EMERGENCY NURSING CARE

ACUTE GASTRITIS

PUTU GEDE SURYA SWARNATA

3
TINGKAT IV A/ SEMESTER VII
PRODI S.Tr. KEPERAWATAN

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
JURUSAN KEPERAWATAN
TAHUN 2020
 POLYTECHNIC OF HEALTH DENPASAR Name:W L
DOB: 13-12-1995
EMERGENCY NURSING CARE MRN: 2321
Gender: Female
Date : 27/6/2021 Time : 14. 00 WITA
Complaints on admission to hospital :
The patient came to the emergency room with complaints of heartburn, the patient was sweating, holding his stomach. The
patient's family said that before getting sick, the patient had followed the trend of a slightly extreme artist-style diet so that the
patient did not eat rice for more than 4 days. The patient has an obsession to lose weight. While the patient was working at
home, suddenly the patient complained of excruciating abdominal pain, his face was pale, sweaty, and weak. The patient's
family then took the patient to the nearest hospital. When examined, the family said the patient last ate at 11.00 with only one
sweet potato.
History of Disease/Medication:
The patient's family said that the patient had no history of hereditary disease but the patient had had an acute ulcer as a
teenager.
Allergy History: [ ]No[ ] Yes, Type : ________________________
Triage labels: [ ] P 1 [ ] P 2 []P3 [ ]P4 [ ]P5

AIRWAY

Breath effort: [ ] Yes[ ] TidakRespiration Rate: 20 bpm

Foreign object: [ ] No[ ] Yes, Explain ___________________
Breath sound: [ ] Ronchi[ ] Wheezing[ ] Gurgling[ ] Stridor[ ] Vesikuler

BREATHING

Type of breathing: [ ] Tachipnea[ ] Bradipnea[ ] Normal[ ] Apnea

chest muscle retraction: [ ] Yes[ ] No
Abnormalities of chest wall: [ ] Injury[ ] Wounds[ ] None
PRIMARY SURVEY

Lung Development: [ ] Symmetrical[ ] Asymmetric

CIRCULATION

Pulse : [ ] Not Palpable [  ] Palpable, is it... [ ] Strong [ ] Weak

CRT : [ ] <2 sec [ ] >2 detik Acral : [  ] Warm [ ] Cold
Skin Tone : [ ] Normal [  ] Pale [ ] Yellow
Bleeding : [  ] No [ ] Yes, is it... [ ] Controlled [ ] Not Controlled
Pulse : 90 bpm Blood pressure : 120/90mmHg Temperature : 36.50C
DISABILITY

Response: [ ] Alert[ ] Verbal[ ] Pain[ ] Unrespons

Pupil: [ ] Isokor[ ] AnisokorGCS : E4V5M5 = 14
Reflex: +/+
Pain: [ ] No[ ] Yes : NRS/BPS/WBS 7Location of pain: ulu hati
Spread: [ ] Yes[ ] NoPain duration: persistent
Faktor pemicu/pemberat : bila di tekan, digerakkan

Medical Diagnosis: acute gastritis Behavioral Pain Scale

Pain Scale:
NRS (Number Scale) for age > 7 years
WBS (Face Scale) for 3 -7 years old or uncooperative patient
BPS for unconscious patients

