GASTRITIS NURSING ASSISTANCE

A. NURSING PROTECTION FORMAT

No. Register : 101.8680

Space : Bougenvile

MRS Dates / Hours : 28 September 2012 / 21.00 hrs

Date of Review : September 29, 2012

Medical Diagnosis : Gastritis

1. IDENTITY
a. Patient Biodata

Name : Tn. S

Gender : Male

Age : 35 years old

Religion : Islam

Tribe / nation : Indonesia

Education : High School

Occupation : entrepreneur

Address : Bojong Menteng Rt. 03 / IX Kelurahan Pasir Kuda

Village

b. Person in charge

Name : Ny. N

Age : 33 years old

Gender : Female

Religion : Islam
 Occupation : Housewife

Relationship with px : Wife

Address : Bojong Menteng Rt. 03 / IX Kelurahan Pasir Kuda

Village

2. MEDICAL HISTORY
a. Main complaint
Patients complain of abdominal pain
b. Current Illness History
Patients say that every morning after waking the patient often feel pain in the left
side of the abdomen. The pain is like kneading and feeling hot. It can show pain
but can not describe it, can not be overcome with over long position of breath and
distraksi. Patients say they feel better when they are lying down. Patients also
complain of nausea and vomiting that makes the patient's appetite decrease.
Patients said this complaint occurred almost a week until finally he was taken to
IGD RSI S on 28 September 2012 at 21.00 pm.
c. Past medical history
The patient said that he had been treated at RSI S with the same disease (gastritis)
on April 5, 2009, and was given Antacid medication.
d. Family Disease History
In the family no one has a hereditary disease such as Diabetes Mellitus and
Hypertension and infectious diseases such as Hepatitis and tuberculosis.

3. DAILY ACTIVITY PATTERNS

a. Nutrition
At Home: eating irregularly 1-2x a day. Always eat exhausted 1 portion.
Patients say not Have restrictions on food, patients drink 6-7 glasses (
1500-1700cc) daily.
At the Hospital: the patient says morning only eat porridge half / 4
servings because patients feel sick every time want to eat and after eating
the patient often vomiting. Patients drink 4 to 5 glasses of water (1000-
1200cc) daily.
b. Elimination
In home: the patient says CHAPTER 1x daily in the morning with
consistency of soft, yellow, distinctive odor and no complaints in bowel
movement.
BAK Clients 2-6x daily with yellow, distinctive odor, and patient no
difficulty in the BAK.
At the Hospital: the patient said during hospitalization of the CHAPTER
client with a frequency of 1x a day, hard consistency (small round shape),
black color, distinctive odor and the patient complaining is difficult to
defecate.
Patients say BAK with a 5-6x daily frequency of yellowish color,
distinctive odor and no complaints in the BAK.
c. Rest and Sleep
At home: the patient says sleep for 7 hours start sleeping at 22.00 WIB
and wake up at 05.00 WIB. Patients rarely take a nap.
At the Hospital: the patient says sleep for 9 hours starting at 21:00 pm,
when the night is often awakened because of the hot atmosphere, the
patient woke up at 06.00 pm.
d. Physical Activity
At Home: the patient can perform daily activities without the help of
others or tools.
At the Hospital: the patient say can do be able to perform daily activities
according to ability, the patient to the bathroom assisted by the family, the
patient has no difficulty in doing personal hygiene, the patient says more
lying in bed because the stomach ache when moving.
e. Personal Hygiene
At Home: Client shower 2 times a day ie morning and afternoon, shampoo
2 times a week, change clothes 1 times a day, and no disturbance
whatsoever.
At the Hospital: the patient is wiped by the family twice a day ie morning
and evening with no soap.
4. PSYCHOSOCIAL DATA
a. Emotion Status
The patient's emotion is stable.
b. Self concept
Body Image: The patient knows that he is ill and needs treatment to
recover quickly
Self Ideal: the patient feels well treated by the nurse and gets sufficient
attention from the family
Self Eksterm: patients say want to get well soon and go home
Role: the patient as the head of the family.
Identity: a patient named Tn. "S" with the age of 35 years addressed at
Bojong Menteng Rt. 03 / IX Kelurahan Pasir Kuda Village
c. Social interaction
The patient relationship with the nurse and other patients in one room is good.
Patients are also cooperative and can interact well with health personnel as well
as their relationship with family is also good.
d. Spiritual
Patients are Muslims, before the illness he obedient worship, but now can not run
the prayers five times. The patient can only pray for his recovery.

