DATA ANALYSIS

 
PATIENT NAME : Mrs. N
AGE : 60 Years
NOT. REGISTER : 009973
 
OBJECTIVE DATA (DO) RELATED NURSING PROBLEMS
SUBJECTIVE DATA (DS) FACTORS/RISK (E) (P)
 
1 Biological injury  
Objective Data agent Acute pain (D.007)
     The patient said weakness and    
dizziness in the lower abdomen on a    
scale of 6    
     
     
Subjective Data:    
Patient looks weak    
- Can't activity    
- BP 100/70 mmHg    
     
     
2:  Subjective data :    
   
     Patient says weak and dizzy    
Objective Data:  
said the appetite was reduced, the  
patient only used up half and the patient  
defecated 5 times liquid  
   
Objective Data:  
GDS 529 mg/Dl  
- The patient looks lethargic  
- Installed 0.9 . NaCl infusion  
- on the back of the patient's left hand  
since June 29, 2018  
   
 
 
 
 
 
 
 
 NURSING DIAGNOSIS
 
PATIENT NAME : Mrs. N
AGE : 60 Years
NOT. REGISTER : 009973
 
NO DATE NURSING DIAGNOSES DATE SIGNATURE
APPEAR (IDHS) SOLVED
1 29 jan 2021 Biological injury agents associated    
    with acute pain characterized by 29 jan 2021 Emi Thessalonica
    the patient saying the patient said    
    weakness and dizziness and the    
    patient said lower abdominal pain    
    with a pain scale of 6. The patient    
    looked weak    
    BP 100/70 mmHg    
         
         
         
         
         
       
       
       
       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 PLANNING ( 4 PLANNING)
 
 
PATIENT NAME :  Ny . N             
AGE : 60 Years                           
REGISTER NO : 009973                           
 
NURSING DIAGNOSIS : Biological injury agent associated with acute pain
 
1. SIKI: pain level
a.                                        Complaints of pain Maintained /increased at   5                        
b.                                        Restless Maintained/ improved at 5                                                           
c.                                         Appetite Maintained/ improved
at 5                                                                    
d.                                                                               Maintained/ improved
at 5                                         
a.                                                                                  Maintained/improved
on                                         
b.                                                                                  Maintained/improved
on                                         
c.                                                                                   Maintained/improved
on                                         
d.                                                                                  Maintained/improved
on                                         
e.                                                                                  Maintained/improved
on                                         
f.                                                                                    Maintained/improved
on                                         
g.                                                                                  Maintained/improved
on                                         
 
2. SIKI : Fluid status
a.                                                                                Maintained /improved at 5
b.                                                                               Maintained /improved
at 5                                         
c.                                                                                Maintained /improved
at 5                                         
d.                                                                               Maintained /improved
on                                         
e.                                                                                Maintained/improved
on                                         
f.                                                                                 Maintained/improved
on                                         
g.                                                                                Maintained/improved
on                                         
h.                                                                               Maintained/improved on                                        
 

NURSING CARE PLAN

 
PATIENT NAME : Ny . N               
AGE : 60 Years                           
NO. REGISTER : 009973              
NO NURSING DIAGNOSES INTERVENTION
  (SIKI)
 
1. Biological injury agents associated with  
acute pain characterized by the patient Pain management: (I.08238)
saying the patient said weakness and Observations :
dizziness and the patient said lower Identify pain scale
abdominal pain with a pain scale of 6. - Monitor side effects of analgesic use
The patient looked weak - Identify factors that aggravate and
BP 100/70 mmHg relieve pain
  Therapeutic:
  rest and sleep facilities
  - Consideration of the type and source of
  pain in the selection of pain relief
  strategies
  Education:
  Explain the causes, periods and triggers of
  pain
  - Explain pain relief strategies
  -
   
   
   
   
   
   
   
   
   
   
   
   
   
   
 
 
 
 
 
 
                                NURSING ACTIONS
PATIENT NAME : Mrs. N
AGE : 60 Years
REGISTER NO. : 009973
NO NO.DX DATE/HOUR NURSING ACTIONS SIGN
HAND
2 2 30 jan 2021 Conducting Assessment Emi Thessalonica
    08:00  
      Measuring the patient's TTV  
      BP : 100/70 mmHg  
      Temperature : 36.2 C  
       
Pulse: 88 x/minute
       
      RR : 22x/minute  
         
       
- Provide a semi-Fowler/Fowler position
       
      according to the patient's needs.  
    10.00    
      - Patients feel comfortable when given a Emi thessalonica
     
      semi-Fowler's position.
     
     
   
- Control of environmental aggravating pain
  14.00
    ( eg room temperature, lighting, noise)
    - Facilitates rest and sleep
   
- Consider the type and source of pain in the
   
    selection of pain relief strategies
    - Advise self-monitoring of pain
    - Advise use of analgesics appropriately
   
    - Teach non-pharmacological techniques to
  16.00 reduce pain
  - Collaborative administration of analgesics
 
                                                
 EVALUATION
 
 
N AMA PATIENT : Ny . N             
U MUR : 60 years old                        
N OMOR REGISTER : 009 973
NO NO. DX DATE HOURS                                 EVALUATION
2 2 29 / 01 /202 1 S:
    08.00
      The patient said that the lower abdominal pain was reduced
      on a pain scale of six
       
    10.00 O:
      - the patient looks pale, can't move well
      - vital signs
      Body Temperature : 362ºC
    Pulse: 88x/minute
  Breathing: 22 x/minute
14.00  
  A:
16.00 Problem Not resolved
   
  Q:
  Intervention continued
 
- Observing non-verbal reactions to discomfort
- Position semi-fowler or fowler
- Give warm drink
- Consider the type and source of pain in choosing a pain
relief strategy
- Collaborative giving relieves pain