Student name : Maisya

SRN : 1614401320216
Date & hour of assessment : 07-02-2018

A. ASSESSMENT
1. PATIENT IDENTITY

a. Patient's name : Miss.H

b. Date of birth / age :03-07-1974/44 years old

c. Religion : Moeslem
d. Education : D3 Midwife
e. Address : Tamban
f. No CM : 137-78-xx
g. Medical diagnosis : Kista Endometriosis

2. IDENTITY OF PARENT / RESPONSIBILITY

a. Name :Mr.A
b. Age : 25 years old
c. Religion : Moeslem
d. Education : Student
e. Work : labor
f. Relationship with patient: child

Origin of patient : × Outpatient

√ Inpatient

× Referrals
A. PRE OPERATION

1. Main Complaint:
2. History of disease: × DM × Asthma × Hepatitis × Heart × Hypertension × HIV
×None
3. Seat Operation / Anesthesia: × Yes √ No
4. Allergy Allergies: × Yes, mention .................. × None
5. Type of Operation: Carnialtomy
6. TTV: Temperature: 36,70c, pulse: 80 bites/ mnt, Respiration: 20 times / mnt,
TD: 120/70 MmHg
7. TB / BB: 155 cm/ 61 kg
8. Blood Type: A
PSYCHOSOCIAL / SPIRITUAL HISTORY
9. Emotional Status
√Calm ×Confused ×Cooperative , ×Uncooperative ,× Crying , × Withdrawal
10. Anxiety Level: × No Anxiety, √Anxiety
11. Anxious Scale: × 0 = Not anxious

×1 = Disclosure of concern
√ 2 = High attention level

× 3 = Concerns are not focused

× 4 = Simpate-adrenal response
× 5 = Panic

12. Skala Nyeri menurut VAS ( Visual Analog Scale )

No pain Mild pain Moderate pain Severe pain Very Pain Unrestrained pain
√ 0-1 × 2-3 ×4-5

× 6-7 × 8-9 × 10

13. Secondary Survey, do it head to toe by priority:

 Normal If Not normal, explain

Yes No
√ 𝚇
Head
√ 𝚇
Neck

√ 𝚇
Chest

√ 𝚇 There is a cyst and will be performed

Abdomen abdominal surgery at 11:30

√ 𝚇 Client is famale , there is no problem

Genitalia in the client reproduction section

√ 𝚇
Integumen

Ekstremitas √ 𝚇

14. Results of Supporting Data

15. Laboratory:

HB ( 9,1 g/dl ) Ureum : 34 mg/dl

Ht : 26,9 g/dl Creatinin : 0,72
Leukosit : 60 g/dl SGOT : 33 IU
PT : 11,1 detik SGPT : 15 IU
APTT : 22,4 detik GDS : 92 g/dl

B. INTRA OPERATION

1. Anesthesia begins hours: 11.30

2. Surgical starts at hour: 11.35
3. Type of anesthesia:
× Spinal √ General / general anesthesia × Local × Block node □ ...............
4. Operating position:
√supine × litotomy × stomach / knee chees × lateral: × right × left × other ......
5. Anesthesia Note: 6A
6. Installation of tools:
Airway: √ Attached ETT no: 7 , × Installed LMA no: ........ √ OPA √ O2 Nasal
7. TTV: Temperature 36,8 O C, pulse 70 bites / mnt, palpable ×strong, × weak,
× regular, √ irregular, RR x 22 x/ mnt, TD134/80 mmHg, saturation O2: 98 %

8. Secondary Survey, do the head to toe by priority

Normal If Not normal, explain

Yes No
√ 𝚇𝚇
Head
√ 𝚇
Neck

Chest √ 𝚇

√ 𝚇 There is a cyst do performed

Abdomen abdominal surgery
 √ 𝚇 Client is famale , there is no problem
Genitalia in the client reproduction
section,using chateter

