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Rencana, Implementasi, EvaluasiTanggal / Jam
Diagnosa Keperawatan
Tujuan Intervensi Implementasi Evaluasi
28 September 2015/ 18.00 Wita
Nyeri Akut NOC: Pain Level Pain Control Comfort LevelSetelah dilakukan tindakan keperawatan selama 3 x 24 jam nyeri yang dialami klien terkontrol, dengan kriteria hasil: Mampu mengontrol
nyeri (tahu penyebab nyeri, mampu menggunakan tehnik nonfarmakologi untuk mengurangi nyeri, mencari bantuan)
Melaporkan bahwa nyeri terkontrol dengan menggunakan manajemen nyeri dan dapat beradaptasi
Mampu mengenali nyeri (skala, intensitas, frekuensi dan tanda nyeri)
Menyatakan rasa
NIC :Pain Management
Lakukan pengkajian nyeri secara komprehensif termasuk lokasi, karakteristik, durasi, frekuensi, kualitas dan faktor presipitasi
Observasi reaksi nonverbal dari ketidaknyamanan
Bantu pasien dan keluarga untuk mencari dan menemukan dukungan
Kontrol lingkungan yang dapat mempengaruhi nyeri seperti suhu ruangan, pencahayaan dan kebisingan
Kurangi faktor presipitasi nyeri
Kaji tipe dan sumber nyeri untuk menentukan intervensi
Ajarkan tentang teknik non farmakologi: napas
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nyaman setelah nyeri berkurang
Tanda vital dalam rentang normal
dala, relaksasi, distraksi, kompres hangat/ dingin
Berikan analgetik untuk mengurangi nyeri
Tingkatkan istirahat Berikan informasi tentang
nyeri seperti penyebab nyeri, berapa lama nyeri akan berkurang dan antisipasi ketidaknyamanan dari prosedur
Monitor vital sign sebelum dan sesudah pemberian analgesik pertama kali
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.. .........Tanggal / Jam
Diagnosa Keperawatan
Tujuan Intervensi Implementasi Evaluasi
28 September 2015/ 19.00 Wita
Risiko Kekurangan Volume Cairan
NOC: Fluid Balance HydrationSetelah dilakukan tindakan keperawatan selama 2 x 24 jam tidak terjadi kekurangan volume cairan, dengan kriteria hasil: Tekanan darah, nadi,
suhu tubuh dalam batas normal
Tidak ada tanda-tanda dehidrasi, turgor kulit baik, membran mukosa lembab, tidak ada rasa haus yang berlebihan
NIC :Fluid Management Pertahankan catatan
intake dan output yang akurat
Monitor status hidrasi (kelembaban membran mukosa, nadi adekuat, tekanan darah ortostatik), jika diperlukan
Monitor hasil lab yang sesuai dengan retensi cairan (BUN , Hmt , osmolalitas urin, albumin, total protein )
Monitor vital sign setiap 15menit – 1 jam
Kolaborasi pemberian cairan IV
Monitor status nutrisi Berikan cairan oral Dorong keluarga untuk
membantu pasien makan
Kolaborasi dokter jika tanda cairan berlebih
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muncul meburuk Atur kemungkinan
tranfusi Persiapan untuk tranfusi Pasang kateter jika
perlu Monitor intake dan urin
output setiap 8 jam
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Tanggal / Jam
Diagnosa Keperawat
anTujuan Intervensi Implementasi Evaluasi
28 September 2015/ 19.30 Wita
Ansietas NOC: Anxiety ControlSetelah dilakukan tindakan keperawatan selama 2 x 24 jam kecemasan pasien teratasi, dengan kriteria hasil: Vital sign dalam batas
normal Postur tubuh, ekspresi
wajah, bahasa tubuh dan tingkat aktivitas menunjukkan berkurangnya kecemasan
NIC :Anxiety Reduction Gunakan pendekatan yang
menenangkan Nyatakan dengan jelas
harapan terhadap pelaku pasien
Jelaskan semua prosedur dan apa yang dirasakan selama prosedur
Temani pasien untuk memberikan keamanan dan mengurangi takut
Berikan informasi faktual mengenai diagnosis, tindakan prognosis
Libatkan keluarga untuk mendampingi klien
Instruksikan pada pasien untuk menggunakan tehnik relaksasi
Dengarkan dengan penuh perhatian
Identifikasi tingkat kecemasan
Bantu pasien mengenal situasi yang menimbulkan
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kecemasan Dorong pasien untuk
mengungkapkan perasaan, ketakutan, persepsi
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