Askep Hepatoma | Relaxation (Psychology) | Pain

Nama Mahasiswa NPM Hari/ Tanggal Ruangan A. Assessment 1.

Client Identity Name Gender Age Address Education Occupation Marital Status Religion Tribe / Nation MRS Date Medical Diagnosa No. RM Date of Assessment

: M. Luthfianoor Ryfani : 010028 D3 KI : : Flamboyan (Penyakit Dalam Pria)

: : : : : : : : : : : : :

Mr. I Male 53 Years Barabai Elementary School Farmer Married Islam Banjarese / Indonesian June 27th, 2012 Hepatoma 99.90.79 July 2, 2012

2. Identity of Responsible Person Name : Mr. A Gender : Male Age : 29 Years Occupation : Swasta Address : Barabai Relationship With the Client : Son B. Medical History 1. Main Complain The client said that his stomach is hurt when the assessment was done on July 2nd, 2012. 2. History of Present Disease The client had stomachache on July 1st, 2012 and was taken to the hospital in Barabai, after being examinde, the client was referred to RSUD Ulin on July 2nd, 2012 and being hospitalized in Flamboyan Ward to get further treatment. 3. History of Previous Disease The client said that he never had the disease he sufferred now. 4. History of Family’s Disease The client said that none of the client’s family had sufferred the disease that client sufferred, there was only one family member that ever had blind gut/appendix

Mouth and Dental The condition of mouth and dental were not really clean. There was no bleeding or inflammation. 8. the client’s ears looked clean. Olfactory function was good (could distinguish smells) 6. The client’s skin turgor was good (back less than 2 seconds) 3. client did not use visual aids. Skin The general condition of the client’s skin was normal. 7. the client did not use respiratory aids. The client breathed normaly through nose. the client's eyes looked clean. the client’s skin was clean enough.. 5. Sight and Eyes The structure of the client's eyes left and right were symmetrical. and Circulation Shape of the chest was normal. the client also has no limited neck motion. there were no secretions that came out. The client could swallow food. there were no lesions on the client’s head.C. there was no secretions in the eye. Chest. There was no inflammation in the oral cavity. . Olfactory and Nasal The client's nose was clean. Hearing function was good. Head and Neck The client’s hair distribution was equitable. Hearing and Ear The ears’ structure looked symmetrical. no dirt that came out. there were no blisters on the skin. and there were no hearing aids on the client’s ears. General Condition the client level of consciousness is at compas mentis. Conjunctiva anemis. clammy skin dry and warm. The taste function was good. The client’s lip mucosa looked dry. Physical Examination 1. chewing function was good. Respiration. There was no thyroid gland enlargement and no enlargement of lymph nodes on the client’s neck. symmetrical when respiration and also ekxpiration. with GCS: Eye : 4 (spontaneous eye opening) Verbal : 5 (conscious response and there is orientation) Motor : 6 (motoric response as instructed) Meanwhile the client vital signs as follows TD : 110/70 mmHg Rr : 20 x/minute T : 36o C N : 88 x/minute 2. 4.

9. infuse was attached on left upper extrimity. Abdoment Abdominal skin is clean. Nutrition At home At hospital 4. there were no deformities on lower extrimities. 10. there was no aids such as catheter attached in client’s genital. Elimination At home : the client ate three times a day with a fairly balance diet. client’s reproduction system is normal. : the client BAB 1-2 times a day and BAK 3-5 times a day. the client needed help from other people for assistance. Physical. Upper Extrimity and Lower Extrimity The Client’s upper extrimities were symmetrical between left and right. the client’s abdomen slightly bent. such as rice. 2. 3. Muscle strenght scale: 3 3 3 3 3 3 3 3 0 1 2 3 4 5 = = = = = = 3 3 3 3 3 3 3 3 no contraction (paralysis) there were no movements. Lower extrimities’ shape were symmetrical between left and right. There was no disorder on upper extrimities. D. Activity and Rest At home : The Client slept for 6 – 8 hours at night and 2-3 hours during the day. supervision. full muscle movement againts gravity and support. At hospital : the client never took a shower. there were no lesions or blisters. and Spiritual Needs 1. palpable/visible muscle contraction. but the client swabbed by his family. and vegetable. 11. Psychological. Personal Hygiene At home : the client took a shower twice a day. At Hospital : the client said that he was hard to sleep and the activity was helped by the family. Sexsual. and instruction. the client felt the pain in the upper right abdomen. The client only slept 4 – 5 hours on night. normal movement againts gravity normal movement againts gravity with a little resistance full normal movement againts gravity with full resistance The cilent’s activity scale was 2. . : the client only ate the food provided by hospital. brushed his teeth three times a day and changed clothes twice a day. side dishes. Genetalia dan Reproduction The Client is a male.

