No Data analysis Etiology Problem

1. Subjective data : Stimulation of pain pain

Clients say pain in the operating area. stimulates
Nociceptors in prifel
Objective Data:
- When reviewing the results of
observations Impression of pain is
Clients installed IVFD RL 20x / continued by fibers
Minute. Saraf afferen (A-
- Paien seems to hold back pain, Be delta & C) to
careful when moving. Spinal cord
- TTV: Through the back
Blood Pressure: 110/70 horn
Q: 36,8 C. RR: 22x / m, Pulse: 85x / m.
Scale 5 Pain (Moderate Pain)
Implus synapses on
PQRST pain assessment: Substance gelatinosa
1. Provocative: Factors that cause pain, (lamina II and III)
due to incision surgery.
2. Quality: Missing pain
3. Region: Pain spreads from the Implus passes the
incision area to the operation of the spinothalamus tract
abdominal abdomen
4. Scale: Pain on a scale of 5
(moderate) Implus goes into
5. Time: 1-2 Minutes reticular formation

Pain

2. Subjective data Surgery surgery Intoleranso activity

- The client says lethargic and weak Appendicitis
- Clients say it is difficult to move due
to appendicitis surgery scars.
Incision wound
Objective Data:
- General Conditions: tired
- The client is just lying in bed Limitations of
- All activities are assisted by the physical mobility
family
- Awareness:
Composmentis Activity intolerance
(Eye: 4, Verval: 5 Motoric: 6)
- TTV Client:
Blood Pressure: 110/70
Q: 36,8 C.
RR: 22x / m,
Pulse: 885x / m
3. Subjective Data: Appendicitis Knowledge
- The client said he was not aware of Deficiency
the illness
- Clients say they are still confused with Change in health
the disease and how to treat it status

Objective Data:
- Clients often ask about their condition Less information
- The client looks confused

Lack of knowledge
about conditions,
prognosis and health
needs

Definitive knowledge

4. Subjective data : Surgical surgery Risk of infection

- Clients say pain in former areas of
appendicitis surgery.
Insitis wounds
Objective Data:
- Examination of the abdominal area
- Blood Pressure: 110/70 Increased pathogen
- T: 36.8 C, RR: 22x / m, exposure from the
- Pulse: 85x / m environment

Entrance Pathogen

Risk of infection
Nursing problems that arise
1. Acute pain
2. Activity intolerance
3. Knowledge deficiency
4. Risk of infection

The priority of problems is based on nursing problems

1. Acute pain associated with Biological injury agents (incisions)
2. Activity intolerance related to bed rest
3. Knowledge deficiency is related to lack of information
4. Risk of infection associated with surgical incisions

Nursing diagnoses based on priority problems

1. Acute pain associated with Biological injury agents (lika incision)
2. Activity intolerance related to bed rest
3. Knowledge definition is related to lack of information
4. Risk of infection associated with surgical incision