STIKES RS.

BAPTIS KEDIRI
PRODI KEPERAWATAN PROGRAM SARJANA
ASUHAN KEPERAWATAN MEDIKAL BEDAH

STUDENT NAME : Febinda Dwi Arimbi

NIM : 01.2.16.00539

ROOM : IRJ

THE DATE : 12 Desember 2018

1. BIODATA :
Name : Tn. D No.Reg: 473966
Age : 47 Year
Gender : Male
Religian :Christiani
Address : Mojoroto-Kediri
Education : High School
Ocupation : Entrepreur
MRS Date : 12 December 2018
Assessment Date : 12 December 2018
Blood Group :-
Medical Diagnosis : Glaucoma

2. MAIN COMPLAINT
The patien said it felt blurred like there was dirt on the left eye felt since 1 week
ago

3. HISTORY OF DISEASE NOW

The patien said he came to the eye poly because the left eye blurred like ther
was dirt and pain with a pain scale 5 since 1 week ago. The diagnosed
Glaucoma

4. PAST DISEASE HISTORY

The patient said that he had never been hospitalized because of glaucoma
5. FAMILY HEALTH HISTORY
The patient said the family had no history of Glaucoma

6. SOCIAL AND SPIRITUAL PSYCHOLOGICAL HISTORY

The patient said he always worshiped all the time and always went to church

7. DAY-ACTIVITY PATTERN
(Eat, rest, sleep, elimination, activity, cleanliness and sexual)
Activity daily
No At home in the hospital
living
1 Meeting the Eating and drinking Eating and drinking
nutritional and Amount : Amount :
fluid needs Type: Type:
1) Rice: 1 (portion) 1) Rice: (portion)
2) Side dishes: there / no, 2) Side dishes: there /
Vegetable / Animal no,
3) Vegetables: Yes / no Vegetable / Animal
4) Drink: 6-7 glass / day 3) Vegetables: Yes / no
Abstinence: 4) Drink: cc / day
There is no Abstinence:
Eating / Drinking Eating / Drinking
Difficulties: Difficulties:
There is no Efforts to Overcome
Efforts to Overcome Difficulties:
Difficulties:
There is no

2 Elimination pattern BAK: 2 x / day BAK: x / day

Amount: 600 cc Amount: cc
BAB: 1 X/day BAB:
Consistency: Consistency:
Mushy Problems and how to
Problems and how to solve: solve:
There is no
3 Sleep rest patterns Day: 1 Hours Day:
Afternoon: - Hours Afternoon:
Night: 7 Hours Night:
Sleep Disorders: Sleep Disorders:
 There is no Use of sleeping pills:
Use of sleeping pills:
There is no
4 Personal Hygiene Bathing Frequency: 2 x / Bathing
(personal hygiene) day Frequency: ....... x /
Hair washing frequency: day
2x/week Hair washing
Toothbrushing frequency: frequency:
2x/day Toothbrushing
State of the nail: frequency:
short and clean nails State of the nail:
Change clothes : Change clothes :
2x/day
5 Other Activities Routine activities : Routine activities :
Work Activities undertaken
Activities undertaken at at leisure:
leisure:
Gathering with family

8. STATE / APPEARANCE / GENERAL IMPRESSION OF PATIENTS

The general state of the patient is weak, composmentist awareness, the patient
appears to be wearing sunglasses

9. VITAL SIGN
Body Temperatur :36,5 ºC
Pulse : 84 x/minute
Blood Pressure : 150/90 mmHg
Breathing : 20 x/minute
TT / TB : 72 Kg, 168 cm

10. PHYSICAL EXAMINATION

A. Head and Neck Examination :
Head: black hair, no dandruff, no lesions
Eyes: dazzled when exposed to the sun
Nose: no lesions are seen, no tenderness
Mouth: chapped lips, no stomatitis
Neck: no tenderness, no enlargement of the thyroid gland
B. Skin and Nail Integration Check:
Skin
Inspection: brown skin color, no lesions
Palpation: good skin turgor, no edema, no tenderness
Nail
Inspection: short and clean nails
Palpation: CRT <2 seconds

