You are on page 1of 22



1.1 Background
Varicella, commonly known in the United States as chickenpox, is caused
by the varicella-zoster virus. This disease is generally considered a mild viral
disease, limiting itself to occasional complications. Before the United States, this
disease is caused as many as 100 deaths annually. Before varicella vaccination
became widespread in the United States, this disease caused as many as 100
deaths each year. Since the varicella vaccine was introduced in the United States
in 1995, the disease incidence has substantially decreased. Because varicella
vaccines were introduced in the United States in 1995, the incidence of the disease
has substantially decreased.
Even today, varicella is not really tame. One study showed that almost
1:50 cases of varicella were associated with complications. Among the most
serious complications of varicella pneumonia and encephalitis, both are associated
with high mortality. In addition, concerns have been raised regarding the
relationship of varicella with severe invasive group A streptococcus disease.
The United States adopted universal vaccination against varicella in 1995,
which reduced the mortality and morbidity rates of this disease. For obvious
reasons, unvaccinated children remain vulnerable. Children with varicella expose
adult contacts in the household, school, and child care center with severe risks,
even fatal illnesses. Varicella is common and very contagious and affects almost
all vulnerable children before adolescence.
Both cases in the household are often more severe. School or contact a
child care center is associated with a lower transmission rate but is still
significant. Vulnerable children rarely get the disease by contacting adults with
zoster. Maximum transmission occurs during late winter and spring.
Varicella is associated with a humoral and cell-mediated immune response.
This response induces long-lasting immunity. Repeat subclinical infections can
occur in these people, but the second attack of chickenpox is very rare in
immunocompetent people. Re-exposure and subclinical infection can function to
increase immunity obtained after episodes of chickenpox, this can change in the
post vaccine era.

1.2 The Purpose

- General Purpose
The author is able to make care for infants and toddlers with Varicella.
- Special Purpose
The author is expected to be able to:
a. Understanding of varicella disease (definition, etiology, clinical,
pathophysiological manifestations, investigations, complications,
and treatment in varicella cases).
b. Understanding nursing care for infants and toddler patients with
1.3 Benefits
It is hoped that after reading a paper about varicella, it can provide benefits:
a. Students are able to understand the definition, etiology, clinical,
pathophysiological manifestations, investigation, complications, and
treatment of varicella cases.
b. Students are able to understand nursing care for infants and toddler
patients with varicella.

2.1. Basic Concept of Varicella

Varicella comes from Latin, Varicella. In Indonesia, this disease is known as
chickenpox, while abroad is known as Chicken - pox. Varicella is a contagious
infectious disease caused by the Varicella Zoster virus, characterized by a typical
eruption on the skin.
Varicella or chickenpox is a highly contagious disease caused by the
Varicella Zoster virus with symptoms of fever and red spots which then contain
Varicella is an acute and contagious viral infectious disease, which is caused
by Varicella Zoster Virus (VZV) and attacks the skin and mucosa, characterized
by the presence of vesicles. (Rampengan, 2008)
Varicella (Chickenpox) is a common infectious disease that usually occurs
in children and is a result of the primary infection of the Varicella Zoster Virus.
Varicella in children has a distinctive form in the form of a short prodromal period
that does not even exist and with the presence of itchy patches accompanied by
papules, vesicles, pustules, and ultimately, crusta, although many skin lesions do
not develop until vesicles.
June M. Thomson defines varicella as a disease caused by an acute, highly
contagious varicella-zoster (V-virus) virus that generally treats children, which is
characterized by sudden fever, males and maculopapular skin eruptions for several
hours which then turn into vesicles for 3-4 days and can leave scabs (Thomson,
1986, p. 1483).
Whereas according to Adhi Varicella Djuanda which has a synonym for
chickenpox or chickenpox is a primary acute infection by the varicella-zoster
virus which attacks the skin and mucosa which clinically have constitutional
symptoms, polymorphic skin abnormalities, especially in the central part of the
body (Djuanda, 1993).

2.2 Epidemiology
Cosmopolitically spread, it attacks mainly children but can also attack
adults. Transmission of this disease aerogenously. The transmission period of
approximately 7 hearts is calculated from the appearance of skin symptoms.

