WOC POST OP

Nc : Anxiety Sistostomi

Incision wound tissue damage Open wound

tissue damage
Contact with the outside
air

Release of chemical
mediators bradykinin NC : High risk of
infection

activation of
nociceptors

Impulse dorsal
column

thalamus

cerebral cortex

interpretation pain

NC : Acute Pain
3.2 Data Analisys Post Op

Data Problem Etiologi

Ds : Acute Pain Related to the presence of tissue
 Patient says pain when damage due to postoperative
moving. wound
Do :
 P = incision wound caused
by surgery. Q= punctured.
R= lower abdomen. S= >4
scale. T= when patient
moving.
 Seemed to grimace in pain
patients.
 Sign vital :
BP = > 120/80 mmHg
P = >60-100x/minutes.
Ds : - High Risk of Infection Related to incision wound
Do : caused by surgery
 Postoperative incisional
wound
 3.3 Intervention

Post OP

Nursing of diagnosys Goal and Expected Intervention Rationale

Outcomes
1. Acute pain related to Acute pain can be 1. Explain to the patient 1. The patient was
the presence of tissue
resolved after the act about the nursing cooperative
damage due to
postoperative wound of nursing about 2x24 procedure.
characterized by
hours with expected 2. Note the pains 2. To help evaluate the
Patient says pain
when moving. P = outcomes : location, time place of obstruction
incision wound
1. Client reported no intensity scale (0-10) and cause pain.
caused by surgery.
Q= punctured. R= pain on urination pain.
lower abdomen. S=
2. No pain in the
>4 scale. T= when
3. Relaxation, avoid
patient moving. uretra 3. Divert attention to the
Seemed to grimace too feel the pain.
3. No grimace when fun.
in pain patients. Sign
vital : will urination
BP = > 120/80 4. Ask the patient about 4. By asking pain it
4. Scale normal = 0
mmHg, P = >60- the pain that is felt can be seen whether
5. Vital signs normal :
100x/ minutes. the patient felt pain
BP >120/80
is reduced or not
mmHg, P >60-
5. Observation of vital
100x/ minutes.
signs
5. To determine
interventions.

2. The risk of infection The risk of infection 1. Explain to the 1. The patient was
associated with the can be resolved after
patient about the cooperative
presence of the act of nursing
postoperative during 5x24 hours nursing
incisional wounds with the objectives and
procedure.
are characterized by criteria :
the presence of post 1. Patient was 2. Wash hands 2. Hands washing
operative incisional cooperative before and after
to maintain
wound. 2. No change procedures
  temperature sterility to
3. No pus
prevent infection
4. No skin redness
3. aseptic manner
3. Clean the wound to prevent
incision with
infection due to
aseptic measures
bacterial growth