CONCEPT OF NURSING

IN PATIENTS WITH ABDOMINAL TUMOR

1. Assessment

a. IDENTITY OF CLIENTS
1. Name :
2. Gender :
3. Age :
4. Work :
5. Religion :
6. Tribe :
7. Address :
b. Main complaint
c. Disease history now
d. Disease history ago
e. family history of disease
f. Physical examination

2. Nursing diagnoses

1. Determination of nursing diagnosis must be based on data analysis of the

results of the assessment , the nursing diagnoses were found grouped into
the actual diagnosis , potential and possibilities. ( Budianna Keliat , 1994.1
2. Some nursing diagnoses that may occur in patients with abdominal tumors ,
among others :

pre operation :
a) Anxiety b / d changes in health status .
b ) pain ( acute ) b / d of disease processes
c) Lack of knowledge regarding prognisis and treatment needs .
.
post operation :
a) High risk of fluid volume deficiency associated with surgery.
b ) Pain related to disruptions in the continuity of the network as a result of
surgery .
c ) Risk of infection associated with the surgical wound .

After formulating nursing diagnoses , created an action plan to reduce , eliminate and
prevent the problem client . ( Budianna Keliat , 1994 , 16 )
 Pre Operation
1. Anxiety / anxiety associated with changes in health status
Possible evidenced by : an increase in tension , restlessness , expressing concerns
about the changes in life events .

Expected results :
a) Demonstrate the proper range of feeling and reduced fear
b ) Relaxed and report on the level of anxiety decreases can be overcome .
c ) Demonstrate the use of effective coping mechanisms and active participation in
the regulation of drugs .

Intervention Rational

1 ) Encourage the client to express 1 ) Provide an opportunity to examine

his thoughts and feelings .
2 ) Provide an open environment
where clients feel safe to discuss his
feelings .
1 ) Maintain frequent contact with
clients .
the realistic fear and misconceptions
about diagnosis.
2 ) Assist the client to feel welcome on
their condition without feeling judged
and increase the sense of honor.
3 ) Provide the belief that the client
does not own or rejected.

2 ) Help clients / families in

recognizing and classifying the fear
to begin to develop coping strategies 4 ) Support and counseling as often as
. necessary to enable individuals to
recognize and deal with fear .
5 ) Provide accurate information
5 ) Can reduce anxiety

2. Pain associated with the disease process .

Possible evidenced by : complaints of pain , the response of the autonomic

nervous, cautious behavior

Expected results :
a ) To report a perceived pain decreased or disappeared
b ) Following the rules prescribed pharmacological
 intervation Rational

1 ) Determine the history of pain 1) The information provides a baseline

such as the location , duration and
for evaluating the needs / effectiveness
scale .
of the intervention.
2 ) Provide basic comfort
2) It enhances relaxation
measures eg massage his back and
fun activities for example music .
3) Allow clients to participate actively
3 ) Encourage the use of skills
using relaxation skills in enhancing the sense of control.
Management of pain such deep
breath .
4) Analgesics can inhibit pain
4 ) Collaboration analgetik as
stimulus.
indicated.

3. Knowledge anomalous C b / d to lack of information

Objective : can disclose accurate information about the diagnosis and treatment rules .
.
Intervensi Rasional

1 ) Review the client / person 1) Validate current level of

tedekat understanding special understanding to identify learning
diagnosis , alternative treatment and needs and basic memberiakan
the nature of hope . treatment where clients make
informed decisions .

2 ) Determine the client's 2 ) Assist identifiokasi ideas,

perceptions about cancer and cancer attitudes , fears , misconceptions ,
treatment . and kesenjanagan pengetahaun about
cancer .

3 ) contribute to the assessment of

3 ) Provide accurate and clear cancer diagnosis , provide the
information in a way that is real but necessary information for the time to
sensitive. absorb it .

