NURSING CARE PLAN

HEMATEMESIS

Lecturer : M.Nur Hasan, MNS

Compiled by :

Desma Anggraini (181608)

Nabila Murti Ananda (181622)
Niken Sari Widyaningrum (181624)
Pradita Diyan Pertiwi (181629)

POLITEKNIK KESEHATAN KARYA HUSADA YOGYAKARTA

Jl. Tentara Rakyat Mataram No. 11 B Yogyakarta

2018/2019
 NURSING CARE PLAN FORM

Student Name : Date : 7 November 2019

Patient Identifier : Tn.X (37 years old) Patient Medical Diagnosis : Hematemesis

No. Assesment Nursing Goals And Nursing Implementation Evaluation

Data Diagnosis Outcome Intervention

Subjective : Acute Pain After taking Pain At 8 am : S:

patients say related to nursing actions Management : -I did reviewed The patient said the
chest pain Biological for 2x24 hours - I Will do a compre pain in his chest was
often Injuries the level of pain compre hensive pain reduced
Objective : Agents with the expected hensive pain
The patient result : assessment. At 8.15 am : O :
seemed to 1. long episode of -I will find out - I did found out - Patients rarely grin
grin with pain (disappears) with patients with patients because pain is
pain, 2. Holding the the factors that the factors that reduced
The patient pain area can reduce can reduce - The patient is not
seemed to (reduced) pain. pain. hlding his chest
hold his chest 3. repoeted pain -I will teach the
(reduced) principles of At 10 am : A:
Diagnosis : pain -I did taught the The problem is
Acute Pain management. principles of partially resolved.
related to -I will pain
Biological collaboration management P:
Injuries with patient, Continue Intervention
Agents as and the health At 12 am :
evidenced by team to choose - I did
(AEB) and take non- collaborated
frequent chest pharmacolog with patient,
pain and grin ical pain and the health
while holding reduction team to choose
 the chest measures. and take non-
pharmacolog
ical pain
reduction
measures.

2. Subjective: Fluid volume after 2X24 hours Fluid At 9 am S:

The patient deficient of nursing action Management: - I did monitored the patient says
says vomiting related to the deficit in fluid - I will Maintain the patient's nausea, and feels weak
six times , Fluid loss volume returns to an accurate vital signs
and two times through an normal, with the intake or 10:15 O:
vomiting abnormal following criteria: record output - Idid patients look pale, dry
blood. route 1. blood (patient) maintained an lip mucosa
pressure - I will monitor accurate intake
Objective : ( not hydration or record A:
- Patients disturbed ) status (for output (patient) The problem is
appear limp 2. radial pulse example, moist partially resolved
,pale ,dry lip ( not mucous At 10:20 am
mucosa. disturbed ) membranes, - I did monitored P:
- BP : 90/70 3. skin turgor adequate pulse hydration Continue intervention
mmHg ( not rate, and status (for - Monitor
- Temperature disturbed ) orthostatic example, moist nutritional
: 38,5 C 4. mucous blood pressure) mucous status
- RR : 20 x/ membrane - I will monitor membranes, - monitor
minute moisture patient ttv adequate heart hydration status
- Pulse : ( not - Iwill support rate, and (for example,
70x/minute disturbed ) the patient and orthostatic moist mucous
5. balance of family to assist blood pressure) membranes,
intake and in the proper At 12 am adequate heart
output within feeding - I did monitored rate, and
 Diagnosis : 24 hours - I will offer nutritional orthostatic
Fluid (not light meals status blood pressure)
volume disturbed ) - I will monitor
deficient nutritional
related to status
Fluid loss
through an
abnormal
route as
evidenced
by (AEB)
Vomiting
six times
and appear
limp ,pale
,dry lip
mucosa.
BP : 90/70
mmHg
Temperature
: 38,5 C
RR : 20 x/
minute
Pulse :
70x/minute

3. Subjective: Nutritional After taking Nutrition At 8 am S

The patient imbalance nursing actions Management - I did - The patient said
said no grave related to for 2x24 hours - I will determined that he did not feel
lust because Psychosocial the Nutrition determine the the patien’s vomiting
he wanted to disorders Status with the patien’s nutritional - The patient said
vomit route expected results : nutritional status and there was already
1. Nutrional status and ability an appetite
Objective : Intake ( Not ability (patient) (patient) to O
Pale mucous deviated from to meet meet - The patient does
membranes normal ) nutritional nutritional not seem limp
2. Food Supply needs needs - The patient does
Diagnosis : ( Not deviated - I will not look pale
Nutritional from normal ) Identification At 8.30 am A
imbalance 3. Fluid Intake (presentce of) - I did Identify - The problem is
related to ( Not deviated allergies or (presence of) partially resolved
Psychosocial from normal ) food tolerance allergies or P
disorders 4. Hydration of the patient food Continue intervention
route as ( Not deviated - I will Instruct intolerances
evidenced by from normal ) patient about of the patient
(AEB) no nutritional
appetite and needs At 9 am
Pale mucous - I will Assist - I did
membranes the patient in Instructed
determining patients about
the fod nutritional
guidelines or needs
pyramid that is
most sitable At 9.30
for meeting - I did Assisted
nutritional and patients in
preference determining
requirements the most
- I will Give suitable fod
food choices or pyramid
while guidelines to
 offeringguidan meet
ce on healthy nutritional
food choices,if requirements
needed and
- I will Help the preferences
patient open requirements
food
packaging,cut At 10 am
food and eat,if - I did
needed Provided
- I will Monitor food choices
calori and food while
intake offering
- I will Monitor guidance on
the tendency healthy food
for weight loss choices, if
and increase necessary
- I will Instruct
patient to At 10.30 am
monitor calorie I did Helped
and food patients
intake (eg open food
eating diary) packages,
- Encourage cut food and
(doing) how to eat, if
prepare food necessary
(safely) and
food prevation At 11 am
techniques - I did
Give direction Monitored
calorie and
 food intake

At 11.30 am
- I did
Monitored
the
tendency for
weight loss
and increase

At 12 am
- I did
Instructed
the patient
to monitor
calorie and
food intake
(e eating
diary)

At 12.30 pm
- I did
Encourage
d (doing)
how to
prepare
food
(safely)
and food
prevention
techniques
 At 13 pm
- I did gave
direction
4. Subjective : Hyperthermia After taking Faver At 8 am : S:
The patient related to nursing actions treatment - I did - Patient said his
says the body Disease for 2x24 hours 1. I will Monitor monitored body was
is hot process the the temperature relaxed and his
thermoregulation temperature and other head had
Objective : expected result : and other vital vital signs desreased
- The patient 1. Sweating signs At 9 am :
looks when it’s hot 2. I will - I did O:
nervous ( not administer the administered - The pasient
- BP : 90/70 disturbed) patient a the patient a seem calm
mmHg 2. Hyperthermia blanket or light blanket or - Temperature
- Temperature (noting ) clothing, light clothing, 37,6 C
: 38,5 C 3. Discoloration depending on depending on
- RR : 20 x/ of the skin ( the faver phase the faver A:
minute noting ) 3. I will phase The problem is
- Pulse : 4. Dehydration Administer IV At 10 am : partially resolved.
70x/minute ( noting ) drug or fluids - I did P:
for example ( Administered Continue
Diagnosis : antipyretics, IV drug or intervention
Hyperthermia antibacterial fluids for
related to agents and example (
Disease antichills antipyretics,
process as agents. antibacterial
evidenced by 4. I will report agents and
(AEB) body moisture of the antichills
feels hot and lips and dry agents.
fidgety mucosa At 10.30 am
BP : 90/70 - I did
mmHg reported
Temperature : moisture of
38,5 C the lips and
RR : 20 x/ dry mucosa
minute At 11.30 am
Pulse : - I did
70x/minute consulted
with doctor
about the
condition
patient