Nursing Care

On Mr. A with Disorders Of The Digestive System

Ileus Obstruction
In III-A Room RSUD dr. Soekardjo Tasikmalaya

1. Assessment
A. Data Collection
1) Patient Identity
Name : Mr. A
Age : 27 years old
Gender : Male
Marital status : Married
Education : SMA
Occupation : The mechanic
Religion : Islam
Address : Nagrak, Lengkongjaya, Cigalontang
No Medrek : 16470846
Date of entry : 14 December 2017
Date of review : 15 December 2017 at 09.00 a.m
Medical diagnosis : Ileus Obstruction + Post-Op LE + Colostomy
Identity Of The Person In Charge
Name : Mrs. R
Age : 25 years old
Gender : Female
Marital status : Married
Education : SMA
Occupation : Housewife
2) History of The Disease
a. Main complaint
The patient complained of surgical pain in the abdomen
b. Current medical history
At the time of assessment on December 15, 20117 at 09.00 a.m, the patient
complained of surgical pain in the abdomen. The pain feels like being stabbed and
burning. The pain is felt in the stitch area in the abdomen with pain scale 3 of
indicator 0-5. The pain will increase as the body is moved, and will decrease when
the body is rested.
c. Previous Medical History
The patient said he had experienced intestinal cramps, bloody, and had been treated
in Jasa Kartini Hospital for 2 days, and then the patient refer to RSUD dr.
Soekardjo.
d. Family Health History
The patients say there is no family member who has the same disease with the
patient.
e. Genogram
f. Activity Of Daily Living
No Activity Of Daily Living Before After
1. Nutrition
 a. Weight 55 kg 45 kg
b. Height 165 cm 165 cm
c. Ability
-chew Good Disturbed
-swallows Good Disturbed
-total / partial assistance Nothing NGT
d. Frequency 3x/days 3x/days
e. Meal portion 1 portion ½ portion
f. Foods that cause allergies Nothing Nothing
g. Favorite food
nothing nothing
2. Fluid
a. Intake
-oral
-type Water Water
-Quantity 1500 cc/days 800 cc/days
-total / partial assistance Nothing NGT
-intravenous Nothing Ringer laktat
-Quantity Nothing 500 ml
b. Ouput
-type urine Urine
-Quantity 300 cc 400 cc
3 Elimination
a. BAB 1x/days -
-frequency 3-6x/days 5-6x/days
b. BAK
-frequency
4 Sleep and rest
-Frequency 7 hours 5-6 hours
-Complaint - -
-sleep disorder - -
5 Personal hygiene
a. Take a bath
-frequency 2x/day -
-total / partial assistance - -
b. brush your teeth 2x/day 1x/day
c. hair washing 1x/week -
d. nail clipper 1x/week -
e. change dress 2x/day 2x/day
6 Activity
a. physical mobilization Normal Disturbed
b. Sports - -
c. recreation - -

