I.

NURSING INTERVENTION
Name : Mr.A Registration Number : 25609
Age : 53 years old Room : IRNA III
A. Problem priority
1. Impaired pain comfort
2. Activity intolerance
3. Disturbed sleep pattern
B. Nursing Intervention
Nu Dia Nursing Goals Intervention Rational
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.
1 After doing the 1. Assess pain scale 1. To find out the
1
nursing cares level of pain felt
for 2x24 hours by the patient.
is expected to 2. Give a cold 2. Actions that
reduce pain compress, teach reduce cerebral
with the results relaxation vascular pressure
criteria: techniques and block
1. The patient effective
looks sympathetic
relaxed. responses and
2. Reporting relieve headaches
reduced 3. Help the patient 3. Dizziness is
pain in ambulation as always related to
3. Vital signs needed headaches.
in a normal 4. Collaboration in 4. Treating pain.
limits providing
4. The patient analgesics
points to the
 pain scale in
number 3
(0-10)
2 nursing 1. Assess the 1. Determine the
2 After
patient's response choice of the next
action for 2x24
to activity. intervention.
hours, activity
intolerance is
expected to be 2. Observation of 2. Knowing
vital signs parameters helps
resolved by the
and examines
results criteria:
physiological
1. The patient
responses to
can move
activities.
without the
3. Teach ways to 3. Helps balance
help of
save energy between supply
others.
and O2 needs
2. Get to the
toilet by
4. Give 4. Progress in
yourself
encouragement to activity to prevent
without the
do activities sudden increase
help of
in heart work
others.
3. Muscle
strength
4 4
4 4
3 After nursing 1. Create a calm and 1. Improve sleep
3
action for 2x24 comfortable comfort and
hours, it is environment physiological or
expected that psychological
sleep rest support.
pattern 2. Give patients the 2. Storage of energy
disorders can be opportunity to and improve
resolved with sleep / rest coping abilities
the results 3. Evaluate stress 3. Assess the need
criteria: levels, monitor and identify
1. Able to headache appropriate
create an complaints interventions
adequate 4. Complete the 4. If new routines
sleep sleep schedule contain as many
pattern 6-8 regularly aspects of old
hours per habits, stress and
day related anxiety
2. Looks like can be reduced
you can get 5. Encourage eating 5. Increases the
enough rest small meals and / relaxation effect
3. Vital signs or warm milk
are within before going to
normal bed, do massase
limits your back, turn
4. Ananemic soft music
conjunctiva 6. Collaboration of 6. May be given to
sedative, hypnotic help patients
drugs as indicated sleep / rest