Student name: Maisya

SRN : 1614401320216
Date & hour of assessment : 06-02-2018
A. ASSESSMENT
1. PATIENT IDENTITY

a. Patient's name : Mrs.D

b. Date of birth / age :03-02-1981 / 37 years old
c. Religion : Moeslem
d. Education : Senior High School
e. Address : Puruk cahu
f. No CM :1-37-80-xx
g. Medical diagnosis : Brain Tumor

2. IDENTITY OF PARENT / RESPONSIBILITY

a. Name : Miss .P
b. Age : 58 years Old
c. Religion : moeslem
d. Education : Jonior High School
e. Work : housewife
f. Relationship with patient : parent

Origin of patient : × Outpatient

√ Inpatient

× Referrals
A. PRE OPERATION

1. Main Complaint:
2. History of disease: × DM × Asthma × Hepatitis × Heart × Hypertension × HIV
×None
3. Seat Operation / Anesthesia: × Yes √ No
4. Allergy Allergies: × Yes, mention .................. × None

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5. Type of Operation: Carnialtomy
6. Vital Sign :

Temp: 36,40c, pulse:100 bites/ mnt, Respiration: 20 times / mnt , TD: 120/80
MmHg
7. TB / BB: 162 cm/ 80 kg
8. Blood Type: B
PSYCHOSOCIAL / SPIRITUAL HISTORY
9. Emotional Status
√Calm ×Confused ×Cooperative , ×Uncooperative ,× Crying , × Withdrawal
10. Anxiety Level: × No Anxiety, √Anxiety
11. Anxious Scale: × 0 = Not anxious

×1 = Disclosure of concern
√ 2 = High attention level

× 3 = Concerns are not focused

× 4 = Simpate-adrenal response
× 5 = Panic

12. Skala Nyeri menurut VAS ( Visual Analog Scale )

No pain Mild pain Moderate pain Severe pain Very Pain Unrestrained pain
√ 0-1 × 2-3 ×4-5

× 6-7 × 8-9 × 10

13. Secondary Survey, do it head to toe by priority:

Normal If Not normal, explain

Yes No

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 𝚇 √ There is swelling (bumps) around the
Head face to the head

√ 𝚇
Neck

√ 𝚇
Chest

√ 𝚇
Abdomen

√ 𝚇
Genitalia

√ 𝚇
Integumen

Ekstremitas √ 𝚇

14. Results of Supporting Data

15. Laboratory:

HB ( 13,5 g/dl ) Ureum : 15 mg/dl

Ht : 41,0 g/dl Creatinin : 0,49
Leukosit : 10,93 g/dl SGOT : 43 IU
PT : 9,8 detik SGPT : 32 IU
APTT : 18,2 detik GDS : -

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B. INTRA OPERATION

1. Anesthesia begins hours: 10.10

2. Surgical starts at hour: 10.30
3. Type of anesthesia:
× Spinal √ General / general anesthesia × Local × Block node □ ...............
4. Operating position:
√supine × litotomy × stomach / knee chees × lateral: × right × left × other ......
5. Anesthesia Note: 6A
6. Installation of tools:
Airway: √ Attached ETT no: 7 , × Installed LMA no: ........ √ OPA √ O2 Nasal
7. TTV: Temperature 36,6 O C, pulse 90 bites / mnt, palpable ×strong, × weak,
× regular, √ irregular, RR x 22 x/ mnt, TD130/70 mmHg, saturation O2: 4 %

8. Secondary Survey, do the head to toe by priority

Normal If Not normal, explain

Yes No
𝚇 √ Carnialtomy surgery performed, 10.30
Head hour head section surgery

√ 𝚇
Neck

Chest √ 𝚇

√ 𝚇
Abdomen

√ 𝚇
Genitalia Client is famele,using chateter

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 Integumen √ 𝚇

Ekstremitas
√ 𝚇

Total liquid entering

□ Infusion:1500 cc
□ Transfusions: 3 cc

Total fluid out

□ Urine: 250 cc
□ Bleeding: 3 cc
Liquid balance: 3 cc
C. POST OPERATIONS
1. Patient moves to:
Move to ICU / PICU / NICU, clock_14.00 Wib RR, clock 14.10 Wib
2. RR Complaints: × Nausea × Vomiting dizziness √ Surgical pain × Legs feel
numbness × Shivering other ... ..
3. General Condition: ×Good, √ Moderate × Severe pain
4. TTV: Suhu : 35,5oC, pulse 90 bites / mnt, RR: 21 x / min, TD 110/80 mmHg,
Sat O2: 3%

5. Awareness: ×CM, √Apathy, ×Somnolen, × Soporo, ×Coma

6. Secondary Survey, do the head to toe by priority:

the head to toe by priority

Normal If Not normal, explain

Yes No
there are stitches about >2 cm after
Head √ 𝚇 Carnialtomy surgery performed, 10.30
hour head section surgery

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 Neck √ 𝚇

Chest √ 𝚇

Abdomen √ 𝚇

Client is famele,using chateter

Genitalia √ 𝚇

Integumen √ 𝚇

Ekstremitas
√ 𝚇

Skala Nyeri menurut VAS ( Visual Analog Scale )

No pain Mild pain Moderate pain Severe pain Very Pain Unrestrained pain
× 0-1 √ 2-3 × 4-5

× 6-7 × 8-9 × 10

II. DATA ANALYSIS

Symptom Problem Etiologi

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Pre Operasi Anxiety Lack of under - standing of

DS: The client said he was procedure

anxious and worried about

his operation today
DO: client looks nervous,
client face tense, confusion
and look weak
Scale anxiety is 2 (high
attention level )
Clien look ask abaout
procedure operation
Vital sign :
-Bp :120/80Mmhg
-P : 100 bites/minute
-R : 20 times /minute
- T : 36,4 o C

