NURSING CARE

ON MR. H WITH MEDICAL DIAGNOSIS OF PAIN ACUTE

CHOLESTEROLOLASIS WITH FULFILLING THE NEED FOR COMFORT
IN THE CLASS III MALE KENANGA ROOM
SUNAN KALIJAGA HOSPITAL DEMAK
Student name : Iftah Sofia Syfa
Place practice : Kenanga Room Sunan Kalijaga Hospital Demak
Date practice : 29 October 2018
A. Assessment
Mr. H entered the hospital on October 31 ,2018 at 03.36 a.m with complaints of
right upper abdominal pain , pain like stabbing , pain during activity and pain disappearing
with a scale of 6 since yesterday ( 1 day ago) at 12.00 p.m. When he arrived at the UGD
the patient was infused and given hyosinextra medicine as much as 0,3 mg ( Intra vein).
The assessment was conducted on October 31, 2018 in 05.00 a.m after an action was taken
in UGD . The patient says pain diecreases from scale 6 to scale 5 and the patient was moved
to the retirement room to get further treatment.
I. Identity patient
Biodata
Name : Mr.H
Age/ date of birth : 47 years old / May 23 , 1961
Work : Farmer
Education : Senior High School
Sex : Male
Region : Moeslem
Mental status : Good
Address : Sidokumpul 003/001 Guntur Demak
Date entered : October 31 , 2018 ( 03.36 a.m)
Date assessment : October 31 , 2018 ( 05.00 a.m)
Number register : RG00857611
Diagnose : Choleolitiasis

Responsible person
Name : Mr. Imran Firdaus
Address : Sidokumpul 003/001 Guntur Demak
Age : 56 years old
Work : Farmer
Relation with patient : Cousin
II. Medical story
a. Main complaint
The patient complaints of right upper abdominal pain , pain like stabbing ,
pain during activity and pain disappearing with a scale of 5 .Pain will usually appear
at night.
b. Current Medical History
The patient complaints of right upper abdominal pain , pain like stabbing ,
pain during activity and pain disappearing with a scale of 5, pain arises since
yesterday with pain such as stabbing , nausea , vomiting , the body does not feel
hot , BAK smoothly . Until his family takes it to the Sunan Kalijaga Hospital
Demak there is October 31, 2018 in 03.31 a.m and it is recommended to do
hospitalization in the class 3 male retirement room. The patient was transferred
from UGD room to Kenanga room at 05.00 a.m with infusion og RL and had been
administered as much 0,3 mg of hyosinextra medication trough the infusion tube
and the pain was to begin to decrease.
c. Past medical history
Patient said he have never experienced a disease like what he feel now
d. Family health history
The patient’s family said that in they family there was no one suffering from
the disease as the patirnt had.
III. Physical examination
- General condition : weak
- Awareness : composmentis
- GCS : 15
- Vital sign
Blood pleasure : 140/ 90 mmHg
Pulse : 90x/m
RR : 30x/m
Temperature : 36 C
1. Head
Mesosephal
Hair : not fall out , not greasy , no lice
Scalp: clean and no dandruff
There is no headache
2. Eye
Eye sharpness : far away
Inflammation : nothing
Sclera : not ikterik
Comjungtiva : anemic
Pupil : isokor
Pain : none
 Field of view : far away
Notwearing glasses
3. Noise
Polip , sinusitis : nothing
Bleeding, inflammation , secretions : none
Pen function
4. Ear
Pain , fluid , cerumen , inflammation : none
Hearing function : normal
5. Mounth
Lips : cracked , dry
Teeth : clen , no dental carries
Gum : no bleeding
Tongue : clean
No inflammation
Normal speech function
Normal tasting fungtion
Bad breath : typical
6. Neck
Stiff neck : none
Difficult to swallow : none
Gland enlargement : none
Increased jugular vein : none
7. Chest
Shape : symmetrical
Lung expansion : normal
Cough, x- ray examination : normal ,no lumps
Breath sounds : vesicular
8. Heart
Chest pain : none
Heart rate : normal
Palpitations heart sounds : deafness
9. Abdomen
Tenderness : there is
Tenderness in the right upper abdomen
Bown noise : 40x / menit (hyperperistaltic)
Lumps, liver enlargement spleen : none
Acohtes : none
Abdominal sounds : Tympanic , supple
10. Musculoskeletal
Muscle strength : strong
Muscle tone : none
Stiff joints : none
 Atrophy : none
ROM : none
Trauma , pain , lesion : none
Reflek : normal
Skin : normal

