Nama Mahasiswa NPM Hari/ Tanggal Ruangan A. Assessment 1.

Client Identity Name Gender Age Address Education Occupation Marital Status Religion Tribe / Nation MRS Date Medical Diagnosa No. RM Date of Assessment

: M. Luthfianoor Ryfani : 010028 D3 KI : : Flamboyan (Penyakit Dalam Pria)

: : : : : : : : : : : : :

Mr. I Male 53 Years Barabai Elementary School Farmer Married Islam Banjarese / Indonesian June 27th, 2012 Hepatoma 99.90.79 July 2, 2012

2. Identity of Responsible Person Name : Mr. A Gender : Male Age : 29 Years Occupation : Swasta Address : Barabai Relationship With the Client : Son B. Medical History 1. Main Complain The client said that his stomach is hurt when the assessment was done on July 2nd, 2012. 2. History of Present Disease The client had stomachache on July 1st, 2012 and was taken to the hospital in Barabai, after being examinde, the client was referred to RSUD Ulin on July 2nd, 2012 and being hospitalized in Flamboyan Ward to get further treatment. 3. History of Previous Disease The client said that he never had the disease he sufferred now. 4. History of Familys Disease The client said that none of the clients family had sufferred the disease that client sufferred, there was only one family member that ever had blind gut/appendix

C. Physical Examination 1. General Condition the client level of consciousness is at compas mentis, with GCS: Eye : 4 (spontaneous eye opening) Verbal : 5 (conscious response and there is orientation) Motor : 6 (motoric response as instructed) Meanwhile the client vital signs as follows TD : 110/70 mmHg Rr : 20 x/minute T : 36o C N : 88 x/minute 2. Skin The general condition of the clients skin was normal, the clients skin was clean enough, clammy skin dry and warm, there were no blisters on the skin. The clients skin turgor was good (back less than 2 seconds) 3. Head and Neck The clients hair distribution was equitable, there were no lesions on the clients head. There was no thyroid gland enlargement and no enlargement of lymph nodes on the clients neck, the client also has no limited neck motion. 4. Sight and Eyes The structure of the client's eyes left and right were symmetrical, the client's eyes looked clean, there was no secretions in the eye. Conjunctiva anemis, client did not use visual aids. 5. Olfactory and Nasal The client's nose was clean; there were no secretions that came out. There was no bleeding or inflammation. Olfactory function was good (could distinguish smells) 6. Hearing and Ear The ears structure looked symmetrical, the clients ears looked clean, no dirt that came out. Hearing function was good, and there were no hearing aids on the clients ears. 7. Mouth and Dental The condition of mouth and dental were not really clean. The clients lip mucosa looked dry. There was no inflammation in the oral cavity. The taste function was good, chewing function was good. The client could swallow food.

8. Chest, Respiration, and Circulation Shape of the chest was normal, symmetrical when respiration and also ekxpiration,. The client breathed normaly through nose, the client did not use respiratory aids.

9. Abdoment Abdominal skin is clean, there were no lesions or blisters, the clients abdomen slightly bent, the client felt the pain in the upper right abdomen. 10. Genetalia dan Reproduction The Client is a male, clients reproduction system is normal, there was no aids such as catheter attached in clients genital. 11. Upper Extrimity and Lower Extrimity The Clients upper extrimities were symmetrical between left and right, infuse was attached on left upper extrimity. There was no disorder on upper extrimities. Lower extrimities shape were symmetrical between left and right, there were no deformities on lower extrimities. Muscle strenght scale: 3 3 3 3 3 3 3 3 0 1 2 3 4 5 = = = = = = 3 3 3 3 3 3 3 3

no contraction (paralysis) there were no movements, palpable/visible muscle contraction. full muscle movement againts gravity and support. normal movement againts gravity normal movement againts gravity with a little resistance full normal movement againts gravity with full resistance

The cilents activity scale was 2, the client needed help from other people for assistance, supervision, and instruction. D. Physical, Psychological, Sexsual, and Spiritual Needs 1. Activity and Rest At home : The Client slept for 6 8 hours at night and 2-3 hours during the day. At Hospital : the client said that he was hard to sleep and the activity was helped by the family. The client only slept 4 5 hours on night. 2. Personal Hygiene At home : the client took a shower twice a day, brushed his teeth three times a day and changed clothes twice a day. At hospital : the client never took a shower, but the client swabbed by his family. 3. Nutrition At home At hospital 4. Elimination At home

: the client ate three times a day with a fairly balance diet, such as rice, side dishes, and vegetable. : the client only ate the food provided by hospital.