C. Breast and Underarm Examination (If needed):

Not reviewed

D. Chest / Thorax Examination :

Thorax Inspection:
The chest looks symmetrical, there are no chest deformities such as barrel
chest, funnel chest, pigeon chest and khyposcoliosis, no lumps /
enlargements, no lesions / lesions
Lungs:
Palpation: right and left chest retractions are the same, no enlargement /
lump, no tenderness
Percussion: sonor lung sounds at 12 percussion points
Auscultation: vesicular breath sounds

E. Heart Check:
Inspection: no visible enlargement / lump, no visible ictus cordis
Palpation: not palpable enlargement / swelling, no tenderness
Percussion: deaf heart sound
Auscultation: heart sounds S1 and S2 single lub-dup, no additional heart
sounds are heard

F. Abdomen Examination:
Inspection: no visible injuries / lesions, no visible enlargement / bump
Auscultation: bowel bissing 12 x / minute
Palpation: not palpable enlargement / lump, no tenderness
Percussion: sounds tympanic
G. Sex Check and surrounding area (if needed):
Genetalist : Not reviewed
Anus : Not reviewed
 H. Musculoskeletal examination:
MMT :
5 5
5 5

Information :
5: Can defy gravity and can lift no defense

H. Neurology Examination:
GCS:
Eye 4 : can open eyes spontaneously
Verbal 5: can speak well
Motor 6: can move following orders
J. Mental Status Check:
Appearance and behavior of patients: patients look neat, good behavior
Speak: clear, both with normal intonation
Mood: The patient says it is uncomfortable because the eyes are blurred and
painful
Cognition: awareness, orientation, attention, memory = good

11. Medical Support Examination:

Date:
No Inspection Results Norm Value Interpretation of
Results
Not reviewed

12. Implementation / Therapy:

Istonik 5mg/ml 2x1
Glikoseka 250mg 2x1 PO
13. Clients / Family expectations regarding the ailment:
Patients say they hope to get better soon and the eyes don't blur anymore

Kediri, 12 December 2018

Student Signature

( )

DATA ANALYSIS
PATIENT'S NAME : Tn. D
AGE : 47 Year
NO. REGISTER : 473566

SOFT DATA PROBLEM LIKELY CAUSES

OBJECTIVE DATA
SUBJECTIVE DATA
Ds: The patient said it felt Disease related disorders Discomfort
blurred, like there was dirt
in the left eye, felt since 1
week ago.

Do:- composmentis
awareness
- patients without wearing
sunglasses

Ds: The patient said the left Biological injury agency Acute pain
eye was aching like a
pricking with a pain scale
of 5 since 1 week ago.

Do: - general condition of

the patient is weak
- composmentis awareness

LIST OF NURSING DIAGNOSIS

PATIENT’S NAME : Tn. D
AGE : 47 Year
NO. REGISTER : 473566
NO DATE NURSING DIAGNOSES DATE SIGNATURE
APPEAR TERATASI
1. 12-12-2018 Disorders of comfort
associated with disorders
associated with the disease
are marked by the patient
said it felt blurred, like
there was dirt in the left
eye, felt since 1 week ago.
Composmentis awareness,
patients without wearing
sunglasses.

2. 12-12-2018 Acute pain is associated

with biological injury
agents that are
characterized by patients
saying the left eye was
aching like a pricking with
a pain scale of 5 since 1
week ago. General
condition of the patient is
weak, composmentis
awareness.

