Data Analysis

Data
DS :
-

Masalah
Impaired skin integrity

Etiologi
Side effects

Clients complain skin feels

chemotherapy

dry

treatment

of

Clients say reddish spots

on the hands and feet and
itchy

Clients say hair loss

DO :
-

Dry Skin palpable

There are red spots on the

hands and feet

Mucosa lips client looked

dry

Client graying hair and hair

spread unevenly

DS :
-

Changes
The client complained of
pain when swallowing food

The

client

distractions
and

says
while

drinking

no
eating

like

there

canker sores in the mouth

and tongue
-

The client says it can not

distinguish the taste of food

DO :
-

There

stomatitis

on

the

mouth and tongue

-

The client looked in pain

while eating and drinking

Looks white patches in the

mouth and tongue

membrane

in

the

oral

mucous

Side

effects

chemotherapy
treatment

of

DS :

Nausea
-

Side

Clients say feel sick

effects

of

chemotherapy
treatment

Clients say the sour taste in

the mouth

DO :
-

Clients are more often seen

spitting

Increased

sensation

of

swallowing
-

Bowel sounds 10 x / min

Percussion

on

the

abdomen, sounding timpani

on the right and lower left
quadrant, and the dimmed
sound in the upper right
quadrant of the abdomen.

Data
DS :

scientific explanations
Definition: changes in

Planning (NOC)
After the act of nursing

Client complain his skin

the

for

feels dry

dermis due to the side

epidermis

and

1x6

hours

of

impaired skin integrity

Intervention (NIC)
R
1. Assess the cause 1
of damage to skin
integrity

Clients say reddish spots

effects

of

on the hands and feet

chemotherapy

reduced.

Criteria Results:

and itchy
-

is

side

DO :
Client skin palpable dry

There are red spots on

of
/

chemotherapy
2. Client

care skin damage

3. The client is able

Client hair is graying and

hair spread unevenly

to

baby

demonstrate

how to skin care

nurse taught
4. Skin
client

lotion,

oil,

skin

moisturizers Other
/ aloe vera
the

side

4. Suggest

to

wear

loose clothing / soft

5. Encourage
to

improve

the

nutritional intake of
high protein

After the act of nursing 1. Assess the health

The client complained of

mucosa

for

pain when swallowing

cavity due to the side

improvements mucous

food
The

effects

membranes

client

says

no

distractions while eating

and drinking like there
canker
-

sores

in

the

mouth and tongue edge

The client says he can
not distinguish the taste

of

1x4

hours,

Criteria Results:
1.

free

There stomatitis on the

edge of the mouth and
The client looked in pain
while
drinking

eating

and

hygiene patient
2. Observations

of

changes

the

in

integrity of the oral

of

mucosa:

mucous membrane

redness

inflammation
/ lesion

or
client

complaints
intact

3. Clients

regarding

changes

in the oral mucosa:

thrush

demonstrate
maintain

dry

3. Assess

2. Mucous

techniques

tongue

and dental and oral

of

and pink and moist

DO :

oral

membranes

of food
-

chemotherapy

the

clients

Definition: Disorders lip

in

/ chemotherapy

palpable humid
DS :

effects of treatment

to cope with skin

Client Mucosa looked dry

care

3. Explain

understands how

the hands and feet

-

effects

treatment

skin

1. Clients know the

Clients say hair loss

2. Teach how to use a

and

other

eating disorders
to 4. Teach you how to
the

care oral mucosa

integrity of the oral

(oral hygiene, and

mucosa

use lip balm mint)

Looks white patches in

5. Instruct client to

the mouth and tongue

avoid hot and spicy

DS :

Definition: A wavelike

After the act of nursing

foods
1. Assess the cause

Clients say feel nauseous

sensation unpleasant to

for 1x4 hours, nausea

nausea or vomiting

Clients say the sour taste

the back of the throat,

can be solved

in the mouth

epigastric, or through

Criteria Results;

the abdomen that can /

1. Clients say nausea

DO:
-

Clients are more often do not induce vomiting

seen spitting

Increased

2. The corresponding

sensation

of

swallowing

tolerances are met

nutrient intake

Bowel sound 10 x / min

Percussion
abdomen,

is reduced

on

3. The client is able to

2. Assess for signs of

a lack of fluids
3. Teach
breathing
techniques to treat
nausea
4. Encourage clients
to

drink

the

cope with nausea

water

sounding

in a way that taught

ginger

timpani on the right and

lower left quadrant, and
the faint sound in the

nurses

deep

warm
water

5. Encourage clients
to suck sweets
6. Collaboration

in

upper right quadrant of

giving antiemetics

the abdomen.

(Ondasentron
mg)

IMPLEMENTASI
N Day
o

Time

Date

No

Implementation

Outcome

Diagno
sis

Monday

10.00

August

WITA

10, 2015

10.05

1.

Assessing

the

causes

of

damage to skin integrity

cause of damage to the

2. Teach you how to use a skin

WITA

care

lotion,

baby

oil,

skin

moisturizers Other / aloe vera

10.10
WITA
10.13

3. Explain

the

side

1. Clients determine the

effects

integrity of the skin due

to side effects of the
treatment/

of

treatment / chemotherapy

chemotherapy
2. The client is able to

4. Advise to wear loose clothing /

soft

demonstrate

how

to

skin care nurse taught

WITA

5. Advise patients to increase their

10.15

intake of high-protein nutrition

3. Clients know the side

effects of treatment /

WITA

chemotherapy
4. Clients

demonstrated

using loose clothing and

soft
5. Clients

meet

carbohydrate
2

Monday

10.17

August

WITA

with

meal

is

porridge with milk

1. Assess the health and dental 1. oral hygiene and dental
and oral hygiene patient

10, 2015

clients looked dirty

2. Mengbservasi to changes in the 2. The mucous membrane

10.20

integrity of the oral mucosa: dry

of the tongue and the

WITA

or redness

edge of the mouth are

10.22
WITA

3. Assess

client

complaints

regarding changes in the oral

lips look dry

mucosa: thrush and other eating 3. The client says there

disorders

canker

4. Teach you how to care oral

10.25

stomatitis and mucosal

mucosa

(oral

higyen,

lip

sores

on

the

tongue and the edge of

the

mouth

and

pain

WITA

moisturizer and use a mint)

when swallowing food

5. Instruct client to avoid hot and 4. Clients

10.30

spicy foods

demonstrate

techniques to maintain

WITA

the integrity of the oral

mucosa
5. Clients say avoid hot and

Monday

10.32

August

WITA

10, 2015

10.35

spicy foods
1. Assessing the causes of nausea 1. The client knows the
or vomiting
2. Assess for signs of deficiency

WITA
10.40
WITA
10.43
WITA

caiaran

3. Teach

breathing

sweets

clients

chemotherapy
2. Signs of lack of fluids

water / water ginger

WITA
WITA

deep

4. Advise clients to drink warm

5. Encourage

vomiting due to the side

effects of treatment /

techniques to treat nausea

10.45
10.47

cause of nausea and

such as dry mouth, thirst,

decreased urine output,

to

suck

dry skin, dizziness and

fatigue tend not happen

6. Collaborate in the delivery of 3. The client is able to

antiemetic (Ondasentron 8 mg)

demonstrate

deep

breath to reduce nausea

4. The client is able to
demonstrate
warm

water

ginger

in

to

drink

water

reducing

nausea
5. The client is able to
demonstrate

to

suck

sweets to reduce nausea

6. Clients say nausea is
reduced