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Assesment Naris Wari Maswaiyah Qonita RegB 076
Assesment Naris Wari Maswaiyah Qonita RegB 076
NIM : P27820720076
Prodi : Pend. Profesi Ners Jenjang Sarjana
Terapan Semester 3
Dosen : Nurul Arifah,S.Pd.,S.Kep.,Ns.,M.Tefl., M. Kep.
Matkul : Bahasa Inggis 2
NURSING CARE
NEED SECURITY AND COMFORTABLE
A. PENGAKAJIAN
I. Identification of patients
Name : ny X
Age : thirty seven years
Family : five people
Last education : elementary school
Occupation : housewife
Address : Garut
Hospital admission date : 17 mei 2020
Diagnostic medic : effusion fleura
DATA FOCUS
Name: ny "R" needs: security and comfort
Age: 39 years old room: surgical treatment
Gender: female date: 17 Februari 2021
DATA ANALYSIS
V. DIAGNOOSA NURSING
Impaired sense of comfort associated with shortness
Objective: after the act of nursing 2x24 hours expected of patients showed
comfort with criteria results:
a. Shortness bekurang
b. Pain is reduced
c. Cheerful facial expressions
VI. INTERVENTION NURSING
1. Assess breathing pattern
Rational: to determine the pattern of breathing
2. Observation of vital signs
Rational: to recognize and facilitate action
3. Give a comfortable position
Rational: to reduce pain with semi-Fowler's position
4. Create a quiet neighborhood
Rational: to improve comfort
5. Collaboration with other nurses and other medical team in delivering
drugs
Rational: to reduce the complaints
VII. IMPLEMENTATION OF NURSING
1. Assess breathing pattern
Results: Respiratory 32x / i
2. Observe vital signs
Results: vital signs
Blood pressure: 100/70 mmHg
Temperature: 37 c
Breathing: 70x / i
3. Provide a comfortable position possible (semi-Fowler)
Results: The patient can perform semi-Fowler's position
4. Creating an environment that is quiet
Results: The patients can calm
5. Treatment with nurses and other medical team in delivering drugs
Results: The administration of analgesic drugs