At hospital : The client BAB once a day and BAK 2 – 4 times a day. the client and family prayed so that the client could recover soon and he could gather with his family again. E. the client does not have any sexuality problem. Spiritual The client is a moslem.The client said that his activity was helped by the family.The client said that his stomach is hurt. the client is married.Muscle strength 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 . 6. Data Focus Subjective Data . there were many of his relatives came to visit him. .The client looked limp .The client looked holding his stomach . The client looked patient in facing his disease.The client looked weak . the client’s relationship with doctor. 7. Inspection .Client’s activity scale was 2 . nurse.The client’s family said that the client was a little bit worry about his disease.Breath sound was vascular . 5.Pulse : 88 x / min .The client looked pale .The client said that he was difficult to sleep. pain in the abdomen S = pain scale 2 .Client’s abdomen was bigger F. . and other medical team was good. Psychosocial The client’s relationship with his family is good.P = liver inflammation Q = like being stabbed R = in the stomach. Pharmachological theraphy . . Objective Data 1. Sexuality The client’s gender is male.

Data Analysis No Supporting Data 1 SD: The client felt the pain in stomach OD: P : liver inflammation Q : like being stabbed R : on upper right abdomen S : scale 2 T : intermitten / come and go The client hold his stomach 2 Problem Severe Pain Ethiology Physical injury agent SD: Change in .The client said that he was difficult to sleeping pattern sleep .The client looked limp and weak SD: . Supporting Examination Laboratory Result Examination Result Reference Value Unit Methode H.The client said that he slept for 3 – 4 hours OD: .The client said that the activity was being helped by family OD: .The client looked weak . 2012 G.USG result on July 2nd.Muscle scale / activity scale 2 3333 3333 3333 3333 Activity intolerance Pain in the abdomen 3 Decrease in muscle strength 4 SD: The cilent’s family said that the client was feeling worry about his disease OD: The client often asked about his disease Anxiety Disease process .

The client said that the activity was After nursing care was being provided for 3 days. with criteria: .Reduce the client’s pain .Colaboration in . Anxiety related to abdomen enlargement. I.Examine activity limit and muscle strength .The client did not looke weak . .Overcome the giving client’s pain analgetic.The client could sleep . with criteria: . Activity intolerance related to decrease of muscle strength 4.Reduce pain so that the client could sleep .Provide dry warm compress . the client could rest.Knowing Client’s general condition 2 Change in sleeping After the nursing pattern related to pain in care provided for 3 the abdomen days.Examine pain characteristic .Calm face expression Intervention . Severe pain related to physical injury agent 2.Comfortable comfortable position could position for the increase comfort client .Problem Priority 1. the client’s comfort level was increase.Teach relaxation technique .Colaboration with doctor in giving analgetic .Provide a .Knowing client’s condition 3 Activity intolerance related to decrease of muscle strength.So that the client explanation to knew the the client about impotance of the impotnce of sleeping for his resting and health sleeping .The client reported that the pain was reduced with scale 0-1 . activity intolerance could be resolved with criteria result: .Give .Knowing pain characteristic .Adjust client’s position as comfortable as possible . Intervention No Nursing Diagnosa 1 Severe pain related to physical injury agent Objective After the nursing care provided for 1 day.Reduce the pain .Reduce pain .Observe TTV Rational . Change in sleeping pattern related to pain in the abdomen 3. indicated by: .

The client could do activity . Observe TTV . Provide dry warm compress 4.The client looked weak .Activity scale: 2 .Help client’s activity Anxiety related to abdomen enlargement After nursing care was provided for 1 day. client’s anxiety was gone with criteria result: . .Pointed out his perception about his anxiety . .Activity scale 0 .Suggest the client’s family to help the client in doing his activity.Muscle scale 5555 5555 5555 5555 . 2012 Dx Implementation 1.Encourage the client to express his feeling about his disease . Implentation No Day/Date Time 1 Monday July 2nd. Teach relaxation technique The client looked comfortable The client’s pain was reduced The client still need relaxation technique exercise TD = 110/70 mmHg N = 88 x/m 5.Teach client and his family to do active ROM .The client looked calm .So that the client felt calm .Put the things that client needed near him .Muscle scale 3333 3333 3333 3333 .Prevent joints contraction and prevent atrophy .Train the client’s independence .Colaboration with doctor to explain about his diseas .So that the client felt calm .So that the client knew about his disease J. Examine pain characteristic P Q R S T = = = = = Evaluation liver inflammation like being stabbed in upper right abdomen scale 2 come and go I 2.The client was not weak anymore .being helped by family . Adjust client’s position as comfortable as possible 3.The client did not ask about his disease anymore.

