Definition

Dyspepsia is a collection of clinical complaints / symptoms consisting of persistent

discomfort / pain in the upper stomach or recurrence of classic gastroesophageal
reflux complaints in the form of heartburn and gastric acid regurgitation which is no
longer considered dyspepsia (Mansjoer A edition III , 2000 p: 488).

Etiology
1. Changes in diet2. The effect of drugs that are taken in excess and for a long time 3.
Cigarette alcohol and nicotine4. Stress5. Gastrointestinal tumors or cancer

Pathophysiology
Changes in irregular eating patterns, unclear drugs, substances such as nicotine and
alcohol as well as mental stress conditions, less food intake so that the stomach will
empty, gastric emptying can result in erosion of the stomach due to friction between the
walls of the stomach , this condition can result in an increase in HCL production which will
stimulate acidic conditions in the stomach, so that stimulation in the medulla oblongata
brings vomiting impulses so that the intake is inadequate both food and fluids.

Signs and symptoms

1. Abdominal pain (abdominal discomfort) 2. Pain in the gut3. Nausea, sometimes

vomiting 4. Decreased appetite 5. Feel full quickly 6. Flatulence7. Burning sensation in
the chest and stomach 8. Regurgitation (discharge from the stomach suddenly)

Medical Management

1.Non pharmacologic management. Avoid foods that can increase stomach acid b.
Avoiding risk factors such as alcohol, sedentary foods, excessive drugs, cigarette
nicotine, and stress c. Adjust your diet.

2.Pharmacological management, namely: Until now there is no satisfactory treatment

regimen, especially in anticipating relapses. This is understandable because the
pathophysiological process is still unclear. It has been reported that up to 70% of DF
cases are placebo-responsive. The drugs given include antacids (neutralize stomach
acid), anticholinergic (inhibits stomach acid excretion) and prokinetic (prevents
vomiting).
 NURSING CARE IN NY.J WITH THE CASE OF
DISPEPSIA

IN THE VIP ROOM 4

PUSKESMAS
I. ASSESSMENT
CIHAURBEUTI
a. Identity

1. Name : Mrs. J.

2. Age : 62th
 3. Female gender

4. Status : Marry

5. Education : sd /
equivalent

6. Profession : Housewife
7. Religion : Islam

8. No Medrek :-

9. Entry Date: 24/02/2021

10. Assessment Date: 24/02/2021

11. Medical Diagnose: Dyspepsia

12. Address : Sukahurip

b. Responsible Identity

13. Name : Mrs.Y

14. Age : 40 th

15. Female gender

16. Education : sd / equivalent

17. Profession : Housewife

18. Relationship : Family

19. Address : Sukahurip

c. History of Disease

1) Main complaint

The patient said dizziness, nausea, difficulty sleeping

2) Current Disease History

P = the client says that the pain will be felt when the client eats
something sour and spicy.
 Q = the client said the pain was felt in the gut and the lower right
side of the stomach, and the knee to the leg.

R = client said pain in the gut

S = client says the pain felt on a scale of 4

T = the client said the pain was felt for ± 1 day

3) Past medical history

Mrs. J said the disease used to be hypertension

4) Family History of Illness

The patient said that he did not have a family history of illness

d. Daily Living / ADL Activity History

No. Needs Before getting After being sick

sick

1. Nutrition

a) BB 55 52

b) TB 160 160

c) Diet - -

d) Chewing ability Good Good

e) Swallowing ability Good Good

f) Partial total assistance Not helped Partially

assisted
g) Frequency of eating 3x1 / day
2x1 / day
h) Meal portions 1 portion runs
out 1 portion of
porridge is not
i) Foods that cause allergies finished
Nothing Nothing
j) Preferred food
 All kinds of porridge
food

2. Fluid

a) Intake

1. Oral

 Jens Water Water

 amount 2 liters 2 liters

 Total / partial assistance Not helped Partially

assisted
2. Intravenous

 Type
Ringer's lactate
 amount 1,000cc / 20
b) Output tpm
Urine
 Type
1.5 liters Urine
 amount
1 liter / day

3. Elimination

a. CHAPTER

*frequency 2x / day 1x / day

*consistency Soft Soft

*color Yellow It's a little

brown
*complaint No complaints
No complaints
Not with help
Not with help
* total / partial assistance