4 ) Review the rules of special
treatment and the use of medications
that are sold freely .
5 ) Review the client / person nearest
the importance of maintaining
optimal nutritional status .
6 ) Encourage and increase fluid
intake and diet and regular exercise .
4 ) Improving the ability to regulate
perwatan yourself and avoid
potential complications , reactions /
drug interactions .
5 ) Increase welfare , facilitate
recovery and client sibility tolerate
the treatment .
6 ) meperbaiki consistency of the
stool and stimulate peristaltic
 Post Operasi

a. High risk of fluid volume deficiency associated with surgery.

Goal: Maintain adequate fluid volume premises moist mucous membranes , skin
turgor and capillary good vital signs stable and adequate output Urien .

Intervensi Rasional

1. Monitor vital signs frequently. 1. The early signs of intestinal

Check with a wound dressing often hemorrhage and hematoma formation
during the first 24 hours for signs of which can cause shock hepovelemik .
bright red blood and excessive .

2. periver pulse palpation . Evaluation 2. Provide information about the

of capillary refill skin turgor , and the general circulation volume and
status of the mucous membrane . hydration level .

3. Look for edema . 3. Edema can occur Because fluid

4. Monitor the input and output .
5. Monitor body temperature .
n you
displacement with respect to
decreased levels of albumin ( protein )
.
4. The direct indicator of hydration
organs and functions. Provide
guidelines for fluid replacement .
5. A low fever is common during the
first 24-48 hours and can increase
fluid loss .
 b . Pain related to disruptions in the continuity of the network as a result of
surgery .
Objective : Pain can be reduced
Criteria : The client expresses the pain has subsided and normal facial
expressions .

Intervensi Rasional

1. Assess the characteristics of pain . . Knowing the level of pain experienced

by the client as a reference for further
2. Measure vital signs intervention .

3. Teach relaxation techniques . 2. Knowing the progress or deviations

from expected results .

4. Teach a deep breath and coughing are 3. To relax the muscles , thereby
effective . reducing pain .

4. With a deep breath and cough that

5. Management of analgesic drug can effectively reduce blood pressure in
administration . the abdomen that can cause painful
stimuli .

5. Drug analgesics may reduce or

eliminate the pain .

c . Risk of infection associated with the surgical wound .

Objective : The risk of infection does not occur .

Criteria : The wound healed well , verband not wet and there are no signs of infection (
calor , dolor , rubor , tumor ) .

Intervensi Rasional

1. Assess for signs of infection and vital 1. Know the signs of infection and
sign. determine interventions.

2. Use of septic and antiseptic 2. Can prevent contamination with the

techniques . bacteria causing the infection.

3. The bandages were wet and dirty can

3. Replace verband . be a breeding ground for germs that

4. Provide education about how to
prevent infection .
5. Management of administration of
antibiotics .
cause infections .
4. It gives understanding to the client in
order to find out more about wound care
.
5. Antibiotics can kill germs that cause
infection .

4. Implementation
Adapted to the implementation of interventions listed in nursing plans are set and client
response time .

5. Evaluation
Evaluation is the last part of the nursing process all stages of the nursing process should be
evaluated .
The results of nursing care in accordance with the objectives that have been set . This
evaluation is based on the expected results or changes in the client . The targets of
evaluation on the client with abdominal tumors :

The results of pre -operative :

a. The client can show behavioral changes that are expected in the statement of
purpose .
b. The pain that is felt by the client is lost

Results Postoperative :
a. There is a shortage of fluid volume
b. There is no pain
c. There are no signs of infection .
d. Nutrition met.
e. There is no disruption of integrity .
 BIBLIOGRAPHY

Carpenito, Lynda Juall. 1995. Diagnosa keperawatan Aplikasi pada Praktek Klinik Edisi
6. Jakarta : EGC.
Ganong, F. William. 1998.Buku Ajar Fisiologi Kedokteran Edisi 17. Jakarta : EGC.
Marrilyn, E. Doengus. 1999. Rencana Asuhan Keperawatan Pedoman Untuk Perencanaan
dan Pendokumentasian Perawatan Pasien, Edisi 3. Jakarta : EGC.
Smelster, Suzanne C. 2001. Keperawatan Medikal Bedah, Edisi 8, Vol. 2. Jakarta : EGC.