ENGLISH III

ARRANGED BY:
WELI DASMULYANA
On Friday 12 April 2019 at 09.00 WIB.Tn.H had a motorcycle accident
because it was grazed by one of the motorbikes. Then Mr. H fell on his
stomach on his right and then his right leg was hit by asphalt because
the patient used his right leg as a pedestal. Then Mr. H was immediately
taken to the nearest hospital. After that, in the emergency room the
patient is immediately examined by the emergency room nurse and
after the examination is performed and given an action in the
emergency room, the patient is taken to the operating room. When the
assessment was carried out it was found that the patient had a tibia
fracture or broken bone in the right leg, and the patient appeared to
wince in pain. After the assessment and actions in the patient's room
are ordered to rest.
 A. Assessment

1. Patien Identity
Name : Tn. H
Age : 49 tahun
2. Identity of the person
Gender : Laki-laki responsible
Occupation: Swasta
Education : SD 3. Main Complain
Address : Jambi Pain in the lower rigt leg
Religion : Islam
Date of Entry :12 April 2019
No. RM : 147689
Medical diagnosis : Fraktur
tibia
4. Medical history now
The patient's family said that the patient had a broken bone
because the patient had a motorcycle accident on Saturday,
April 12, 2019 ,. Some time after the accident the patient is
taken to the hospital and given treatment only aids,
bandages and other measures. then the patient is taken to
the operating room to be given further treatment. The next
day the patient was given an x-ray examination, laboratory
and EKG (Electro Cardio Grafi).
at the time of the study which is the week of April 13, 2019
the patient said pain in his right leg. Pain arises when
moving, pain such as prickling, pain continues continuously
stops if the position is comfortable and not moving
5. Previous Medical History
6. Family Health History
7. Daily Patterns of Life
8. Physical examination
9. Laboratory examination results
 B. Diagnosis

1. Acute pain is related to agents that

cause physical injury,
2. Physical mobility constraints related to
damage n euromuskuler and
musculoskeletal
Data analysis
Date / hour Focus data Problem Etiology TTD

Sabtu 12 - DS: The patient said pain in his right leg, Acute pain physical injury
pain scale: 6
04-19 DO:
P : The right leg hurts when moving
Q : Pain like prickling
R : Right leg attaches to the knee
( 1/3 proximal right to the tibia bone )
S : Pain scale: 6
Q : Pain continues to stop when the
position is comfortable and not
moving .
The patient seemed to be in pain , the
patient's facial expression seemed tense

Sabtu 12 - DS: Barriers to Neuromuscular and

The patient said to be afraid to move and
04-19 physical musculoskeletal damage
pain in the right leg if moving and the
right leg could not be moved and pain if mobility
moving

DO : The patient looks bedrest , the

position of the leg elevation , the patient
looks weak , the patient looks afraid of
moving , In his activity the patient is
assisted by family and nurses
 Intervention
TTD
Date / No. Goals and Criteria Intervention Rational
Time Dx Results

Sabtu 1 After 3 × 24 hours 1. Teach and push for stress management 1. To know the
12 -04- of nursing action (relaxation, deep breathing, imagination, development of
19
is expected to therapeutic touch). the client's health.
reduce or 2. Set a safe and comfortable
disappear pain position. Maintain immobilization on the 2. Reduces pain and
with the following affected part. movement. Pain
criteria: 3. Collaboration with doctors in providing and spasm are
Pain scale 2-3. analgesics. controlled by
Relaxed and calm . immobilization.
facial expression
The patient looks 3. Treatment
relaxed. program to reduce
Assess the level of pain.
pain with
the PQRST standa
rd
Sabtu 2 After 3 × 24 hours 1. (Range of Motion) passive and active. 1. Elevation position
12 - of nursing action reduces edema.
04-19
is expected the
problem of 2. Help and encourage patients to carry out 2. Increase muscle
physical mobility treatment activities gradually. strength.
obstacles can be
overcome with 3. Mobilization
the expected 3. Give help in using the motion tool. reduces
results: complications.
The patient's
mobility ability 4. Minimizes pain and prevents wrong 4. Train the muscles
increases. position. and joints so as
The patient is not not to experience
afraid to move. contractures and
The patient is able complications.
to move
gradually.
The patient is able
to use aids.
 Implementation
Date / No Implementation Patient response TT D
time Dx

Sabtu 1 1.Teach and push for the 1. The patient performs stress
management of stress
12 - management by relaxing deep
(relaxation, deep
04-19 breathing, imagination, breathing
therapeutic touch).

2. takes a safe and 2. The patient has arranged a

comfortable comfortable position
position. Maintain
immobilization on the
affected part.

3. laboratory with a doctor 3. To reduce pain

in administering
analgesics.
Sabt 2 1. Help and encourage 1. To practice moving the affected
u 12 - the patient to part
04-19 perform
maintenance
activities gradually.
2.Providing assistance 2. To help
in using the move
motion tool.
3.Minimizes pain and
3. Adjust the position to reduce pain
prevents wrong
position.
 Evaluation
No Dx Evaluation
S: The patient says pain in his leg, still feels if to move but
1 decreases with deep breathing, P: Pain if to move Q: Pain
like prickling R: Pain in the fracture part S: Pain scale 6 T:
Pain continues to stop if comfortable position and and not
moving.
O: The patient appears to be in pain, facial expressions are
tense
A: The problem of acute pain has not been resolved
P: Continue intervention:

S: The patient said that he was afraid to move, the patient

2 said it was painful to move.
O: The patient looks bedrest, the patient is supine sleeping
with the elevation of the patient's right thigh on the pillow,
the patient looks scared and in pain when moving, the daily
activity needs of the patient are helped by the family and the
patient looks weak.
A: The problem of physical mobility obstacles has not been
overcome
P: Continue intervention: