TUGAS BAHASA INGGRIS

NURSING ASSESSMENT OF PEPTIC ULCER

Dosen Pembimbing : Asrin, MN

WAHYU ANDIKA

P1337420217024

3A

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN SEMARANG
PRODI DIII KEPERAWATAN PURWOKERTO
2019

Nursing Assessment of Peptic Ulcer

1. History of Disease
a. Past history
The patient said that he had experienced peptic ulcer pain.
b. Current history
Clients come to the hospital with complaints of feeling pain in the abdomen,
heartburn and nausea and vomiting.
The patient says that pain arises moments / hours after eating or when hungry or
while sleeping at midnight. Nature of complaint (periodic / sudden).
c. Family history
Infectious or hereditary disease in the family: The client's mother suffers from an
ulcer.

2. Physical Assesment

a. General situation
General appearance : The client looks neat
Clients appear healthy / sick / seriously ill : sick
Awareness : conscious
GCS : E4V5M6
BB : 50 kg
TB : 165 cm
b. Vital sign
TD : 120/80 mmHg
ND : 80x / minute
RR : 20 x / minute
S : 370C
c. Skin
Skin color (cyanosis, jaundice, pale) : Pale
Humidity : dry
Skin turgor : good
Presence / absence of edema : no edema
d. Eye
Vision function : Good
Palpebra : Open / closed
 Pupil size : Normal
Conjunctiva : Anemis
Sklera : Anikterik
Lens / iris : Normal
Palpebra edema: No edema
e. Mouth and throat
Mucous membrane : Dry
Oral hygiene : Good
Tooth condition : Good.
Inflammatory signs (lips, gums, tongue) : none
Trismus : Difficulty
Swallowing : None
f. Abdomen
Inspection : sympathetic abdominal shape or not,
Palpation : presence / absence of tenderness, lumps
Percussion : liver limit, kidney limit, lien limit, presence / absence of stomach fluid
accumulation (bloating).
Auscultation : bowel sounds, venous noise, liver friction and spleen

3. Diagnosis Evaluation
Endoscopy

4. Laboratory Study

a. Physical examination may reveal pain, epigastric pain, and abdominal tenderness.
b. Noisy bowel may be absent.
c. Examination with barium of the upper GI tract can indicate ulcers, but endoscopy is
the diagnostic test of choice.
d. Upper endoscopy is used to identify inflammatory changes, ulcers and lesions.
Through endoscopy the mucosa can be directly seen and biopsy obtained.
Endoscopy has been known to detect some lesions that are not visible through X-ray
examination because of their size or location.
e. Stool can be taken every day until the laboratory report is negative for faint blood.
f. Gastric secretory examination is a decisive value in diagnosing aclorhidria (there is
no hydrochloric acid in gastric sap) and zollinger-ellison syndrome. Pain that is
lost with food or antacids and the absence of pain that arises also identifies the
presence of ulcers.
g. The presence of H. pylori can be found with biopsy and histiology through culture,
although this is a special laboratory test. And serological tests for antibodies to H.
Pyloriantigens.