Nama : Lathifath’ul Rahayuningrum

NIM : 131711133055

Kelas : A2

1) You are assigned to ambulate Mr Y, who has abdominal surgery 24 hours ago. Mr Y weighs
125 kg and is 187 cm tall. He has a client-controlled analgesia (PCA) system for pain control.
His IV fluids are running at 100 mL/h and he has two IV antibiotics scheduled to run every 6
hours. Please complete patient’s data, analyse the data and formulate the nursing diagnoses
for Mr Y!

The patient’s data

Name : Mr. Y

Gender : Male

Weights : 125 kg

Tall : 187 cm

Medical therapy :

- Controlled analgesia (PCA) system for pain control

- Abdominal surgery 24 hours ago
- IV fluids are running at 100 mL/h
- Two IV antibiotics every 6 hours

Analyse the data

Numbe Date Data Etiology Problem

r
1 13 June 2018 DS: The patient feels pain in his Controlled Acute pain
stomach analgesia
P: Postoperative abdominal pain (PCA)
Q: Pain like being stabbed
R: Abdominal pain
S: Scale of pain 8
T: Pain is felt after 24 hours of
surgery

DO:
-   The patient appears to be
holding pain
 Nursing Diagnosis
1. Obesity

Obesity is related with a body mass index> 30 kg / m2, with evidence by BMI Mr. Y is 35, 7
which means it exceeds the normal BMI limit (Obesity 00232)

2.Acute Pain
Acute pain is related with complaints about the characteristics of pain using standard pain
instruments, as evidenced by Mr. The instrument is attached to PCA to control pain (Acute
Pain 00132)

3. Obstacles to Physical Mobility

Related with pain (attached PCA), physical not fit and sedentary lifestyle (Mr. Y 125 kg body
weight) (Obstacles to Physical Mobility 00085)

4. Gastrointestinal Motility Dysfunction

Related with abdominal pain with the characteristics of Mr. Y had surgery on the abdomen
that allowed pain to arise so PCA instrument was paired (Gastrointestinal Motility
Dysfunction 00196)

5. Risk of infection
Related with obesity with the characteristics of BMI from Mr. Y is 35.7 which means it
exceeds the normal BMI limit (Risk of infection 00004)

2) You have been assigned to care for a client in a medical ward who are suffering chronic
kidney disease. The patient complained of unbearable thirst while the patients are
experiencing fluid volume excess, acute lung oedema and full body oedema. Please complete
patient’s data, analyse the data and formulate the nursing diagnoses for this patient.

The patient’s data

Name : Mr. X (client in a medical ward)

Medical complains :

- Chronic kidney disease

- Fluid volume excess
- Acute lung oedema
- Full body oedema
- Unbearable thirst

Analyse the data :

Numbe Date Data Etiology Problem

r
1 13 June 2018 DS : Unbearable thirst Controlled Acute pain
 P:  analgesia
Q: Pain like being stabbed (PCA)
R: Abdominal pain
S: Scale of pain 8
T: Since he diagnosed with
chronic kidney.

DO:
- The patient has chronic kidney
disease.
- The patient has edema.

Nursing diagnoses :

1. Advantages Fluid Volume

Related with nutritional intake or (water and sodium retention) proven by the client
experiencing full body edema (Advantages Fluid Volume 00026)

2. Liquid Volume Deficient

Related with disorders that affect fluid absorption, proven by unbearable thirst (Liquid
Volume Deficient 00027)

3. Risk of Electrolyte Imbalance

Related with kidney diffusion, and excess fluid volume as evidenced by clients suffering
from chronic kidney and excess fluid volume (Risk of Electrolyte Imbalance 00195)