5. PHYSICAL EXAMINATION
a. General Condition
General state is lacking
b. Awareness
CM (Composmentis) 4-5-6
c. Vital sign
TD : 120/80 mmHg S: 37 C
N : 80 x / min
RR : 20 x / mind
1) Scalp : No lesions, no tumors, black hair, no pain press
2) Face : Symmetrical face shape, no injuries, no edema.
3) Eyes : Symmetrical, conjunctiva not anemic, good vision function.
4) Nose : Symmetrical shape there is no polyp, no complaints and
abnormalities in the nose.
5) Ear : Symmetrical shape, not using hearing aids.
6) Mouth : Lips appear dry with clean teeth, no bleeding and swelling of
the gums.
7) Neck : There is no thyroid enlargement.
8) Chest and Thorak :
Inspection: symmetrical shape
Palpation: no lumps and pain press
Percussion: the lungs of the sonor
Auscultation: vesicular lung sounds, normal heart sound (1,2)
9) Abdomen :
Inspection: symmetrical, flat
Palpation: no tenderness of the abdomen (solar plexus)
Percussion: timpani
Auscultation: bowel sounds 8x / min
10) Extremities :
Upper extremity: RL 20 tpm infusion (drops per minute)
infused on the left hand, no oedem.
Lower limb: no injuries, no paralysis, and no oedem.
11) Genetalia : No catheter installed.
B. DATA ANALYSIS

NO. ASSESSMENT ETIOLOGY PROBLEM

29 DS: Inflammation of the Impaired sense of

September gastric mucosal comfort (Pain)
1. Tn. "S" says that the area of his
2012 wall (gastric)
solar plexus is hot and burning

2. Mr. "S" says the kalaunyerinya

disappear if the epigastrium on tap

3. Mr. "S" complained of frequent

nausea and vomiting

DO:

1. The medical diagnosis of Mr.

"S" is a gastritis

2. The client pain scale 7 of the

scale (0-10)

3. Tenderness in the uluhati area

(epigastrium) Mr. "S"

DS: Nutrition Diet disorders: less

1. Mr. "S" often feels nausea and fulfillment is than body
vomiting inadequate requirements
2. Mr. "S" says that he lost his
appetite
3. Mr. "S" often feels full
DO:
1. Medical Diagnosis of Mr. "S" is
Gastritis
2. Mr. "S" looks weak and not
energized

3. Awareness Mr. "S"

Composmentis
 DS: Less activity constipation
1. Mr. "S" said at the hospital BAB
with the consistency of hard feces
2. Tn. "S" says more lying on the
spot
DO:
1. Palpation of the abdomen:
palpable hard in the lower left
abdomen
2. Auscultation of the abdomen:
peristaltic 4x / mnt
3. sleep because the stomach ache
when moving

DS: Less information Lack of knowledge

1.Tn. "S" says the thing that is
thought about the disease is heart
disease because in the pit of the
stomach feels sore, and hot

DO:

1. Mr. "S" looked confused about

his illness

C. NURSING DIAGNOSES
1. Impaired sense of comfort (Pain with scale 7 of the scale range (0-10) associated
inflammation of the gastric mucosal wall (gastric)
2. Dietary disorders (less than body requirements) associated with inadequate nutrition
fulfillment
3. Constipation associated with less activity
4. Lack of knowledge related to lack of information
 D. NURSING CARE PLAN