h. Psychological Aspects
 The patient looks lying limp and always inquire about his illness. He was grateful
because his wife always accompanied him. The patient say want to go home and get
together with his family
i. Social Aspect
The patients can adapt and socialize with their environment. Relationship with a
nurse is very good , the patient always follow the treatment. Many relatives of his
family who visited him.
j. Spiritual Aspect
The patients and families adhere to the religion of Islam. The patients always pray
for healing disease.
k. Physical Examination
1) General Status
Cnsciousness: composmentis, Eye 4, Motorik 6, Verbal 5, GCS 15
Blood pressure : 120/90 mmHg
Pulse : 98x/minute
Respiration rate : 24x/minute
Temperature : 36,4
2) The Senses System
a. Eye
Inspection : shape of the eyes is symmetrical, conjunctiva pale, sclera
anikterik, the pupil isokor and respond to light.
b. Nose
Inspection : the shape of the nose is symmetrical, the nasal mucosa moist,
discharge (-). NGT (+)
Palpation : Tenderness (-), lump (-), tumor (-)
c. Mouth
Inspection : the shape of the mouth is symmetrical, a full set of teeth, false
teeth (-), the mucosa of the lip dry, stomatitis (-), cyanosis (-)
palpation : tenderness (-), lump (-), tumor (-)
d. Ear
Inspection : the shape of the ear is symmetrical, cerumen (-), hearing loss (-)
lesions (-)
palpation tenderness (-), tumor (-)
3) Cardiovascular System
Inspection : lymph node enlargement (-), increased JVP (-),
Palpation : the pulse frequency 98x/min, Capilary refill time < 2 seconds
Auscultation : blood Pressure 120/90 mmHg, heart sounds S1-S2 (normal)
4) Respiratory System
Inspection : the shape of the nose is normal, chest is symmetrical, chest
retraction (+)
Palpation : respiration rate 24x/minute.
Percussion : sonor in both the field of lung
Asukultasi : breath sounds vesicular, rocnhi (-). wheezing (-)
5) Digestive System
Inspection : shape of abdomen convex, there is a colostomy in the abdomen
right and left, the wound operation (+)
auscultation : bowelsounds 2x/minute
percussion : tympanic sound
 Palpation : pain of the operation wound, abdominal distension
6) endocrine system
Inspection : movement of the neck free not limited to, changes in hair color (-),
polyuria (-), polydipsia (-), temperature of 36.4
palpation : increased JVP (-), enlargement of the thyroid gland (-)
7) Integument System
Inspection : skin color white, edema (-), lesion (+)
Palpation : temperature of 36.4, bump (+), skin turgor good
8) Musculoskeletal System
ekstermitas top : muscle strength left/right : 4/4, range of motion (+), cramps ( -
) pain (-), muscle spasm (-)
ekstermitas under : muscle strength a child/left 3/3, range of motion (+), cramps
(+), tenderness (-), muscle spasm (-)
9) Nervous system
Headache (+), seizure (-), nasalah memory (-), the function of vision, hearing,
tasting, smell better, function of sensory pain (+)
l. Diagnostic Examination
No. Lab : LAB20171472186
Date : 15 December 2017
No. Register : RI20160600715
No. RM : 16470846
Result of laboratory examination :
Checking type Results Normal Value Unit method
Hematology
Hemoglobin 10,0 F: 12-16, M: 14-18 g/dl Auto analyzer
Hematokrit 31 F: 36-45, M: 46-50 % Auto analyzer
Leukosit 8.800 Adult: 5000-10.000 /mm3 Auto analyzer
Child: 7.000-17.000
Trombosit 290.00 250.000-350.000 /mm3 Auto analyzer
Liver/Heart
Protein Total 4,33 6,6-8,3 g/dl Biuret Colorimetric
Albumin 2,52 3,5-5,0 g/dl BCO colorimetric
Globulin 1,81 g/dl
Elektrolit I≤E
Natrium 134 135-145 mmol/L I≤E
Kalium 3,6 3,5-5,5 mmol/L I≤E
Kalsium 1,23 1,10-1,40 mmol/L

m. Therapy
Ringer Laktat 20tpm
Ceftriaxone 2x1 gr
Metro Infuse 3x500 gr
Rantin 2x1 amp
Ketorolat 2x1 amp
Metoclopramid 2x1 amp
B. Analisa Data
No Symptom Etiologi Problem
1 DS : Ileus Obstruvtion Acute pain
the patient complained of surgical
pain in the abdomen. The pain feels surgical procedure
like being stabbed and burning. LE + colostomy
DO:
pain scale 3 of indicator 0-5. Physical injury
agent
(Post-Op LE +
Colostomy)
2 DS: Ileus Obstruction Imbalanced
the patient said no appetite nutrition: less than
the body feels limp abdominal body
DO : distention requirements
attached NGT
dysfunction
motilitas bowel

anorexia

3 DS: invasive action High risk of

The client complains of pain in the infection
postoperative wound section, (surgery) There is
DO: postoperative
There is a postoperative wound on
the client's abdomen wound High risk of
infection

2. Nursing Diagnosis
I. Pain associated with surgical wound
II. Nutrition imbalances are less than necessarily related to nutritional absorption disorders
III. High risk of infection associated with invasive surgery

