Asuhan Keperawatan pada Pasien dengan Low Back Pain di Rumah Sakit Umum Daerah dr. Zainoel Abidin Banda Aceh

Abstract

This case study aimed to provide nursing care for Mrs. AN with low back pain in the Mina 2 Ward at dr. Zainoel Abidin Regional General Hospital in Banda Aceh. Data collection in this case study was conducted through observation, head-to-toe physical examination, and interviews with the patient and family members. Nursing care was implemented from August 7–13, 2025. The patient experienced intermittent lower back pain lasting approximately 15 minutes with a pain scale of 5 (Numeric Rating Scale/NRS), a history of falling from a motorcycle one year earlier, decreased muscle strength with a grade of 3, reduced range of motion, capillary refill time (CRT) >2 seconds, hemoglobin level of 7.6 g/dL, dependence in activities of daily living (ADL), and a geriatric fall risk score of 3. Interventions were implemented for five days and included William’s Flexion Exercise (WFE), Range of Motion (ROM) exercises, 15° leg elevation exercises, collaboration in administering Packed Red Cell (PRC) transfusion, assistance with Activities of Daily Living (ADL), self-care support, education on fall risk prevention, and collaboration in medication administration. The evaluation results showed that one problem was resolved (the risk of falls). In contrast, four problems were partially resolved, as indicated by a pain scale reduction to 3 (NRS), an increased hemoglobin level to 10.8 g/dL, improved muscle strength to grade 4, and ADL performed with family assistance. Recommendations include routinely performing William’s Flexion Exercises to reduce pain and ROM exercises to improve range of motion and muscle strength.