Académique Documents
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Lecture:
Dwi Priyantini, S.Kep.,Ns., M.Si
Group’s Name:
PERIODE 2016-2017
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
HANDOVER OF PATIENTS
Has accepted new patients
Name : Tn.Hariyono (62th) Sex : Male/Female
No.Reg : Date :10 February 2016
Medical Diagnosis : Time : 06.00
Doctor who cure :
Originally room : IGD In to the room : Rubby
1. Client Condition :
Awareness : Composmentis GCS : 456
TTV : 140/80 mmHg , pulse : 93 bpm , reg/irreg , strong /weak , temp : 373 oC , RR :
20x/minuts, Rhonchi : / , Wheezing : / , retr : , Type :
KU : pain in the gut
Medical devices used : -infusion: (date & time , residue: cc)
-
2. Handover of Drugs
The List of Drugs Received
No Drugs name Dosage Total
4. Special Note
(……………..………..) (……………….…)
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
(Sutrisno) ( )
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
APPROVAL
Medical form for action**
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
To myself*/Wife*/Husband*/Children*/Father*/Mother*/My siblings* with :
Name :
Age : Sex : L/P
Address :
Proof of identity/ KTP :
Treat at :
I understand the need and benefits of measures as necessary as above to me, including the
risks and complications that may arise. I also realized that doctors and nurse have done a best
effort. However it is dependent on almighty God permits one to the success of medical measures.
The statement I made this agreement full awareness andwithout coercion.
Surabaya,
…………………………..
Witness Doctor Maker a statement
(………………….) (………….………..) (……………..…………..)
(………………….)
CONSULTATION SHEET
To Yth: Prof./DR/Dr……………………………………………
Consult Date…………………………………………………….
Dear Prof./DR/Dr,
Please helpcolleagues to (*) (*) Circle appropriate
1. Consultation/ an action problem medic today
2. Caring together for further
3. Expert care case for further
On this patient, we will care with……………………………………….......................................
……………………………………………………………………………………………………..
Information Clinic are important currently :
Greeting Colleagues,
Prof./DR/Dr…………………………………….
If you need, use the back page.
CONSULTATON ANSWER
Date : Time :
Dear, Prof./DR/Dr…………………………..
After consultation request our colleagues in the evaluation of patient currently get.
Suggestions Medical action/ curing :
I. IDENTITY
1. Name : Hariyanto
2. Age : 62 th
3. Sex : Male
4. Religion : Islam
5. Tribes : Java
6. Status married : Married
7. Education :
8. Work : Superrannuation
9. Address and no.telp :
10. Person in change :
6. History of alergy
Food ( - ), Type…..
Drugs ( - ), Type…..
b. Personal Hygiene
At Home At the Hospital
Take a bath: 2 x/days Take a bath /swabbed: 2 x/days
Brush your teeth : 2 x/day Brush your teeth : 2 x/day
Hair wash : 3 x/week Hair wash : 3x/day
Cut nails: 1 x/week Cut nails: 1x/day
c.activity everyday
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………
d.Recreation
Watching TV (√) , listening to music / video (-) , reading books/newspapers (√) , take a
walk(√) , etc,mention …………………………………………………………………………
e. sports : (-) not (√) yes , kind : take a walk (√) . running/jogging (√) ,etc mention………
3. Sleep and Rest Patterns
At home In the hospital
Sleep time : Afternoon ……..,……… Sleep time : Afternoon ……..,………
Night……,…….. Night……,……..
Sleep hours total : Sleep our total:
Problems in hospital : (√) Nothing ( ) wake up early ( ) nightmare
( ) insomnia etc, ………………..
1. Metabolic – Nutrition Patterns
a. Eat patterns
At home In Hospital
Frequency : Often ( ),rarely ( ) Frequency : often ( ), rarely ( )
Type : Type :
Total : Total :
Prohibition :
Favorite food :
Appetite : (√) normal ( ) Increased ( ) decreased
( ) Nausea ( ) vomit ... .. cc ( ) stomatitis
Difficulty swallowing : () Yes (√) not
Dentures : () Yes (√) not
NG Tube : () Yes (√) not
b. drinking patterns
At home in the hospital
c. Frequency: frequent (), rarely () Frequency: frequent (), rarely ()
d. Types : Types :
e. Total : Total :
f. abstinence :
g. Favorite food:
2. Elimination pattern
a. Defecate
At home in the hospital
Frequency : Frequency :
Consistency : Consistency :
Color : Color :
( ) yellow
( ) mix with blood
( ) etc,…………..
