Nama : Ni Putu Angelina

NIM : 200120
Tingkat : 2B
Tugas : Bahasa Inggris

Case
Mr. S is 29 years old and came to Woodward Hospital on March 18, 2022. The patient was
brought to the emergency room by his family with complaints of pain in the lower left
abdomen radiating to the left waist, accompanied by cloudy yellow urine. pain is felt on a
scale of 4. the patient says the pain is like being pricked. From the results of the examination
of vital signs, blood pressure : 140/99 mmHg, respiration: 20x/minute, pulse: 100x/minute,
temperature: 36℃. In the emergency room the patient is given RL therapy of 20 tpm (IV),
and given cetorolax (IV). After that the patient is moved to the inpatient room for further
treatment.

A. ASSESSMENT
Date of entry: 18 March 2022
Date of assessment: March 18, 2022
No. REG: 50530
Space: Zamrud Room
Medical diagnosis:
1. Client identity
Name: Mr. S
Age: 29 years old
Religion : Chritian
Gender : Male
Occupation: Business man
Address: Jl. Woodward No. 1 Palu
Person in charge :
Name: Mr. J
Age: 57 years old
Gender : Male
relationship with clients: Grandfather

2. Main Complaints
Patient complain of pain
3. Health History
a. Current medical history the patient was taken to the emergency room on
march 18, 2022, escorted by the family with complaints of pain in the lower
left abdomen radiating to the left waist, accompanied by cloudy yellow
urine. at the time of the assessment on March 18, 2022 the patient appeared
to be grimacing, composmentist awareness, seemed to hold on to the left
lower abdomen, the patient complained of pain in the left lower abdomen
with a pain scale of 4. and the pain increased when the patient was urinating.
The patient's family assists the patient in meeting the patient's needs.
b. Medical History First
The patient also has no history off hereditary and other infectious disease.
c. Family Health History
The patient’s family says no family member has a hereditary or other
infectious disease.

4. Physical Examination
1. general state : weak
2. awareness : compos mentis
3. Vital signs :
Blood pressure: 140/99 mmHg
Respiration: 20x/minute
Pulse: 100x/minute
Temperatur: 36℃
4. Extremitas
- Above : in the upper limb, hands can be moved properely
- Lower : in the lower, legs can be moved properely
5. Therapy
1. RL 20 tpm fluid
2. Ranitidin 1 ampoule/12 jam
3. Santagesik 1 ampoule/8 jam
4. Ciprofioxacin 0,2 gram/ 12 jam

A. DATA ANALYSIS

NO. DATA Etiology Problem

1 Objective data :
1. The patient is grimacing
2. Pain scale 4 physiological injury Acute pain
3. Vital signs : agent
Blood pressure: 140/99
mmHg
Respiration: 20x/minute
Pulse: 100x/minute
Temperature: 36℃

Subjective data :
1. The patient reports pain in
the lower left abdomen
2. The patient says cramping in
the stomach
3. Patient says pain when
urinating
4. The patient says the pain is
like being stabbed
5. The patient said the pain
wast felt for about 2 minutes
B. NURSING DIAGNOSES
 NO Nursing diagnoses Date found Initials Date resolved initials
1 Acute Pain 18-3-2022

C. INTERVENTION

NO Objectives and Nursing intervention Rational Initials

outcome criteria
1 After nursing a. Observation
actions for 2 x 24 1. Vital signs
hours it is expected Blood pressure:
that the pain felt by 140/99 mmHg
the patient is Respiration:
reduced with the 20x/minute
outcome criteria: Pulse:
1. being able to 100x/minute
control the pain Temperature:
felt 36℃
2. reporting the 2. Pain scale
pain level is identification
reduced 3. Identify the
3. stating a sense location of the
of comfort after pain
the pain is b. Therapeutic
reduced 4. Provide non-
pharmacologica
l techniques to
reduce pain
5. Environmental
control that
exacerbates
pain.
c. Education
6. Teach non-
pharmacologica
l techniques to
reduce pain
B. IMPLEMENTATION

NO Date Implementation Respont to result Initials

1 18-3-2022 *(08.00) observing pain scale Blood pressure:
*(08.05) observing the 140/99 mmHg
location of the pain Respiration:
*(09.00) provide non- 20x/minute
pharmacological techniques Pulse: 100x/minute
such as encouraging patients Temperature: 36℃
to listen to music when they
feel pain
*(09.15) recommend the
patient if the room
temperature is too cold then
the room temperature is raised
*(10.00) teach deep breathing
relaxation techniques
*(11.00) measure vital signs:

C. EVALUATION

Date NO Nursing evaluation Initials

Monday,18 March 1 S The patient said that he still had pain when
2022 urinating

O. The patient's facial expression still looks a

little grimace when the pain arises
Pain scale 4

A Problem not resolved

P Continue Intervention 1,2, & 6

2
S The patient says the pain is getting less
 O The patient does not appear to be grimacing
Tuesday,19 March Pain scale 3
2022

A The problem is resolved

P continue deep breathing exercise

intervention If pain occurs

NURSING CARE IN TN. S WITH URYNARY TRACT

INFECTION
 IN THE ZAMRUD OF THE WOODWARD HOSPITAL

ARRANGED BY :
NI PUTU ANGELINA

DIII NURSING STUDY PROGRAM

HEALTH SCIENCES COLLEGE PALU SALVATION ARMY
2022 ACADEMIC YEAR