STIKES RS.

BAPTIS KEDIRI
UNDERGRADUATE NURSING STUDY PROGRAM
SURGICAL MEDICAL NURSING CARE

STUDENT NAME : Millitio Christiantoro

NIM : 01.2.19.00697
ROOM :-
DATE : 07 Juli 2022

1. BIOGRAPHY :
Name : Ny. B. S No.Reg: 343477
Age : 40 years
Gender : Woman
Religion : Protestant Christianity
Address :-
Education : High School
Work : House Wife
Date MRS : 06 Juli 2022
Date of review : 07 Juli 2022
Blood type : No review
Medical diagnosis : Angina Pektoris

2. MAIN COMPLAINT
The patient complains of pain, pain appears when the patient is tilted right / left and at rest, the
pain in the left chest radiates to the back back, the pain scale 4 is moderate pain, the pain is felt
continuously.

3. CURRENT HISTORY OF THE DISEASE

The patient said that he was escorted by his nephew to the hospital on July 06, 2022 with
complaints Pain appeared when the patient tilted the right/left body and at rest, the pain spread
to the back of the back of the left chest spreading to the back of the back, scale 4 moderate pain
and the pain was felt continuously.

4. PAST HISTORY OF THE DISEASE

The patient's family said the patient had a history of heart disease, the patient routinely took the
drug but it had been 2 months since the patient had never been to the hospital.

5. FAMILY MEDICAL HISTORY

The patient said none of the family members suffered from infectious diseases, declining,
chronic as well as none in the family experienced similar diseases.

Genogram :

1
 = woman

= male

= marriage line
= line age

= dead

= stay at home

= patient

6. PSYCHOSOCIAL AND SPIRITUAL HISTORY

The patient said he realized that he was sick and was able to accept himself with the situation
the patient was suffering from at the moment and sought confidence for the healing process.
The patient also said that he was not comfortable at all in this kind of sick condition

7. DAILY ACTIVITY PATTERNS ( Eating, resting, sleeping, elimination, activities, hygiene and
sexual ).
Activity
No Daily Living Before illness After illness
(ADL)
1. Fulfillment of Eat/Drink Eat/Drink
Nutritional Amount : 3x/per day Amount: 3x/per day only a few
and Fluid Kind: mouthfuls of spoons
needs 1) Rice: white (portion) Kind:
2) Side dishes: any/no, 1) Rice: white(portion)
vegetable/animal 2) Side dishes: any/no,
3) Vegetable : presence / absence vegetable/animal
4) Drink : 1000cc/day 3) Vegetable : presence / absence
Restrictions: 4) Drink: 500cc/7 hours
Vegetable – vegetable and animal Restrictions:
vegetables Recommended food menu from the
Difficulty Eating/Drinking: hospital
No difficulties Difficulty Eating/Drinking:
Efforts to overcome difficulties: The patient eats only a few
No difficulties tablespoons of intake
Efforts to Overcome Difficulties:
Still feed even a few tablespoons
2. Elimination BAK : 5x/day BAK : 1x/day
pattern Amount : 1000cc Amount : 1500cc

CHAPTER : 1-2x/day CHAPTER :-

Consistency: Consistency:
It is yellow in color and smells -
characteristic of feces
Problems and how to solve them:
Problems and how to solve them: The patient has not had any bowel
No problem movements since entering the
hospital at all

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 Activity
No Daily Living Before illness After illness
(ADL)
3. sleep rest Noon : 3hrs Noon : 2 hours
patterns Afternoon : 2hrs Afternoon : 3 hours
Night : 4hrs Night : 6hrs
Sleep Disorders : Sleep Disorders :
No sleep disorders The patient has insomnia due to
Use of Sleeping Pills : perceived pain
Not using sleeping pills Use of Sleeping Pills :
The patient does not use sleeping
pills
4. Personal 1. Bath Frequency: 3x/day 1. Bath Frequency: 2x/day
Hygiene
2. Frequency of washing hair: once 2. Frequency of washing hair:
every 1 week Once every 1 week