Problem in the hospital : ( ) constipation ( ) diarrhea ( ) incontinence
Colostomy :( ) Yes ( ) No
b. Urination
At Home In the Hospital
Frequency : ………x/days Frequency : ……..x/days
Total : …………..cc Total : …………..cc
Color : …………… Color : ……………
Problems in the Hospital : ( ) disuria ( ) aucturia ( ) hematuria
( ) retensi ( ) ickontinen
Cateter : Yes,Cateter…………………….
8. Sensing system
Vision (Eye)
Shape : ( √ ) Normal ( ) Eksoptalmus ( ) Endoftalmus
( ) others ………………….
Pupil : ( √ ) Isokor ( ) anisokor
( ) Miosis ( ) Midriasis
Light reflex : …./…..
Sclera : (√ ) clear ( ) cloudy ( ) others
Eye movement : ( √ ) Normal ( ) Abnormal info………………
Color blindness : ( ) yes, type ( ) parcial ( ) total (√ )no
Smell (Nose)
Shape : (√ ) Normal ( ) Deviasi
Disturbance smell : ( ) yes (√ ) no
Hearing( Ear )
Auricle : (√ ) Normal ( ) Abnormal Info ………………..
Tympanic Membrane : ( ) bright ( ) redness ( ) cloudy
Otorrhoea (bleeding) : ( ) yes (√ ) no
Hearing loss : ( ) yes ( √ ) no
Tinnitus : ( ) yes (√ ) no
Taste : (√ ) Normal ( ) no feel
( ) others
Touch : (√ ) Normal ( ) abnormal, mention …………………….
Female
Breast :
Shape : ( ) symmetrical ( ) asymmetrical
abnormal : ( ) yes,type….. ( ) no
Sex :
shape : ( ) Normal ( ) no
vaginal discharge: ( ) yes ( ) no
Menstrual cycle : ……….days
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
INTERVENSI KEPERAWATAN
No. Nursing Objectives and Criteria Results Intervention TTD
diagnoses
15/0 Anxiety about Having performed for 1x24 1. Use BHSP approach
2/20 the procedure hour nursing care is expected 2. Explain all procedures,
16 execution to decrease anxiety and the what is felt during the
patient and family understand procedure, and objective
the procedures for procedures performed
implementing the DLA, DCA
marked by KH: 3. Listen attentively.
Not able to identify and 4. Make a back / neck rub to
express the anxiety that is felt. relieve anxiety.
vital signs within normal 5. Teach relaxation
limits. techniques to reduce
middle excretion showed anxiety
reduced anxiety 6. Collaborate to reduce
Clients say know and anxiety by drug delivery.
understand the procedures for
implementing the DLA
INTERVENSI KEPERAWATAN
No. Nurses Purpose and Criteria Result Intervention TTD
Diagnosis
18/0 Acute pain by After 3x24 hours of nursing 1. Assess the patient’s pain
2/20 surgery care for the expected reduced scale
16 pain, KH : 2. Teach pain management
Patient seemed calm 3. Observation TTV
Patient said it wasn’t 4. Collaboration with
painfull medical team
Painfull After 3x24 hours of nursing 1. Assess the patient’s pain
19/0 care for the expected reduced scale
2/20 pain, KH : 2. Teach pain management
16 Patient seemed calm 3. Observation TTV
Patient said it wasn’t 4. Collaboration with
painfull medical team
IMPLEMENTATION & EVALUATION
Date Nurses Time Implemention Paraf Formative Evaluation
Diagnosis SOAPIE/ Notes
Development
14/0 Intolerance 06.30 Switch to night shift S = patients expressed
2/20 Activity 07.00 Good general state, akral no pain
16 HKM, spontaneous O = patient seemed calm
breath A = the issue isnot
08.00 Educationn to patients resolved
11.30 Observation TTV : TD= P = interventions
110/80, pulse= 60, RR= continued
30, temp= 36 ̊ R/observastionTTV,
13.45 Switch to morning shift education activity
14/0 Intolerance 14.00 Conscious general state, S = patients expressed
2/20 Activity akral HKM,spontaneous no pain
16 breath, GCS 456 O = patient seemed calm
16.00 Observation TTV: TD = A = problems resolved
120/80, pulse =68, RR = partially
18, tenp = 36 ̊ P = interventions
continued at this night
1. ObservationTTV
2. Education to limit the
activity
3. BC
14/0 Intolerance 20.45 Afternoon shift S = patients expressed
2/20 Activity 04.00 Help ADC patient no pain
16 05.00 Obs TTV : TD= 120/80, O = patient seemed calm