Integumen √ 𝚇

Ekstremitas
√ 𝚇

Total liquid entering

□ Infusion:500 cc
□ Transfusions: 500 cc

Total fluid out

□ Urine: 100 cc
□ Bleeding: 500 cc

Liquid balance: 500 cc

C. POST OPERATIONS

1. Patient moves to:

Move to ICU / PICU / NICU, clock_13.40 Wib RR, clock 14.20 Wib
2. RR Complaints: × Nausea × Vomiting dizziness √ Surgical pain × Legs feel
numbness × Shivering other ... ..
3. General Condition: ×Good, √ Moderate × Severe pain
4. TTV: Suhu : 36,5oC, pulse 82 bites / mnt, RR: 22 x / min, TD 117/80 mmHg,
Sat O2: 99%

5. Awareness: ×CM, √Apathy, ×Somnolen, × Soporo, ×Coma

6. Secondary Survey, do the head to toe by priority:

the head to toe by priority

Normal If Not normal, explain

Yes No

Head √ 𝚇

Neck √ 𝚇
Chest
√ 𝚇
There are results of stitches in the
Abdomen √ 𝚇 stomach section about 2-3 cm after
surgery on the abdomen...
Client is famale , there is no problem
Genitalia √ 𝚇 in the client reproduction
section,using chateter

Integumen √ 𝚇

Ekstremitas
√ 𝚇

Skala Nyeri menurut VAS ( Visual Analog Scale )

No pain Mild pain Moderate pain Severe pain Very Pain Unrestrained pain
× 0-1 √ 2-3 × 4-5

× 6-7 × 8-9 × 10

II. DATA ANALYSIS

Symptom Problem Etiologi
Pre Operasi Anxiety Lack of under - standing of

DS: The client said he was procedure

anxious and worried about

his operation today
DO: client looks nervous,
client face tense, confusion
and look weak
Scale anxiety is 2 (high
attention level )
Clien look ask abaout
procedure operation
Vital sign :
-Bp : 120/70 Mmhg
-P : 80 bites/minute
-R : 20 times /minute
- T : 36,7o C
Intra Operation Risk of infection
DS: -
DO: - It appears that the
client performed abdominal
surgery using blades,
surgical scissors, syringes
and other equipment
- during client operation
given anesthesia
-Client using infusion
-Client using O2: 3% -
Client using chateter
Vital sign:
-Bp: 134 / 80Mmhg
-P: 70 bites / minute
-R: 20 times / minute –
- T: 36.8o

Post intervention
DS: The client says that he
feels pain in the wound in
his stomach.
P: Client feels pain due to
post operation wound.
Q: The client says the pain is
throbbing.
R: The client feels the pain
in his stomach.
S: The pain scale
experienced by clients is 2
(being).
0: No pain
1: Mild pain
 2: Moderate pain
3: Severe pain
4: Unbearable pain
T : pain sometimes
DO:
-Clients are still seen
grimacing in pain as they
move.
- Pain scale 2 (medium).
- TTV
BP: 117/80 mmHg
P: 82 times / minute
T: 36.9 oC
R: 22 times / min

III. NURSING DIAGNOSES

Pre operation:
1. Anxiety Related to lack of understanding of procedure
Intra Operations:
1. risk of infection
Post Operation:
1. Painful discomfort associated with incision injury

IV. NURSING PLAN (including pre, intra and post operation)

No Nursing Goal intervention Rational
Diagnose
1 Anxiety After the do 1.Asses 1.anxiety is highly
Related to Nursing action client’s level of indivifualized,normal
lack of Anxiety was anxiety physical and
solved yed physicological response
understanding with criteria : 2. use presence 2.touching technique can
of procedure verbalization touch and relaxing patient
of feeling less communication
anxious technique 3. approach and
relaxed facial 3. Approach motivation help the
expression and and motivate patient to internalize
body the patient to perceived anxiety
movement express
after given thoughts and 4. creates a sense of
nursing feelings confidence in the patient
intervention 4. Give that he / she is able to
positive overcome the
reinforcement problem and give self
to continue confidence which is
daily activities proved by the
despite being recognition of others for
anxious. his ability.
5. Encourage 5.creates a feeling of
the patient to calm and comfort.
use relaxation 6.increase knowledge,
techniques reduce anxiety
6. Provide
factual (real
and true)
information to
patients and
families
regarding
diagnosis,
treatment and
 prognosis.

