ENGLISH III

ARRANGED BY:
WELI DASMULYANA
On Friday 12 April 2019 at 09.00 WIB.Tn.H had a motorcycle accident because it was grazed by one of the motorbikes. Then Mr. H fell on his stomach on his right
and then his right leg was hit by asphalt because the patient used his right leg as a pedestal. Then Mr. H was immediately taken to the nearest hospital. After
that, in the emergency room the patient is immediately examined by the emergency room nurse and after the examination is performed and given an action in
the emergency room, the patient is taken to the operating room. When the assessment was carried out it was found that the patient had a tibia fracture or broken
bone in the right leg, and the patient appeared to wince in pain. After the assessment and actions in the patient's room are ordered to rest.
 A. Assessment

1. Patien Identity
Name  :   Tn. H
Age :   49 tahun 2. Identity of the person
Gender:   Laki-laki responsible
Occupation :   Swasta
3. Main Complain
Education :   SD
Pain in the lower rigt leg
Address  :   Jambi
Religion :   Islam
Date of Entry :12 April 2019
No. RM :   147689
Medical diagnosis :   Fraktur
tibia
4. Medical history now
The patient's family said that the patient had a
broken bone because the patient had a motorcycle
accident on Saturday, April 12, 2019 ,. Some time
after the accident the patient is taken to the hospital
and given treatment only aids, bandages and other
measures. then the patient is taken to the operating
room to be given further treatment. The next day
the patient was given an x-ray examination,
laboratory and EKG (Electro Cardio Grafi).
at the time of the study which is the week of April
13, 2019 the patient said pain in his right leg. Pain
arises when moving, pain such as prickling, pain
continues continuously stops if the position is
comfortable and not moving
NEX
T …..

5. Previous Medical History

6. Family Health History
7. Daily Patterns of Life
8. Physical examination
9. Laboratory examination results
 B. Diagnosis

1. Acute pain is related to agents

that cause physical injury,
2. Physical mobility constraints
related to
damage n euromuskuler and
musculoskeletal
Data analysis

Date / hour Focus data Problem Etiology TTD

Sabtu  12 DS: The patient said pain in his right Acute pain physical injury  
leg, pain scale: 6 
-04-19  DO:
P : The right leg hurts when moving
Q : Pain like prickling  
R : Right leg attaches to the knee
( 1/3 proximal right to the tibia bone )
S : Pain scale: 6      
Q : Pain continues to stop when the
position is comfortable and not
moving .      
The patient seemed to be in pain , the
patient's facial expression seemed tense
 
Sabtu  12  DS: Barriers to Neuromuscular and
The patient said to be afraid to move and
-04-19  pain in the right leg if moving and the physical musculoskeletal damage
right leg could not be moved and pain if mobility
moving
 
DO : The patient looks bedrest , the
position of the leg elevation , the patient
looks weak , the patient looks afraid of
moving , In his activity the patient is
assisted by family and nurses
 Intervention

TTD
Date / No.  Goals and Criteria Intervention Rational
Time Dx Results

 
 Sabtu  1 After 3 × 24 hours 1. Teach and push for stress management 1. To know the
12 -04- of nursing action (relaxation, deep breathing, imagination, development of
19 
is expected to therapeutic touch). the client's health.
reduce or 2. Set a safe and comfortable  
disappear pain position. Maintain immobilization on the 2. Reduces pain and
with the following affected part. movement. Pain
criteria: 3. Collaboration with doctors in providing and spasm are
Pain scale 2-3. analgesics. controlled by
Relaxed and calm                                            . immobilization.
facial expression  
The patient looks 3. Treatment
relaxed. program to reduce
Assess the level pain.
of pain with
the PQRST standa
rd 
 Sabtu 2 After 3 × 24 1. (Range of Motion) passive and active. 1. Elevation position
 12 hours of nursing   reduces edema.
-04-19 
action is expected    
the problem of 2. Help and encourage patients to carry out 2. Increase muscle
physical mobility treatment activities gradually. strength.
obstacles can be    
overcome with   3. Mobilization
the expected 3. Give help in using the motion tool. reduces
results:   complications.
The patient's    
mobility ability 4. Minimizes pain and prevents wrong 4. Train the muscles
increases. position. and joints so as
The patient is not not to experience
afraid to move. contractures and
The patient is able complications.
to move
gradually.
The patient is able
to use aids.
 Implementation

Date / No Implementation Patient response TT D

time Dx
 Sabtu  1 1.Teach and push for the 1. The patient performs stress  
management of stress
 12 management by relaxing deep
(relaxation, deep
-04-19 breathing
breathing, imagination,
therapeutic touch).   
2. The patient has arranged a
2. takes a safe and
comfortable comfortable position
position. Maintain  
immobilization on the   
affected part. 3. To reduce pain
3. laboratory with a doctor
in administering
analgesics.
 N
e
x
t
 Sabt  2 1. Help and encourage   1. To practice moving the affected  
u  12 the patient to part                                                                                  
                                                                                           
-04- perform
                                                                         
19 maintenance
 
activities gradually.
2.Providing assistance 2. To help move      
in using the                                                                                            
                                                                                           
motion tool.                                                

3.Minimizes pain and 3.       Adjust the position to reduce pain

                                                                                                      
prevents wrong
                                                                                       
position.                                                      

 
 Evaluation

No Dx Evaluation
S: The patient says pain in his leg, still feels if to move but
1 decreases with deep breathing, P: Pain if to move Q: Pain
like prickling R: Pain in the fracture part S: Pain scale 6 T:
Pain continues to stop if comfortable position and and not
moving.   
O: The patient appears to be in pain, facial expressions are
tense
A: The problem of acute pain has not been resolved  
P: Continue intervention: 

S: The patient said that he was afraid to move, the patient

2 said it was painful to move.
O: The patient looks bedrest, the patient is supine sleeping
with the elevation of the patient's right thigh on the pillow,
the patient looks scared and in pain when moving, the daily
activity needs of the patient are helped by the family and the
patient looks weak.
A: The problem of physical mobility obstacles has not been
overcome
P: Continue intervention: