Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
A. Patient Identity
Name :Mr. M.S
Age :68 years ,1 mounth
Addres :Guntung manggis, Landasan Ulin
Medical diagnose :Benigna Prostat Hiperplasi (BPH)
Date of Entry :20 february 2018
Date of Assessment :20 february 2018 ,10:15 am
B. Data Focus
Subjective Data
patients said “ I the frequent urinating”
patients said “ night last ,I pee as much as 5 times”
patients said “when peeing, I feeling unsatisfied”
patients said “ I fell pain in the lower part of the stomach in hypogastrum when
want pee”
patients said “ pain extends to the waist”
patients said “ complaint felt this almost 2 years”
patients said “ I anxious with the my condition here and anxious when his illness
later will deteriorate”
patients said the fear when his illness worse and should be in operation
patien said “ I less understand my illness”
Objective Data
D. Data Analisis
OD:
patients look shows the area of pain
P: when peeing and when want pee
(movement)
Q: poignant
R:The lower abdominal area at the
hypogastrum quadrant 8
S: scale medium5-6/10, pain extends to the
waist
T: 30 minutes, missing pain arising
Vital sign (20 february,2018) (09:20)
Blood preasure :130 /80
Frequency breath :21 times minutes
Frequency pulse :79 times minute
Temperature :37,0 C
3 SD Anciety Lack of knowledge
patients say the anxious with the condition
patients say anxious when his illness later
will deteriorate
patients say the fear when his illness worse
and should be in operation.
patien says less understand his illness
OD
the patient looks anxious with his condition
patients often look a lot of inquires about
his or her concerns with the doctor
O:
When Assessment doctor, patient stomach don’t distention and patien look
not bloated
Urine complete (08/02/2018)
-color :light yellow
-clarity :clar
-Bj :1015
-PH 5,0
Nursing Intervention:
NIC
Pain Management
1).Do pain study comprehensively include the location, characteristics, duration,
frequency and quality factor of precipitation
2).Observations of nonverbal reactions and discomfort
3). Environmental controls that can affect pain such as room temperature, lighting
and noise
4). Reduce the pain of precipitation factors
5).Select and do the handling of pain (Pharmacology, Pharmacology and inter
personal)
6). Select and do the handling of pain (Pharmacology, Pharmacology and inter
personal
Evaluation
S:
Patient say at rest the pain is reduce but patients difficult to break because the
feeling always want to pee
Patient say difficult not to focus with feel his pain
Patient say try to get more of rest
O:
Patient looks to relaxation , but the patient look still seem to focus to his pain
Doctor don’t prescribing medications analgesic
P: when peeing
Q:seperti poignant
R:The lower abdominal area at the hypogastrum quadrant 8
S: scale medium5-6/10, pain extends to the waist
T: 30 minutes, missing pain arising
A: problem not is resolved
3. Nursing Diagnose :
Goals /NOC
· Anxiety self-control
· Anxiety levels
· Coping with
The Criteria Of The Results:
· The client was able to identify and express the symptoms of anxiety.
· Identify, disclose and demonstrate techniques for mengontol anxious.
· Vital sign in the normal range.
· Posture, facial expressions, body language and level of aktivfitas shows
decreased anxiety.
NIC/Intervention
Anxiety Reduction (decrease in anxiety)
1) Explain all procedures and what is felt during the procedure
2) Accompany patients to provide security and reduce fear
3) Push the family to accompany patients
4) Listen attentively
5) Identification of the level of anxiety
6) Help your patients recognize situations that cause anxiety
7) Encourage the patient to express feelings, fears, perceptions
8) Instruct the patient to use relaxation techniques
9) provide information about the patient's disease
Implementation
S:
O: