DATA ANALYSIS

DATA ETIOLOGY PROBLEM

DS: Trauma to bone (accident) ACUTE PAIN
- The patient says pain in the
left chest area. Broken
Sciatic nerve clip
DO:
P: Physical injury. Network continuity
Q: It hurts like to be interruption
depressed while moving.
R: Left thigh Pressing pain in the joints
S: Scale 8
T: Disappear and feel pain Neurotran pain stimulation
when traveling and
reduce rest Release of prostaglandic
- Cold and pale mediators
- TTV:
TD: 100/70 mmHg Severe and acute pain
T: 37oC response
RR: 22 x / m
P: 88x / m. Acute pain

DS: Left thigh fracture Barriers to physical mobility

- The client said it was
difficult to move because his open complex fracture
left thigh hurt.
Neurovascular damage pain
DO:
- Great pain arises when inability to move thighs
moving left, because of a decrease in
- The client looked grimace in muscle strength
pain from his left thigh bone.
Barriers to physical mobility

The client does not understand Lack of knowledge

the disease

Don't understand the treatment

of fractures

Lack of knowledge

NURSING DIAGNOSIS

1. Acute pain is associated with a physical injury agent (fracture wound) which is
characterized by a painful facial expression
2. The barriers to physical mobility associated with musculoskeletal disorders are
characterized by a decrease in the ability to perform fine motor skills
3. Lack of knowledge is related to cognitive limitations, incorrect interpregnation of
information is characterized by a lack of desire to seek information, do not know the
source of information.
 NURSING INTERVENTION

NO DIAGNOSIS NOC NIC RATIONAL

1 Acute pain is associated After nursing measures 1. assess the 1. To find out
with physical injury agents 1 x 24 hours the level of pain the scale of pain
(fracture wounds) which patient's pain is 2. observation felt by the client
are characterized by reduced and can be of vital signs and as a basis
painful facial expressions resolved 3. provide a for further
indicator comfortable intervention
1.Recognize 2 4 position 2. Changes in
when pain 4. teach vital signs are
occurs relaxation indicators in
techniques implementing
2.use 2 4 further
preventive intervention
measures 3. A
comfortable
3. use the 2 4 position is given
pain to reduce stress
reduction in the area of
analgesic pain
action 4. Smooth
4. explain 2 4 circulation of
the causes O2 to such a
5.Controlled 2 4 high tissue can
pain reports relax the

Indicator: muscles so that

1. Never shows the pain

2. Rarely shows decreases

3. sometimes seen
4. often shows
 5. consistently shows

2 The barriers to physical after being given 1. observe the 1. To determine

mobility associated with nursing care 1 x 24 level of ability of the extent
musculoskeletal disorders hours barriers to the patient's which
are characterized by a reduced patient activities activities can
decrease in the ability to mobility or completed 2. observation tolerated by
perform fine motor skills indicator of client progress clients and
1.maintain 2 4 in activities as an indicator
weight 3. help clients of intervention
meet the needs Furthermore
2.Walk with 2 4 of daily 2. Can know so
effective activities. far
steps 4. help clients where is the
and involve development /
3. walk 2 4 families in ROM situation
slowly client in
4. walk at 2 4 fulfilling
medium daily life
speed activities
5. Walking 2 4 3. So the client
does not fall feels

Indicator: attention and

1. Never displayed needs

2. Rarely displayed client's daily

3. Sometimes it looks activities

4. Perform often can be fulfilled

5. Show consistently 4. Can improve

client
tolerance inside
activity and can
 be feet and
fingers

3 Lack of knowledge is after being given 1. explain the 1. For patients

related to cognitive nursing care 1 x 24 pathophysiology to understand
limitations, hours less patient of the disease disease.
misinterpretation of knowledge or and
information is completed how it relates to 2. Keep the
characterized by a lack of Indicator anatomy patient aware of
desire to seek information, 1. the patient 2 5 and physiology, the process
do not know the source of and family in the right way. trip that
information. express an happened to
understanding the disease
of the disease
and the 3. make the
treatment patient know
program signs and
2. Patients 2 5 symptoms of
and families the disease.
can do the
procedure 4. so that the
correctly patient
described understands the
3. patients 2 5 disease
and families
are able to 5. Keep the
explain again patient know
what nurses the exact cause
do illness

Indicator:
 1. no knowledge
2. Limited knowledge
3. medium knowledge
4. a lot of knowledge
very much knowledge

IMPLEMENTATION AND EVALUATION

NO DIAGNOSIS Date/time IMPLEMENTATION Date/time EVALUATION ttd

1 Acute pain is 13 Mei 1. assess the level of 13 mei S:
associated with 2019 pain felt by patients 2019 - patients say
physical injury 09.00 am 2. observe the 9.30 am that pain
agents (fracture patient's vital signs felt is moderate
wounds) which 3. giving the patient a pain
are characterized comfortable position - the patient
by painful facial 4. teach and support says the pain
expressions clients to carry out lost
relaxation techniques. O:
- grimacing
expression
- Vital signs:
BP: 100/70
mmhg
T: 70 C
P: 88x / m
R: 22x / m

A: The
 problem has not
been resolved
P: Continue
intervention.
2 The barriers to 1. Assess the level of S:
physical mobility reliability of patient - Patients say
associated with activities pain when
musculoskeletal 2. observe the move on
disorders are development of the - The patient
characterized by a patient's progress in says he can't
decrease in the activity move freely.
ability to perform 3. Involve patients / - Clients say
fine motor skills families in every that pain
therapeutic / nursing feeling is
action moderate pain
4. help clian and O:
involve the family in - It seems the
ROM exercises patient's needs
fulfilled in bed
- Looks
wrapped in
cloth with a
stem
bamboo
- Daily living
activities are
served
in bed
A: the problem
isn't over yet
P: Continue
 intervention
3 Lack of 1, giving an S:
knowledge is assessment of the - the patient
related to level of patient says he
cognitive knowledge about the understands and
limitations, disease process can repeat
misinterpretation 2. explain the signs what was said
of information is and symptoms that nurse about the
characterized by a usually appear in the disease.
lack of desire to disease
seek information, 3. help patients O:
do not know the understand the - the patient
source of symptoms and seems to
information. process of the disease understand
4. identify possible what the nurse
causes in the right said
way
A: The
problem has
been overcome

P: intervention
stopped