Score BPS : <5 : patient does not have pain

≥5 : patient pain
 EMERGENCY NURSING DIAGNOSIS EMERGENCY NURSING PLAN
 Ineffective airway clearance  Monitor fluid in, fluid out and fluid balance
 Aspiration risk  Monitor the client's skin and oral mucosal turgor
 Ineffective breathing pattern  Monitor vital signs periodically (heart rate, blood
pressure, MAP)
 Impaired gas exchange
 Monitor the client's body temperature
 Impaired spontaneous ventilation
 Provide head up position as indicated
 Diarrhea
 Collaborative IV fluid administration as indicated
 Deficiency/Risk of lack of fluid volume
 ECG Monitor
 Excess fluid volume
 Perform urinary catheter insertion as indicated
 Ineffective/Risk of ineffective peripheral tissue perfusion
 Monitor the client's respiratory status (depth, rate, breath
 Acute pain
sounds, use of accessory muscles to breathe)
 Risk of nutritional deficit
 Monitor client's SaO2 status
 Decreased/Risk of decreased cardiac output
 Give O2 as indicated
 Risk of ineffective gastrointestinal perfusion
 Open the airway with head tilt chin lift or jaw thrust
 Risk of ineffective renal perfusion
manouver
 Risk of bleeding
 Remove foreign body, do suction
 Risk of shock
 Install OPA, NPA, ETT, collar brace as indicated
 Urinary retention
 Install NGT
 Risk of electrolyte imbalance
 Overcome pain (delegative administration of analgesics)
 Risk of unstable blood glucose levels
 Monitor level of consciousness periodically
 Risk of fluid volume imbalance
 Monitor the results of laboratory tests
 Risk of ineffective cerebral tissue perfusion
 Monitor nausea and vomiting
 Hyperthermia  Identification of weight changes
 Hypothermia  Identify diet
 Ineffective thermoregulation  Monitor the client's body temperature
 Risk of violent behavior towards others  Give transfusion if necessary
 Risk of violent behavior towards oneself  Apply pressure bandage to the bleeding site
 ............................................................................................  Give a warm compress
 ............................................................................................  Monitor for signs of shock
 ............................................................................................  Monitor for signs of increased intracranial pressure
 ............................................................................................  Provide artificial respiration, mechanical ventilation,
 ............................................................................................ ventilation with a ventilator
 ............................................................................................  Apply foot/hand/chest restraints as needed
 ............................................................................................  Provide a non-threatening environment
 ............................................................................................  Identify the location, characteristics, duration, frequency,
 ............................................................................................ quality, intensity of pain
 ............................................................................................  Identify pain scale
 ............................................................................................  Identify factors that exacerbate and relieve pain
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 COMPREHENSIVE OBSERVATION
27/6/21 27/6/21 27/6/21 27/6/21
Date
14.00 14.30 15.00 15.30
Time
pulse Temperature
(●) (X)

blood
pressure
(↨)

200

150

100

50

Respiration 20 20 20 18
Pain scale (0-10) 7 6 5 4
E 4 4 4 4
V 5 5 5 5
GCS
M 5 5 5 5
Total 14 14 14 14
R. Pupil Left/Right +/+ +/+ +/+ +/+
Name/signature Surya Surya Surya Surya

FLUIDS OBSERVATION
LIQUID IN LIQUID OUT
Date Time Liquid type No. Bottle IV Oral/NGT Drain NGT Urine Defecate
27/6/21 14.10 Asering 14 
tpm
27/6/21 14.10 Drip 
omeprazole
8 mg
27/6/21 14.15 Santagenik 
3x1 gr
 NURSING IMPLEMENTATION

NAME/
DATE TIME NURSING ACTIONS FORMATIVE EVALUATION
SIGNATURE
27/6/21 14.00  Monitor vital signs periodically SD : The patient's family said that Surya
wita (heart rate, blood pressure, before the illness, the patient's diet
MAP) was irregular due to an unhealthy
 Monitor the client's skin and diet. Patients only eat when
oral mucosal turgor hungry, eat 2 times a day without
 Identify eating patterns rice.
OD: the patient's skin turgor is
slow and looks pale, the patient's
oral mucosa is dry, the results of
TTV are obtained:
BP: 120/90 mmHg, pulse 90 bpm,
temperature 36,50C.
14.05  Identify the location, DS: the patient said that he had Surya
wita characteristics, duration, pain in his stomach, precisely in
frequency, quality, intensity of the pit of the stomach, the pain
pain was prickling, duration ± 2-5
 Identify pain scale minutes, the pain was persistent,
 Identify factors that aggravate the pain scale was 7.
and relieve pain DO : the patient is grimacing,
 Monitor nausea and vomiting holding his stomach, epigastric
tenderness (+).
14.10  Collaboration of IV fluids as DS :- Surya
wita indicated DO: Asering IVFD installed 14
tpm
14.15  Carry out laboratory tests DS :- Surya
wita DO: waiting for the results of the
examination
14.20  Overcoming pain (delegative DS :- Surya
wita administration of analgesics) DO: the patient was given a
 Collaborative administration of Santagenic drug 3x1 g and
gastritis medication omeprazole drip 8 mg given IV