7x / day
3-4x / day
 b. BAK - -

*frequency Clear yellow Clear yellow

*consistency Not with help Partially

assisted
*color
* total / partial support 8 hours / day

There is no
difficulty 4 hours / day
4 Sleep rest
There are no There is
a. Long sleep
distractions difficulty
b. Trouble getting to sleep sleeping
because of pain
Hard to sleep
c. Sleep disturbance
Nothing

Nothing
d. Habits before bed

5 Personal hygiene

a. Bath

*frequency 2x / day 1x / day on a

washcloth
* total / partial assistance Not helped
Total help
* bathing habits Nothing
Nothing
b. tooth brush 2x / day
1x / day
c. hair washing 2x / day
Not
d. nail clipper 1x / week
Never
4x / day
e. change clothes
 1x / day

6 Activity

a. Physical mobility The patient's Lack of

body movement
movements are because the
normal without patient's right
disturbance hand was put in
the IV infusion,
and the leg was
painful

1x / week Never
b. Sports
1x / month Never
c. Recreation

e. Psychological Data

The client does not look stressed and anxious, is able to communicate
well, the client considers his illness as a test from the creator, the client
feels the disease can heal quickly.

f. Social Data

Clients can hang out with nurses, doctors, and families with a good
attitude.

g. Spirtual Data

The client and family are Muslim, even though the client is sick, they never
leave the prayer.

h. Physical examination

1. General circumstances

The client looks limp, limp, and is lying on the bed

  Consciousness compos mentis, which is a normal state, fully
conscious.

 GCS = 15

4 = eye opening response

5 = verbal response

6 = motor response
following commands

 TTV

TD = 120 / 80mmHg

N = 75x / minute

RR = 24x / minute

S = 36.5 C

 Physical growth

Weight = 52

Height = 160

Posture: slouch

2. Head to toe check

 Head and neck = mesochepal shape, clean scalp, decreased hair

growth, gray hair color, no lesions or bumps. Symmetrical head
and neck. In the neck there is no enlargement of the thyroid gland
and lymph nodes, the neck can be moved right and left.

 Eye vision = the structure of the eye looks symmetrical, good

eye hygiene (no secret attached to the eye), conjunctiva is not
anemic, scelera is not icteric, there are no abnormalities in the
eye such as strabismus (squint), eyes can be moved in any
direction, no abnormalities in vision, the client does not appear
to be using sight tools such as glasses

 Skin = skin looks symmetrical, skin hygiene is good, the skin

feels slightly moist, there are no lesions, the skin turgor returns
 ± 2 seconds, the skin feels warm, the skin color is olive

 Smell and nose = symmetrical nasal structure, good nasal

hygiene, no secretions in the nose, no inflammation, bleeding
and pain, good olfactory function

 Hearing and ear = right and left ear symmetrical structure, there
is no seminyang out, there is no inflammation, bleeding, and pain,
the client says his ears are not buzzing, hearing function is good,
the client does not appear to be using hearing aids

 The mouth and teeth = the structure of the mouth and teeth looks
symmetrical, the lip nucleus looks yellow, oral hygiene and teeth
are quite good, there is no inflammation and bleeding in the
gums, the tongue looks clean and the client does not use
dentures

 Chest, breathing and circulation = symmetrical chest shape,

breath rate 24x / minute, no pain, press on the chest, the client
breathes through the nose, no additional breath sounds such as
wheezing or roaring, CTR returns 3 seconds per minute

 Abdomen = symptomatic abdominal structure, the abdomen

looks flat, (there is no lump) when the percussion sounds a
hypertympanic sound, the client says that his stomach feels
bloated, when the palpation is painful, the client says pain in the
upper part, pain on a scale of 3

 Genitalia and reproduction = female sex clients, the client does

not have complaints or disturbances in the reproductive system

 Upper and lower extremities = symmetrical (left and right) upper

and lower limb structures, no deformity, the client's right hand is
attached to the RL 20tpm infusion, the client looks weak, the
client says pain from knee to leg, client said before he did too
much activity.