NO DATE/ NURSING AIM/ INTERVENTION RATIONAL

. HOUR DIAGNOSES CRITERIA RESULT

1. 29 Comfort discomfort Pain The client pain 1.Please note the 1.nyeri not always but if
September (Pain) associated is reduced with no pain complaint, there should be compared
2012 with inflammation of inflammation or including location, with previous patient pain
the gastric mucosal irritation of the duration, intensity symptoms, which can help
wall (gastric) T.S.S. gastric (scale 0-10) diagnose the etiology of
mucosa within 2 x 2. Review the factors bleeding and the
24 hours with that increase or occurrence of
criteria: decrease pain complications.
1.Scala's pain scale 3. Give the food a 2. help in making diagnosis
decreases little but often as and therapeutic needs.
2.Tn.S not indicated for the 3. the food has acid
merasanyeri on patient neutralizing effect, also
epigastrium 4. Help activate destroys the gastric
(uluhati) range of active / content.Makan slightly
3.Tn.S does not passive motion prevents distension and
wince (not 5.Provide frequent gastrin output
abdominal tender) oral treatment and 4. decrease joint stiffness,
comfort measures minimize pain discomfort.
(back massage,
5. Breath odor because
position change)
tertahanya sekretmulut
Collaboration:
cause no appetite and can
1. Give the drug as increase nausea. Gingivitis
indicated, eg: and dental problems may
Antacids increase

2.Antikolinergik
(misal : belladonna,
1.menurunkan keasaman
atropin)
gaster dengan absorbsi
 Or by neutralizing the
chemistry
2. given at bedtime to
decrease gastric motility,
suppress acid production,
slow gastric emptying, and
eliminate nocturnal pain.

2. Dietary disorders: Diet from Tn.S 1. Weigh the weight 1. Evaluate the
less than body
regularly enough to as indicated effectiveness or need to
requirements
associated with meet the 2.Acultural bowing change nutrition
inadequate nutrition nutritional needs 3. Give food in small 2. Helps in determining
fulfillment
within 2 x 24 hours quantities and in the response to eating or
with the criteria: frequent and regular developing complications
1.Client is not mual time 3. Improve the process of
2.Clients do not 4. Determine foods digestion and tolerance of
feel pain due to that do not form gas. the patient to the
gastritis or 5. Provide regular nutrients provided and
irritation of the oral, frequent and can improve patient
gastric mucosa regular treatment cooperation while eating
including oil for lips 4. Can affect appetite /
digestion and limit
nutritional input
5. Prevent discomfort due
to dry mouth and ruptured
lips caused by fluid
restriction

3. Constipation is CHAPTER of Tn.S 1. Teach over the 1.Many activities can

associated with less smoothly with can baring once every 2 stimulate peristalsis
activity do activity (many hours 2.Many drink to melt
motion) in bed 2.Committed to thefeses
within 2 x 24 hours clients to drink a lot 3.Serat very function to
with criterion: (10-12 glasses) smooth the process of
1.Feses soft 3.Committed to defecation because fiber
 (normal) clients to eat high can soften the consistency
2. Easy defecation fiber (papaya) of feces
process 4. Collaboration of
4.Untuk melancarkan
laxative drug
proses defekasi
delivery.

4. Lack of knowledge is Tn.S find out the 1. Assess the level of 1. To know to what extent
associated with lack problem he was knowledge about the the client's knowledge
of information experiencing by disease makes it easier to provide
providing 2. Give health counseling
information on the education about the 2. To add information
problem from Tn.S disease 3.To increase the spirit
within 1 x 24 hours 3.Client motivation and hope the client will do
with criteria: to perform advice in a positive thing for health
1.Tn.S know about health education 4. To increase client
illness and not 4.Provide knowledge
misperception opportunities for
2.Tn.S is not clients to ask about
confused about his the illness
health problems