NURSING CARE

COMFORTABLE NEED OF PAIN

Student name : Tata Yulia Deasal Sabella

Place of Practice : RSUD dr. Loekmono Hadi Kudus, Cempaka 2

Assessment Date : 15 October 2019

A. ASSESSMENT

I. Identification of patients

Name : Ny. S

Age : 40 years / 23 March 1987

Occupation : housewife and farmer

Education : Elementary school

Gender : Female

Religion : Islam

Marital status : Married

Address : Mlaten RT 03/ RW 04 Mijen, Demak Jateng

Hospital admission date : 15 October 2019, 9 PM

Assessment date : 15 October 2019

No. RM : 817427

Medical diagnosis : uterine myoma

Person in charge

Name : Mr. S

Age : 20 years

Occupation : farmer

Hub with client : child

Address : Mlaten RT 03/ RW 04 Mijen, Demak Jateng

B. DISEASE HISTORY

1. Main Complaint

The patient said pain in the surgical wound, pain in the lower abdomen.

2. Current disease history

The patient said pain in the surgical wound in the lower abdominal area, pain such as
pricking, disappearing arising, catheter attached, and feel the heat in the surgical wound.

3. Past Healty History

The patient said that he had never had a new operation this time, he had hypertension

4. The state of family health

Patients and families say they do not have infectious and hereditary diseases such as
hypertension, diabetes mellitus, hepatitis and tuberculosis.

5. Physical examination

General situation : weak

Awareness : composmentis

Vital signs : Blood pressure = 130/90 mmHg

Body temperature = 37℃

Pulse = 90x / minute

Respiratory = 26x / minute

Height = 155 cm

Weight = 54 kg

Head : Mesocepal

Nose : no polyps, normal olfaction

Ears : no cerumen, good hearing function

Mouth : Lips = no cracks

Teeth = no carries

Tongue = not dirty

Neck : no thyroid enlargement

Upper extremity : RL infusion is attached to the left hand

 Lower extremity : in good condition

Abdomen :I = flat there is a surgery on the lower abdomen

A = peristalsis

Pa = pressure pain (+), period (-)

Pe = tympanic

Lungs :I = symmetrical normal chest shape

Pa = no tenderness, no crepitus

Pe = sonor

A = vesicular, no ronchi and no whezing

Heart :I = ictuscordis not visible

Pa = upper limit = ICS linear parasternal system

Waistline = ICS parastusa sinistra

Right border = ICS V linear parasternal dekstra

Left border = ICS V 2 cm medial linear midclavicula sinistra

Pe = ictus cordis is not strong enough to lift

A = regular, noisy (-)

6. Patterns of daily life

a. Health perception and maintenance

Patients and families if sick, the family immediately brought for treatment to recover
quickly and be able to reactivate.

b. Nutritional pattern

Before getting sick: Eat one serving of side dishes and vegetables, eat 3 times a day,
drink 5-6 glasses per day

During illness: Eat 3 times a day with the hospital diet menu and appetite is disturbed

c. Elimination pattern

Before getting sick: CHAPTER 1 x daily with soft consistency, BAK 5-6 x daily
smoothly

During illness: CHAPTER 2 times daily with soft consistency, brownish yellow color,
BAK 3-4 times daily smoothly and clear yellow color
 e. Sleep and rest patterns

Before getting sick: the client says sleeps ± 7 hours and naps ± 2 hours / day

During illness: the patient's rest is slightly disturbed due to pain and the atmosphere in
the hospital

f. Perceptual pattern

The patient's vision is good, the hearing is still normal, the sense of taste is good

g. Pattern of self-perception

The patient receives the pain he is suffering from

h. Patterns of sexuality and reproduction

  The patient is married and has 2 children

i. Coping management pattern

The patient still spends a lot of time resting. The patient is open and his family supports
every nursing action given by the nurse

j. Relationship role patterns

The patient lives with the child

k. Value and belief system

   Patients who are Muslim, believe sick and healthy are God's will

7. Therapy

1. Infusion RL drip tramadol 1 amp, 28 tpm

2. Ceftriaxion injection 1 gram 2 x 1 through iv
3. Tranexamic Acid Injection 2 mg 3 x 1 through iv
4. Injection of ketorolac 2 mg 3 x 1 through iv
5. DC stays 24 hours
LABORATORY EXAMINATION

Date : 16 October 2019

Reference
Examination Result Unit Method
Value
HEMATOLOGI
Darah Rutin
Hemoglobin 12.5 12-14 g/dl Colorimetric
Hematokrit 35.2 37-43 % Analyzer
Leukosit 4.6 4-10 x10^3/UI Impedance
Trombosit 289 150-400 x10^3/UI Impedance
MCV 79 81-99 Fl Analyzer
MCH 28 28-33 Pg Analyzer
MCHC 35 32-36 g/dl Analyzer
Eritrosit 4.44 3.5-4.5 X10^6/ul Impedance
KIMIA DARAH
Asam urat 3.84 2.6-6 Mg.dl Uricase
SG OT 34.4 <30 u/l IFCC
SE PT 78.5 <31 u/l IFCC
Trigli serido 117.4 <150 Mg/dl Peroxidase
Ureum 15 15.39 Mg/dl Urease
Cholestrol 184.4 <200 Mg/dl Oxidase-PAP
Creatinin 0.9 0.6-1.1 Mg/dl Al kaline
pirocate
Glucosa 93 <180 Mg/dl Oxidase-PAP
HEPATITIS
Hbs Ag Negative Negative

