N

O
1

Nursing Diagnosis

Nursing Goals

Nursing Intervention

Acute pain related After doing the nursing

to

the

physical care,

injury agents

client

comfort

level increase with the

comprehensively about the

criteria :

pain include the Provocative,

Client reporting

that the pain was

been decrease

calm& could have

a rest.
Vital sign in a

120/80 mmHg, P :

to handle the pain.

Colaboration with the doctor

to

with

procedures.

the

Free from the

infection

symptom
The
leukosit
number is in a
normal limit (4-

11.000)
Vital sign in a
normal limits.

analgetic

to

Observation the symptom of

systemic and local infection

Preserve the environment with
the aseptic technic during the

decreased imunity, criteria :

an

post cares, theres no risk of

wound, infection

give

decrease the pain.

Risk of infection After doing the nursing

invasive

past experiences of pain.

Give the restful environment.
Educate the client about the
( relaxation, distraction, etc)

20x/minutes.)

operative

teurapeutic

normal limit ( BP :

R : 16-

to

uncomfortable.
Use
the

the

nonpharmacologi

60-100x/minutes.

related

of

comunication to knowing the

from 5 to 2.
Face expression

Quality, Region, Scale, Time.

Observation the nonverbal
responses

decrease
Pain scale has

Interviewing

installation of the equipment.

Do the wound care, Dressing
the infuse and also the DC

everyday.
Increase the nutrition intake and

the adequate fluid.

Teach the client family and or
the client about the symptom of
an infection and reported if the
infection happened.

Colaboration with the doctor to

give an antibiotic accordingly
to the programs

IV. Nursing Care Plan

V. IMPLEMENTATION AND EVALUATION

Nursing
Diagnosi

Date

Implementation

Evaluation

s
18/11/2016
08.00 am

02.00 pm
-

Do assement pain to the

S : Patient said the pain like

a punctured

patient
Check the vital of signs

patient
Teach of the technique

relaxation to thre patient

Give ketorolac inj

10.00 am

10.30 am
11.30 am

30mg/iv

O : Scale of pain 5, T : 36,7

0

C, R : 18x/m, P : 82x/m,

BP : 110/80 mmHg
A : Acute pain resolved in
part

Mona

P : continue intervention
Mona

18/11/16
08.30 am

02.00 pm
-

Do dressing iv line and

S:O : area around insertion, iv

urinary catheter
Assess the sign and

symptom of infection
Give ceftriaxone inj

10.00 am
11.00 am
2

line and urinary catheter

have no sign of infection
T : 36,7 0C, R : 18x/m, P :

1g/iv
Ovi

82x/m, BP : 110/80 mmHg

A : the problem is solved
P :continue intervention
Ovi

19/10/16
10.00 am
10.30 am

Pukul 02.00pm
-

Check the vital of signs

S : patient say the pain is

patient
Encourage patient to do

reduced

O : Scale of pain 3, T : 36,7

11.30 am
-

deep breathing relaxation

technique
Give ketorolac inj

BP : 110/70 mmHg

C, R : 18x/m, P : 78x/m,

A : Acute pain resolved in

30mg/iv

part
Tiara

P : continue intervention
Tiara

19/11/16
08.30 am

02.00 pm
-

Do dressing iv line and

S:O : area around insertion, iv

urinary catheter
Do the wound care with

aseptic technicque
Assess the sign and

symptom of infection
Give ceftriaxone inj

10.00 am
11.00 am

line and urinary catheter

have no sign of infection

1g/iv

T : 36,6 0C, R : 18x/m, P :

78x/m, BP : 110/70 mmHg
A : the problem is solved

Sufi

P :continue intervention
Sufi

20/11/16
10.00 am
10.30 am

02.00pm
-

Check the vital of signs

S : patient say the pain is

patient
Encourage patient to do

reduced

deep breathing relaxation

1
11.30 am

technique
Give ketorolac inj

O : Scale of pain 2, T : 36,5

0

C, R : 18x/m, P : 88x/m,

BP : 110/80 mmHg
A : Acute pain is solved

30mg/iv
Ilham

P : stop intervention
Ilham

20/11/16
08.30 am
10.00 am

02.00 pm
-

Do the wound care with

S:-

aseptic technicque
Assess the sign and

O : area around insertion, iv

symptom of infection
Give ceftriaxone inj

1g/iv
Teach patient to do

11.00 am

preventive infection after

line and urinary catheter

have no sign of infection
T : 36,5 0C, R : 18x/m, P :
88x/m, BP : 110/70 mmHg
A : the problem is solved

treatment

P :continue intervention
Sufi

Sufi