RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. Nyeri Akut b.d. agen cedera biologis

Tujuan : Setelah dilakukan tindakan keperawatan selama 5x24 jam
klien dapat merasakan penurunan rasa nyeri
Kriteria Hasil : Menunjuk skala 4 pada indikator NOC
NOC : Pain Control
N
O
1

INDIKATOR

Recognize pain onset

Describe causal factors

Uses analgesic as recommended

Recognize associated symptoms

of pain

Reports pain controlled

Keterangan Penilaian :
1
2
3
4
5

:
:
:
:
:

Never
Rarely
Sometimes
Often
Consistenly

Intervensi NIC :

Assure patient attentive analgesic care

Consider type and source of pain when selecting painrelief

strategy
Explore patients current use of pharmacological methods of

pain relief
Teach about pharmacological methods of pain relief
Encourage patient to use adequate pain medication

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. Impaired Urinary Elimination b.d. frekuensi
berkemih
Tujuan : Setelah dilakukan tindakan keperawatan selama 3x24 jam
Kriteria Hasil : Menunjuk skala pada indikator NOC
NOC : Urinary Elimination
N
O
1

INDIKATOR

Elimination pattern

Urine colour

Pain with urination

Burning with urination

Urinary frequency

Urine clarity

Keterangan Penilaian :
1
2
3
4
5

: Severely
: Substantially
: Moderately
:Mildly
: Not

Intervensi NIC : Urinary Elimination Management

Monitor urinary elimination including frequency, consistency,

odor, volume, and colour, as appropriate

Teach patient sign and symptoms of urinary tract infections
Instruct patient to monitor for sign and symptoms of urinary

tract infection
Restrict fluids, as neede
Instruct patient to empty bladder prior to relevant procedures.

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. Risk for Infection b.d
Tujuan : Setelah dilakukan tindakan keperawatan selama 5x24 jam
klien dapat merasakan penurunan rasa nyeri
Kriteria Hasil : Menunjuk skala pada indikator NOC
NOC : Risk Control : Infectious Process
N
O
1

INDIKATOR

Identifies infection risk in

everyday situation
Identifies personal sign and
symptoms that indicate potential
risk
Monitors time of infectious
disease incubation period
Practices action to promote fluid
intake

2
3
4
5

Takes immediate action to reduce

risk
Keterangan Penilaian :
1
2
3
4
5

:
:
:
:
:

Never
Rarely
Sometimes
Often
Consistenly

Intervensi NIC : Infection Control

Use intermittent catheterization to reduce the incidence of

bladder infection
Encourage fluid intake, as appropriate
Administer antibiotics therapy, as appropriate
Instruct patient to take antibiotics, as prescribe
Promote appropriate nutritional intake
Encourage fluid intake, as appropriate