NURSING PLAN
PATIENT’S NAME : Tn. D
AGE : 47 Year
NO. REGISTER : 473566

Nursing diagnoses : Disorders associated with discomfort associated with

diseases

1. NOC: Convenience (Code 2008)

a. Support as needed Maintained / enhanced on 3
b. Treatment as needed Maintained / enhanced on 4
c. Maintained / enhanced on
d. Maintained / enhanced on
e. Maintained / enhanced on
f. Maintained / enhanced on
g. Maintained / enhanced on
h. Maintained / enhanced on
i. Maintained / enhanced on
j. Maintained / enhanced on
k. Maintained / enhanced on
2. NOC............................................................................................................ (Code...........)
a. ...................................................... Maintained / enhanced on ......................
b. ..................................................... Maintained / enhanced on ......................
c. ...................................................... Maintained / enhanced on ......................
d. ..................................................... Maintained / enhanced on ......................
e. ...................................................... Maintained / enhanced on .....................
f. ...................................................... Maintained / enhanced on ......................
g. ..................................................... Maintained / enhanced on ......................
h. ..................................................... Maintained / enhanced on ......................
i. ...................................................... Maintained / enhanced on .....................
j. ...................................................... Maintained / enhanced on ......................
k. ..................................................... Maintained / enhanced on .....................

NURSING PLAN

PATIENT’S NAME : Tn. D

AGE : 47 Year
NO. REGISTER : 473566

Nursing diagnoses : Acute pain associated with biological injury agents

1. NOC: Pain control (Code 1605)

a. Describe the causative factors Maintained / enhanced on 4
b. Recognize when pain occurs Maintained / enhanced on 4
c. Use precautions Maintained / enhanced on 4
 d. ..................................................... Maintained / enhanced on .....................
e. ...................................................... Maintained / enhanced on ......................
f. ...................................................... Maintained / enhanced on .....................
g. ..................................................... Maintained / enhanced on ......................
h. ..................................................... Maintained / enhanced on ......................
i. ...................................................... Maintained / enhanced on .....................
j. ...................................................... Maintained / enhanced on ......................
k. ..................................................... Maintained / enhanced on ......................
2. NOC: Pain level (Code)
a. Facial pain expression Maintained / enhanced on 4
b. Pain reported Maintained / enhanced on 4
c. ...................................................... Maintained / enhanced on ......................
d. ..................................................... Maintained / enhanced on ......................
e. ...................................................... Maintained / enhanced on ......................
f. ...................................................... Maintained / enhanced on ......................
g. ..................................................... Maintained / enhanced on ......................
h. ..................................................... Maintained / enhanced on ......................
i. ...................................................... Maintained / enhanced on ......................
j. ...................................................... Maintained / enhanced on ......................
k. ..................................................... Maintained / enhanced on ......................
 NURSING PLAN
PATIENT’S NAME : Tn. D
UMUR : 47 Year
NO.REGISTER : 473566

NO NURSING DIAGNOSES INTERVENTION RATIONAL

1.. Disorders of comfort associated with O: Measuring the degree of anxiety factors that - To find out the level of anxiety that is disturbing
disorders associated with the disease are cause anxiety levels of knowledge - In order to help patients in the psychological
marked by the patient said it felt blurred, like N: Give psychological support aspect, provide motivation to continue to carry out
there was dirt in the left eye, felt since 1 E: Provide education to control discomfort treatment
week ago. Composmentis awareness, C: Collaboration with doctors and other health - To help patients get rid of anxiety
patients without wearing sunglasses. teams for further action - To be given further therapy, both through medical
measures and drug administration

NURSING PLAN
PATIENT’S NAME : Tn. D
UMUR : 47 Year
NO.REGISTER : 473566

NO NURSING DIAGNOSES INTERVENTION RATIONAL

2. Acute pain is associated with biological O: Observe for pain which includes the location of - To find out the location, origin and severity of pain
injury agents that are characterized by the severity of the pain, and trigger factors - To help patients / families how to deal with
patients saying the left eye was aching like a N: Give information about pain such as the cause discomfort
pricking with a pain scale of 5 since 1 week of pain, the duration of pain will be felt and - To help patients control pain
ago. General condition of the patient is weak, anticipation of ineffectiveness - To get a way to control pain with non-
composmentis awareness. E: Teach the principles of pain management pharmacological techniques
C: Collaboration with patients / closest people and
other health teams to see and implement pain relief
measures with nonpharmacology as needed