IV. Patterens of daily life

1. Perception and maintenance of health
- Before illness : patient and their family say health is a very important thing , if
there the family sick it will immediately be taken to health services
- During illness : the patient said abdominal pain and pain so the family took her
to Sunan Kalijaga Hospital Demak in October 31 , 2018
2. Patterens of nutritional and metabolic
- Before illness : patient say he eat 3 times a day with 1 portion of food consumed
and drink as much as 2 liters a day
- During illness : patient say he just eat a little because the stomach feels nauseous
and patient wants to vomit by only consuming ¼ portion of eating and drink as
much 1,5 liter.
3. Patterens of elimination
- Before illness : patient says in a day defecate as much as 1 time with yellow
stool , distinctive odor , and in normal amounts. Tub as much 6 x a day with
clear yellow , distinctive smell , and the amout of 1500 ml a day
- During illness : patient says in a day defecate as much as 2 time with yellow
stool , distinctive odor , and in normal amounts. Tub as much 5 x a day with
clear yellow , distinctive smell , and the amout of 1200 ml a day
4. Patterens of activity and practice
- Before illness : patients says he can do activity and work everyday
- During illness : patients says durning illness he can’t do activity and give help
from her family
5. Patterens of rest and sleep
- Before illness : patients says no there are disturbance sleep , and patient sleep
for 7-8 clock a day
- During illness : patients says pain in the right upper abdomen and can’t to sleep
. always awakened because he feel painfull , he just sleep 4 clock a day
6. Patterens of sensory and cognitive
- Before illness : patient know with the blend community and can to know her
family
- During illness : patient know with the blend community and can to know her
family
7. Patterens of role and relation
- Before illness : patient said often blend with the community
- During illness: patient said can’t often blend with the community
8. Patterens of reproduction
 - Before illness : patient is male and not there disturbance genetaly
- During illness : patient is male and not there disturbance genetaly
9. Patterens of self perception
- Before illness : patient said he want always health and can to work
- During illness : patient said he want get well soon and can to work
10. Patterens of coping mechanism
- Before illness : patient say not illness when do activity or when he work
- During illness : The patient complaints pain
11. Patterens of trust value
- Before illness :patient said pray 5 times and moslem
- During illness :patient said pray 5 times and moslem

V. Theraphy Program
1. Infusion RL 20 tpm
2. Hyosinextra 3 x 1 (0,3 ml IV) (05.00 a.m , 12.00 p.m , 24.00 a.m)
3. Ketorolac 3 x1 ( 1 ml IV) (05.00 a.m , 12.00 p.m , 24.00 a.m)
4. Ranitidine 2 x 1 ( 2 ml IV) (12.00 p.m , 24.00 a.m)
5. Ceftriaction 1 x 1 (5 ml IV) (24.00 a.m)
VI. Examination

Examination Result Normal Interpretasi

13,7 F : 12 – 16 Gr %
Haemoglobin M : 12,5 - 18
40,2 40 – 52
Hematokrit -
17,4 3,8 – 10,6 Rb/mm3
Leukosit
736.000 150 – 400 Rb/mm3
Trombosit
3,5 3,8 – 5,1 Mg/dl
Albumin
55 10 – 50 Mg/dl
Ureum