3. Brushing frequency of teeth: 3x 3. Frequency of brushing teeth:

each bath 2x each bath

4. Nail State: Normal nails 4. Nail State:

Normal nails
5. Change clothes: 3x/day after every
shower 5. Change clothes:
2x/day after each shower
5. Other Routine activities: Routine activities:
Activities The patient performs his obligations Limited activity of patients who are
as a housewife only lying on the mattress

Activities carried out in free time: Activities carried out in free time:
The patient exercises and cleans the Watching tv and communicating
house with other patients

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8. THE PATIENT'S STATE/APPEARANCE/GENERAL IMPRESSION
The patient looks grimacing, uncomfortable, weak and complains of pain.

9. VITAL SIGNS
Body Temperature : 36.5ºC
Pulse : 63x/min
Blood Pressure: 100/60mmHg
Breathing : 20x/min
TT / TB : ……………………………Kg, …………….cm

10. PHYSICAL EXAMINATION

A. Head and Neck Examination
Inspect :- Even and unchanged hair spread
- No lesions
- No bumps
- No bleeding
- Size and cough
Palpation : - No Tenderness, No lumps
Neck:
Inspection: No visible enlargement of the lymph glands and thyroid gland
Palpation: No tenderness
B. Skin and Nail Integument Examination:
Skin:
Inspection: Skin color is ripe, ugly tugor like wrinkles
Palpation: Moist skin
Nail:
Inspection: Nails are short, clean and normal, crt <2seconds

C. Breast and Armpit Examination ( When necessary ):

No review

D. Chest/ThoracIc Examination
Thorax Inspection :
- Inspection: Rapid breathing, breathing frequency 20, development of the chest parallel,
symmetrical
- Palpation: Tactile fremitus (vibration) of the right and left gropings are the same
- Percussion: Sonor
- Auscultation: Sounds ronki (like the sound of hair friction)
- Polanafas: Regular rhythm, no reflex cough, non productive

E. Cardiac Examination :
- Inspection: Ictus cordis not seen on ics 5
- Palpation: Palpable ictus cordis 2cm from md clavicula sinistra
- Percussion: The sensitive sound of ICS 2 parasternum dextra (upper limit), ICS 3.4
marketternal (lower limit) – right heart. The sensitive sound of ICS 2 parasternum
sinistra (upper limit), ICS 6 – left heart (dilated heart)
- Auscultation: BJ 1 heard in ICS 5 sinistra and ICS 3 sinistra parasternum, Bj 2 heard in
ICS 2 both sinistra and dextra, voices 1-2 regular, weak

F. Abdominal Examination :
- Inpection: the right abdomen is equal to the left
- Auscultation: intestinal peristalsis 22x/min
- Palpation: palpable hepar
- Percussion: the sound of a tympani

G. Examination of the Genitals and surrounding areas (if needed):

Genetalis :- No study was carried out
Anus : - No study is carried out

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 H. Musculoskeletal Examination :
- Muscle spasms
- Vulvus, tissue damage
- Crepitation
- Disambiguation
- Muscle strength
5 5
5 5
Information:
- Patients are advised to bedrest
- ADL (eating/drinking, toileting, personal hygiene) assisted by nurses and families

I. Neurological Examination:
- Patient consciousness: composmentis
- GCS = E4, V5, M6
E4 = spontaneous eye-opening
V5= good orientation
M6= following commands

J. Mental Status Check :

The patient seems calm and cooperative when invited to communicate, orientation towards
people, places, and times is good.

