DATA FOKUS

Patient Name: Mr. D Age: 60 Years

No. Medical Records: 12.82.05 Gender: Male

Data subjektif Data objektif

- Patient says no appetite -The patient looks weak just lying in bed
- The patient says pain when moving the right -Patient looks difficult to move the upper and
extremity lower extremities on the right
P: The pain increases with activity -The patient has an assering infusion
Q: The pain feels like being stabbed - The patient has a urinary catheter in place
R: Right upper and lower extremities ttv results
S: Pain scale 5 (moderate pain) BP: 142/82mmHg
T: 5 minutes N : 90x/minute
S : 36.9° C
Rr: 20x/minute
SPO: 98
 ANALISIS DATA

Patient Name: Mr. D Age: 60 Years

No. Medical Records: 12.82.05 Gender: Male

No Data Masalah Etiologi

1 Data subjektif : acute pain physical harming
- Patient says no appetite agent
- The patient says pain when moving
the right extremity
P: The pain increases with activity
Q: The pain feels like being stabbed
R: Right upper and lower extremities
S: Pain scale 5 (moderate pain)
T: 5 minutes
Data objektif :
-The patient looks weak just lying in bed
-Patient looks difficult to move the
upper and lower extremities on the
right
-The patient has an assering infusion
- The patient has a urinary catheter in
place
ttv results
BP: 142/82mmHg
N : 90x/minute
S : 36.9° C
Rr: 20x/minute
SPO: 98
 RENCANA ASUHAN KEPERAWATAN
Patient Name: Mr. D Age: 60 Years

No. Medical Records: 12.82.05 Gender: Male

No Diagnosa Tujuan dan kriteria Intervensi Rasional Paraf

keperawatan hasil
1 Acute pain After nursing Pain Management I.08238 1. Measuring the Devi
related to actions for 3x24 Observation: scale of pain felt
physical hours it is expected 1. Identify a pain scale by the patient
injurious agents that the pain level 2. Identify factors that 2. Can reduce pain
has not been will decrease. By aggravate and relieve pain by knowing the
resolved yield criteria: Therapeutic : aggravating
-The ability to 3. Environmental controls factors.
complete activities that exacerbate pain such 3.Normal
increases as room temperature temperature
-Complaints of pain Education : makes comfort
decreased 4. Describe non- when resting
-Withdraw down pharmacological techniques 4. Teach the
-Nausea decreased to reduce pain patient ways to
-Pulse rate Collaboration: relieve pain
improved 5. Administration of 5. Analgesic drugs
analgesic drugs such as: can relieve the pain
katerolac that is felt.
 IMPLEMENTASI ASUHAN KEPERAWATAN
Patient Name: Mr. D Age: 60 Years

No. Medical Records: 12.82.05 Gender: Male

Hari, tanggal Diagnosa Implementasi Respon Paraf

dan jam keperawatan
Senin, 22 mei Nyeri akut 1. Identify a pain scale Rs : The patient Devi
09.00 b.d agen says it hurts when
pencedera doing the movement
fisik Ro: The patient
looks grimacing in
pain

10.00 Nyeri akut 2.Identify factors that Rs : The patient's

b.d agen aggravate and relieve pain family said that he
pencedera did not feel pain at
fisik rest
Ro: Pain felt by the
patient when
moving

10.30 Nyeri akut 3. Control environments that Rs: The patient says
b.d agen exacerbate pain, such as comfortable with a
pencedera room temperature normal room
fisik temperature of
25°C
Ro : The patient
looks comfortable
with a temperature
of 25°C
11.30 Nyeri akut 4. Describe non- Rs: The patient's
b.d agen pharmacological techniques family says they
pencedera to reduce pain understand.
fisik Relaxation exercises
Ro: The patient's
family helps the
patient recover
12.00
Nyeri akut 5. Administration of Rs: The patient says
b.d agen analgesic drugs such as: the pain is reduced
pencedera katerolac (scale 3)
fisik Ro: The patient's
pain is reduced

Selasa, 23 Nyeri akut 1. Control environments that Rs: the patient says
mei b.d agen exacerbate pain, such as he is comfortable
09.00 pencedera room temperature with a normal
fisik temperature of
25°C
Ro: the patient looks
comfortable

11.40 Nyeri akut 2. Describe non- Rs: the patient says

b.d agen pharmacological techniques he is diligent in
pencedera to reduce pain doing relaxation to
fisik relieve pain
Ro: the patient's
grimace is reduced

13.00 Nyeri akut 3. Administration of analgesic Rs: the patient says

b.d agen drugs such as: katerolac the pain has
 pencedera decreased but
sometimes it occurs
Ro: the patient's
pain is slightly
reduced

Rabu, 24 Acute pain Control environments that Rs: the patient says
mei related to exacerbate pain, such as the temperature is
09.00 physical room temperature quite comfortable
injurious Ro: The patient is
agents comfortable with a
has not temperature of
been 25°C
resolved
10.00 Acute pain Identify a pain scale Rs: the patient says
related to the pain has
physical decreased with a
injurious scale of 2
agents Ro: The patient can
has not move
been
12.00 resolved Administration of analgesic Rs: the patient says
Acute pain drugs such as: katerolac the pain has
related to decreased
physical Ro: The patient can
injurious move normally
agents
has not
been
resolved
 EVALUASI/CATATAN PERKEMBANGAN ASUHAN KEPERAWATAN

Patient Name: Mr. D Age: 60 Years

No. Medical Records: 12.82.05 Gender: Male

Diagnosa keperawatan Hari tanggal Evaluasi SOAP

Acute pain related to Senin, 22 mei S : The patient says it hurts when doing Devi
physical injurious 12.00 the movement, The patient's family said
agents has not been that he did not feel pain at rest, The
resolved patient says comfortable with a normal
room temperature of 25°C, The patient's
family says they understand. Relaxation
exercises, The patient says the pain is
reduced (scale 3)

O: The patient looks grimacing in pain,

Pain felt by the patient when moving, The
patient looks comfortable with a
temperature of 25°C, The patient's family
helps the patient recover, The patient's
pain is reduced

A: Acute pain related to physical injurious

agents has not been resolved

P: continue intervention: Describe non-

pharmacological techniques to reduce
pain
Acute pain related to Selasa, 23 mei S: the patient says he is comfortable with Devi
physical injurious 12.00 a normal temperature of 25°C, the
agents has not been patient says he is diligent in doing
resolved relaxation to relieve pain, the patient says
the pain has decreased but sometimes it
occurs

O: The patient is comfortable with a

temperature of 25°C, the patient's pain is
slightly reduced, the patient's grimace is
reduced

A: Acute pain related to physical injurious

agents has not been resolved

P: continue intervention: Administration of

analgesic drugs such as: katerolac

Acute pain related to Rabu, 24 Mei S: the patient says the temperature is Devi
physical injurious 13.00 quite comfortable, the patient says the
agents has not been pain has decreased with a scale of 2, the
resolved patient says the pain has decreased

O: The patient is comfortable with a

temperature of 25°C, The patient can
move, The patient can move normally

A: Acute pain associated with the

physically injurious agent is resolved

P: Advise patient to be outpatient