2 Risk of 1.Assess the 1.rabor,kalor,dolor,tumor

infection signs of and function of laesa on
infection client
2. perform 2. to prevent the
wound care infection entered the
3. use strerile wound
technique 3.sterile technique is one
4. hand of way to prevent port do
hygiene entery of infection
5.collaboration 4. To prevent the
in administered infection because of the
drug : hand of nurse
Antibiotics 5. Antibiotic is drug to
prevent the infection

3 Painful Aim: 1. Assess pain, 1. Useful in monitoring

discomfort After the act of note location, the effectiveness of
associated nursing the characteristics, drugs, the progress of
with incision pain can be scale (0-10). healing. Changes in pain
injury resolved or Investigate and characteristics indicate
handled report changes an abscess.
properly. in pain 2. Reduced abdominal
Results appropriately. stress that increases with
criteria: supine position.
· Reporting of 2. Maintain a 3. Increase the
lost or semi fowler normalization of organ
controlled break position. function, eg stimulate
pain. 3. Encourage peristaltic and smooth
 · Reveals the early flatus, and decrease
method of ambulation abdominal discomfort.
giving up pain 4. Give an ice 4. Eliminate and reduce
relief. pack on the pain melelui nerve
· Demonstrate abdomen endings
the use of 5. Give note: do not do hot
relaxation analgesic some compress as it may cause
techniques and indication network congestion.
entertainment 5. Eliminating pain
activities as a facilitates collaboration
pain reliever with other therapeutic
interventions.

V. IMPLEMENTATION (including pre, intra and post operation)

No Day/date Time DX implementation Evaluation Sign
1 Monday, 10.40 I 1. Asesting - client identity
Feb,07th2018 patient identity is correct
10.45 2.helps to -all the client's
undress clients clothes are
and replace removed and the
them with lien has changed
patient clothes patient's clothes-
10.50 3. Asesting client level of
client’s level of anxiety was
anxiety mild
10.55 4. Using - The touch and
presence touch Cummunicating
and with patient
communication before client
technique
11.00 5. Encouraging enter the
the patient to operating theatie
use relaxation - Nursing
techniques. teaching client
6. Assesting to do relaxation
13.40 pain, note technique and
location, client follow it
characteristics, 6. The client
scale (0-10). says that he
Investigate and feels pain in the
report changes wound in his
in pain stomach.
appropriately P: Client feels
7. . Maintain a pain due to post
semi fowler operation
break position wound.
Q: The client
says the pain is
throbbing.
R: The client
feels the pain in
his stomach.
S: The pain
scale
experienced by
clients is 2
(being).
0: No pain
1: Mild pain
2: Moderate
pain
 3: Severe pain
4: Unbearable
pain
T : pain
sometimes

7. The client is
already in
position

VI. EVALUATION: (includes pre, intra and post operation)

No Day/date time dx Ealuation

time
1 Wednesday , 10.35 I S : Client said that her
Feb,07th anxiety was reduce after
2018 nurse have conversation with
him
O :- Client anxious was
reduce
- client expression was
relax
- client movement was
calm
Scale anxiety client is 1
Vital sign :
-Bp : 130/80Mmhg
14.00 -P : 90 bites/minute
-R : 21 times /minute
- T : 36,0o C
A : Anxiety Problem was
reduced
P : stop the intervention

S: client says still pain

The pain scale experienced by
clients is 1 (being).
0: No pain
1: Mild pain
2: Moderate pain
3: Severe pain
4: Unbearable pain
T : pain sometimes
0: clients are weak, and
appear in pain
A: diagnosed Painful
discomfort associated with
incision injury has not been
resolved
P: Continue the intervention