Nama: Dina Fajarina

Nim : 1911020136

Class : 8C

Hipertention

Analysis Data

DS :

• client said headache And uncomfortable in nape

DO :

• The client looks limp and just lie down Sleep

• P : There is pressure high blood pressure
• Q: As stabbed and pressed
• R : section head back, neck and nape
• S:3
• Q: Disappeared Blood pressure: 170/90 mm Hg N : 65x/minute RR: 20x/minute
• T :36 C

Nursing diagnosis : Acute pain related to physiological agents of injury

(D.0077)

Nursing Outcome

After taking action from 2x24 hours expected pain problems criteria can be resolved results :

1. Client says reduced pain

2. Clients know bear pain

3. Clients can use non technique pharmacology

4. Clients are not nervous

Intervention Nursing

Observation:

Identification of locations,characteristic, frequency, frequency,

quality, pain intensity

Identify a pain scale

Identification of non-pain response oral

Therapeutic:

Provide techniques nonpharmacology for pain relief (eg. music therapy, aromatherapy,

guided mechanical engineering)

Education:
 Describe the cause, period,and pain triggers

Teach techniques nonpharmacology for reduce pain

Collaboration:

• Collaborative administration of analgesics, if necessary

Implemention nursing

Day 1

• Help patient ientification of locations,characteristic, frequency, frequency,

quality, pain intensity,Identify a pain scale,Identification of non-pain response oral
• Help patient Provide techniques nonpharmacology for pain relief (eg. music therapy,
aromatherapy,guided mechanical engineering)
• Help patient Describe the cause, period,and pain triggers

Day 2

• Help patient ientification of locations,characteristic, frequency, frequency,

quality, pain intensity,Identify a pain scale,Identification of non-pain response oral
• Help patient Provide techniques nonpharmacology for pain relief (eg. music therapy,
aromatherapy,guided mechanical engineering)
• Help patient Describe the cause, period,and pain triggers
• Help patient to pain medication

Evaluation nursing

Day 1

S: The patient complains of pain in the back of the head

0: The patient is grimacing

The patient seems to have trouble sleeping

a : not resolved

1. Client says reduced pain 3

2. Clients know bear pain 3

3. Clients can use non technique pharmacology 3

4. Clients are not nervous 3

p: continue the intervention by monitoring the patient's pain and providing pain relief therapy

Day 2

S : The patient says the pain has decreased, pain in the back of the head
0: The patient is no longer grimacing

The patient appears to be sleeping comfortably

a : partially resolved

1. Client says reduced pain 4

2. Clients know bear pain 4

3. Clients can use non technique pharmacology 4

4. Clients are not nervous 4

p: continue the intervention by monitoring the patient's pain, monitoring the pain scale and
providing pain relief therapy