Name : Nisa Aisah Murti

Medical Diagnose : Postoperative Lipoma

Nursing
No Asessment Intervention
Diagnose
1. Subjective Data: Damage skin NOC :
- Patients say there are integrity related to After 3x24 hours of
postoperative wounds postoperative treatment, it is expected
resulting from removal surgery that skin damage can be
of fat on the back. resolved with the results :
- Observe the patient's
Objective Data: condition
- There is wound - Clean wounds and
dressing in the upper change bandages
right back of ± 12 cm x 8 regularly.
cm. Wound dressing - Education of patients
looks clean, no discharge and families to
is seen. maintain body
hygiene, especially in
areas that have been
injured.
- Education for
improving nutrition.
- Collaboration with
doctors to administer
antibiotics if needed
Implementation
NIC : S:
- Observe the patient's
condition and the
wound condition
- Perform wound care:
- Clean wounds, change O:
bandages, and
administer antiseptic
drugs
- Educate patients and
families to maintain a
hygine, especially in
areas that have injuries.
- Educate patients to
improve nutrition by
consuming high-calorie
high-protein foods.
A: Problem partially resolved
P: intervention continued
Evaluation Sign
- - The patient feels more
comfortable and better
after the wound’s
cleaned.
- The patient looks more Nisa
comfortable after the
wound’s cleaned.
- There are ± 8 cm of
sewing wounds, 8
stitches with simple
hecting, there’s no
discharge, no redness.
- The skin around the
wound looks brown in
color, looks good, has
good elasticity.
- Collaborate with doctors
when administering
antibiotics if needed
Subjective data :
- Patient said he felt pain
in the upper right back
due to the postoperative
wound. pain is felt like
being pricked with a
scale 4. pain comes
when the back is pressed
or touched
Objective Data:
- Post surgery wound
removal of lipoma in the
right upper back.
- The patient appears to
hold pain when the
wound is touched.
- TD: 120/90 mmHg
- N: 78x / m
Accute pain NOC: pain control NIC: Pain Management S:
related to physical After nursing actions for - Perform a - Patients say feel more
injury (surgery) 1x2 hours, pain can be comprehensive comfortable after doing
controlled with the assessment. Assess deep breath pain
results: location, characteristics, management techniques.
- Verbalizes pain relief onset, duration, - Patients say will do this
- Demonstrates use of frequency, quality and technique if pain arises.
appropriate relaxation severity of pain O: Nisa
skills. - Observe for nonverbal - Patients can do deep
- Reports pain indicators of pain: breathing well.
management methods moaning, guarding, - Patients look more calm
relieve pain to a crying, facial grimace. after doing deep
satisfactory level - Use non- breathing relaxation
- Reports ability to get pharmacological pain techniques.
enough sleep and rest. relief deep breathing. A: Problem partially resolved
- Displays improved - improve rest. P: Intervention is continued
vital signs - Collaborate on
administer analgesics