Nama : Olga Febri Cantikasari

Nim : 1911102411121

A. Nursing Process
1. Client’s Condition
Subjective Data
 The client said pain in the area of the operation wound while doing activities
Objective Data
 Client A 30 years old
 Post appendiktomy client 24 hours ago
 The client seemed to grimace while doing the activity
 Blood pressure 110/70 mmHg, pulse 84 x/minute, temperature 36,5 degrees c
2. Nursing Diagnoses
 Discomfort pain associated with postoperative wounds
3. Special Purpose
 Pain is reduce until it disappears and the client is calm
4. Nursing Actions
 Teach clients deep breath relaxation techniques

B. The Process Of Implementing The Action

 Orientation Phase
1. Therapeutic Greetings
“Assalamualaikum ma’am I’m Olga nurse who will be on duty this morning, starting from 07.00
to 14.00 pm. How is your condition this morning? Are there any complaints”
2. Evaluation and Validation
3. Contract
“ma’am you said earlier that the scar from the surgery was painful when moving and breathing,
to overcome the pain, my mother will help her by teaching deep breathing relaxation
techniques,it will take approximately 15 minutes in this room.”
 Work Phase

“I will wash my hands first, ma’am”

“I closed the curtains, ma’am (after that the nurse washed her hands again with the handrub).”

“before we start, are you in a comportable position? Alright then”

“first I will give you an example and then we do it together after that you do it yourself”

“breathing relaxation techniques in the way, namely inhale deeply through the nose then hold for a
while then exhale slowly through the mouth” “so we do it together, ma’am”
“now you do it yourself”….. “very good, repeat this exercise until you feel pain is not felt”

“Until here, there is something you want to ask, ma’am? If there is something that is not understood,
you can immediately ask me directly”

 Termination Phase
1. Evaluation of client responses to nursing actions
Client Evaluation (subjective)
“the client said she felt more comfortable”
Nurse Evaluation (objective after reinforcement)
“the client looks calm and happy to do the exercise”
2. Client follow-up actions (what the client needs to train according to the results of the actions
taken)
“ok ma’am, you can do this relaxation technique whenever you feel pain”
3. Upcoming Contract
Topic : ma’am soon I’II be back to check your vital signs after doing the exercise, the time is
approximately 10 minutes and the place is in your room now.