Name 

                                      : ny "N"
Hospital admission date          : 22 February 2021
Diagnostic medic                    : effusion fleura

Subjectiv Objektif data Diagnosa NOC NIC Rasional Evaluasi

e data Nursing
1. The 1.The Impaired after the 1.Assess 1.to S : patients
sense of act of breathing determine say
patient patient comfort nursing pattern the pattern claustrophobi
said appears pale associate 2x24 hours of c when
d with expected breathing sleeping on
congested shortness of patients 2.Observation 2. to their backs
2. Patients showed of vital signs recognize  Clients say
while
seems weak comfort and pain in the
sleeping
with facilitate chest
on their criteria action  Clients say
3. grimacing
backs results: often cough
facial a. 3.Give a 3. to O: patient
expression Shortness comfortable reduce appears pale
2. reduced position pain with  patients
b. Pain is semi- seems weak
Patients 4.
reduced Fowler's  grimacing
report Observation c. Cheerful position. facial
pain in of vital signs facial expressions
expression 4.Collaboratio 4. to  observation
the chest Blood s n with other reduce the of vital signs
area pressure: nurses and complaint Blood
other medical s pressure:
100/70
team in 100 /
3. mmHg delivering 70mmHg
Patients Temperature drugs temperature:
37 C
say often : 37 c Pulse: 70x / i
cough Nadi: 70x / i Respiratory:
32x / i
Respiratory: A: Issues not
32x / i resolved
interference
comfort
P: continue
intervention