11. Medical Support Examination

Date : 07 juli 2022
No Examination Result Normal Values Interplay Results
1 Darah rutin
- Hb 10.8 g/dL 12.0 – 16 Menurun
- Ht 33.8% 37.0 – 47.0 Menurun
- MCV 73.8 fl 81.0 – 96.0 Menurun
- MCH 23.6 pg 27.0 – 36.0 Menurun
- Lekosit 10.43 10ul 4.0 – 10.0 Meningkat
- Limfosit 3.75 103/ul 1.00 – 3.70 Meningkat
- Monosit 0.79 103/ul 0.00 – 0.70 Meningkat
Serologi
- Troponin I <0.10 ug/l <0.60 Normal
Kimia darah
- Glukosa sewaktu 102 mg/dL 70 – 150 Normal
- Kreatinin darah 0.58 mg/dL 0.6 – 1.1
Elektrolit Menurun
- Natrium darah 140 mmol/L 132 – 147
- Kalium darah 3.8 mmol/L 3.5 – 4.5
Normal
EKG Lead II III avF - Normal
(gelombang T
inversi) Iskemik inferior

12. Implementation / Therapi :

Ranitidine 2x50 mg/iv
- drugs used to deal with symptoms or diseases related to the production of excess acid in
the stomach. Excessive production of stomach acid can make trigger irritation and
inflammation of the walls of the stomach and gastrointestinal tract
Furosemide 1x20 mg/iv
- diuretic class drugs that are useful for removing excess fluid from the body through
urine. The drug is often used to cope with edema (accumulation of fluid in the body) or
hypertension (high blood pressure).
Simvastatin 1x10 mg/oral
- drugs to lower cholesterol levels in the blood. The drug is available in the form of tablets
with a simvastatin content of 10 mg and 20 mg. The use of simvastatin accompanied by a
low-cholesterol diet can prevent heart attacks and strokes.
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 Aspilet 1x80 mg/oral
- Medications to reduce fever, relieve headaches, toothaches and muscle pain belonging to
the nonsteroidal anti-inflammatory group or NSAIDs. In addition, aspilets are also used
to treat and prevent chest pain in heart attacks
Ramipril 1x2.5 mg/oral
- ACE inhibitor drugs that are beneficial for overcoming high blood pressure or
hypertension. The drug works by inhibiting hormones that convert angiotensin I into
angiotensin II. Angiotensin II is a substance that makes blood vessels narrow

13. Client/Family Expectations in relation to his illness :

The patient hopes to recover quickly and can perform his obligations again as a housewife

Kediri , ………………………
Student Signature,

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 DATA ANALYSIS

PATIENT NAME : Mrs. B. S

AGE : 40 Years Old
REGISTER NO. : 343477
OBJECTIVE DATA (DO) RELATED NURSING ISSUES
SUBJECTIVE DATA (DS) FACTORS/RISKS (E) (P)

DS: The patient said the pain in the Physiological injury agent Acute Pain (D.0077)
left chest radiated to the back of the (ischemia)
back. Q: pain appears when the
patient is tilted left/right and at rest.
Q: The pain radiates all the way to
the back of the back. R:the left chest
spreads to the back of the back. S:
pain scale 4, moderate pain. Q: the
pain is felt continuously
DO: - The patient seems to wince
S: 36.5ºC
P: 20x/min
N: 63x/min
TD: 100/60mmHg

DS: Patient says looking tired

DO: - The patient appears limp Imbalance between supply Activity intolerance
- Mounted O2 nasal canul 4 lpm and oxygen demand (D.0056)
- ADL assisted by nurses and
families
- ECG: Inverted T wave (inversion)
in leads II, III, avF

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 LIST OF NURSING DIAGNOSES

PATIENT NAME : Mrs. B. S

AGE : 40 Years Old
REGISTER NO. : 343477
NO DATE NURSING DIAGNOSIS DATE SIGNATURE
APPEAR (SDKI) RESOLVED
1 07 Juli 2022 Acute pain b/d physiological
injury agent (ischemia)

2 07 Juli 2022 Activity intolerance b/d

imbalance between supply and
oxygen demand

NURSING CARE PLAN

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PATIENT NAME : Mrs. B. S
AGE : 40 Years Old
REGISTER NO : 343477

NURSING DIAGNOSIS : Acute Pain

1. SIKI : Pain Levels
a. Pain Complaints Maintained/increased at 5(Decreased)
b. Grimace Maintained/increased at 5(Decreased)
c. Blood pressure Maintained/increased at 5(Improved)
d. Appetite Maintained/increased at 5(Improved)