Observe TTV . Examine pain characteristic The client felt calm 4 Tuesday July 3rd. Adjust client’s position as comfortable as possible 3. 2 1. 2012 The client understood about his disease P = liver inflammation Q = like being stabbed R = in upper right abdomen S = scale 2 T = come and go The client looked comfortable The client’s pain was reduced The client could do relaxation technique by himself TD = 110/70 mmHg I 2. client in doing his activity 1. 2. Provide dry warm compress 4. Give explanation to the client about the impotnce of resting and sleeping The client was calm when the analgetic was given The client felt comfortable The client understood nurse’s explanation II 3 3. Teach client and his family to do active ROM The client coul do the active ROM with a help by his family The client could take the things he needed by himself III 3.5o C 6. Suggest the client’s family to help The client’s family helped the client in doing his activity. Pointed out his perception about his anxiety 3. Encourage the client to express The client felt more calm his feeling about his disease IV 2.R = 22 x/m T = 36. Put the things that client needed near him 4. Teach relaxation technique 5. Examine activity limit and muscle The client’s family said that strength the client had difficulty in doing his activity and the activity was helped by the family. Colaboration in giving analgetic. Provide a comfortable position for the client 2. Colaboration with doctor to explain about his diseas 1. Colaboration with doctor in giving analgetic 1.

Adjust client’s position as comfortable as possible 3. Examine pain characteristic 7 Wednesday July 4th. Observe TTV TD = 120/80 mmHg N = 80 x/m R = 22 x/m T = 36. Colaboration in giving analgetic. Colaboration in giving analgetic. Provide a comfortable position for the client The client was calm when the analgetic was given The client felt comfortable 6 III 2.2o C 6. Examine activity limit and muscle strength III 2. 8 II 2. 5 II 2. Teach client and his family to do active ROM 3. Colaboration with doctor in giving analgetic 1.N = 88 x/m R = 22 x/m T = 36. Provide a comfortable position for the client 9 Reduced factors causing the sleep deprivation on the client Client’s activity scale was 1 Muscle scale 5555 5555 5555 5555 The client could do the active ROM by himself . 2012 I 2. Teach client and his family to do active ROM 1.2o C The client was calm when the analgetic was given The client felt comfortable 4. Examine activity limit and muscle strength Reduced factors causing the sleep deprivation on the client Client’s activity scale was 2 Muscle scale 4444 4444 4444 4444 The client could do the active ROM by himself The client could take the things he needed by himself P = liver inflammation Q = like being stabbed R = in upper right abdomen S = scale 1 T = come and go The client looked comfortable 1. Put the things that client needed near him 1. Colaboration with doctor in giving analgetic 1.

Evaluation No Day/Date 1 Monday July 2nd. 2012 Time Dx 2 3 4 5 Tuesday July 3rd.K. 2012 6 Evaluation Result S = the client said that his stomach was hurt O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 2 T = come and go A = problem was not resolved P = continue the intervention  Assess pain characteristic  Adjust client’s position as comfortable as possible  Provide dry warm compress  Teach relaxation technique  Observe TTV  Colaborate in giving analgetic S = the client said that he would try to sleep O = the client understood the importance of resting and sleepjng A = problem was partially resolved P = continue the intervention  Provide comfortable position for the client  Colaboration with doctor in giving analgetic S = the client said that his activity was helped by his family O = the client looked weak A = problem was not resolved P = continue the intervention  Assess activity limit and muscle strength  Teach active ROM to the client and his family  Put things that the client needed near him S = the client said that he understood about his disease O = the client looked calm A = anxiety problem was resolved P = stop the intervention S = the client said that his stomach was hurt O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 1 T = come and go A = problem was partially resolved P = continue the intervention  Assess pain characteristic  Adjust client’s position as comfortable as possible  Observe TTV  Colaborate in giving analgetic S = the client said that he could rest .

7 8 Wednesday July 4th. the client went home S = the client said that he can do his activity by himself O = the client’s family only helped in some activity Muscle scale 5555 5555 5555 5555 Activity scale 2 A = problem was resolved P = intervention was stopped. 2012 9 10 O = the client was slept at noon A = problem was partially resolved P = continue the intervention  Provide comfortable position for the client  Colaboration with doctor in giving analgetic S = the client said that sometimes his activity was helped by his family O = the client’s family still helped client’s activity A = problem was partially resolved P = continue the intervention  Assess activity limit and muscle strength  Teach active ROM to the client and his family S = the client said that the pain was reduced O = P = liver inflammation Q = like being stabbed R = in upper right abdomen S = pain scale 1 T = come and go A = problem was partially resolved P = intervention was stopped. the client went home . the client went home S = the client said that he could sleep O = the client looked fresh A = problem was resolved P = intervention was stopped.

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