknik relaksasi dan distraksi
12. Menganjurkan pasien untuk melakukan aktifitas sehari hari

sesuai dengan tingkat kemampuan pasien

13. Mengajarkan penkes tentang makanan yang dilarang untuk
pasien

NO
1

IMPLEMENTASI
CATATAN IMPLEMENTASI DAN EVALUASI
TANGGAL JAM
IMPLEMENTASI
EVALUASI
PARAF
26-04-2015 07.00- 1. Mengatur
posisi S:-pasien
mengatakan
06.59
yang nyaman bagi nyeri di ulu hati
WIB
klien
(posisi -pasien mengatakan ingin
semifowler)
muntah
2. Mengkaji keluhan -pasien tidak memiliki
nyeri:
intensitas, nafsu makan
karakteristik, lokasi, O : -pasien tampak
durasi, faktor yang meringis
memperburuk dan -pasien tampak lemah

27-04-2015

07.0015.00
WIB

meredakan
3. Mengawasi TTV
4. Mengkaji keluhan
mual, muntah, sakit
menelan
5. Mencatat
kriteria
muntah
6. Mengawasi
keluaran
dan
masukan cairan
7. Menganjurkan
pasien untuk minum
(dewasa
40-60
cc/kg/jam)
8. Memberikan cairan
sesuai indikasi
9. Memberikan
makanan
sedikit
tapi sering, dan
makanan
kecil
tambahan
yang
tepat
10. Kolaborasi
pemberian obat
11. Mengajarkan teknik
relaksasi
(nafas
dalam)
dan
distraksi.

-terlihat adanya bercak

putih di lidah
-skala nyeri di ulu hati 5
(0-10)
BP: 90/60 mmHg
HR: 120x/menit
RR : 28 x/menit
T : 37,2

1. Mengatur posisi
yang nyaman bagi
klien
2.Mengkaji keluhan
nyeri:
intensitas,
karakteristik, lokasi,
durasi, faktor yang
memperburuk dan
meredakan
3. Mengawasi TTV
4. Mengkaji keluhan
mual, muntah, sakit
menelan
5. Mencatat kriteria
muntah
6. Mengawasi keluaran
dan masukan cairan
7. Menganjurkan pasien
untuk minum (dewasa
40-60 cc/kg/jam)
8. Memberikan cairan

S:-pasien
mengatakan
tidak terlalu nyeri di ulu
hati
- mual dan muntah sudah
berkurang
-pasien mulai memiliki
nafsu makan, makan habis
porsi
-pasien mengatakan sudah
dapat beraktifitas sendiri
-Pasien memahami penkes
yang diberikan perawat
O : -pasien terlihat lebih
rileks
-pasien masih tampak
lebih segar
-bercak putih di lidah
berkurang
-skala nyeri di ulu hati 2
(0-10)
BP: 110/70 mmHg

Height : 150 cm
Weight : 41 kg

A:masalah belum teratasi

P:Intervensi dilanjutkan
(1,2,3,4,5,6,7,8,9,10,11,12,
14,15)

sesuai

indikasi

Memberikan
dan
sayur
hangat

9.
bubur
selagi

HR: 100x/menit
RR : 24 x/menit
T : 36,7

10.
Kolaborasi Height : 150 cm
Weight : 41 kg
pemberian obat
A:masalah belum teratasi
11. Menganjurkan
pasien untuk
melakukan aktifitas
sehari hari sesuai
dengan tingkat
kemampuan pasien
12. Mengajarkan
penkes tentang
makanan yang
dilarang untuk
pasien

P:Intervensi dilanjutkan
(1,2,3,4,5,6,7,8,9,10,11,12,
14,15)