NURSING DOCUMENTATION

A. ASSESSMENT
1. Data
a. Patient Record
Surname : Atmadiyanti
First name : Ayu Lita
Gender : Female
DOB : 28 08 1995
Place of birth : Tangerang, Indonesia
Address :
Occupation : College student
Marital status : Single
Next of kin :
Contact no. :
Smoking intake : n/a
Alcohol intake : n/a
Reason for admission : Abdominal pain and vomitting
Medical history :
Family history : Her father had maag
Allergies : cassava leaves
Diagnosis : chronic gastritis

b. Medical history:
1) Keluhan utama saat dikaji : pain in the pit of stomach
2) Riwayat Kesehatan Sekarang : she complained that she had
pain in the pit of stomach in the last three days, loss
appetite, flutulance, nausea and anorexia
3) Riwayat Kesehatan Dahulu : -
4) Riwayat kesehatan keluarga : her father had maag
5) Riwayat sosial : irregular eating habit, she often eat spicy
and sour foods, lack of sleep, stress, staying up until late
with a cup of coffee every night.
c. Data Biologis
1) Assessment
a) Keadaan Umum
(1) Kesadaran : composmentis
b) Vital signs
(1) Temperature : 37,2
(2) Heart rate : 120 x/minute
 (3) Respiratory rate : 25 x/minute
(4) Blood Pressure : 90/60 mmHg
(5) Height : 150 cm
(6) Weight : 41 kg
c) Physical assessment
(1) Head
- Skin : normal, there arent any lesion
- Face : pale
- Eyes : Konjungtiva anemis
- Mouth : white patches on the tongue
(2) Neck
Normal
(3) Thorax and lungs
Respiratory rate : 25x/min (tachipnea)
(4) Heart
- Heart rate : 120x/min (takikardia)
- Blood pressure : 90/60 mmHg
(5) Abdomen
- Pain in the pit of stomach, flatulance, thympany
(6) Extremity
- normal
d. Data Psikologis
a. Emotional status
She felt stress
b. Pola Komunikasi
She can do communication well and cooperative

2. ANALISA DATA
No Data Etiologi Masalah
1 Ds : she said pain Precipitating factors Pain related to
in the pit of inflammation
stomach Inflammation of gastric of gastric
Do : she looks mucosa layer mucosa layer.
pale.
BP: 90/60 mmHg Gastritis
HR : 120x/menit
RR : 25 x/menit HCL increase
T : 37,2
Irritation

Exfoliation

Erosion of mucosa layer

 Pain
2 Ds : she said that Precipitating factors Deficit fluid
she had nausea. volume related
Do : she looks Inflammation of gastric to nausea.
pale, there are mucosa layer
white patches on
the tongue. Gastritis
BP: 90/60 mmHg
HR: 120x/menit HCL increase
RR : 58 x/menit
T : 37,2 Suppress the gag reflex
Height : 150 cm
Weight : 41 kg Nausea

Deficit fluid volume

3 Ds : she said that Precipitating factors Imbalance

she had loss nutrition: less
appetite, Inflammation of gastric than body
flatulance and mucosa layer requirements
anorexia related to
Do : she looks Gastritis insufficient
pale, there are interest in food.
white patches on HCL increase
the tongue.
BP: 90/60 mmHg Sensation of fullness
HR: 120x/menit
RR : 58 x/menit Anorexia
T : 37,2
Height : 150 cm loss appetite
Weight : 41 kg.
decrease nutritional
intake

imbalance nutrition:
less than body
requirements
 NURSING CARE PLAN

NO NURSING AIM PLANNING

DIAGNOSIS INTERVENTION RATIONAL
1. Pain related to Dalam 1x24 1. Adjust the 1. Proper and
inflammation of jam, position that is comfortable position
gastric mucosa comfortable for client can decrease
for client. risk of pain.
layer.

2. Assess pain 2. To compare with

scale (0-10). previous pain scale to
prevent complication.

3. Assess the 3. Assist in making

aggravate nursing diagnosis and
factors and gives the right therapy
Kaji ulang
faktor yang
meningkatkan
atau
menurunkan
nyeri.

4. Gives little 4. Foods have acid

portion of neutralizing effects,
foods but and also can destroy
often. gastric content. Eat
with a little portion
can prevent gastrin
distentsion.
5. Teach the 5. It can make client feels
client better and forget the
distraction and pain for a while.
relaxation
technique.

6. Collaboration 6. Decrease acid gaster

with other with absorbtion or
health care chemical neutralizing.
staffs to give It is given in the night
right to decrease gastric
indication motility, suppress acid
medicine. For production, decelerate
example : process emptying
Antacid gastric, and relieve
nocturnal pain.
2. Deficit fluid 1. Take a note of 1. Help to differ gastric
volume related to vomit criteria. distress causes.
nausea. Yellow-greenish
gallblader contents
shows that pilorus is
opening. Fecal
contents shows
intestines obstruction.
Bright red blood
indicates that there is
arterial bleeding acute.

2. Look out for 2. Alteration in blood

vital signs. pressure and heart rate
can be used for
presupposition of
blood loss

3. Look out fot 3. Gives an orientation

input and for replacement fluids.
output fluid
volume.

