Nursing Resume

A. Patient Identity
Name :Mr. M.S
Age :68 years ,1 mounth
Addres :Guntung manggis, Landasan Ulin
Medical diagnose :Benigna Prostat Hiperplasi (BPH)
Date of Entry :20 february 2018
Date of Assessment :20 february 2018 ,10:15 am
B. Data Focus
Subjective Data
 patients said “ I the frequent urinating”
 patients said “ night last ,I pee as much as 5 times”
 patients said “when peeing, I feeling unsatisfied”
 patients said “ I fell pain in the lower part of the stomach in hypogastrum when
want pee”
 patients said “ pain extends to the waist”
 patients said “ complaint felt this almost 2 years”
 patients said “ I anxious with the my condition here and anxious when his illness
later will deteriorate”
 patients said the fear when his illness worse and should be in operation
 patien said “ I less understand my illness”
Objective Data

 patient looks anxious with his condition
 patients are seen at the moment waiting for the queue back into the toilet
 patients often look a lot of inquires about his or her concerns with the doctor
 patients look shows the area of pain wirh assesment
 P: when want peeing
Q: poignant
R:The lower abdominal area at the hypogastrum quadrant 8
S: scale medium5-6/10, pain extends to the waist
T: 30 minutes, missing pain arising
C. Additional Data
a. Vital sign (20 february,2018) (09:20)
Blood preasure :130 /80
Frequency breath :21 times minutes
Frequency pulse :79 times minute
Temperature :37,0 C
b. Examination of Supporting
 Laboratory (19/02/2018 results normal value
- blood glocuse 87 mg 60-115mg/100ml
-blood Glocuse 2 hour PP 116mg/ -125mg/100ml
-cholesterol 194mg 130-200mg/100ml
-ureum 69mg 15-50mg/100ml
-creatinin 21mg until 1,4/100ml
-Uric acid 10,2mg man 3,4-7,0mg/100ml
Triglyorieda 100 <175mg /100ml
LDL 117 -150mg/dl
HDL 60 man 35-55/dl
Urine complete (08/02/2018)
-color light yellow
-clarity clar
-Bj 1015
-PH 5,0

USG : suspek right kidney, opaque stone ,spendolisis lumbalisis (L2-5)

BNO : neproliatatis cause not bilateral obstruction
classification of prostate

D. Data Analisis

No Data Problem Etiology
1 SD: retention of urine to high pressure
 patients said “ I the frequent urinating” urethral
 patients said “ night last ,I pee as much as
5 times”
 patients said “when peeing, I feeling
unsatisfied”
OD:
 patients are seen at the moment waiting for
the queue back into the toilet
 USG : suspek right kidney, opaque stone
,spendolisis lumbalisis (L2-5)
 BNO : neproliatatis cause not bilateral
obstruction ,classification of prostate
2 DS : Acute pain Agent injury fisic
 patients say the pain in the lower part of the (spasme
stomach in hypogastrum when want pee gallbladder)
and when pee
 patients said “ pain extends to the waist”

OD:
 patients look shows the area of pain
 P: when peeing and when want pee
(movement)
Q: poignant
R:The lower abdominal area at the
hypogastrum quadrant 8
S: scale medium5-6/10, pain extends to the
waist
T: 30 minutes, missing pain arising
Vital sign (20 february,2018) (09:20)
Blood preasure :130 /80
Frequency breath :21 times minutes
Frequency pulse :79 times minute
Temperature :37,0 C
3 SD Anciety Lack of knowledge
 patients say the anxious with the condition
 patients say anxious when his illness later
will deteriorate
 patients say the fear when his illness worse
and should be in operation.
 patien says less understand his illness
OD
 the patient looks anxious with his condition
 patients often look a lot of inquires about
his or her concerns with the doctor

E. Nursing Care Plan (NANDA NIC NOC 2015)
1. Nursing diagnose : retention of urine releataed to high pressure urethral
Goals/NOC
 Urinary elimination
 Urinary continence
The Criteria Of The Results:
 Bladder empty in full
 There is no residual urine > 100-200 cc
 Free from UTI
 No spasme bladder
 Balanced fluid balance
NIC/Intervention
Urinary Retention Care
1) Monitor intake and output
2) Monitor the use of the medicine antikolionergik
3) Monitor the degree of bladder distensi
4) Instruct patient and family to take down the urine output
5) Provide privacy for the Elimination
6) Instruct of reflex bladder with a cold compress on the abdomen
7) Katerisasi if necessary
8) Monitor for signs and symptoms of UTI (heat, hematuria, a change in the
smell and consistency of urine)
9) Collaboration with doctor medicine farmakologi
Implementation
2). Monitor the use of the medicine antikolionergik
3). Monitor the degree of bladder distensi
4) Instruct patient to take down the urine output
6). Instruct of reflex bladder with a cold compress on the abdomen
8).Monitor for signs and symptoms of UTI (heat, hematuria, a change in the smell
and consistency of urine)
9). Collaboration with doctor given : vesicare 1x1 mg/day ,indication s
symptomatic therapy for urinary incontinence and urinary frequency or
increased and the desire for micturition in patients with overaktif bladder
syndrome.
Evaluation
S:
 patient say don’t consume medicine antikolionergik
 patient say when at home forget to remember the view counters frequency
spending urine times a day
 patient say will cold compress on the abdomen when abdomen

