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    Nursing Care (Bing 1)

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    Shafira Chusna
    Patient Y, a 42-year-old housewife, presented with abdominal pain and a lump in her lower abdomen. She was diagnosed with myoma uteri and planned for surgery. On examination, she had abdominal tenderness and a lump was palpated. Laboratory results were normal except for elevated blood glucose. Nursing diagnoses included acute pain from the myoma mass and risk of nutritional imbalance due to low intake. Nursing interventions focused on pain management through positioning and deep breathing. Nutrition was addressed by providing small, frequent meals and encouraging soft foods.

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    Nursing Care (Bing 1)

    Uploaded by

    Shafira Chusna
    213 views6 pages
    Patient Y, a 42-year-old housewife, presented with abdominal pain and a lump in her lower abdomen. She was diagnosed with myoma uteri and planned for surgery. On examination, she had abdominal tenderness and a lump was palpated. Laboratory results were normal except for elevated blood glucose. Nursing diagnoses included acute pain from the myoma mass and risk of nutritional imbalance due to low intake. Nursing interventions focused on pain management through positioning and deep breathing. Nutrition was addressed by providing small, frequent meals and encouraging soft foods.

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    Patient Y, a 42-year-old housewife, presented with abdominal pain and a lump in her lower abdomen. She was diagnosed with myoma uteri and planned for surgery. On examination, she had abdominal tenderness and a lump was palpated. Laboratory results were normal except for elevated blood glucose. Nursing diagnoses included acute pain from the myoma mass and risk of nutritional imbalance due to low intake. Nursing interventions focused on pain management through positioning and deep breathing. Nutrition was addressed by providing small, frequent meals and encouraging soft foods.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    213 views6 pages

    Nursing Care (Bing 1)

    Uploaded by

    Shafira Chusna
    Patient Y, a 42-year-old housewife, presented with abdominal pain and a lump in her lower abdomen. She was diagnosed with myoma uteri and planned for surgery. On examination, she had abdominal tenderness and a lump was palpated. Laboratory results were normal except for elevated blood glucose. Nursing diagnoses included acute pain from the myoma mass and risk of nutritional imbalance due to low intake. Nursing interventions focused on pain management through positioning and deep breathing. Nutrition was addressed by providing small, frequent meals and encouraging soft foods.

