Name : Ajeng Triastiti Dinillah

English Level A

THE FORMAT OF NURSING CARE

POLY : INTERNIST
I. INVESTIGATION
- Name : Mr. B
- Age : 36 y.o
- Sex : male
- Occupation : farmer
- Religion : muslim
- Ethnic group : java
- Language : Indonesa/Javanes
- Education : elementary school
- Address : khairil anwar street
- Dx.medic : apendicitis
Responsible person
- Name : Mrs. S
- Telephone : 082 333 xxx xxx
II. FOCUS OF DATA
- Subjective Data
Summary :
The client said that his abdomen is pain. The regio in the right side, the scale is 9
from 10, pain likes a bite, the pain will incrase when he work and will be decrase
when he get rest. Client said he sick like this about 4 weeks and he checked to
Afiat Hospital.
- Objective Data
General conditon : weak
Blood pressure : 100/60 mmHg
Respiration : 26 bpm
Pulse : 80 bpm
Temperature : 38,9 ̊C

Abdomen : no inflame, pain in the right side (at Mc.Burney sign), abdominal
swelling, cramping

USG : the appendix is dilated about ±8mm (diameter)

III. NURSING DIAGNOSIS

1. Accute pain
2. Anxiety
3. Risk of infection
 Name : Ajeng Triastiti Dinillah
English Level A

IV.NURSING CARE PLAN FOR APPENDICITIS

- Ns. Diagnose : accute pain

- Goal : within our 8 hour span of care patient will be alleviated
from pain
- Ns. Intervention :
1. Independen
a. Facilitate on the provision of non pharmacologic such us back
rubbing and change the position
R/ To provide comfort
b. Facilitate on encouging the patient to have adequate rest periods
R/ To promote wellness and prevent fatigue
c. Move patient slowly and deliberately
R/ To minimize pain of movement
d. Facilitate on teaching the client about deep breathing exercises
R/ To teach the client way to control pain
e. Encourage verbalization of feelings about pain
R/ To assess the level of pain
f. Reposition periodially
R/ Prevent or reduces incidence complication of skin
g. Instruct the client to minimize activities that will put pressure on his
abdomen
R/ Have a lot of activities can result in pain
h. Encourage patient to have diversional activities such us mobile
internet and watching tv
R/ To alleviate pain
2. Collaborration
a. Administer analgesics as doctors`s order
R/ To maintain accetable level in pain and notify doctor if regiment
in adequate to meet pain control goal

- Ns. Diagnose : anxiety

- Goal : within 24 hours span of care patient will be able to
undestand and
demonstrate positive coping mechanism and describe a
reduction in the level of anxiety
- Ns. Intervention :
1. Independen
a. Establish rapport
R/ To gain trust and cooperation
b. Asses awarenes of patient about anxiety
R/ Validate the feeling and communicate acceptance of the feelings
c. Provide accurate information to the client
R/ Helps the client to identify what is reality based
d. Facilitate the provision of calm and quiet environment
R/ To prevent worsening of the condition and reduce stress level
e. Provide comfort measure
R/ To help the patient relax
 Name : Ajeng Triastiti Dinillah
English Level A

f. Encourage patient to talk about anxious feeling

R/ Talking about anxiety producing situations and anxious feelings
can help the person percieve the situation in less threatening
manner
2. Collaborration
a. Administer sedative as doctors`s order
R/ To maintain accetable level in anxiety notify doctor if regiment
in adequate to anxiety control goal

- Ns. Diagnose : risk of infection

- Goal : within our 36 hours span of care patient will be alleviated
from infection
- Ns. Intervention :
1. Independen
a. Observe the vital sign
R/ To identify what the reality based
b. Facilitate the patient to have a good hygiene
R/ To decrease risk infection
2. Collaborration
b. Administer antibiotics as doctors`s order
R/ To maintain accetable level in infection and notify doctor if
regiment in adequate to meet infection control goal