O:
 When Assessment doctor, patient stomach don’t distention and patien look
not bloated
 Urine complete (08/02/2018)
-color :light yellow
-clarity :clar
-Bj :1015
-PH 5,0

A: problem is not resolved
P: continue intervention 2,3,4,6,8,9

2. Nursing diagnose : Acute pain releted to Agent injury fisic (spasme
gallbladder)
Goals noc :
-Pain Level,
-Pain control
- Comfort level

The Criteria Of The Results:
-Able to control the pain (know the causes of pain, being able to use the method
nonfarmakologi to reduce pain, seek help)
-Reported that the pain was reduced with the use of pain management
-Able to recognize pain (intensity, frequency, scale and signs of pain)
- Declare a sense of comfort after the pain is reduced

Nursing Intervention:
NIC
Pain Management
1).Do pain study comprehensively include the location, characteristics, duration,
frequency and quality factor of precipitation
2).Observations of nonverbal reactions and discomfort
3). Environmental controls that can affect pain such as room temperature, lighting
and noise
4). Reduce the pain of precipitation factors
5).Select and do the handling of pain (Pharmacology, Pharmacology and inter
personal)

6). Select and do the handling of pain (Pharmacology, Pharmacology and inter
personal

7).Teach to Non pharmacological techniques

8). Boost rest

9). colaboration with doctors given analgesics
10). Monitoring patient acceptance of pain manajement
Implementation

1).Do pain study comprehensively include the location, characteristics, duration,
frequency and quality factor of precipitation
4). Reduce the pain of precipitation factors
7).Teach to Non pharmacological techniques (relaxation)

8). Boost rest

9). colaboration with doctors given analgesics

Evaluation
S:
 Patient say at rest the pain is reduce but patients difficult to break because the
feeling always want to pee
 Patient say difficult not to focus with feel his pain
 Patient say try to get more of rest

O:

 Patient looks to relaxation , but the patient look still seem to focus to his pain
 Doctor don’t prescribing medications analgesic
 P: when peeing
Q:seperti poignant
R:The lower abdominal area at the hypogastrum quadrant 8
S: scale medium5-6/10, pain extends to the waist
T: 30 minutes, missing pain arising
A: problem not is resolved

P:continue intervention 1,4,7,8,9

3. Nursing Diagnose :
Goals /NOC
· Anxiety self-control
· Anxiety levels
· Coping with
The Criteria Of The Results:
· The client was able to identify and express the symptoms of anxiety.
· Identify, disclose and demonstrate techniques for mengontol anxious.
· Vital sign in the normal range.
· Posture, facial expressions, body language and level of aktivfitas shows
decreased anxiety.

NIC/Intervention
Anxiety Reduction (decrease in anxiety)
1) Explain all procedures and what is felt during the procedure
2) Accompany patients to provide security and reduce fear
3) Push the family to accompany patients
4) Listen attentively
5) Identification of the level of anxiety
6) Help your patients recognize situations that cause anxiety
7) Encourage the patient to express feelings, fears, perceptions
8) Instruct the patient to use relaxation techniques
9) provide information about the patient's disease

Implementation

2).Accompany patients to provide security and reduce fear
3). Push the family to accompany patients
4). Listen attentively
7). Encourage the patient to express feelings, fears, perceptions
8).Instruct the patient to use relaxation techniques
9). provide information about the patient's disease
Evaluation

S:

 patient say anxious decrease if accompany family
 patient say
 feel appreciated when a nurse or a doctor listent complaint
 patien say fear when his illness worse and should be in operation , because the
patient thinks the operation is where the ailment is severe
 patient say begin to understand the doctor's explanation
 patient say to relaxation

O:

 patient looks quieter when accompanied by family
 after the doctor's explanation patient looks the quiter
 patient looks relaxation with the draw a breath in
Vital sign (20 february,2018) (09:20)
Blood preasure :130 /80
Frequency breath :18 times minutes
Frequency pulse :68 times minute
Temperature :37,0 C

A: problem most resolved

P: continue intervention 2,3,4,7,8,9