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BY GROUP 3

 Dian Wulandari (10217016)  Nurul Hidayah (10217046)

 Elvita Ratna K.D (10217020)  Odya Hafidz P. (10217047)

 Hanan Agustin (10217033)  Prita Rizkita (10217048)

 Lia Hayu R. (10217038)  Suci Agustina (10217058)

 Linda Krisdayanti (10217039)  Whika Cofi A. (10217063)


CASE

Ms. D (40 years old) is an traffic accident victim. When ambulance medical services teams
arrived on the location, Mr. D was sitting down the street and with pair face expression. He
told us that his right leg was badly painful. There’s no open injury appear on his leg, but
there’s a swollen right leg and bruises on it. He can’t move his right leg, but he can make a
little movement for his toes. Mr. D vital’s sign results shows : Blood Pressure 140/90 mmHg,
HR 100x/minutes, RR 24x/minutes, temperature 36.50C.
DS :
He told us that his right leg was badly painful. There’s no open injury appear on his leg, but
there’s a swollen right leg and bruises on it. He can’t move his right leg, but he can make a
little movement for his toes.

DO :
Assessment of Pain
P : swollen right leg and bruise due to collision
Q : like being gripped
R : right foot
S:5
T : continuous

TTV
BP : 140/90 mmHg
HR : 100x/minutes
RR : 24x/minutes
T : 36.50C
Nursing Diagnose : Acute pain associated with physical injury

Goals and Criteria Results

NOC :
Pain level
Pain control
Comfort level

Criteria Results :
Able to control the pain (know the cause of the pain, able to use the techniques non-
pharmacological to reduce the pain, search help)
Reported that pain reduced with the use of pain management
Able to recognize the pain (scale, intensity, frequency, and signs of pain)
Expressed a sense of comfort after the pain is reduced
Intervention

NIC
Pain Management

Do a comprehensive assessment of pain including location, characteristic, duration,


frequency, quality, and precipitation factors.
Observations nonverbal reaction from the discomfort.
Subtract the precipitation factors of pain.
Examine the type and source of pain to determine intervention.
Teach non-pharmacological techniques.
Give analgesics to reduce pain
Increase rest.

Analgesic Administration

Specify location, characteristic, quality, and degree of pain before administration of the drug
Check the doctor’s instructions about the type of drug, dosage, and frequency
Check history of allergies
Define the choice of analgesic depends on the type and severity of the pain
Monitor vital signs before and after administration on first analgesics
Evaluation of the effectiveness of analgesics, signs, and symptoms
Rational

1. Knowing the pain by the patient


2. Knowing the response patients against the pain
3. Can reduce the pain patients
4. Knowing the development of the pain and determine the next intervention
5. Can reduce pain that is felt the patient
6. Analgesic serves as a depressant central nervous system so that can reduce or eliminate the pain
7. Break that is quite can reduce pain
8. Make sure didn’t happen mistake in the provision of
9. As a reference to in the provision doses of drugs that right
10. Avoid the redness, itchy, and the effects of the other of giving a drug that is wrong
11. Reduce pain perceived patients thai it can determine the next intervention
12. Knowing status changes the health of the patient after giving the drug
13. To provide information to help in deciding choice/effectiveness intervention
EVALUATION

No : 1

Nursing Diagnose
Acute pain associated with physical injury

Evaluation
S : Patient said the pain is reduced
O : Assessment of Pain
P : swollen right leg and bruise due to collision
Q : like being gripped
R : right foot
S:3
T : continuous

TTV
BP : 120/70 mmHg
HR : 68x/minutes
RR : 20x/minutes
T : 36.50C
A : The issue has not been resolved
P : Continued Intervention