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    Nursing Care

    Patient Y with a Diagnosis of Myoma Uterine


    In the Ayyub I ward Muhammadiyah Hospital Semarang

    A. Assessment
    Assessment date : April 25, 2019
    1. Client Identity
    Name : Mrs. Y
    Age : 42 years old
    Address : West Udowo
    Occupation : Housewife
    Religon : Islam
    Medical Dx : Myoma Uteri
    2. Identity of Person in Charge
    Name : Mr. A
    Address : West Udowo
    Relationship : Husband
    B. Medical History
    1. Current Medical History
    On April 24, 2019 at 17:00 patients complained of abdominal pain and felt a lump in
    the lower abdomen so the family was taken to the hospital and now treated in Ayyub
    1's ward and planning an operation on April 26, 2019 at 16.00
    2. Past Medical History
    The client said that for about 1 year she felt sick and knew that she had myoma but
    was afraid of surgery and she was take a medicine pain only
    3. Family Health History
    The client said his family has never experienced an illness like this
    C. Main Complaints
    The patient said abdominal pain disappeared in the lower right quadrant
    D. History of Obstetrics and Gynecology
    1. Menstrual History
     Menarche: 14th
     Menstrual cycle: 28 days
     Long period: 4-5 days
    2. Marriage History
    The patient is married once at the age of 23 with her husband
    3. History of Reproductive Disorders
    The patient has had a myoma since 2018 and when having sexual intercourse his
    stomach feels painful
    E. Physical examination
    1. General situation: weak
    2. Awareness: Composmentis
    3. Nutritional status
    a. Weight: 90kg
    b. Height: 155cm
    c. BMI: 37.5 (obese)
    4. Vital sign
    a. Blood pressure: 140/83 mmHg
    b. Pulse: 75 x / min
    c. Temperature: 37.50C
    d. Respiratory rate: 24 x / min
    e. GCS: 15
    5. Abdomen
    Inspection : asymmetrical shape, noticeable abdominal distension and ascites
    Auscultation : intestinal peristalsis are heard
    Percussion : tympanic voice in the left abdomen, faint sound in the right abdomen
    Palpation : palpable soft tenderness in the lower right quadrant, felt a slight lump
    at the bottom
    6. Genetalia
    Look clean, evenly distributed genetalia hair
    7. Extremities
    Above: infused RL 20 drops per minute, complete limbs can be moved properly, no
    edema
    Below: complete limbs can be moved, no edema and varicose veins
    F. Supporting Data
    April 24, 2019 normal
    1. Hemoglobin : 13.9 g / dL 11.7-15.5
    2. Blood glucose : 160 75-140
    3. HbsAg : negative negative <0.13 positive> 0.13
    G. Data Clasification
    Focus Data Problem Etiology
    DS: The client said that the Acute pain Myoma Uteri
    pain in the right side of the
    abdomen
    P: Pain comes suddenly
    Q: squeezed and hot
    R: right abdomen
    S: 5
    T: missing arise
    DO: Clients hold pain
    TD: 140/83 mmHg
    N: 75 x / min
    S: 37.50C
    RR: 24x / min
    GCS: 15
    Abdominal examination:
    tympanic voice in the left
    abdomen, faint sound in the
    right abdomen asymmetrical
    shape, noticeable distension
    of the abdomen and ascites,
    palpable abdominal
    palpitations there is
    tenderness in the lower right
    quadrant, there is a slight
    lump in the lower part
    DS: The patient said the The risk of nutritional intake is inadequate
    appetite was reduced, only imbalance is less than the
    3-4 spoonfuls in the body's needs
    hospital, feeling nauseous
    DO: Clients appear weak
    Nutritional status :
    Weight: 90kg
    Height: 155cm
    Body Mass Index: 37.5
    (obesity)

    H. Nursing Diagnoses
    1. Acute pain associated with insisting myoma mass
    2. The risk of nutritional imbalance is less than the body's needs related to inadequate
    intake
    I. Nursing Intervention
    Dx Objectives and Outcome Criteria Intervention
    1. After performing the procedure 3x24 hours the 1. Review the location of
    patient is expected to no longer feel pain with the pain, characteristics,
    Criteria Results: duration and scale
    1. The patient says pain is reduced 2. Assess TTV
    2. Facial expressions appear relaxed 3. Adjust the position as
    3. Patients take natural breath independently comfortable as possible
    4. Teach
    nonpharmacological
    pain management (deep
    breathing)
    5. Explain the cause of
    pain experienced by the
    patient
    6. Collaborative analgesic
    giving
    2. After 3x24 hours of nursing action is expected the 1. Observation of nausea,
    patient's nutrition is sufficient with the Criteria vomiting
    Results: 2. Give small but frequent
    1. Increased appetite meals
    2. The patient does not vomit 3. Give the patient favorite
    foods, and give while
    warm
    4. Encourage the patient to
    eat soft foods

    J. Implementation & Evalution


    Date Dx Implementation Evaluation
    25/4/2019 1 1. reviewing TTV S: The patient said he felt
    20.15 2. review the location of comfortable, the patient
    pain, characteristics, said pain was a result of the
    20.20 duration and scale swelling due to myoma
    20.30 3. adjust the position as O: face still tense withstand
    comfortable as pain, the patient looks able
    21.00 possible to practice deep breathing
    4. teach TD: 140 / 83mmHg
    nonpharmacological N: 75x / minute
    pain management RR: 24x / minute
    (deep breathing) A: the problem has not been
    5. explain the causes of resolved
    pain experienced by P: monitor vital sign
    patients
    6. Collaborating analytic
    giving
    25/4/2019 2 1. Observing nausea, S: The patient said the
    20.20 vomiting appetite was reduced by
    20.25 2. Give small but only 3-4 tablespoons in the
    frequent meals hospital and still felt
    3. Give the patient a nauseous
    favorite food, and give O: general situation is still
    while warm weak
    4. Encourage patients to A: the problem has not been
    eat soft foods resolved
    P: observation nausea, feed
    small portions but

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