: the client BAB 1-2 times a day and BAK 3-5 times a day.

At hospital

: The client BAB once a day and BAK 2 4 times a day.

5. Sexuality The clients gender is male, the client is married, the client does not have any sexuality problem. 6. Psychosocial The clients relationship with his family is good, there were many of his relatives came to visit him, the clients relationship with doctor, nurse, and other medical team was good. 7. Spiritual The client is a moslem. The client looked patient in facing his disease, the client and family prayed so that the client could recover soon and he could gather with his family again. E. Data Focus Subjective Data - The client said that his stomach is hurt. - The client said that he was difficult to sleep. - The client said that his activity was helped by the family. - The clients family said that the client was a little bit worry about his disease. Objective Data 1. Inspection - The client looked holding his stomach - The client looked limp - The client looked weak - The client looked pale - Muscle strength 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 - Clients activity scale was 2 - Pulse : 88 x / min - Breath sound was vascular - P = liver inflammation Q = like being stabbed R = in the stomach, pain in the abdomen S = pain scale 2 - Clients abdomen was bigger

F. Pharmachological theraphy

USG result on July 2nd, 2012

G. Supporting Examination Laboratory Result Examination Result

Reference Value

Unit

Methode

H. Data Analysis No Supporting Data 1 SD: The client felt the pain in stomach OD: P : liver inflammation Q : like being stabbed R : on upper right abdomen S : scale 2 T : intermitten / come and go The client hold his stomach 2

Problem Severe Pain

Ethiology Physical injury agent

SD: Change in - The client said that he was difficult to sleeping pattern sleep - The client said that he slept for 3 4 hours OD: - The client looked limp and weak SD: - The client said that the activity was being helped by family OD: - The client looked weak - Muscle scale / activity scale 2 3333 3333 3333 3333 Activity intolerance

Pain in the abdomen

Decrease in muscle strength

SD: The cilents family said that the client was feeling worry about his disease OD: The client often asked about his disease

Anxiety

Disease process

Problem Priority 1. Severe pain related to physical injury agent 2. Change in sleeping pattern related to pain in the abdomen 3. Activity intolerance related to decrease of muscle strength 4. Anxiety related to abdomen enlargement. I. Intervention No Nursing Diagnosa 1 Severe pain related to physical injury agent

Objective After the nursing care provided for 1 day, the clients comfort level was increase, with criteria: - The client reported that the pain was reduced with scale 0-1 - Calm face expression

Intervention - Examine pain characteristic - Adjust clients position as comfortable as possible - Provide dry warm compress - Teach relaxation technique - Observe TTV

Rational - Knowing pain characteristic - Reduce pain

- Reduce the pain

- Reduce the clients pain - Knowing Clients general condition

Change in sleeping After the nursing pattern related to pain in care provided for 3 the abdomen days, the client could rest, with criteria: - The client could sleep - The client did not looke weak

- Colaboration in - Overcome the giving clients pain analgetic. - Provide a - Comfortable comfortable position could position for the increase comfort client - Give - So that the client explanation to knew the the client about impotance of the impotnce of sleeping for his resting and health sleeping - Colaboration with doctor in giving analgetic - Examine activity limit and muscle strength - Reduce pain so that the client could sleep - Knowing clients condition

Activity intolerance related to decrease of muscle strength, indicated by: - The client said that the activity was

After nursing care was being provided for 3 days, activity intolerance could be resolved with criteria result:

being helped by family - The client looked weak - Muscle scale 3333 3333 3333 3333 - Activity scale: 2

- The client could do activity - The client was not weak anymore - Activity scale 0 - Muscle scale 5555 5555 5555 5555

- Teach client and his family to do active ROM - Put the things that client needed near him - Suggest the clients family to help the client in doing his activity. - Encourage the client to express his feeling about his disease - Pointed out his perception about his anxiety - Colaboration with doctor to explain about his diseas

- Prevent joints contraction and prevent atrophy - Train the clients independence

- Help clients activity

Anxiety related to abdomen enlargement

After nursing care was provided for 1 day, clients anxiety was gone with criteria result: - The client looked calm - The client did not ask about his disease anymore.