14.30  Monitor vital signs periodically DS :- Surya

wita (heart rate, blood pressure, DO: the patient's skin turgor is
MAP) slow and looks pale, the patient's
 Monitor the client's skin and oral oral mucosa is dry, the results of
mucosal turgor TTV are obtained:
BP: 120/80 mmHg, pulse 85 bpm,
temperature 36.00C.
14.25  Identify the location, DS : the patient says pain in the Surya
wita characteristics, duration, stomach, to be precise in the pit of
frequency, quality, intensity of the stomach, pain is like being
pain stabbed, duration ± 2-5 minutes,
 Identify pain scale the pain feels persistent, pain scale
6. The patient says he feels a little
nauseous and wants to vomit
DO : the patient is grimacing,
holding his stomach, epigastric
tenderness (+).
15.00  Monitor vital signs periodically DS :- Surya
wita (heart rate, blood pressure, DO: the patient's skin turgor is
MAP) slow and looks pale, the patient's
 Monitor the client's skin and oral oral mucosa is dry, the results of
mucosal turgor TTV are obtained:
BP: 120/80 mmHg, pulse 80 bpm,

 Monitor the results of laboratory
tests
15.15  Identify the location,
wita characteristics, duration,
frequency, quality, intensity of
pain
 Identify pain scale
15.20  Monitor nausea and vomiting
wita  Identify changes in body weight
15.30  Monitor vital signs periodically
wita (heart rate, blood pressure,
MAP)
 Monitor the client's skin and oral
mucosal turgor
15.45  Identify the location,
wita characteristics, duration,
frequency, quality, intensity of
pain
 Identify pain scale
temperature 36.00C.
Complete blood count results Surya
obtained: Erythrocytes (RBC)
2,232 106 /µL (), Hemoglobin,
6,52 g/dL (), HCT 18,47 % ()
DS: the patient said the pain in the Surya
stomach began to decrease, to be
precise in the solar plexus, the
pain was like being stabbed, the
duration was ±2-5 minutes, the
pain felt persistent, the pain scale
was 5.
DO : the patient is grimacing,
holding his stomach, epigastric
tenderness (+).
DS : The patient said he felt a Surya
little nauseous and wanted to
vomit. The patient's family said
the patient did not experience a
drastic weight loss.
DO: the patient looks cooperative
DS :- Surya
DO: the patient's skin turgor is
slow and looks pale starting to
decrease, the patient's oral mucosa
is dry, the results of TTV are
obtained:
BP: 120/80 mmHg, pulse
80x/min, temperature 36.00C.
DS: the patient said the pain in the Surya
stomach began to decrease, to be
precise in the pit of the stomach,
the pain felt like being pricked,
the duration was ±2-5 minutes, the
pain felt constant, the pain scale
was 4.
DO: the patient appears to be
grimacing starting to decrease,
epigastric tenderness (+).
 NURSING EVALUATION (SUMATIVE EVALUATION)
Evaluation Name/
NO Nursing Diagnoses
(S-O-A-P) Signature
1. Acute pain associated with biologic pecendera S : the patient said that the pain in the Surya
agents (gastritis) is characterized by the patient stomach began to decrease, to be precise
complaining of pain in the solar plexus area, the in the pit of the stomach, the pain felt like
pain feels like being pricked, sweating, avoiding being pricked, the duration was ±2-5
painful positions, epigastric tenderness (+). minutes, the pain felt constant, the pain
scale was 4.
O: the patient appears to be grimacing
starting to decrease, epigastric tenderness
(+). TTV results obtained:
BP: 120/80 mmHg, pulse 80 bpm,
temperature 36.00C.
A: the problem of acute pain is partially
resolved
P: continue pain management
interventions in the treatment room
2. The risk of nutritional deficit is evidenced by S :- Surya
psychological factors (reluctance to eat). O: the patient's skin turgor is slow and
looks pale starting to decrease, the
patient's oral mucosa is dry, the results of
TTV are obtained:
BP: 120/80 mmHg, pulse 80 bpm,
temperature 36.00C.
A: the problem of risk of nutritional
deficit is partially resolved
P : Continue the nutrition management
intervention in the treatment room.