 Supporting data

1. Laboratory
o Hemoglobin =

o Hematocrit =
 o The number of leukocytes =

o The number of erythrocytes =

2. Imaging Check = no

3. Terapy

o 500cc (20 tpm) RL infusion fluid

o On and setron

o Ranitidine

II. DATA ANALYSIS

No. Data Etiology Problem

1. DS: Gastric mucosal irritation Pain discomfort

 The patient said ↓

heartburn
Heartburn
Patient says dizzy ↓ discomfort discomfort
pain
DO:

The patient looks grimacing in

pain

The patient appears limp

T = 120 / 80mmHg

P = 75x / minute

R = 24x / minute

S = 36.3C

2. So = 98%
DS: Reduced nutrition Nutritional imbalance is
less than necessary
 Patient says nausea ↓
and vomiting
Nauseous vomit
  The patient says eat ↓
and drink a little
Nutritional imbalance less
DO: than the body's needs

 The general condition

of the patient is
weakness, weakness,
dry lips, looks pale,
does not eat out, and
nausea

 T = 120 / 80mmHg

P = 76x / minute

R = 24x / minute

S = 36.5c

So = 98%

III. NURSING DIAGNOSES

1. Pain discomfort associated with irritation of the gastric mucosa

2. Nutritional imbalance less than the body's needs associated with anorexia.

IV. NURSING CARE PLAN & IMPLEMENTATION

No. Nursing Diagnose Destination Intervention Rational

1. Pain discomfort After receiving 1. Perform a 1. To determin

associated with treatment for 3x 24 comprehensive pain duration, lo
irritation of the gastric hours, the problem of assessment and frequen
mucosa pain and discomfort quality of pa
2. Give it a break in the
can be resolved, with
semifowler position 2. To reduce p
the following criteria:
relaxing dee
3. Give a warm
1. Pain is gone can reduce
DS: compress to the
2. The patient abdomen 3. With therap
  The patient said does not cry out 3. Teach deep breath communica
heartburn in pain relaxation techniques
The good th
 Patient says 3. Able to control that the pat
dizzy anxiety happy and c
5. Use therapeutic
reduce or di
4. Control pain communication
DO: pain
techniques to
The patient looks determine the 4. To meet the
grimacing in pain patient's pain nutritional n
experience the patient's
The patient appears
limp

T = 120 / 80mmHg

P = 75x / minute

R = 24x / minute

S = 36.3C

So = 98%
2. Nutritional imbalance After getting treatment 1. Monitor nausea and 1. To overcom
less than the body's for 3x 24 hours, the vomiting nausea that
needs are associated problem of nutritional feels
2. Suggest patient to
with anorexia imbalance less than
increase Fe intake 2. To overcom
the body's needs can
clients want
be resolved 3. Instruct patient to
increase protein and 3. To resolve t
Result criteria:
DS: vitamin C. back in nor
circumstan
 Patient says 4. Instruct patient to eat
1. The patient with porcised kits but
nausea and
wants to eat frequently
vomiting
2. The patient 5. Collaboration with
 The patient says
looks refreshed ahligizi to determine
eat and drink a
the number of
little 3. Do not feel
calories and nutrients
nauseous and
DO: that patients need
vomiting
 The general 6. Provide information
4. There is an
about nutritional
 condition of the increase in needs
patient is weight in
weakness, accordance
weakness, dry with the
lips, looks pale, objectives
does not eat
5. There are no
out, and nausea
malnutrition
 T = 120 / signs
80mmHg
6. Improves the
P = 76x / minute taste function
of swallowing
R = 24x / minute
7. There was no
S = 36.5c significant
reduction in
So = 98%
body weight

IMPLEMENTATION

NO Nursing diagnoses Implementation

1 Pain discomfort associated with irritation of 1. Assess the frequency of pain

the gastric mucosa
2. Increase rest

3. Encourage rest in a semipowler

position

4. Encourage deep breath relaxation

techniques

5. Give a warm compress

2 Nutritional imbalance less than the body's 1. Encourage small, frequent meals
needs are associated with anorexia
2. Administration of injection drug
ondansetron 2x1 (1 amp)

3. Administration of 2x1 (1 amp)

ranitidine injection

4. Installation of RL 500cc 20
tpm of
 infusion fluid

V. EVALUATION

Date No DF Evaluation Initials

24 1 S = osb came with complaints of nausea, vomiting,

dizziness

O = T: 120/80 mmHg

P: 76 R: 24

S: 36.5 So: 98%

Warm akral, attached RL infusion, smooth droplets,

no phlebitis

A: the problem has not been resolved

P: continue the intervention

25 2 S: os said I was still nauseous, dizziness lessened,

already wanted to eat little by little

O: T: 120/80 mmHg

P: 76 R: 24

S: 36.5 So: 97%

The client still looks

limp

A: The problem is partially resolved

P: continue the intervention

26 3 S: os said that she was no longer nauseous, vomited,
already wanted to eat, was able to sleep, no
dizziness

O: T: 120/80 mmHg

P: 76 R: 24

S: 36.5 So: 98%

The client seemed more excited and refreshed

A: problem is resolved

P: go home