Nursing Care For An.

 M With
  Intra Abdomen Tumors 
In the Ground Floor Children's Room
Central General Hospital RSUD Ali Hanafiah Batusangkar
 

by:Neli Apriyenti
NIM : 1914201084
 Nursing Care An. M with Intra Abdomen Tumors
In the Children's Room Lt. Basic, RSUD Ali Hanafiah

I. ASSESSMENT

A.Demographic Data
1. Client / Patient
1) Date of assessment : Monday, October 8, 2019 (preoperative)                   
Wednesday, October 10, 2019 (post operation)
    2) Entry date : October 6, 2019                   
    3) Room : Ground Floor Children                                 
     4) Identity     
• Name : An. M                                         
• Date of birth / age : September 6, 2006             
• Gender : Male                           
• Religion : Islam                                         
• Medical diagnosis : Intra-Abdomen Tumor             
B.client history
1.Medical history
Main complaint
 The client complains of pain in the abdomen when touched

or moved with a pain scale 3. Pain disappears.

Current medical history

 The referral client from HC Tanjung Baru came to RS Ali

Hanafiah with his family due to stomach pain . Clients

come from IGD is mounted infusion Lacta Ringer t .
After surgery hungry as tomy and ileostomy on October 9,
2019 clients complained of pain with a scale of 7 (severe
pain). Clients installed NGT, Infusion, DC and drainage with
brownish yellow liquid.
 
C.Family Health History

 M child's family has no history of infectious

and hereditary diseases and previous similar
diseases 
D.Current Disease History

 General Appearance
General condition
 Clients seem calm, sometimes crying when in
pain. Infused.
 TTV
 1) Respiration : 24 x per minute                                 
 2) Temperature : 37 o C                                 
 3) Pulse : 110 x minute                                 
 4) Blood pressure : 110/70 mmHg                   
 Use of breathing aids
 Clients do not use breathing aids.
 Head to toe:
      
 Head :
 Nose (olfaction):
 Ears (hearing):
 Mouth and teeth:
 Thoraks:
 Abdomen :
 Reproduction :
 Extremities:
 E. Supporting Examination
 Laboratory
 Therapy
F. Classification of data
G. Data analysis              
II. DATA ANALYSIS
NO DATA PROBLEM ETIOLOGY
0 1. Pre Operation: Acute pain Abdominal dementia
DS: The client complained of pain in the abdomen,
the family said the client cried when pain came.
P: Abdominal dementia
Q: like punctured
R: In the abdomen
S: Scale in number 3
Q: Missing arises
DO: Composition of the patient's condition, pain
scale 3 (mild pain) was measured with a face baker
scale.
Abdominal circumference: 68 cm
Vital sign :
TD: 110/70 mmHg
Pulse: 110 x / minute
RR: 24 x / minute
Temperature: 37 O C
Pre Operation: Acute pain Abdominal
DS: The client complained of pain in the abdomen, the family said the client cried when pain dementia
came.
P: Abdominal dementia
Q: like punctured
R: In the abdomen
S: Scale in number 3
Q: Missing arises
DO: Composition of the patient's condition, pain scale 3 (mild pain) was measured with a face
baker scale.
Abdominal circumference: 68 cm
Vital sign :
TD: 110/70 mmHg
Pulse: 110 x / minute
RR: 24 x / minute
Temperature: 37 O C
Post operation
DS: client complains of pain around the area of the surgical wound (abdomen)
P: postoperative wound
Q: like slashed
R: area of the surgical wound (abdomen)
S: The scale at number 7 (severe pain), measured by the wong baker scale face.
Q: continuously Acute pain
DO: Complementary patient condition , pain scale 7 (severe pain) . Injury agent (
65cm belly circumference postoperative
Vital sign : wound)
TD: 110/ 8 0 mmHg, Pulse: 110 x / minute, RR: 24 x / minute,Temperature: 37 O C
0 2. DS: Mrs. clients say if the post op Damage to skin Operation action
wound client has not been integrity
replaced Mrs. clients tell the
client feel pain in the postoperative
wounds, but did not have a fever,
the family do not know the
condition of the wound
DO:
Post op injuries have not been
opened during H + 1 laparastomy
and ileostomy. , the wound looks
elongated in the area of the lower
left abdomen. Wound length is 10
cm. Wound width is 1 cm. there is a
stoma (post ileostomy) . There is no
permeability. Pain scale 7 (severe
pain)
III.PROBLEM LIST

NO Date Found DX PEM Date Resolved TTD

1 October 8, 2019 01 Not resolved yet

2. October 10 , 2019 02 Not resolved yet

IV.N URSING PLAN

INTERVENTION
DATE / DX
NO
HOUR PEM Purpose Action
1 October 8, 01 After taking nursing Perform a
2019 actions for 5 x24 hours comprehensive
9:00 p.m. the patient is expected pain assessment
to be able to cope with including location,
pain with the following characteristics,
criteria: duration,
a. The client reports frequency, quality,
that pain is reduced and precipitation
by using pain factors
management Monitor vital signs
b. Able to recognize Teach about non-
pain pharmacological
c. Expressing comfort techniques
after the pain is Increase rest
reduced Collaboration of
analgesics
2 October 8 , 2019 02 NOC:
9:30 p.m.
a. Tissue integrity: skin and mucous Pressure Management
b. Membranes
c. Wound healing: primary and secondary Keep the skin clean to keep it clean and dry
After taking nursing actions for 3 x 24 hours Mobilize the patient (change the position of
the patient) every 2 hours
Damage to the integrity of the patient's skin is Monitor patient activity and mobilization
resolved with the following criteria: Wound observation: location, dimensions,
depth of wound, characteristics, color
d. Good skin integrity can be maintained of fluid, granulation, necrotic tissue,
(sensation, elasticity, temperature, signs of local infection, tract formation
hydration, pigmentation) Perform wound care techniques with sterile
e. There are no sores / lesions on the skin
f. P erfusi jar InGaN well
g. M enunjukkan understanding y an g
good d a l a m skin repair process and
prevent recurring injuries
h. Able to protect the skin and
maintain skin moisture and natural care
i. Indicates the occurrence of the wound
healing process
 V.IMPLEMENTATION
Day, No. Nursing Implementation The response
date , diagnoses
hour
Monday, 01 - Comprehensive assessment of DS: The client says his stomach
October pain, including location , characteristics, feels painful and tightens.
8, 2019 duration, frequency, quality and precipitation P: Abdominal dementia
21:00 factors Q: Like being pricked
21:30 - M em onitor vital signs R: Abdominal region
- Encourage clients to increase S: pain scale 3 (mild pain)
rest Q: Missing arises
DO:
The client seems to be in pain.
Pain scale 3 (mild pain) . Belly
circumference 68cm
 VI.E VALUATION

Date and time Nursing diagnoses Progress notes

Monday, October 8, Acute pain S : The client says his stomach hurts and feels tight.
2019
P: Abdominal dementia
Q: It's like being stabbed
R: Abdomen
S: Scale 3 (mild pain)
Q: Missing arises
O : The client looks in pain, but still in good
condition.
Good general state, compocmentis awareness. Pain
scale 3 (mild pain) . Belly circumference 68 cm
Pulse frequency: 110 x / minute
Breathing frequency: 24 x / minute
Temperature: 37 O C
A : the problem has not been resolved
P : Continue intervention