2.3 Etiology
Varicella is caused by Varicella Zoster Virus (VZV), including the Herpes
Virus group with a diameter of approximately 150-200 nm. The core of the virus
is called Capsid, consisting of proteins and DNA with double chains, namely short
chains (S) and long chains (L) and forming a line with a molecular weight of 100
million arranged from 162 capsomirs and very infectious.
Varicella Zoster Virus (VZV) can be found in vesicle fluid and in the blood
of Varicella patients so that it is easily cultured in a medium consisting of human
embryonic pulmonary fibroblasts.
Varicella Zoster Virus (VZV) can cause Varicella and Herpes Zoster. The
first contact with this disease will cause Varicella, whereas if there is a re-attack,
what will appear is Herpes Zoster, so Varicella is often referred to as the primary
infection of this virus.

2.4 Pathophysiology
Hematogen Spread. Varicella Zoster Viruses also infect satellite cells around
the neurons in the dorsal root ganglion of the spinal cord. From here the virus can
cause symptoms in the form of Herpes Zoster again. Around 250 - 500 lumps will
appear to spread throughout the body, including the face, scalp, inner mouth, eyes,
including the most intimate parts of the body. But in less than a week, the lesion
will dry out and at the same time it will itch. Within 1-3 weeks the marks on the
dry skin will be released. The Varicella Zoster virus causes chickenpox to move
from one person to another through spit saliva that comes from coughing or
sneezing patients and being airlifted or in direct contact with infected skin.
This virus enters the human body through the lungs and spreads to the body
through the lymph nodes. After passing the 14 days period this virus will spread
rapidly to the skin tissue. Indeed, this disease should be experienced in childhood
and if it is an adult. Because often parents let their children get chickenpox earlier.
Varicella generally attacks children; in four dozen countries, 90% of
varicella cases occur before the age of 15 years. In children, this disease is
generally not very severe.
But in tropical countries, such as in Indonesia, more teenagers and adults are
attacked by Varicella. Fifty percent of varicella cases occur above the age of 15
years. Thus increasing age in adolescents and adults, the symptoms of varicella
are increasingly gaining weight.

2.5 Sign / Symptoms

Beginning with symptoms of weakening body condition.
 Dizzy.
 Fever and sometimes accompanied by coughing.
 Within 24 hours, spots develop into lesions (similar to the skin that is lifted
due to burning).
 Finally become a lump - a small lump filled with fluid.
Before the appearance of an eruption on the skin, patients usually complain
of feeling unwell, lethargy, no appetite and headaches. A day or two later, a typical
skin eruption appears.
The eruption of the skin begins with reddish spots (macules), which then
turn into papules (small protrusions on the skin), the papules then turn into
vesicles (small bubbles filled with clear liquid) and finally the fluid in the bubble
becomes cloudy (pustules). If there is no infection, usually pustel will dry up
without leaving an abscess.

2.6. Signs and symptoms

Varicella incubation period varies between 10-21 days, averaging 10-14
days. Spread of varicella mainly directly through the air by means of spit saliva.
Generally contracted in family or school. (Rampengan, 2008).
The course of the disease is divided into 2 stages, namely:
Prodromal Stadium 24 hours before skin disorders arise, there are symptoms
of not too high heat, feeling weak (malaise), headache, anorexia, feeling of
heaviness in the back and sometimes accompanied by dry cough followed by
erythema in the skin can be scarlatinaform or morbiliform. Heat usually
disappears in 4 days, when body heat persists it is necessary to suspect
complications or disorders of immunity.
Eruption stage: begins when erythema develops rapidly (within a few hours)
turns into a small macula, then reddish papules then become vesicles. These
vesicles are usually small, contain clear liquid, not umbilicated with an
erythematous base, easily broken and dry to form crusts, this shape is very typical
and better known as "dew drops" / "tears".\
Skin lesions begin to appear in the body area and then spread centrifugally
to peripheral areas such as the face and extremities. On the way
this disease will get a distinctive sign that is seen in the form of papules,
vesicles, crusts at the same time, where this condition is called polymorph. The
number of lesions on the skin can be 250-500, but sometimes it can only be 10 or
more up to 1500. New lesions persist for 3-5 days, lesions often form a crusting
on the 6th day (days 2 to 12 ) and complete recovery on the 16th day (7th to 34th
Late or late eruptions turn into crusting and healing, usually found in
patients with impaired cellular immunity. If secondary infection occurs, around
the lesion will appear reddish and swollen and clear vesicle fluid turns to pus
accompanied by general lymphadenopathy. Vesicles are not only found on the
skin, but also in the mucosa of the mouth, eyes and pharynx.
In patients with varicella accompanied by immunity deficiency (immune
deficiency) often causes a typical clinical picture in the form of bleeding, is
progressive and spreads into a systemic infection. Similarly, patients who are
getting immunosuppressive. This is caused by the occurrence of lymphopenia.
In pregnant women who suffer from varicella can cause several problems in
babies who will be born and depend on the mother's pregnancy, including:
a. Neonatal Varicella
Neonatal varicella can be a serious disease, this depends on when the
mother has varicella and labor.
- If the pregnant woman is infected with varicella 5 days before
parturition or 2 days after parturition, it means that the baby is infected
when the second viremia is from the mother, the baby is infected
transplasental, but does not get immunity from the mother because
there is not enough time for the mother to produce antibodies. In this
situation, babies born will experience severe varicella and spread.
Need to be given prophylaxis or treatment with varicella-zoster
immune globulin (VZIG) and acyclovir. If not treated adequately, the
death rate is 30%. The main cause of death due to severe pneumonia
and fulminant hepatitis.
- If the mother is infected with varicella more than 5 days antepartum,
so that the mother has enough time to produce antibodies and can be
passed on to the baby. A term baby will suffer from mild varicella
because of the weakening by transplasental antibodies from the
mother. Treatment with VZIG is not necessary, but acyclovir can be
considered for use, depending on the condition of the baby.

b. Congenital varicella syndrome

Congenital varicella is found in infants with mothers who suffer from
varicella in the first or second trimester of gestation with a 2% incidence.
Clinical manifestations can be intrauterine growth retardation,
microcephaly, cortical atrophy, limb hypoplasia, microftalmin, cataracts,
chorioretinitis and scarring of the skin. The severity of symptoms in infants is not
related to the severity of the disease in the mother. Pregnant women with zoster
are not associated with abnormalities in infants.

c. Infantile zoster
This disease often appears in the age of a baby in the first year, this is due to
maternal varicella infection after the 20th gestational period. This disease often
affects the nerves of the thoracic dermatome.
2.7 Pathogenesis
Varicella Zooster virus enters the respiratory mucosa or oropharynx, then
viral replication spreads through the blood vessels and lymph (first viremia) then
multiplies in endhotellial reticulo cells after it spreads through the blood vessels
(second viremia), fever and malaise arise.
The onset of the lesion on the skin may be an infection of the endothelial
capillaries in the papillary dermis spread to epithelial cells in the epidermis, skin
follicles and sebaceous glands and swelling occurs. The first lesion is
characterized by the presence of macules that develop rapidly into papules,
vesicles and eventually become crusts. Seldom lesions are rare in the form of
macules and papules. This vesicle will be in the cell layer under the skin. And
forms the roof of the stratum corneum and lusidum, while the base is a deeper
layer. Cell degeneration will be followed by the formation of many nucleated
giant cells, where most of these cells contain an intranuclear type A inclusion
body. Airborne droplet transmission. Viruses can be sedentary and latent in nerve
cells. Then reactivity can occur, herpes zoster can occur.

2.8 Complications
Complications of varicella in children are usually rare and more frequent
in adults.
1. Secondary infection
Secondary infections caused by Staphylococci or Streptococci and cause
cellulitis, furuncles. Secondary infections in the skin mostly in the age group
under 5 years. Found in 5-10% of children. There is a secondary infection if the
systemic manifestations do not disappear within 3-4 days or even worsen

2. Brain
This complication is more often due to impaired immunity. "Acute
postinfectious cerebellar ataxia" is the most common complication in the brain (1:
4000 cases of varicella). Ataxia arises suddenly usually at 2-3 weeks after
varicella and persists for 2 months. Clinically ranging from mild to severe, while
sensorium remains normal even though the ataxia is severe. The prognosis of this
condition is good, although some children may experience incoordination or

"Encephalitis" is found in 1 in 1000 varicella cases and presents with symptoms of

cerebellar ataxia and usually occurs between days 3 to 8 after the onset of rash.
Usually fatal.

3. Pneumonitis
This complication is more common in malignancies, neonates,
immunodeficiencies, and adults. A baby 13 days with complications from
pneumonitis was reported and died at the age of 30 days.
The clinical features of pneumonitis are persistently high heat, coughing,
shortness of breath, tachypnoea and sometimes cyanosis and hemoptoe. On
radiological examination, a nodular radio-opaque image is obtained in both lungs.

4. Reye's syndrome
This complication is less common. With the following symptoms, namely
nausea and vomiting, hepatomegaly and laboratory tests found an increase in
SPGT and SGOT and ammonia.

5. Hepatitis
Can occur but rarely.

6. Other complications
Like arthritis, thrombocytopenia purpura, myocarditis, keratitis. Patients
need to be consulted to a specialist if any of the following symptoms are found:
 Progressive or severe varicella
 Life-threatening complications such as pneumonia, encephalitis
 Severe secondary bacterial infections especially from group A
Streptococcus which can trigger rapid skin necrosis and "Toxic Shock
 Patients with severe complications need to be treated in a hospital or if
necessary an ICU
 Indications for treatment in the ICU / NICU include:
- Loss of consciousness
- Seizures
- It's hard to walk
- Respiratory disorders
- Cyanosis
- Oxygen saturation decreases
 All neonates are born to mothers who suffer from varicella less than 5 days
before giving birth or 2 days after giving birth.

2.9 Treatment
Because it is generally mild, most sufferers do not need special therapy
other than resting and giving adequate fluid intake. What is often a problem is the
itching that accompanies eruption. If you don't hold it, your finger will want to
scratch it. The problem is, if it is badly scratched, scar tissue can appear on the
broken bubble marks. Certainly not interesting to see.

* General
a. Isolation to prevent transmission.
b. A highly nutritious diet (High in Calories and Proteins).
c. If the fever is high, compress with warm water.
d. Try to avoid infection of the skin, for example antiseptic administration in
bath water.
e. Try to keep the vesicles from breaking.
- Don't scratch the vesicles.
- Do not leave the nails long.
- If you want to dry your body, just brush the towel over the skin, do not
rub it.

* Pharmacology:
Topical medicine
Local treatment can be given Kalamin lotion or salicylic powder 1%.

Antipyretic / analgesic
Usually used aspirin, acetaminophen, ibuprofen.

The antihistamine group that can be used, namely Diphenhydramine, is
available in liquid form (12.5 mg / 5 mL), capsules (25 mg / 50 mg) and injection
(10 and 50 mg / mL). The dose is 5 mg / kg / day, divided into 3 times.

Anti-viral drugs
Vidarabin (adenosine arabinoside)
Vidarabin is an antiviral drug that is obtained from phosphorylase in cells
and in the form of triphosphate, inhibits viral DNA polymerase. Dosage: 10-20
mg / kg body weight / day, given a daily 12-hour infusion, 5-7 days. In giving
vidarabin, vesicles disappear quickly in 5 days.
Side effects:
- Neurological disorders include tremors, seizures
- Hematological disorders in the form of neutropenia, thrombocytopenia
- Gastrointestinal disorders include vomiting and elevation of SGPT and

Acyclovir = 9 (2 hydroxy ethoxy metal) Guanine

Acyclovir is one of the most widely used antiviruses these days. Acyclovir
is better than vidarabin. This drug works by inhibiting the polymerase DNA of the
Herpes virus and ending viral replication. This drug can reduce the increase in
lesions on the skin and the length of heat, if given in 24 hours the emergence of
In small children without complications, the use of this drug is less useful
and is not recommended routinely so that Acyclovir is more widely used in
patients with complications or patients with impaired immunity. This drug does
not reduce skin itching, complications or secondary transmission.
Dosage: 5-10 mg / kg BB divided into 4-5 doses / day, can be given orally
or iv / drip every 8 hours for 5-7 days. With a dose not to exceed 3200 mg / day.
Available in capsules (200 mg / 400 mg / 800 mg), liquid (400 mg / 5 mL),
injection (500 mg / 5 mL).
Side effects:
Kidney disorders include renal insufficiency, malaise and indigestion.

Adequate diet:
- Give full food and not be restricted
- Sometimes patients experience anorexia, they should be motivated to drink a
lot to maintain hydration status. Sufficient liquid is very necessary if the
patient is given Acyclovir, because this drug can crystallize in the renal
tubules if the patient is dehydrated.

2.10 Prevention
Prevention of varicella zoster virus infection is done by passive or active

Active immunization
Performed by giving live attenuated varicella vaccines originating from
OKA Strains with a high immunogenicity effect and a fairly high level of
protection ranging from 71-100% and possibly longer. Can be given to healthy
children or patients with leukemia, immunodeficiency. Post-contact patients can
be given this vaccine within 72 hours with the intention of being preventive or
reducing symptoms of the disease.
The recommended dose is 0.5 mL subcutaneously. Giving this vaccine
turned out to be quite safe. Can be given along with MMR with the same
protection power and side effects only in the form of light rash.

Side effects:
Side effects are usually absent, but if they are present they are usually mild.

Passive immunization
Performed by giving Zoster Immune Globulin (ZIG) and Zoster Immune
Plasma (ZIP).
Zoster Immune Globulin (ZIG) is a globulin-gama with high antibody titers and is
obtained from patients who have recovered from shingles infection. Dosage of
Zoster Immune Globulin (ZIG): 0.6 mL / kg of intramuscular given as much as 5
mL within 72 hours after contact. Indications for the administration of Zoster
Immunoglobulin are:
- Neonates born to mothers suffer from varicella 5 days before parturition or
2 days after giving birth.
- People with leukemia or varicella-infected lymphomas that have not been
vaccinated before.
- HIV sufferers or other disorders of immunity.
- Patients are receiving immunosuppressant treatment such as
But in children with immunological deficiency, leukemia or other
malignancies, the administration of Zoster Immune Globulin (ZIG) does not cause
perfect prevention, again it is necessary to have Zoster Immune Globulin (ZIG)
with high titers and greater amounts.
Zoster Immune Plasma (ZIP) is a plasma derived from patients who have
just recovered from herpes zoster and given intravenously as much as 3-14.3 mL /
kg body weight. Giving Zoster Immune Plasma (ZIP) in 1-7 days after contact
with varicella patients in children with immunological deficiency, leukemia, or
other malignancies results in a reduced incidence of varicella and changes in the
course of varicella disease to be mild and can prevent varicella for the second

2.11. Auxiliary diagnosis

Tzanck experiments can be carried out by making a clear preparation
stained with Giemsa. The material is taken from the basic scrapings of vesicles
and multinucleated cells will be found.

2.12. Comparative diagnosis

It must be distinguished from variola, this disease is more severe, gives a
picture of monomorph, and its spread begins from the acral part of the body
namely the palms of the hands and soles of the feet.

2.13. Prognosis
With careful care and always pay attention to personal hygiene and the
environment provides a good prognosis and the possibility of scarring is only a
little, unless the client does scratching/other actions that cause deeper skin
2.14 WOC

Virus Varicella


breath mucosa


the virus spreads


Blood vessels lymph (first viremia)


endhotellial reticulo cell

spread through blood vessels (second viremia)

fever and malaise

2.15 Nursing Care Concepts
A. Assessment
1. Client Identity
Includes: name, age, register number, gender, status, address, date of hospital
admission, medical diagnosis.

2. Main Complaint
the client comes with a complaint of fever, like a cold and there is a fever
containing water around his body.

3. Medical History
a. Current History
the client feels his body feels hot like a cold and there is a red rash on his body and
pain when held.

b. First Medical History

The client has never experienced skin disease before.

c. Family Health History

usually a contagious disease, family members have the risk of being infected with
old contacts. Previously, the client's client had experienced chickenpox and the client often
visited his neighbors when his chickenpox had dried up. No family member has the same
complaint as him.

B. Physical examination
a. the general condition of the client usually the patient feels weak, not feeling well, no
appetite and headache.
b. nervous system: no disturbance of sensory peripheral nerve function, and normal
motor peripheral nerves.
c. respiratory system: there is no interference with the respiratory system
d. musculoskeletal system: absence of impaired motor peripheral nerve function
weakness or paralysis of the muscles of the hands and feet.
e. integumentary system: there are lesions and rashes on the skin and an increase in body
temperature or fever as well as changes in vital signs. In the study of the skin found
vesicles - painful vesicles when held when palpated there are bumps that are uneven
with the surface of the skin
C. Supporting investigation
Leukocyte examination usually shows normal, low, or slightly elevated results
Multinucleated giant cells on Tzanck smear examination of skin blisters are positive results
on tissue culture examination.

D. Nursing diagnoses
1. Acute pain associated with skin lesions (chicken pox)
2. Changes in nutrition less than the body's needs are related to anorexia
3. Damage to the integrity of the skin associated with skin lesions
4. Hyperthermia is associated with the infection process
5. Lack of knowledge related to limited exposure

