in the public hospital on Purwokerto, Especially Mawar room there

are two patients. First patients name is Ms.W she is stay in room 2. she
has passed apendictomy yesterday. And than second patients name is Mr.
R. he is stay in room 4. Last week he came to hospital her blood glucose
level is high.
07.00 am . on mawar room as always held a meeting morning.
Nurse who night shift tell to morning shift nurse about the patient
condition.
Head ward

: good morning. As usual, every morning we hold meeting

morning. Before it, please one of you report the result of
little ceremony.

Primary nurse

: Oke thanks for this time. I will report the result of

little ceremony. Director of this hospital said later there is a
blood transfer on the hall of hospital. The blood transfer will
be held at 09.00 12.00. so if you can transfer your blood
please you join it. Thanks for your attention.

Head ward

: Oke thanks for your information. Please the night shift tell to
us about the patients condition.

Night shift

: now, I will report the patients condition. In room 2 there is

one patient. The patients name is Ms. W. yesterday she has
passed Laparatomy. Please you nurse M and Nurse R check
her condition to know about her feel. And than in room 4
there is Mr R. last night her blood glucose level is high about
220.this morning please you nurse F and nurse B check her
blood glucose again. And the result please you consult to
doctor H. I think enough from me. Thankyou

Head ward

: Thanks for your report. I hope the day we can do the best
care to our patients. to start our activities today, lets pray
together for our success.

After they pray together they start their activities. Nurse M and nurse
R come to room 2 to perform the assessment. And than nurse F and nurse
B come to room 4 to perform the assessment.
Room 2

Nurse F

: Good morning Ms. W.. how are you today?

Ms. R

: I am not fine. Because I feel pain in my stomach. Especially

in post surgery stitches.

Nurse B

: Let me see the wound

Nurse F

: I see the wound is clean, but the dressing is not dry. if I

give you the pain scale 1 until 10, how much your pain scale
?

Ms. R

: I think my pain scale is 4

Nurse B

: Beside that, What do you feel now ?

Ms. R

: I feel nausea, it make me not interest to eat everything.

Nurse B

: do you eat the food from the hospital? How many spoon you
eat the food?

Mr. R

: I just eat 3 spoon.

Nurse F

: what about your defecation and urination?

Mr. R

Nurse F

: why arent you defecation yet?

Mr. R

: Because I am afraid my stitches will be damaged

Nurse B

: Yes mis I know your feel, all of patient like you they are
afraid to defecation.

Nurse F

: could you sleep last night miss?

Mr.R

: I can sleep last night

Nurse F

: oke thanks for your attention, and 20 minutes ago I will

come here to help you decrease your problem.

Mr. R

: Youre welcome

two days I am not defecation yet.

routine.

But

I am urination

Symptom
DS : Patient said she
feel pain on her
stomach
P : Post
appendictomy
Q : like a pin
R : on her lower
stomach
S : pain scale is 4
T : sometimes pain
DS :
DO; The dressing is
wet
DS : Patient said she
feel nausea
DO :
DS : Patient said two
days she dont
defecation yet.
DO :
DS :

Problem
Acute pain

Etiology
Physical injury agent

Infection risk

Invasive procedures

Nausea

Situational : Pain

Constipation

Abdominal muscle
weakness

Intervention
1. Accute pain related to physical injury agent
NOC : Pain control
NIC 1 : Pain Management
- Assess pain comprehensively
- Teach non- Pharmacological techniques that breath deeply,
relaxatiom, and warm compresses
- Monitor Vital Signs
- Give a comfortable environment
NIC 2 : give analgetik
-

Give an analgetik to decrease pain

2.

Infection risk related to invasive procedures

NOC : Risk Control
NIC 1 : Infection Control
- Wash hands when before and after do nursing care
- Wash hands using antiseptic coir
NIC 2 : Infection Protection
-

Monitor symptom of infection

Maintain aseptic technique in the treatment of the wound

NIC 3 : Drug management

-

Given antibiotic therapy if necessary

3. Nausea related to situation : pain

NOC : Comfort Level
NIC 1 : Fluid Management
- Monitor nutrition status
- Suggest to eat slowly
- Give an instruction to drink 1 hour before, 1 hour after, and
during eat.
NIC 2 : Drug management
- Manage the provision of anti-emetic
4. Constipation related to abdominal muscle weakness
NOC : Bowl Elimination
NIC 1 : constipation management
- Identify factors that cause constipation
- Explain to the patients the benefits of a diet (fluid and dietary
fiber) to elimination
- Collaboration with nutritionists about a diet high fluid and fiber.

Implementation
Acute pain
Nurse f contact to doctor D to consult about Ms. R condition. And nurse B
consult with nutritionist about diet to ms.R.
Nurse F : excuse me, The patient in room 2 said feel pain, and nausea.
Doctor

: what have you do to her?

Nurse F
: I will come to her, I will give breath deeply to decrease her
pain. What drug will be given to her?
Doctor
: given her An analgetik to decrease her pain, and given anti
emetic to decrease her nausea.
Nurse F : when she can go home?
Doctor
: today she cant go home yet because she still feel pain and
how is state of the incision?
Nurse F
bandages.

: The state of the incision is wet, now I will change her

Doctor

: Please you give antibiotic to prevent the infection.

Nurse F

: yes sir, I will do it.

Conversation between nurse B and nutritionist

Nurse B

: excuse me miss, Ms. R cant defecation 2 days yet.

Nutritionist : oke thanks for your information we will give food high fluid
and fiber to help her easier to defecation
Nurse B

: youre welcome

Nurse B
After nurse F consult with the doctor and nurse B consult with nutritionist
they come to Ms. R

Nurse F
: Good morning miss, I come here again to help you miss to
decrease your pain. Should do you feel pain now?
Ms. R

: Yes now I feel pain,

Nurse B
: dont worry miss, we will help you to decrease your pain. By
the way before you come to hospital what do you do if you feel pain ?
Ms. R
: Ussually, if I feel pain I push the part of body is pain. But
now I am afraid to do it, because this stitches is still wet.
Nurse F
: yes right miss, you dont do it, now I will help you to
decrease the pain. You can breath deeply inhale from nose and then
exhale from mouth. Try it miss..
Ms. R try to breath deeply. After that..
Nurse B
Ms. R

: how do you feel after breath deeply ?

: I feel the pain is decrease. Thanks nurse..

Nurse B
: if you feel pain again, you can try that procedure. You
can imagining the condition that make you feel happy.
Ms. R

: yes nurse, I can do it.

Nurse B
: this is medicine to decrease the pain. This medicine
can be eaten after you eat and if you feel pain.
Ms. R

: yes nurse, thank you.

Nurse B
: ok.. now we will come back to my room. If you need
me, you can call me in my room. Fifteen minutes again we will come back
to change your dressing.