2. SIKI : Pain Control

a. Ability to recognize the cause of pain Maintained/enhanced at5(Increased)
b. Ability to use non-pharmacological techniques Maintained/enhanced at 5(Increased)

3. SIKI : Physical mobility

a. Pain Maintained/increased at 5(Decreased)

Description: (retained/improved) cross out one of the

NURSING DIAGNOSIS : Activity Intolerance

1. SIKI : Activity Tolerance

a.Pulse frequency Maintained/increased at 5(Increased)
b.Oxygen saturation Maintained/increased at 4(SimplyIncreate)
c. Feeling of Weakness Maintained/enhanced at 4(Moderately Decreased)
d. Breath Frequency Maintained/increased at 5(Improved)

2. SIKI : Energy Conservation

a. Energy Conservation Techniques Maintained/improved at5(Increased)
b. Effective breathing techniques Maintained/improved at 5(Increased)

3. SIKI :
a. Restlessness Maintained/increased at 5(Decreased)

Description: (retained/improved) cross out one of the

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 NURSING CARE PLAN

PATIENT NAME : Mrs. B. S

AGE : 40 Years Old
REGISTER NO. : 343477

NO NURSING INTERVENTION RATIONAL

DIAGNOSIS (SIKI)
1 Acute pain b/d Pain Management (I.08238) Observation:
physiological injury Observation: 1. Identify / conduct an assessment of location, characteristics,
agent (ischemia) 1. Identify the location, characteristics, duration, frequency, quality, duration, frequency, quality. Pain intensity
intensity of pain 2. Identifying the influence of pain on the patient's quality of life
2. Identify the influence of pain on quality of life
Therapeutic: Therapeutic:
1. Control the environment that aggravates the pain (e.g. room temperature, 1. Controlling the patient's comfortable environment
lighting, noise)
Education:
Education: 1. Teach patients nonpharmacological techniques to reduce pain
1. Teach nonpharmacological techniques to reduce pain
Collaboration:
Collaboration: 1. Collaborating on analgesic administration
1. Collaboration of analgesic administration, if necessary

2 Activity intolerance Energy Management (I.05178) Observation:

b/d imbalance Observation: 1. Identify impaired body functions that cause fatigue in patients
between supply and 1. Identify impaired body functions that cause fatigue Therapeutic:
oxygen demand Therapeutic: 1. Provide a comfortable environment and low stimulus (e.g. light,
1. Provide a comfortable and low stimulus environment (e.g. light, sound, sound, visit)
visit) Education:
Education: 1. Encourage bed rest patients
1. Encourage bed rest Collaboration:
Collaboration: 1. Collaborate with a nutritionist on how to increase food intake
1. Collaboration with nutritionists on how to increase food intake.

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 NURSING ACTIONS

PATIENT NAME : Mrs. B. S

AGE : 40 Years Old
NO. REGISTER : 343477

NO NO.DX Date/Time NURSING ACTIONS SIGN

HAND
1 DX1 07 juli 2022 1. Conduct an assessment of location,
08.00 characteristics, duration, frequency,
quality. The intensity of pain in
patients
Result: P: pain appears when the
patient is tilted left/right and at rest
Q: The pain radiates to the back of
the back
R: the left chest spreads to the back
of the back
S: scale 4, moderate pain
Q: the pain is felt continuously

08.04 2. Identifying the influence of pain

on the patient's quality of life
Result: the look on the patient's
face looks grimacing and the
patient holds the sore area (left
chest)

08.20 3. Teach patients nonpharmacological

techniques to reduce pain
Result: the patient can follow the
nurse's instructions and can do it
properly and correctly 3 times

08.30 4. Controlling the comfortable

environment in the patient

08.45 5. Observing TTV

S: 36.5ºC
P: 20x/min
N: 63x/min
TD: 100/60mmHg

2 DX2 09.00 1. Identify impaired body functions

that cause fatigue in patients
Result: the patient says that if he
moves (left/right tilt) makes the
patient tired and short of breath
2. Provide a comfortable environment
and low stimulus (e.g. light, sound,
visit)
3. Encourage bed rest patients Result:
the patient says that at this time he
is difficult to rest, because the
patient still feels pain. When
moving to the ICCU room, the
patient only sleeps ± 4 hours
4. Collaborate with a nutritionist on
how to increase food intake
5. Observing TTV
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S: 36.5ºC
P: 20x/min
N: 63x/min
TD: 100/60mmHg