- So that the client felt calm

- So that the client felt calm

- So that the client knew about his disease

J. Implentation No Day/Date Time 1 Monday July 2nd, 2012

Dx

Implementation 1. Examine pain characteristic

P Q R S T

= = = = =

Evaluation liver inflammation like being stabbed in upper right abdomen scale 2 come and go

2. Adjust clients position as comfortable as possible 3. Provide dry warm compress 4. Teach relaxation technique

The client looked comfortable The clients pain was reduced The client still need relaxation technique exercise TD = 110/70 mmHg N = 88 x/m

5. Observe TTV

R = 22 x/m T = 36,5o C 6. Colaboration in giving analgetic. 2 1. Provide a comfortable position for the client 2. Give explanation to the client about the impotnce of resting and sleeping The client was calm when the analgetic was given The client felt comfortable The client understood nurses explanation

II

3. Colaboration with doctor in giving analgetic 1. Examine activity limit and muscle The clients family said that strength the client had difficulty in doing his activity and the activity was helped by the family. 2. Teach client and his family to do active ROM The client coul do the active ROM with a help by his family The client could take the things he needed by himself

III

3. Put the things that client needed near him

4. Suggest the clients family to help The clients family helped the client in doing his activity. client in doing his activity 1. Encourage the client to express The client felt more calm his feeling about his disease IV 2. Pointed out his perception about his anxiety 3. Colaboration with doctor to explain about his diseas 1. Examine pain characteristic The client felt calm

Tuesday July 3rd, 2012

The client understood about his disease P = liver inflammation Q = like being stabbed R = in upper right abdomen S = scale 2 T = come and go The client looked comfortable The clients pain was reduced The client could do relaxation technique by himself TD = 110/70 mmHg

2. Adjust clients position as comfortable as possible 3. Provide dry warm compress 4. Teach relaxation technique

5. Observe TTV

N = 88 x/m R = 22 x/m T = 36,2o C 6. Colaboration in giving analgetic. 5 II 2. Colaboration with doctor in giving analgetic 1. Examine activity limit and muscle strength Reduced factors causing the sleep deprivation on the client Clients activity scale was 2 Muscle scale 4444 4444 4444 4444 The client could do the active ROM by himself The client could take the things he needed by himself P = liver inflammation Q = like being stabbed R = in upper right abdomen S = scale 1 T = come and go The client looked comfortable 1. Provide a comfortable position for the client The client was calm when the analgetic was given The client felt comfortable

III

2. Teach client and his family to do active ROM 3. Put the things that client needed near him 1. Examine pain characteristic

Wednesday July 4th, 2012

2. Adjust clients position as comfortable as possible 3. Observe TTV

TD = 120/80 mmHg N = 80 x/m R = 22 x/m T = 36,2o C The client was calm when the analgetic was given The client felt comfortable

4. Colaboration in giving analgetic. 8 II 2. Colaboration with doctor in giving analgetic 1. Examine activity limit and muscle strength III 2. Teach client and his family to do active ROM 1. Provide a comfortable position for the client

Reduced factors causing the sleep deprivation on the client Clients activity scale was 1 Muscle scale 5555 5555 5555 5555 The client could do the active ROM by himself

K. Evaluation No Day/Date 1 Monday July 2nd, 2012

Time

Dx

Tuesday July 3rd, 2012

Evaluation Result S = the client said that his stomach was hurt O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 2 T = come and go A = problem was not resolved P = continue the intervention Assess pain characteristic Adjust clients position as comfortable as possible Provide dry warm compress Teach relaxation technique Observe TTV Colaborate in giving analgetic S = the client said that he would try to sleep O = the client understood the importance of resting and sleepjng A = problem was partially resolved P = continue the intervention Provide comfortable position for the client Colaboration with doctor in giving analgetic S = the client said that his activity was helped by his family O = the client looked weak A = problem was not resolved P = continue the intervention Assess activity limit and muscle strength Teach active ROM to the client and his family Put things that the client needed near him S = the client said that he understood about his disease O = the client looked calm A = anxiety problem was resolved P = stop the intervention S = the client said that his stomach was hurt O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 1 T = come and go A = problem was partially resolved P = continue the intervention Assess pain characteristic Adjust clients position as comfortable as possible Observe TTV Colaborate in giving analgetic S = the client said that he could rest

Wednesday July 4th, 2012

10

O = the client was slept at noon A = problem was partially resolved P = continue the intervention Provide comfortable position for the client Colaboration with doctor in giving analgetic S = the client said that sometimes his activity was helped by his family O = the clients family still helped clients activity A = problem was partially resolved P = continue the intervention Assess activity limit and muscle strength Teach active ROM to the client and his family S = the client said that the pain was reduced O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 1 T = come and go A = problem was partially resolved P = intervention was stopped, the client went home S = the client said that he could sleep O = the client looked fresh A = problem was resolved P = intervention was stopped, the client went home S = the client said that he can do his activity by himself O = the clients family only helped in some activity Muscle scale 5555 5555 5555 5555 Activity scale 2 A = problem was resolved P = intervention was stopped, the client went home