E. Nursing Intervention
No Nursing Diagnose NOC NIC
1 Acute pain After nursing action for 1 x NIC: Pain Management
associated with 24 hours is expected. 1. Perform a
skin lesions NOC: Pain control comprehensive pain
(chicken pox) Purpose: Reduced / lost pain assessment including
Criteria for results: location, characteristics,
- Able to control pain (know duration, frequency,
the cause of pain, be able to quality and precipitation
use non-pharmacological factors
techniques to reduce pain) 2. Obseration of non-
- Report that pain is reduced verbal reactions from
by using pain management discomfort
- Able to recognize pain 3. Teach about non
(scale, intensity, frequency, pharmacology
pain) techniques(relaxation,
- Expressing comfort after distraction)
the pain has diminished. 4. Increase rest
Vital signs in the normal 5. Give analgesics to
range of scale: reduce pain
1 = Never shows 6. Environmental
2 = rarely shows controls that can affect
3 = sometimes shows pain such as room
4 = often shows temperature and lighting
5 = always shows
2 Changes in After nursing action for 1 x
nutrition less than 24 hours is expected.
the body's needs NOC = Nutritional status
are related to Purpose = nutritional status
anorexia fulfilled
Result criteria =
1. Maintaining intake of
2. Maintain weight
3. Report on the strength of
the energy level
Vital signs in the normal
range of scale:
1 = Never shows
2 = rarely shows
3 = sometimes shows
4 = often shows
5 = always shows
3 Damage to the After nursing action for 1 x NIC = Presure
integrity of the 24 hours is expected. Management
skin associated NOC = tissue integrity, skin 1. Encourage the patient
with skin lesions and mucous membranes to wear loose clothing
Purpose = damage to skin 2. Avoid wrinkles on the
integrity does not occur bed
Result criteria = 3. Keep the skin clean
1. Good skin integrity can and dry
be maintained (sensation, 4. Mobilize the patient
elasticity, temperature, (change the position of
hydration, pigmentation) the patient) every 1 hour
2. There are no injuries to 5. Monitor patient
the skin activity and mobilization
3. Good tissue perfusion 6. Monitor patient
4. Able to protect skin and nutrition status
maintain moisture skin
Vital signs in the normal
range of scale:
1 = extreme
2 = weight
3 = medium
4 = light
5 = no interference
4 Hyperthermia is After nursing action for 1 x NIC = temperature
associated with 24 hours is expected. regulation
the infection NOC = Thermoregulation 1. Observation
process Purpose = No increase in 2. Give oral drinks
body temperature 3. Compress with warm
Result criteria = water
1. Body temperature within 4. Collaboration on
normal limits giving antipyretics
2. Pulse and RR are in the
normal range
3. There is no change in
skin color and no dizziness,
feeling comfortable
1 = not normal
2 = far from normal
3 = almost normal
4 = quite normal
5 = normal
5 Lack of After nursing action for 1 x NIC = Teaches the
knowledge related 24 hours is expected. disease process
to limited NOC = Nursing procedure 1. Increase the level of
exposure knowledge knowledge of patients
Objective = It is expected related to specific
that the patient's level of disease processes
knowledge related to the 2. Describe common
disease can increase signs and symptoms of
Result criteria = the disease
1. Describe the procedure 3. Identify possible
2. Explain the purpose of causes
the procedure 4. Discuss treatment
3. Describe the stage of the therapy
procedure 5. Instruct patients and
4. Describe the preventive family to minimize side
relationship with the effects
5. Describe independent
equipment with tools
6. Shows equipment
7. Describe potential
balanced effects
Scale information
1 = none
2 = limited
3 = medium
4 = weight
5 = estensive

F. Evaluation
Date Nursing
-/-/- 1 S = Client Saying the skin still looks scary.
O = Lesions on the right side of the skin and
hypopigmentation and erythematous spots,
infiltrates and nodules
A = The problem has not been resolved
P = Continue the nursing action plan
2 S = Client Says pain begins to decrease, scale of
pain: 3
O = The patient is more comfortable
A = Problem partially resolved
P = Continue the nursing action plan
3 S = The client said his body was still weak to
O = The client still looks weak
A = The problem has not been resolved
P = Continue the nursing action plan
4 S = The client said he still wanted to be alone
and did not want to meet other people except
family and health personnel
O = The patient still looks nervous. more silent
and still do not want to meet other people who
are tired of family and health workers
A = The problem has not been resolved
P = Continue the nursing action plan
June M. Thomson, et. al. (1986). Clinical Nursing Practice, The C.V. Mosby Company,

Tarwoto dan Wartonah. (2000). Kebutuhan Dasar Manusia dan Proses Keperawatan.
Salemba Medika : Jakarta.

Wong, D, L & Whaley. 1993. Nursing Care of Infants and Children 4th Edition. Mosby Year
Book Company : Toronto