ASSESSMENT

Name : Mr. E

Age : 17 Year

Sex : Male

Marital Status : Single

Occupation : Student

Date : August 9, 2019

Time : 14.00 Pm

Primary Language : Indonesia

Arrived Via : Ambulance

From : Other

Family G.P : Parents

Weight : 50 kg

Height : 150 cm

BP : 100 / 80 mmHg

Temp : 36,6 °C
Pulse : 90 times/min
Resp : 22 times/min

1. Reason for admission ( Onset, Duration, Pt’s Perception) :

Client comes with complaints of pain in the right leg due to an accident, it
appears an open wound and fraktur cruris dextra.

2. Usual health status :

The client is planned to have an operation for fitting the right leg on the
client, the client says pain in the right foot, pain arises when the foot is
moved, pain such as a sharp object is pricked and pain is felt continuously,
pain scale 6.

3. Chronology of the illness :

The client came with his family conscious and there was a wound on the
right leg due to an accident, the client is currently being treated in an
emergency department and will undergo surgery.
4. Effect of the illness on the patient’s daily life :
The patient feels pain and is difficult to move his right leg, so that his
activities are assisted by the family

5. Previous hospitalization :
Mr. E said this is the first time being treated at a hospital

6. Pevious Surgery :
Mr. E said this was her first time operating

7. Childhood Diseases :
Mr. E said has no previous disease history
 IMPLEMENTATION

Tanggal Tanggal

No Intervention August 9, 2019

Signature N M E Signature N M E

Dx 1:acute pain r/ t physical injury agent

Do a comprehensive pain
assessment (intensity,
1
characteristics, and the degree
of pain)

Observe non-verbal cues of

2
anxiety

3 Provide a comfortable position

Teaches deep breathing

4
relaxation techniques

Collaboration analgesic drug

5
delivery

6 Monitor vital signs

Dx 2: anxious r/ t surgery

1 Measure vital signs

2 Use a soothing approach

Identify the level of anxiety
3
(Hars)
Teach relaxation techniques and
4
deep breathing distraction
 EVALUATION

NO DATE EVALUATION

DX1 August S: :
9, 2019 Clients say still feel pain in the foot right, pain arises when the foot is moved,
pain such as a sharp object pierced and pain is felt continuously

O:
- Client looked tense and grimaced with pain
- Pain scale 5
- Looks fracture tibia fibula dextra
- Patients were given 30 degree position
- vital sign
BP : 110/80 mmHg
HR : 90 times / min
RR : 22 times / min
Temperature: 36.5 C

A: :
Acute pain r/t physical injury agent is not resolved

P:
- Monitor pain scale
- Monitor vital signs
- Giving analgesic
DX2 August S:
9, 2019 Clients say anxiety is reduced and feel calmer

O: :
- Measuring vital signs
BP: 110 / 80mmHg
HR: 90 times / min
RR: 22 times / min
Temperature: 36,5C
- he level of anxiety (Hars): a score of 10 (mild)
- The client is able to perform deep breathing relaxation techniques

A:
anxious r/ t surgery resolved

P : -Monitor vital signs