ASSESSMENT FORMAT

SURGICAL MEDICAL NURSING

AKPER CONSTRUCTION INSANI SAKTI FULL RIVER

I. BIODATA
A. Patient Identity
Name : Ny.A
Age : Sixteen Years
Gender : Women
Marital status : Single
Education : Students
Profession :-
Address : Sungai Penuh
Hospital Date : Thirteen-June-Two Thousand Twenty
No. Register :-
Room / Room : Mawar VIP
Blood group :A
Date of Assessment : Forteen-June-Two Thousand Twenty
Medical diagnosis : Gastritis

B. Identity of the Person in Charge

Name : Ny.D
Relationship with Patient : Patient’s Mother
Profession : Nurse
Address : Sungai Penuh

II. Main complaint

Patients came to the hospital complaining of fever since two days ago then experienced
hartburn

III. Medical history

A. Now
- The main complaint at the time of hospital admission
When the study was conduted on Thirteen-June-Two Thousand Twenty

- The main complaint when in the data

a. Provocative / palliative
Pain during activity and rest
b. Quality
Abdominal Pain
c. Reguion (Location)
Epigastrium
 d. Severity (Interrupting Activities
Pain scale six
e. Time
Disappear arise

B. The past

- Diseases ever experienced

Diarrhea

- Medical actions / treatments taken

Buy medicine at the pharmacy

- Have been treated / operated on

Never

- The duration of treatment

Never

- Allergy
There is no

IV. HEALTH HISTORY NOW

- Parents
Hypertension

- Siblings
There is no

- Existing hereditary diseases

There is no

- Dead family member

There is no

- Cause of death
There is no

V. PHYSICAL EXAMINATION
A. General conditions
Weak

B. Vital signs
 TD : 100/80 mmHg RR : 21x/Menit
Temperature : 37,5 c BB : 45 cm
Pulse : 100x/Menit TB : 170 cm

DATA ANALYSIS

No Symptom Etiology Problem

1. Ds : -The patient said heartburn Spicy, hot, and sour Acute pain b/d
-The patient says the pain food Biological injury
disappears and is Decreased mucus agents
accompanied by nausea production by columer
cells
Do: - The patient looks grimaced Exofoliation of gastric
and weak mucosal cells
-Pain scale three Erosin
Pain

NURSING DIAGNOSES
- Acute pain b / d biological injury agent d / d patients say uluhati pain, pain
disappeared and the patient looked grimaced and limp with pain scale 3

NURSING PLAN

No Day/Dat Diagnosis Noc Nic

e
/Hour
1 13/June Acute pain After doing nursing care 3. Do a
2020 b/d for 1x24 hours the comprehensive
18.45 biological patient’s pain is expected pain assessment
injury to decrease. 4. Teach
agent d / d With yield criteria : nonpharmacology
patients say 1. Able to control techniques
uluhati pain (relaxation)
pain, pain 2. Able to use non 5. Provide analgesics
disappeared pharmacological to reduce pain
and the techniques to 6. Monitor vital sign
patient reduce pain
looked
grimaced
and limp
 with pain
scale 3

IMPLEMENTATION

No Day/Date Diagnosis Hour of implementation

/Hour
1 13/June Acute pain b / d biological
2020 injury agent d / d patients
say uluhati pain, pain
disappeared and the patient
looked grimaced and limp
with pain scale 3
implementation and results
1. teach about
nonpharmacology techniques
(relaxation techniques)
Results: The patient said that he felt
relaxed after the relaxation technique

2. provide analgesics to reduce

pain
Results: The patient said after
analgesics the pain was reduced

3. Vital sign monitor

Results: TD: 110/70
S: 36.5 C
N: 80 x / i
Rr: 22 x / i

4. increase the rest

Results: the patient appeared to
be resting comfortably

5. Check the doctor's

instructions about the type of
drug
Results: Patients were given
analgesic antacids to neutralize the
origin of the stomach

EVALUATION
S : The patient said that pain in uluhati no longer exists and no nausea anymore
O : The patient no longer grimaces and looks comfortable
A: The problem is resolved
P : Intervention is stopped the patient goes home