B. DATA ANALYSIS

Date Dx Data focus Causes Problem

16 I DS: the patient says that pain in Post OP myoma Acute pain
the surgical scar in the lower uteri Acute pain
October
abdominal area during fallow
2019 activities with pain such as
pricking, heat, and pain
disappear.
DO : patient grimaces in pain
Blood presure = 130 / 90mmHg
Temperature = 37 ℃
Pulse = 90x / minute
Respiratory = 26x / minute

C. NURSING PLANING

No Date Purpose and Criteria Result Intervention TTD

1. 16 October After taking 3 x 24 hours 1. Assess Vital sign
 2019 of nursing action, it is 2. Assess the pain scale
expected that the pain can 3. Teach the patient
be reduced by Criteria relaxation techniques
Results: 4. Collaboration with
1. The pain scale is doctors in drug
reduced to 1 administration
2. The patient is calmer
and relaxed
3. Vital sign is stable
 Blood presure: 120/80
mmHg
 Temperature: 36.5 C
 Pulse : 80 x / minute
 Respiratory: 20 x / minute

D. IMPLEMENTATION

No Date Implementation Response TTD

dx
1. 17 Examine vital signs DS : The patient is willing to be
October measured blood presure,
2019 temperature,pulse, and respiratory
07.00 DO : The patient looks weak
Blood presure : 120/80 mmHg
Temperature : 37,7 ℃
Pulse : 80x/menit
Respiratory : 20x/menit

10.00 Asses the pain scale DS : the patients says pain in the
lower abdomen when moving feels
like being pricked and hot
DO : the patient looks painful on a
scale 5
 15.00 Teach deep breathing DS : Patient is willing
relaxation techniques DO : the patient appears to be
practicing deep breathing relaxation
techniques after being taught

20.00 Carry out DS : the patient says she is willing to

collaboration with a
be given medicine
team of doctors
giving drugs DO : medicine goes in well there is
- injection of
no allergy, the patient looks calm
ceftriaxon 1 gram
through iv
- injection of
tranexamic acid 2 mg
through IV
- injection of
ketorolac 2mg
through IV
- Infusion of RL drip
Tramadol 1 amp 28
tpm
1 18 Examine vital signs DS : patient is willing
October DO : Blood presure : 110/70 mmHg
2019 Temperature : 36,5 C
07.00 Pulse : 78 x/minute
Respiratory : 22 x/minute

08.00 Assess the patients DS : the patient said the pain had
pain scale decreased somewhat
P : suture wound
Q : It's like being pricked
R : lower abdomen
S : scale 3
T : disappear arise

DO : the patient seemed to wince in

09.00 Teach deep breathing
pain
relaxation techniques
DS : the patient understands the nurse
intruction
 10.00 Carry out DS : the patient said that she was
collaboration with a
willing to be given medicine
team of doctors
giving drugs DO : medicine goes in well there is
- injection of
no allergy, the patient looks calm
ceftriaxon 1 gram
through iv
- injection of
tranexamic acid 2
mg through IV
- injection of
ketorolac 2mg
through IV
- Infusion of RL
drip Tramadol 1
amp 28 tpm
1 19 Examine vital signs DS : the patient is willing to be
October measured blood presure,
2019 temperature,pulse, and respiratory
07.00 DO : Blood Presure : 110/70 mmHg
Temperature : 36,5 C
Pulse : 78 x/menit
Respiratory : 22 x/menit

08.00 Assess the patients DS : the patient said the pain had
pain scale decreased somewhat
P : suture wound
Q : It's like being pricked
R : lower abdomen
S : scale 1
T : disappear arise

DO : the patient seemed to wince in

10.00 Teach deep breathing
pain
relaxation techniques
DS : the patient understands the nurse
intruction

DS : the patient said that she was

12.00 Carry out
collaboration with a willing to be given medicine
 team of doctors DO : medicine goes in well there is
giving drugs
no allergy, the patient looks calm
- injection of
ceftriaxon 1 gram
through iv
- injection of
tranexamic acid 2 mg
through IV
- injection of kemolac
2mg through IV
- Infusion of RL drip
Tramadol 1 amp 28
tpm

E. EVALUASI

Date NO DX Evaluation TTD

19 October I S = the patient said the pain had disappeared
2019 and could move normally
O = the patient look calm
Blood presure = 110/70 mmHg
Temperature = 36,5oC
Pulse = 88x/menit
Respiratory = 22x/menit
A = the issue is resolved
P = stop the intervention