TUGAS 3

Nama : Ardaninggar K.R.N.A.W.

NIM : 01.2.17.00594

1. Buat Ringkasan Personal data dari percakapan tersebut

Jawaban : The patient is Mrs.S, she is 54 years old, her religion Moslem, she live
at Kyai Doko Street, Ngasem-Kediri, she is a house-wife, she is married and her
husband is Mr.B. His mobile number is 085234167751. She don’t remember her
blood group. Her family has no offspring and infectious disease. Sometimes, they
suffer from coughing, gastritis, and hyperthermia. She have one sister and two
brothers. She have one daughter and two sons. She live with her husband, her
mother and her youngest son. She can interact well with them and they are
recognized by each other. In her spiritual aspect she usually pray five times a day.
In her activity daily living, she said that every day, she ate three meals /
day with side dishes such as tofu, tempeh,fried chicken and soup. Sometimes, she
take snacks at 10 am and 5 pm. She take three glasses of water / day. And than,
she defecated 6-7 times / day and defecated once / day. When urinating, she felt a
sharp pain in her lower abdomen and her urine was yellowish. But, about
defecating she has no problem, to overcome this problem. During this time to
overcome it only by resting and taking analgesics like mefenamic acid that she
bought at the drugstore. Usually, she take a nap / rest for about two hours. She
spend about seven to eight hours sleeping. Sometimes, she only has five hours to
sleep. Usually, she take a shower twice a day. And than, she wash her hair 3 times
a week. she always brush her teeth twice a day. Usually, she brush her teeth when
she take a shower. She always change clothes after bathing. The routine activities,
she do are cooking, preparing breakfast, and eating caring for her husband and
children, because she is a housewife so she do routine activities. Sometimes she
join activities in her neighborhood. When she has free time, she always watch
television and gather with her family. On weekends she always visit close family
and some famous destinations in Kediri such as Gumul Paradise Island torelax
after work.
 And then the Ns. Anli do a procedure of examination and get results:
She haven’t an abnormality or enlargement on her head. But she have a
little grey hair and look pallid. Her hair easy to fall and she have smooth
hair and no bulges pathologic. She have symmetrical eyes and good blink
reflexes. She have pink conjunctiva and white sclera,her pupil reflex positive.
Then, she haven’t intraocular pressure on eyes and no tenderness.
She have symmetrical nose. No inflammation or secret and no
abnormalities.She also haven’t tenderness or masses on nose. She have
symmetrical auricle. She have clean ears and there’s no lession. Then, no
response to pain, and the cartilage elasticity. There is a cavity; she have white
teeth, and no plaque. She haven’t masses or tumor, swelling and pain on mouth.
Her trachea midline, no lympadenopathy, thyroid. No response to pain when
the neck flexion and extension. No masses or tumor, swelling and pain. When
swallow no masses or enlargement on neck. She haven’t enlargement and there
is chest breathing and abdomen breathing. Her movement lung is normal. In
her chest examination, she hasn’t enlargement and lesion. There is
intercostals retraction and abdomen breathing. The movement lungs are normal.
Sound of percussion is resonant, no sound of added breath, breathing is
regular with frequency is 20 times/minute.The pulse frequency is 80 times /
minute and there is no enlargement. The sound of percussion sounds tympanic,
There is a single sound S1 and S2. There is no additional noise there is tenderness
in the lower abdomen area, examining your stomach, did not find the presence of
surgery, the stomach looks tense. There is no mass or tumor, but it has stomach
complaints, when the stomach is pressed. percussion in the stomach there is a
percussion sound is tympani. There was bowel sounds 7 times / minute.

2. Buat Ringkasan Chief complain yang terdiri PQRST dari percakapan

tersebut.

Jawaban : The patient says she’s got pain since three days ago. It is on her
lower abdomen. She feel sharp pain. She feel pain four times in a day. The
pain can be worse when the abdomen was pressed and when she go to the
bathroom. The pain feel when take a rest.
 3. Buat Tabel Analisis Data (PES - Actual data) dan buat ringkasan tentang
masalah keperawatan dari percakapan tersebut.

Date Symptoms Etiology Problem

22/03/ Objective data : Urinary tract Acute pain
2020 - When urinating, I infection
feel sharp pain in my
lower abdomen and
my urine is yellowish
- Pulse: 80x / minute
- Breath: 20x / minute

Subjective data : The

patient says she’s got
pain since three days
ago. It is on her lower
abdomen. She feel
sharp pain. She feel
pain four times in a
day. The pain can be
worse when the
abdomen was pressed
and when she go to the
bathroom. The pain
feel when take a rest.

Data summary :

On 21 March 2020 subjective data of patients were found to be ill. Hurts like a
sharp object. The location of pain in the lower abdomen, the patient feels pain
four times a day. The pain can be worse when the stomach is pressed and when
she go to the bathroom. And better when resting. Equipped with objective data
that arises during urination, she feel sharp pain in the lower abdomen and her
urine is yellowish caused by the entry of bacteria into the urinary tract through the
urinary hole which can be taken as a diagnosis of acute pain nursing. Patients do
not experience enlargement and lesions. There are intercostals abdominal
retraction and breathing. Normal lung movement. Percussion sounds are
resonance, no additional breath sounds, regular breathing with a frequency of 20
times / minute. The pulse frequency is 80 times / minute and there is no
enlargement. The sound of percussion sounds tympanic, there is a single sound S1
and S2. There is no additional noise there is tenderness in the lower abdomen
area, examining your stomach, did not find the presence of surgery, the stomach
looks tense. There is no mass or tumor, but it has stomach complaints, when the
stomach is pressed. Percussion in the stomach there is a percussion sound is
tympani. There was bowel sounds 7 times / minute.

4. Buat diagnosa keperawatan aktual dari percakapan tersebut.

a. Acute pain related with urinary tract infection