Intra Operasi risk of infection

DS : -

DO :
-Clients undergo claniatomy
surgery
-It seems the client performs
a head opening operation
using a knife, surgical
scissors, syringes and other
equipment
-Client using infus
-Client using O2 : 2 L
-Client using chateter
Vital sign :

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 -Bp : 130/70Mmhg
-P : 90 bites/minute
-R : 22 times /minute
- T : 36,6o C
Post Operasi Risk falls

DS: the client says it feels

pain in the head
P: Post operative pain
Q: pain disappears
R: on the part of the surgical
defensive (head)
S: 7 (0-10)

T : When the client moves a

little

Do: - Client seems weak

- still in full unconscious
condition due to anesthesia
drug anesthesia
- decrease in left lower
eksmoritas

Vital sign :

-Bp : 110/80Mmhg
-P : 90 bites/minute
-R : 21 times /minute
- T : 35,5o C

III. NURSING DIAGNOSES

Pre operation:
1. Anxiety Related to lack of understanding of procedure
Intra Operations:
1. risk of infection related to surgical infective procedures (tissue trauma)

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 Post Operation:
1. Painful discomfort associated with incision injury

IV. NURSING PLAN (including pre, intra and post operation)

No Nursing Goal intervention Rational
Diagnose
1 Anxiety After the do 1.Asses 1.anxiety is highly
Related to Nursing action client’s level of indivifualized,normal
lack of Anxiety was anxiety physical and
understanding solved yed 2. use presence physicological response
of procedure with criteria : touch and 2.touching technique can
verbalization communication relaxing patient
of feeling less technique
anxious 3. Approach 3. approach and
relaxed facial and motivate motivation help the
expression and the patient to patient to internalize
body express perceived anxiety
movement thoughts and
after given feelings 4. creates a sense of
nursing 4. Give confidence in the patient
intervention positive that he / she is able to
reinforcement overcome the
to continue problem and give self
daily activities confidence which is
despite being proved by the
anxious. recognition of others for
5. Encourage his ability.
the patient to 5.creates a feeling of
use relaxation calm and comfort.
techniques 6.increase knowledge,
6. Provide reduce anxiety
factual (real

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 and true)
information to
patients and
families
regarding
diagnosis,
treatment and
prognosis.
2 Risk of 1.Assess the 1.rabor,kalor,dolor,tumor
infection signs of and function of laesa on
infection client
2. perform 2. to prevent the
wound care infection entered the
3. use strerile wound
technique 3.sterile technique is one
4. hand of way to prevent port do
hygiene entery of infection
5.collaboration 4. To prevent the
in administered infection because of the
drug : hand of nurse
Antibiotics 5. Antibiotic is drug to
prevent the infection
3 Painful Aim: 1. Assess pain, 1. Useful in monitoring
discomfort After the act of note location, the effectiveness of
associated nursing the characteristics, drugs, the progress of
with incision pain can be scale (0-10). healing. Changes in pain
injury resolved or Investigate and characteristics indicate
handled report changes an abscess.
properly. in pain 2. Reduced abdominal
Results appropriately. stress that increases with
criteria: supine position.
· Reporting of 2. Maintain a 3. Increase the

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 lost or semi fowler normalization of organ
controlled break position. function, eg stimulate
pain. 3. Encourage peristaltic and smooth
· Reveals the early flatus, and decrease
method of ambulation abdominal discomfort.
giving up pain 4. Give an ice 4. Eliminate and reduce
relief. pack on the pain melelui nerve
· Demonstrate abdomen endings
the use of 5. Give note: do not do hot
relaxation analgesic some compress as it may cause
techniques and indication network congestion.
entertainment 5. Eliminating pain
activities as a facilitates collaboration
pain reliever with other therapeutic
interventions.
V. IMPLEMENTATION (including pre, intra and post operation)
No Day/date Time DX implementation Evaluation Sign
1 Tuesday, 10.00 I 1. Asesting - client identity
Feb,06th2018 patient identity is correct
10.05 2.helps to -all the client's
undress clients clothes are
and replace removed and the
them with lien has changed
patient clothes patient's clothes-
10.20 3. Asesting client level of
client’s level of anxiety was mild
anxiety - The touch and
10.25 4. Using Cummunicating
presence touch with patient
and before client

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 communication enter the
10.30 technique operating theatie
5. Encouraging - Nursing
the patient to teaching client
use relaxation to do relaxation
techniques. technique and
13.00 6. Assesting client follow it
pain, note 6. P: Post
location, operative pain
characteristics, Q: pain
scale (0-10). disappears
Investigate and R: on the part of
report changes the surgical
in pain defensive (head)
appropriately S: 6 (0-10)
13.10 7. . Maintain a T : When the
semi fowler client moves a
break position little

7. The client is
already in
position

VI. EVALUATION: (includes pre, intra and post operation)

No Day/date time time dx Ealuation

1 Tuesday, 10.35 I S : Client said
Feb,06th 2018 that her
anxiety was
reduce after
nurse have
conversation
with him

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 O :- Client
anxious was
reduce
- client
expression
was relax
- client
movement
was calm
Scale anxiety
client is 1
Vital sign : -
Bp :
110/80Mmhg
-P : 90
bites/minute
-R : 21 times
/minute
- T : 35,5o C
A : Anxiety
Problem is
reduced
P : stop the
intervention
13.20 S: client says
still pain
P: Post
operative
pain
Q: pain
disappears

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R: on the part
of the
surgical
defensive
(head)
S: 6 (0-10)

0: clients are
weak, and
appear in pain

A: diagnosed
Painful
discomfort
associated
with incision
injury has not
been resolved
P: Continue
the
intervention

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