3. Nursing Intervention
Diagnosis Goals and results criteria Intervention

1 NOC: NIC:
• Pain Level, 1. Perform a comprehensive pain
• pain control, assessment including location,
• comfort level Once characteristics, duration,
done tinfakan nursing for frequency, quality and
... Patients do not precipitation factors
experience pain, with the 2. Observe nonverbal reactions from
outcome criteria: discomfort
 1. Able to control pain 3. Help patients and families to find
(know the cause of and find support
pain, able to use non- 4. Environmental controls that can
pharmacology affect pain such as room
techniques to reduce temperature, lighting and noise
pain, seek help) 5. Reduce the pain precipitation
2. Reporting that pain factor
is reduced by using 6. Assess the type and source of pain
pain management to determine intervention
3. Be able to recognize 7. Teach about non-pharmacology
pain (scale, intensity, techniques: inhalation, relaxation,
frequency and pain distraction, warm / cold compress
sign) 8. Give analgesics to reduce pain:
4. Declare a sense of 9. Increase rest
comfort after the pain 10. Provide information about pain-
is reduced like causes of pain, how long the
5. Vital signs within the pain will be reduced and anticipate
normal range the discomfort of the procedure
6. No sleep disturbance 11. Monitor vital signs before and
after first analgesic
2 NOC NIC
• Nutritional status: food 1. Weigh BB every day
and fluid intake 2. Assess intake and fluid output
• Nutritional status: 3. Assess skin turgor
nutrient intake 4. Assess for food allergies
• Weight control 5. Assess the amount of nutrients
Results criteria: and calorie content
1. The increase of BB 6. Instruct patient to increase Fe
in accordance with intake
the purpose 7. Make sure the diet is high in
2. Ideal BB in fiber to prevent constipation
accordance with TB 8. Give the selected food
3. Be able to identify
nutritional needs
4. No signs of
malnutrition
5. Indicates improved
taste function of
swallowing
6. There is no
significant BB
decrease

3 NOC: NIC:
• Immune Status 1. Maintain an acceptive technique
• Knowledge: Infection 2. Limit the visitor if necessary
control 3. Wash hands every before and after
 • Risk control the action of nursing
After the action is done 4. Use clothes, gloves as a protective
nursing for ...... device
patients do not 5. Replace the location of IV
experience peripheral and dressing in
infection with criteria accordance with general
result: instructions
1. Client is free from 6. Use intermittent catheter for
signs and symptoms reduce urinary bladder infection
of infection 7. Increase nutrition intake
2. Demonstrate ability 8. Give therapy
to prevent incidence antibiotics:.................................
infection 9. Monitor signs and symptoms of
3. Number of systemic and local infection
leukocytes within 10. Maintain isolation techniques k / p
normal limits 11. Inspection of skin and mucous
4. Demonstrate healthy membranes
life behavior 12. against redness, heat, drainage
5. Immune status, 13. Monitor any injuries
gastrointestinal, 14. Encourage fluid input
genitourinary within 15. Push the break
normal limits 16. Teach patient and family signs and
symptoms of infection
17. Assess body temperature in
neutropenia patients every 4 hours

4. Implementaton of nursing
Diagnosis Time Implementation Results Response
Initials
1 08.30 1. Assess the scale of O: pain scale 2 of
pain indicator (0-5)

2. Assessing TTV T: 120/80 mmhg

P: 86 x / min
R: 24x / min
S: 36.40c

09.30 3. Advise deep - the client is able to

breathing apply deep breath
relaxation
techniques

10.00 4. Provide injection - drugs are injected

therapy to the client
 2 11.00 1. observe the 1. the client seems
nutritional status of being switched
clients lying limp

11.15 2. encourage clients 2. clients seem to

to eat and drink understand and
adequately want to apply it

11.20 3. auskultasi bowel 3. bowel sounds

sounds are not heard

3 13.30 1. doing wound care to the 1. client post operation

client wound replaced
bandages and clients
say feel more
comfortable

2. observe the state of the 2. no signs of infection

client's wound of the client's wound

5. Evaluation
Diagnosis Time Development notes Initials
1 09.15 S: clients say pain in postoperative wound in
abdomen
O: general circumstances of composmentis, the
client seems sick moderately, installed a 20 tpm
futrolit infusion, there appears postoperative
wound in the client's abdomen
A: acute pain
P: Continue the intervention
I:
 examine the scale of pain
 advise to do deep breathing relaxation
techniques
 advise to rest a lot
E: the problem is not resolved
R: continue the intervention

2 11.15 S: clients complain of no appetite

O: the general state of moderate pain, the client
seems to lie limp.
A: nutrition is less than requirement
P: Continue the intervention
 I:
 monitor the nutritional status
 recommend eating and drinking a little
but often
E: the problem is not resolved
R: continue the intervention

3 13.30 S: -
O: There is postoperative wound on the client's
abdomen, no signs of infection of the client's
wound
A: high risk of infection
P: Continue the intervention