Examination USG
There is choleolitiasis 1,78 cm
VII. Data Grouping
Data Subjective Data objective
- General condition: weak
- The patient complaints of right upper - Awareness : composmentis
abdominal pain - Vital sign
- The patient say nausea and vomiting Blood pleasure : 140/ 90 mmHg
- Patient say he just eat a little because Pulse : 90x/m
the stomach feels nauseous and wants RR : 30x/m
to vomit Temperature : 36 C
- patients says durning illness he can’t - Bown noise : 40x / menit
do activity and give help from her (hyperperistaltic)
family - - There is choleolitiasis 1,78 cm
- Patient say hard to sleep - Patient look so pale
- Patient say not comfort with this - Abdominal sounds : Tympanic ,
condition supple
- Patient say Pain will usually appear at - Tenderness in the right upper
night. abdomen
- patient wants to vomit by only
consuming ¼ portion of eating
- GCS 15
- P: when activity
- Q : stabbing
- R: right upper abdomen
- S: 5
- T: disappear
 VIII. Data Focus
Data subjective Data objective
- P: when activity
- The patient complaints of right upper - Q : stabbing
abdominal pain - R: right upper abdomen
- S: 5
- T: disappear
- Vital sign
Blood pleasure : 140/ 90 mmHg
Pulse : 90x/m
RR : 30x/m
Temperature : 36 C
- - There is choleolitiasis 1,78 cm
- Tenderness in the right upper
abdomen
- Bown noise : 40x / menit
- The patient say nausea and vomiting (hyperperistaltic)
- Patient look so pale
- Abdominal sounds : Tympanic ,
supple
- patient wants to vomit by only
consuming ¼ portion of eating

B. Analized Data

Number Sympton etiologi Problem

- S: The patient complaints of right Biologist Pain acute
1. upper abdominal pain agent injury
- O : P: when activity
- Q : stabbing
- R: right upper abdomen
- S: 5
- T: disappear
- Vital sign
Blood pleasure : 140/ 90
mmHg
Pulse : 90x/m
RR : 30x/m
Temperature : 36 C
- - There is choleolitiasis 1,78 cm
Tenderness in the right upper
abdomen
- S : The patient say nausea and Inadequate Nutritional
2. vomiting nutritional imbalance is less
- O : Bown noise : 40x / menit intake than the body’s
(hyperperistaltic) needs
 - Patient look so pale
- Abdominal sounds :
Tympanic , supple
patient wants to vomit by only
consuming ¼ portion of eating

C. Diagnose
1. Pain acute associated Biologist agent injury marked by The patient complaints of right
upper abdominal pain
- O : P: when activity
- Q : stabbing
- R: right upper abdomen
- S: 5
- T: disappear
- Vital sign
Blood pleasure : 140/ 90 mmHg
Pulse : 90x/m
RR : 30x/m
Temperature : 36 C
- - There is choleolitiasis 1,78 cm
- Tenderness in the right upper abdomen
2. Nutritional imbalance is less than the body’s needs associated Inadequate nutritional intake
marked by S : The patient say nausea and vomiting
O : Bown noise : 40x / menit (hyperperistaltic)
Patient look so pale
Abdominal sounds : Tympanic , supple
patient wants to vomit by only consuming ¼ portion of eating

Priority Diagnose

1. Pain acute associated Biologist agent injury marked by The patient complaints of right
upper abdominal pain
- O : P: when activity
- Q : stabbing
- R: right upper abdomen
- S: 5
- T: disappear
- Vital sign
Blood pleasure : 140/ 90 mmHg
Pulse : 90x/m
RR : 30x/m
Temperature : 36 C
- - There is choleolitiasis 1,78 cm
- Tenderness in the right upper abdomen
 NURSING CARE
ON MR. H WITH MEDICAL DIAGNOSIS OF PAIN ACUTE
CHOLESTEROLOLASIS WITH FULFILLING THE NEED FOR COMFORT
IN THE CLASS III MALE KENANGA ROOM
SUNAN KALIJAGA HOSPITAL DEMAK
“ENGLISH TASK”

Name : Iftah Sofia Syfa

NIM : P1337420417007
Class : 2A

DIPLOMA III NURSING OF BLORA

HEALTH POLYTECHNIC OF SEMARANG
2018