4. Suggest the 4. Replace the loss fluids

client to drink and repair fluid
(adult: 40-60 imbalance
cc/kg/hour). immediately.

5. Collaboration 5. Strong fluid intake

with other will decrease risk of
health care dehydration.
staffs to give
client fluids
with proper
indication.
6. Cimetidine dan
6. Collaboration
ranitidine can prevent
with other
gastric acid secretion.
health care
staffs to give
client
cimitidine and
ranitidine
3. Imbalance 1. Give the client 1. Gastric dilatation can
nutrition: less than a little portion be happen if foods are
body requirements of foods and given too fast after
related to give a proper fasting period.
insufficient interest portion for
in food. snacks.
 2. Make a list for 2. Client can be more
available confident and feel she
menu and give has more power to
the client control her foods.
permition to
control the
choice of her
foods.

3. Consultation 3. Intake nutritions

with diet individual can be
specialist to calculated by different
methods.
plan about
calories and
nutrition
intake

1. Mengatur posisi yang nyaman bagi klien

2. Mengkaji keluhan nyeri: intensitas, karakteristik, lokasi, durasi, faktor
yang memperburuk dan meredakan
3. Mengawasi TTV
4. Mengkaji keluhan mual, muntah, sakit menelan
5. Mencatat kriteria muntah
6. Mengawasi keluaran dan masukan cairan
7. Menganjurkan pasien untuk minum (dewasa 40-60 cc/kg/jam)
8. Memberikan cairan sesuai indikasi
9. Memberikan makanan sedikit tapi sering, dan makanan kecil tambahan
yang tepat
10. Kolaborasi pemberian obat
11. Mengajarkan teknik relaksasi dan distraksi
12. Menganjurkan pasien untuk melakukan aktifitas sehari hari sesuai dengan
tingkat kemampuan pasien
13. Mengajarkan penkes tentang makanan yang dilarang untuk pasien
 IMPLEMENTASI
CATATAN IMPLEMENTASI DAN EVALUASI
NO TANGGAL JAM IMPLEMENTASI EVALUASI PARAF
1 26-04-2015 07.00- 1. Mengatur posisi S:-pasien mengatakan
06.59 yang nyaman bagi nyeri di ulu hati
WIB klien (posisi -pasien mengatakan ingin
semifowler) muntah
2. Mengkaji keluhan -pasien tidak memiliki
nyeri: intensitas, nafsu makan
karakteristik, lokasi, O : -pasien tampak
durasi, faktor yang meringis
memperburuk dan -pasien tampak lemah
meredakan -terlihat adanya bercak
3. Mengawasi TTV putih di lidah
4. Mengkaji keluhan -skala nyeri di ulu hati 5
mual, muntah, sakit (0-10)
menelan BP: 90/60 mmHg
5. Mencatat kriteria HR: 120x/menit
muntah RR : 28 x/menit
6. Mengawasi T : 37,2
keluaran dan Height : 150 cm
masukan cairan Weight : 41 kg
7. Menganjurkan A:masalah belum teratasi
pasien untuk minum
(dewasa 40-60 P:Intervensi dilanjutkan
cc/kg/jam) (1,2,3,4,5,6,7,8,9,10,11,12,
8. Memberikan cairan 14,15)
sesuai indikasi
9. Memberikan
makanan sedikit tapi
sering, dan makanan
kecil tambahan yang
tepat
10. Kolaborasi
pemberian obat
11. Mengajarkan teknik
relaksasi (nafas
dalam) dan
distraksi.

27-04-2015 07.00- 1. Mengatur posisi S:-pasien mengatakan

15.00 yang nyaman bagi tidak terlalu nyeri di ulu
WIB klien hati
2.Mengkaji keluhan - mual dan muntah sudah
nyeri: intensitas, berkurang
karakteristik, lokasi, -pasien mulai memiliki
durasi, faktor yang nafsu makan, makan habis
memperburuk dan porsi
meredakan -pasien mengatakan sudah
3. Mengawasi TTV dapat beraktifitas sendiri
 4. Mengkaji keluhan -Pasien memahami penkes
mual, muntah, sakit yang diberikan perawat
menelan O : -pasien terlihat lebih
5. Mencatat kriteria rileks
muntah -pasien masih tampak
6. Mengawasi keluaran lebih segar
dan masukan cairan -bercak putih di lidah
7. Menganjurkan pasien berkurang
untuk minum (dewasa -skala nyeri di ulu hati 2
40-60 cc/kg/jam) (0-10)
8. Memberikan cairan BP: 110/70 mmHg
sesuai indikasi 9. HR: 100x/menit
Memberikan bubur dan RR : 24 x/menit
sayur selagi hangat T : 36,7
10. Kolaborasi Height : 150 cm
pemberian obat Weight : 41 kg
A:masalah belum teratasi
11. Menganjurkan pasien
untuk melakukan aktifitas P:Intervensi dilanjutkan
sehari hari sesuai (1,2,3,4,5,6,7,8,9,10,11,12,
14,15)
dengan tingkat
kemampuan pasien

12. Mengajarkan penkes

tentang makanan yang
dilarang untuk pasien