Sei sulla pagina 1di 11

KONSEP DASAR ASUHAN KEPERAWATAN

The application of the nursing process is done systematically to determine the


client's problem, make a plan to cope, implement and evaluate the success of
the plan will effectively overcome the problem. Nursing process through four
stages, namely:
1. Assessment Data nursing
The data that need to be assessed on a case Ca. Cervical is the subjective data
and objective data are as follows:
a. Biodata
In the biographical data encompasses:
1.) The identity of the client (the wife)
2.) The identity of the husband
b. Data biological / physiological
1.) The main complaint
2.) The main complaint history
Complaints perceived
Since when is felt
The amount of bleeding
Condition / client state
Care has been given
3.) The pattern of reproduction
Menarche
Cycle
The duration
The number of
The nature of blood
dismenorrhoe
Menopause
4.) History of pregnancy and childbirth, and postpartum
5.) History of surgery

6.) The history of having experienced


7.) Family history includes genogram, disease and a history of twin births.
8.) Social history
Social activities
Contraception
9.) history of drug use
10.) The pattern of daily activities
Nutrition includes the types of food, food frequency, appetite, food taboos and
many drink in a day.
Elimination
1. CHAPTER: frequency, color, and consistency.
2. BAK: frequency, number and color.
Rest
Personal hygiene which includes appearance, how many times a day bath.
Recreation in a day, how many times brushing teeth, how many times to wash
your hair in a week and how many times to change clothes in and out.
Drug dependence, cigarettes, and alcohol.
Sexual intercourse.
KB consisting of whether mothers know about birth, the mother agreed to be
acceptors as well as whether the mother never drop out.
11.) Physical Examination
General / consciousness.
Vital signs: BP, N, RR, and S
gynecological examination by inspection, palpation, percussion and
auscultation.
Front: is pale, cloasma gravidarum, whether there is a skin disease, bent or
bluish.
Eyes: how sclera, eyelids and conjungtiva.
Mouth: the state of the lips, sores on the lips, the smell and coughing.
Teeth: hygiene, gingivitis, caries.

Neck: whether there adenoids, enlarged lymph.


chest Fruit: shape, nipple, and cleanliness.
Stomach: form, striae, linea, the belly wound.
Vulva: edema, Chadwick's sign, spending, cleanliness.
Limbs: symmetrical, foot ulcers, varices, edema.
Laboratory tests.
Investigations.
Family planning.
c. psychological data
The person closest to the patient.
Interaction in the family.
Perception of patients against the disease.
The task of development according to current age.
coping mechanise
d. Socioeconomic status.
Financial Problems.
e. Data spiritual
Confidence in the Lord.
Activity religion / belief done.
2. Nursing Diagnosis
According to the Medical Surgical Nursing book pages 1021 - 1061, (Barbara C.
Long, 1996).
a. Impaired sense of comfort associated with pain in the lower right abdomen,
which is characterized by:
- Patients winced in pain
- The existence of a hard-driven tumors in the lower right abdomen.
- Patient restless
b. Anemia associated with chronic bleeding from the birth canal which is
characterized by:

- Hemoglobin decreased.
- The face looks pale
- Pale conjunctiva
- Rapid pulse and small
- Decreased blood pressure
c. Nutrition disorders: lack of demand, associated with the intake of less
characterized by:
- Anorexia
- Stature thin and weak
- Weight loss
- Hemoglobin decreased
d. Anxiety related to lack of knowledge about the disease is characterized by:
- Face listlessness
- Communication is difficult
- Hard to sleep
3. Planning Nursing
a. Impaired sense of comfort associated with pain in the lower right abdomen,
which is characterized by:
- Patients winced in pain
- The existence of a hard-driven tumors in the lower right abdomen.
- Patient restless
The goal of treatment:
A sense of comfort are met
Expected outcomes:
- The pain is reduced
- Patients are not restless
- Patients can sleep in peace
Nursing actions:
1.) Rest in bed.

rational:
With the break will reduce the workload of organs, especially the damaged part,
so that the damage from getting worse and accelerate the healing process.
2.) Exercise breathe in when there is pain.
rational:
There is spasm of muscles, increase circulation and strengthen muscles so that
the pain is reduced.
3.) Give a warm compress on the area of pain.
rational:
Vasodilation occurs that would inhibit pain impulses.
4.) Give menthol ointment over sympisis.
rational:
Can produce a sensation of warmth or cold and will inhibit the transmission of
pain delivery.
5.) Give analgesic and antibiotic treatment appropriate physician orders.
rational:
Analgesic suppress peripheral nerve, thereby reducing pain. Antibiotics will kill
the germs, so as to decrease inflammation and pain decreased.
6.) Give appropriate treatment sitostatica order of a physician.
rational:
Sitostatica (cancer drugs) can destroy cancer cells and also to prevent the
division of cancer cells.
7.) Observation pain threshold.
rational:
Indicator decreasing pain.
8.) Educate about menfaat rest in bed, breathing exercises, warm compresses,
and treatment.
rational:
Established to work - good cooperation between the patient, family and officials
towards the patient's recovery.

b. Anemia associated with chronic bleeding from the birth canal which is
characterized by:
- Hemoglobin decreased.
- The face looks pale
- Pale conjunctiva
- Rapid pulse and small
- Decreased blood pressure
The goal of treatment:
Patient blood needs are met (not anemic)
Expected outcomes:
- The face is not pale
- Hemoglobin rose to 12 grams per cent (minimum)
- Normal blood pressure (120/80 mmHg)
- Normal Nadi: 80 times per minute.
Nursing actions:
1.) Implement appropriate blood transfusion physician orders.
rational:
Can quickly restore blood, transfusion of fresh blood that patients get immediate
rise in hemoglobin levels.
2) Observation of hemoglobin every day by way Sahli.
rational:
Knowing the daily development of hemoglobin,
3.) Observation vital signs: blood pressure, pulse, respiration and state mucosa,
skin and conjunctiva.
rational:
Blood shortage will be reflected in vital signs and color of the mucous
membranes and skin.
4.) Provide education about the benefits of transfusion.
rational:

