Name : Zulifah

NPM : 2020181073

Prodi : D3 Nursing class 2B

A. Nursing diagnosis
1. Ineffectiveness of the airway clearance is associated with excess secretion production
2. Acute pain associated with biologis injury agen

B. Planning and intervention

n Date Nursing Outcome Nursing intervention Signature

o
1 Friday, 3 After being conducted 1. Observe the general state
april 2020 nursing action along 2. Observe the vital sign
2x24 hours, the patient 3. Give the semifowler
will not of breath, position
criteria : 4. Teach effective cough
1. Respiratorion rate 5. Collaboration with the
returns to normal medical team
2. Ease of breathing
2 Friday, 3 After being conducted 1. Observe the general state
april 2020 nursing action along 2. Observe the vital sign
2x24 hours, the patient 3. Observe and assess pain
will not of pain, with characteristic
criteria : 4. Give a comfortable
1. Reduced pain scale position
2. Able to control pain 5. Teach relaxation of deep
breathing
6. Collaboration with the
medical team

C. IMPLEMENTATION

no Date Diagnose Implementation Respons

1 Friday, 1,2 Observing the SD:
3 april general state The patient said tightness and pain in
2020 his chest
OD:
the patient looks weak, tightness and
looks to hold pain
2. Friday, 1,2 Observing the SD :
3 april vital sign Patients are willing to be observed and
 2020 vital sign
OD:
Vital signs
BP : 95/70 mmHg
P : 100x / minute
T : 37,8 oC
RR : 28 x / minute
3 Friday, 1 Giving the SD :
semifowler
3 april The patient said he was willing to be
position
2020 given the semifowler position
OD :
The patient looks more comfortable
4 Friday, 1 Teaching SD :
effective cough
3 april The patient is willing to be taught to
2020 cough effectively
OD :
the patient appears to be following the
nurse’s instructions
5 Friday, 2 Observing and SD :
assess pain
3 april The patient said right chest pain
characteristic
2020 P : patients said pain when on the move
Q : the patient said pain like sharp
object
R : the patient said right chest pain
S : the patient said pain on a scale 6 out
T : the patient said the pain disappeared
OD :
The patient looks in pain
6 Friday, 2 Giving a SD :
comfortable
3 april The patient said comfortable with his
position
2020 position
OD :
The patient looks more comfortable
7 Friday, 2 Teaching SD :
relaxation of
3 april The patient sid he was willing to be
deep breathing
 2020 taught deep breath relaxation
OD :
the patient appears to be following the
nurse’s instructions
8 Friday, 1,2 Collaboration SD :
with the
3 april The patient said he is willing to given
medical team
2020 medicine
OD :
Patient appear to collaborate and
behave when given medical therapy
Ketorolac 30 mg/8 hours
Ondansentron 4 mg/8 hours
Ceftriaxone 1mg/12 hours