A.

PENGAKAJIAN

I. Identification of patients
Name                                       : An "R"
Age                                         : twelve years
Address                                   : Boyolali
Edcarion : Student
Hospital admission date          : 20 februari 2019
Diagnostic medic                    : Hemangioma

II. Family history

1. The main complaint  : a lump in the nose
Nature of complaint                : settle
Location and distribution        : nose
Things that ease / burden        : break / tightness

2. Past health history

Patients say never hospitalized earlier
The patient said he had never had surgery
Patients say no allergies

III. Vital signs:
a. Blood pressure        : 100 / 70mmHg
b. Pulse                        : 70x / i
c. Body temperature   : 37 C
d. Respiratory             : 32x /i

IV. History needs comfort

The patient said he was anxiety about his illness
Patients say never impaired body temperature changes

DATA FOCUS
 Name: An "R"                                                needs: security and comfort
Age: 12 years old                                room: child treatment
Gender: male                                   date: 20 February 2019
Subjective data Objective data

The patient said he was worried about his Patient appears pale
health
Patients seems daydreaming 
the patient's mother said she was worried about
the action being taken to her child patient appears restless

patient said he could not sleep the patient's family always asks about the
indication for nursing action

Observation of vital signs:

Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i

DATA ANALYSIS

Name: An "R"                                                needs: security and comfort

Age: 12 years old                                room: child treatment
Gender: male                                   date: 20 February 2019

DATA ETIOLOGY PROBLEM

Subjective Data permeability changes fleura
1. The patient said congested while
sleeping on their backs Decreased plasma osmotic
pressure
2. Patients report pain in the chest area

3. Patients say often cough Increased systemic capillary

Objective data hydrostatic pressure
1. The patient appears pale
2. Patients seems weak Reduced dranaise limfatif
3. grimacing facial expression
4. Observation of vital signs Pulmonary edema fluid
Blood pressure: 100/70 mmHg movement and passing
Temperature: 37 c through the pleural lining
Nadi: 70x / i viselaris
Respiratory: 32x / i
Increased peritoneal fluid
DIAGNOSA NURSING
Anxiety associated with preoperative measures

Objective: after the act nursing 2x24 hours expected of patients to appear calm with criteria
results:

a. Reduced anxiety
b. The family seemed calm
c. Patient not restless

INTERVENTION NURSING

1. Maintain a calm, non threatening manner while working with the client.
Rational: Anxiety is contagious and may be transferred from health care provider to
client or vice versa. Client develops feeling of security in presence of calm staff
person.
2. Assure client of his or her safety and security.
Rational: The client’s safety is utmost priority. A highly anxious client should not be left
alone as his anxiety will escalate.
3. Maintain calmness in your approach to the client.
Rational: The client will feel more secure if you are calm and inf the client feels you are
in control of the situation.
4. Encourage the client’s participation in relaxation exercises such as deep breathing,
progressive muscle relaxation, guided imagery, meditation and so forth.
Rational: Relaxation exercises are effective nonchemical ways to reduce anxiety.
5. Move the client to a quiet area with minimal stimuli such as a small room or seclusion
area (dim lighting, few people, and so on.)
Rational: Anxious behavior escalates by external stimuli. A smaller or secluded area
enhances a sense of security as compared to a large area which can make the client feel
lost and panicked.

IMPLEMENTATION OF NURSING
1. maintain a calm and non-threatening attitude when working with clients.
Results: The patients can calm
2. Reassure client of his or her safety and security.
Results: the patients is assure about is safety and security.
3. Maintain calmness in your approach to the client.
Results: the patients calm in your approach to the client.
 4. Encourage the client’s participation in relaxation exercises such as deep breathing,
progressive muscle relaxation, guided imagery, meditation and so forth.
Results: the patients is deep breathing exercises
5. Moving the client to a quiet area with minimal stimuli such as a small room or seclusion
area (dim lighting, few people, and so on.)
Results: the patients calm

EVALUATION OF NURSING

 Subjective:
The patient said he was worried about his health
the patient's mother said she was worried about the action being taken to her child
patient said he could not sleep
 Objective:
Patient appears pale
Patients seems daydreaming 
patient appears restless
the patient's family always asks about the indication for nursing action
Observation of vital signs:
Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i
 Assessment:
 Issues not resolved interference comfort
 Planning: continue intervention
1. Maintain a calm, non threatening manner while working with the client.
2. Assure client of his or her safety and security.
3. Maintain calmness in your approach to the client.
4. Encourage the client’s participation in relaxation exercises such as deep breathing,
progressive muscle relaxation, guided imagery, meditation and so forth.
5. Move the client to a quiet area with minimal stimuli such as a small room or seclusion
area (dim lighting, few people, and so on.)