Data Social, Psychology And Economics1. Patient Can Interact With Either One Room To Friend, Family, And Nurse Or Other Health Workers2. Patient Say Receive a Condition That He Felt At This Time.3. Patient Using Health Insurance In The Form Of JamkesdaData SpiritualPatient Say Always Pray To Allah And Submit Or Surrender To Allah. Including Her Pain Related Disease, as well as consider her illness as a trial

Supporting Investigation Date of inspection : 4 January 20141) Hemoglobin Normal : ( 12 14 ) g% = 11,22) Total of white blood cells : ( 5.000 10.000 ) mm3= 6.0003) Segment : ( 50 70 ) %= 724) Lymphoycyte : ( 20 40 ) %= 205) Monocytes : ( 2 8 ) %= 86) Platelet = 231.0007) Hematokrit : ( 37 43 ) %= 34Date of inspection : 5 January 2014HbsAg: Non ReaktifHIV: Non Reaktif

Blood ChemistryTypeResultUnitNormal Limits

SGOT28UIP < 25 / W < 31

SGPT38UIP < 4 / W < 32

Alkali Phospatase101UI74 311

Gama GT79UIP < 38 / W < 25

Total Bilirubin0,7Mg/dl0, 1 , 0

Direct Bilirubin0,2Mg/dl0, 0, 5

Indirect Bilirubin0,5Mg/dl0 0,75

Total Protein7,7Mg/dl6,6 8,7

Albumin3,8g/dl3,2 4,5

Globulin3,9g/dl2,3 3,5

Cholesterol134Mg/dl150 220

Trigiserida109Mg/dl< 200

HDL Cholesterol36Mg/dlP > 35 / W > 45

LDL Cholesterol76Mg/dl< 190

Creatinin0,5Mg/dl0,5 1,5

Ureum20Mg/dl18

Management / Therapy / DietTherapi : RL + Tramadol 1 Amp15 TpmRanitidine2 x 1IVDietBDL

Data FocusA. Data Subjektif1) Patient Say Pain Heartburn, Scale Pain 6, Pulse 78 x/m2) Patient Say Nausea, Dizziness, Loss Of Appetite3) Patient Say it is difficult to sleep, because of the heat and the atmosphere of the rooms were noisyB. Data Objectif1) There is a epigastric tenderness, scale pain 62) Patient only spend servings of food at Hospital3) Patient only sleep 2 3 hours / day, there are eye poke, drums konjungtifa anemic. Blood pressure : 100 / 60 Mmhg4) Seen patient vomit when finishedData AnalysisNoGrouping DataProblemCauses

1.Ds : Patient Say Pain at the epigastric with pain scale is 6Do : there tenderness in epigastric with pain scale is 6 and pulse : 78PainAgent Injury

2.Ds : Patient say nausea, dizziness, no appetiteDo : Patient only spends a quarter of eating in hospitalNutrition less than body requirementsLess intake

3.Ds : Patient say difficult to sleep because of the heat and the atmosphere noisier Do : Patient only sleep 2 3 hours per day there are poke under the eyes conjungtival pallorDisruption of sleep patternsAmbient temperature and noise

Diagnose Nurse1. Pain Acute associated with agent injury marked by patient say pain heartburn, pain scale 6 there is pain press in epigastric. Pulse 78 x/m 2. Deficient nutrition than the body needs associated with less intake of food symptoms by said patient said patient nausea, dizziness, patient say no appetite only spend portion of food in the hospital.3. Trouble Of patterns sleep associated with room temperature and noisy by patient say wakeful, because hot and noisy, atmosphere, patient only sleep 2 3 hours everyday, under the eyes conjungtiva unanemis, blood pressure : 100/60 Mmhg.

Intervention NurseDate /HoursDiagnose NursePourposeIntervention

6 / 1 / 20143 pmPain Acute associated with agent injuryAfter the act of nursing for 2 x 24 hours. expected outcomes with reduced pain : 1. Patient is able to control pain2. Pain can be receive by pain scale 2.3. Patient say comfortable. Feeling after pain is reduced4. Report that pain is reduced by using pain management1. Perform a comprehensive pain assessment, including location, characteristics, duration, frequency, quality factor and precipitation.2. Observation of non verbal reactions of discomfort3. Teach non pharmacological techniques ( deep breathing )4. Give analgesics to reduce pain5. Evaluation of the effectiveness of pain control6. Collaboration with doctor if there is a complaint and the action was not successful pain

6 / 1 / 20144 pm Deficient nutrition than the body needs associated with less intake of food symptomsAfter the act of nursing for 2 x 24 expected nutrient can be resolved with outcomes :1. An increase in body weight in accordancing with purpose.2. Able to identify nutritional needs3. No signs of mal nutrition4. There is no significant weight loss1. Assess for food allergies2. Make sure to eat a diet containing high fiber to prevent constipation3. Provide information about nutritional needs4. Assess patient ability to obtain needed nutrients

6 / 1 / 20145 pmTrouble Of patterns sleep associated with room temperature and noisyAfter nursing care for 1x24 hours, expected trouble of sleep patterns can be resolved with outcomes :1. Patient can be a normal sleep 6 8 hours / day2. Diminish eye poke3. Conjungtiva back pink.4. Face look and fresh feeling while sleeping.

1. Observation of vital sign 2. Create a calm and comfortable environment3. Provide as comfortable a position as possible4. Next time patient minimum number of hours of sleep 6 8 hours / day

ImplementationNoDate / HoursActionEvaluation

1. 7 / 1 / 20148 am1.1 Comprehensively Acsess Pain1.2 Observing Nonverbal reactions of discomfort1.3 Teaches non pharmacological techniques, deep breathing1.5 Evaluating the effectiveness of pain control2.1 Assess for food allergies2.2 Convincing diet hight in fibercontaining meal to prevent constipation2.3 Proding information about the needed nutrition2.4 Assess the patient ability to obtain needed nutrition3.1 Monitor the signs and symptoms of constipationDS: client say pain in heartburn as a puncture puncture,the pain scale 6DO: there tenderness epigastric, paim scale 6, pulse 78 x/mDs : patient say pain in heartburn as in puncture, with scale 6Do : patient looks agitated and grimaceDs : patient say schoolDo : patient looks follow the instructions of nurse and nodDs : patient say reduced pain scale 4Do : Patient looks calm. Pain scaleDs : patient say can not eat acidic food and drinking teaDo : -Ds : patient say schoolDo : Patient nodDs : Patient say schoolDo : Patient looks nodDs : Patient say buy papaya to increase the nutritionalDo : -Ds : Patient say he can not defecate defecation only one time during in patient at the hospital.Do : Patient looks nervous hand stools and brown.Ds : -Do : Bowel 10 x/mDs : Patient Say only slept in the room during the illness, always in aid of her husbandDo : patient seen lying

8 / 1 / 201411 am

12 am3.3 monitor stool : the frequency and volume consistency3.4 provide dulkolax

4.1 observed vital signDS: Patient say not defecateDO: Patient fidgeledDS: Patient say will soon be in useDO: Patient are seen in the auxiliary nurses use dulkolax

DS: patient say dizzinessDO: Blood pressure :100/70 mmHg. Respiratory : 20 x/I. pulse : 85 x/i. temperature ; 36,2 C

12 am3.5 reviewing the minimum number of hours of sleep patient 6 8 hours every day 3.2 creating a quiet environment reduces the number of visitorsDs : patient say no noisier room anymoreDo : Patient looks relaxed

3.3 provide right sim position to sleepDs : Patient say cozyDo : Patient looks relaxed