Diagnosaa

Nyeri (akut) Berhubungan dengan proses penyakit.

Intolensi aktivitas berhubungan dengan kelemahan.

Gangguan pola tidur berhubungan dengan teraktivasi RAS.

1. Kaji riwayat nyeri misalnya lokasi, durasi dan skala.

2. Berikan tindakan kenyaman dasar misal: massage punggung dan aktivitas hiburan misalnya
music.
3. Dorong penggunaan keterampilan penggunaan keterampilan manajement nyeri misalnya
relaksasi napas dalam.
4. Kolaborasi pemberian analgetik sesuai indikasi.

Kaji respon klien terhadap aktivitas

2. Berikan lingkungan tenang.

3. Jelaskan pentingnya istirahat dalam rencana pengobatan

4. Bantu pasien memilih posisi nyaman untuk istirahat/tidur.

1. Kaji pola tidur klien.

2. Ciptakan lingkungan yang menyenangkan.
3. Anjurkan klien untuk banyak istirahat dan tidur yang nyenyak.

Pengkajian fisik

Tanda-tanda vital
Suhu 36-37 oCNadi 60-100x/menit, Tensi rata-rata 130/80 mmhg, RR 16-24x/menit.
 Analisa data

Ds :Klien mengeluh perutnya sakit dan semakin sakit jika bergerak

Do :Klien Nampak gelisah dan tidak focus saat ditanya

Penyebab

Tumor abdomen ukuran massa

Bersifat mekano sensitive terhadap serabut saraf

Pelepasan mediator kimia( bradikinin, prostaglandin, serotonin, histamine)

Nosiseptor di serabut

Korteks serebri

Nyeri dipersepsikan

Diagnosis

1. Pain (acute) Related to the disease process.

2. Activity intolerance related to weakness.

3.Sleep disorders associated with an activated RAS.

Intervention
1. Assess history of pain such as the location, duration and scale.

2. Provide basic comfort measures eg massage his back and fun activities for
example music.

3. Encourage the use of skills using relaxation skills Management of pain such deep
breath.

4. Collaboration analgetik as indicated.

1. Assess client's response to activity

2. Provide quiet environment.

3. Explain the importance of rest in the treatment plan

4. Help the patient choose a comfortable position to rest / sleep.

1. Assess client's sleep patterns.

2. Create a pleasant environment.

3. Encourage clients to a lot of rest and sleep soundly.

physical assessment

Vital sign

Temperature 36-37 Nadi 60-100x / min, blood pressure has an average of 130/80
mmHg, RR 16-24x / min.

Data analysis
Ds: Clients complained stomach pain and more pain when moving

Do: The client seems restless and do not focus when asked

Cause

abdominal tumor mass size

Are mechano-sensitive nerve fibers

Release of chemical mediators (bradykinin, prostaglandins, serotonin, histamine)

Nociceptors in fibers

the cerebral cortex

pain perception