By understanding the patient about the patient transfusion will be participating


in implementing the action transfusion.
5.) Observe for signs of anaphylactic reactions.
rational:
Blood is an antigen for patients. Possibility of antigen-antibody reactions can
occur which lead to a very dangerous shock reaction. With strict observation
preventable fatal reactions.
6) Provide counseling to patients about reactions that may result from a blood
transfusion.
rational:
With the knowledge of the client can be reported immediately if there are signs
of anaphylactic reactions.
c. Nutrition disorders: lack of demand, associated with the intake of less
characterized by:
- Anorexia
- Stature thin and weak
- Weight loss
- Hemoglobin decreased
The goal of treatment:
Patient's nutritional needs are met
Expected outcomes:
- Appetite improved.
- Hemoglobin rose to 12 grams% (minimum)
- Weight gain of at least a half pounds in one week.
- Portions of which served eaten.
Maintenance actions:
1.) Give TKTP food according to the number of calories needed.
rational:
The patient suffered tissue damage and excessive catabolism due to cancer. To
anticipate this situation needs to be given large amounts of calories and protein
quality.

2) Serve the food was varied, clean and warm.


rational:
Smoke wafted foods will stimulate the olfactory nerve and subsequent
unappetizing.
3.) Provide reinforcement (reinforcement / praise) to the patient
Reinforcement will enhance the spirit of the patient's life, for the better
participation.
4.) Tmbang patient body weight per week.
rational:
An indicator of the achievement of treatment goals.
5.) Give medicine physician orders an appetizer fit.
rational:
These drugs will suppress the satiety center in the brain opposite the hunger
center will open resulting in appetite is always there.
6) Provide counseling to patients about the benefits TKTP food and its
relationship to disease.
rational:
Knowledge about the patient will improve patient participation in achieving the
goals of care.
d. Anxiety related to lack of knowledge about the disease is characterized by:
- Face listlessness
- Communication is difficult
- Hard to sleep
The goal of treatment:
Reduced patient anxiety
Expected outcomes:
- Facial expressions do not seem worried
- Good Communication
- Can sleep
- Do not fear.

Maintenance actions:
1) Form a relationship based on mutual trust and open.
rational:
Such an atmosphere will allow the patient to remove the contents of his heart so
that the patient's mental burden will be reduced.
2.) Spend time talking with patients.
rational:
Patients feel inferior and isolated. With these measures the patient will feel more
attention.
3.) Show empathy towards patients
rational:
Empathy increases self-esteem.
4) Assess the tension and fear that can lead to feelings of anxiety.
rational:
Can be used as a guideline to determine the next action
5.) Provide counseling to families in order to provide mental and spiritual support
to patients.
rational:
Family support can increase patient confidence in the face of illness.
4. Implementation
Implementation is the embodiment of the management and treatment plan has
been determined or prepared. In the embodiment of the plan can be addressed
by:
a. That plan.
b. Or delegated to another person who is believed to provide nursing actions,
capable and have the authority to implement the treatment plan.
Principle in the implementation of the treatment plan:
a. Based on the patient's response.
Ready to be implemented or not.
b. Based on resource use: tools, power, etc.
c. Expected to increase self-care and self-reliance of the patient.

d. In accordance with the standards such as: time, situations, and others.
e. Have a legal basis or scientific basis.
f. In accordance with the responsibilities of the profession.
g. Increase cooperation with other professions.
h. All actions are implemented, its implementation on preventive aspects and
i. The application of the method chosen effectively.
j. Pay attention and consider the factors of environmental change.
k. Increasing the participation of the patient.
Activities - activities that must be performed on each implementation of nursing
interventions:
a. Looking back over the existing data on the patient.
b. See if there is new data emerge, changed or not changed.
c. Revise the plan if necessary.
d. Conduct or conduct that assist with client relationship.
e. Determining the needs of nursing assistance.
f. Implement nursing care techniques.
g. Studying the patient's response.
h. Communicating the actions that have been implemented and the response of
patients to other health professionals.
5. Evaluation
Evaluation is the final step of the nursing process. According Lismidar H., et al
(1990), evaluation is a deliberate activity and continuously by involving patients,
nurses and other health team members. In this case the necessary knowledge
about health, pathophysiology and evaluation strategies.
The purpose of evaluation is to assess whether the objectives in nursing plan is
reached or not, and to conduct the review.
In conducting the evaluation, in accordance with the time and date specified in
the statement of purpose. While providing nursing care, nurses constantly collect
new data from patients who later will be used for further evaluation materials. At
the time of the evaluation of the achievement of goals then the nurse look back
on a statement of purpose in the care plan that has been set.
Behavior patients how that is expressed in the destination?

Have the patient was able to show changes in accordance with the expected
behavior in the statement of purpose?
The answer to the two questions above is the basis for the evaluation of goal
achievement. Things that evaluated the ability of patients behave in accordance
with the objectives set out in the nursing plan.
For the evaluation of nursing in cervical cancer refers to the intended purpose,
namely:
a. Is a sense of comfort are met?
b. Is the patient's blood needs are met?
c. Is the patient's nutritional needs are met?
d. Is the patient's anxiety is reduced / lost?