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 NURSING ACTIONS

PATIENT NAME : Mrs. B. S

AGE : 40 Years Old
NO. REGISTER : 343477

NO NO.DX Date/Time NURSING ACTIONS SIGN

HAND
1 DX1 08 juli 2022 1. Conduct an assessment of location,
08.05 characteristics, duration, frequency,
quality. The intensity of pain in
patients
Q: pain appears when the patient is
tilted left/right and at rest
Q: The pain radiates to the back of
the back
R: the left chest spreads to the back
of the back
S: scale 4, moderate pain
Q: the pain is felt continuously
Result: the patient says the pain is
reduced, the pain scale is 1, the
pain is mild

08.10 2. Identifying the influence of pain on

the patient's quality of life
Result: when the patient moves on
the left/right tilt, the patient still
feels pain, facial expressions wince

08.30 3. Teach patients nonpharmacological

techniques to reduce pain
Result: the patient performs a deep
breath technique, whenever the
patient feels pain
08.45 4. Controlling the comfortable
environment in the patient Result:
closing the curtains when patients
sleep and limiting visitors
09.00 5. Observing TTV
S: 35ºC
P: 18x/min
N: 82x/min
TD: 110/70mmHg

2 DX2 09.15 1. Identify impaired body functions

that cause fatigue in patients
Result: The patient says that he is
not tired
09.30 2. Provide a comfortable environment
and low stimulus (e.g. light, sound,
visit Result: the patient says that he
feels more relaxed after the
procedure
09.45 3. Encourage bed rest patients Result:
the patient can rest with calm.
When changing rooms, the patient
sleeps 8 hours at night
10.00 4. Collaborate with a nutritionist on
how to increase food intake Result:
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 the patient eats assisted by the
nurse, the patient spends the
portion of the meal provided and
drinks 250 cc of water
10.20 5. Observing TTV
S: 35ºC
P: 18x/min
N: 82x/min
TD: 110/70mmHg

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 PROGRESS NOTES
PATIENT NAME : Mrs. B. S
AGE : 40 Years Old
NO. REGISTER : 343477

NO NO.DX Time EVALUATION TTD

1 DX1 07 juli Acute pain b/d physiological injury agent
2022 (ischemia)

14.00 S:- the patient says that he still feels pain

pain scale 4 moderate pain

O:- The patient seems to wince

S: 36.5ºC
P: 20x/min
N: 63x/min
TD: 100/60mmHg

A: The problem has not been resolved

Q: Intervention resumed

2 DX2 07 juli Activity intolerance b/d imbalance between

2022 supply and oxygen demand

14.15 S: The patient says that he feels tired

O:- The patient appears weak

S: 36.5ºC
P: 20x/min
N: 63x/min
TD: 100/60mmHg

A: The problem has not been resolved

Q: Intervention resumed

PROGRESS NOTES
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PATIENT NAME : Mrs. B. S
AGE : 40 Years Old
NO. REGISTER : 343477

NO NO.DX Time EVALUATION TTD

1 DX1 08 juli Acute pain b/d physiological injury agent
2022 (ischemia)

14.15 S: the patient says that the pain is reduced, the

scale of 1 pain is mild

O: S: 35ºC
P: 18x/min
N: 82x/min
TD: 110/70mmHg

A: Partially resolved issue

Q: Intervention is maintained

Activity intolerance b/d imbalance between

2 DX2 08 juli supply and oxygen demand
2022

14.30 S: the patient says the fatigue begins to

disappear

O: S: 35ºC
P: 18x/min
N: 82x/min
TD: 110/70mmHg

A: Partially resolved issue

Q: Intervention is maintained

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