N/S = 63/36 and RR= 18 A = problems resolved
05.50 Assess the patient’s pain partially
scale P = interventions
P= post CPAG continued
Q= throbbing pain 1. Observation TTV
R= chest middle 2. Pain scale
S= - 3. Teach management of
T= residential wane pain
06.00 Teach management of
pain
IMPLEMENTATION & EVALUATION
Date Nurses Time Implemention Paraf Formative Evaluation
Diagnosis SOAPIE/ Notes
Development
15/0 Acute pain 13.30 Change to morning S = patients expressed no
2/20 shift pain
16 15.30 Observation TTV : Good general state, akral
TD= 140/80, pulse= 76, HKM, GCS=456
RR= 30, Temp= 36 ̊ Asses the pain
15.30 Good general state, P= post CABG
akral HKM, GCS=456 Q= throbbing pain
16.00 Assess the patient’s R= chest middle
pain scale S= scale 3
P= post CABG T= residential wane
Q= throbbing pain Patient seems touch the
R= chest middle chest when the pain come
S= 3 A = problems not resolved
T= residential wane P = intervention continued
17.30 Teach management of Educatin the patient to
pain bedrest
19.00 Give the terapy Teach the managemet
including the doctor’s of pain
advise Observation TTV
Assess the pain scale
Help ADL
15/0 Intolerance Change to afternoon S = The patient asks that
2/20 Activity shift no pain
16 Keadaan umum baik, O = the patient seems
DCS= 456, Akral calm GCS= 456
HKM A = the problem not
Memberikan edukasi resolved
kepada pasien untuk P = intervention continued
membatasi mobilitasi R/ observation Hv
Observasi TTV : TD= Education the patient to
130/70, S= 36, N= 72, limit the activity and
RR= 20 don’t strong to close
BAB, helpADL pattient
IMPLEMENTION & EVALUATION
( ……………………………. ) ( Sumarmiati)
Witness 1:……………………………(……………………)
Witness 2:……………………………(……………………)
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
No. Day/Dat Name of the Dose Total Info Ttd/ Name of Ttd/ Name Info
e/Time drugs (received/submi submitting of
tted) receiving
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.
ESO:
Residu:
TT
Px/Family
Name Of Accept:
Drugs:
Dose:
Time Name Name Name Name Name Name Name Name
Residu:
TT
Px/Family
Name: No.Reg:
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
MEDICINE GIVING FORMAT ORAL
INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.
ESO:
Residu:
TT
Px/Family
Nama of Accept:
Drugs: Dose:
Time Name Name Name Name Name Name Name Name
ESO:
Residu:
TT
Px/Family
Name : No.Reg :
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
MEDICINE GIVING FORMAT ORAL
INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.
Name Of Accept:
Drugs: Dose:
Time Name Name Name Name Name Name Name Name
8
ESO:
Residu:
TT
Px/Fam
ily
Name Of Accept: 1x1
Drugs: Dose: 4 mg
Time Name Name Name Name Name Name Name Name
8
ESO:
Residu:
TT
Px/Fam
ily
Name : No.Reg :
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
MEDICINE OF DRUGS
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Tim Name Dos TTD Ti Na Dos TTD
Of e of Nurse e Of e of Nurse me me e of Nurse
Drug dru Drug dru Of dru
gs gs Dru gs
g
Date: 8 13. Flumo
11-2- 00 cyl
2016 Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dose TTD Tim Name Dos TTD Ti Na Dos TTD
Of of Nurs e Of e of Nurse me me e of Nurse
Drug drugs e Drug dru Of dru
gs Dru gs
g
Date: 08.0 Biso 1x1 Nita
12-2- 0 Prulul 3x1
2016 Flumo
cyl
Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Tim Name Dos TTD Ti Na Dos TTD
Of e of Nurse e Of e of Nurse me me e of Nurse
Drug dru Drug dru Of dru
gs gs Dru gs
g
Date:
11-2-2016 - Dr.Budi
-
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
LABORATORIUM
NAME : Tn. Hariyono NO.RM :
AGES : 62 year ADRESS : Perum Bumi Margo Permata
SEX :L/P ROOM : Ruby II.2
DOCTOR : DATE MRS :
DATE :
DATE 10/02 13/02 VALUE NORMAL
BLOOD
Routine : B.B.S
Hemoglobin 13,8 13,8 11.5 – 16.0 g/dl
Lekosit/WBC 11,01 9,57 4.0 – 11.00 K/UL
Counting of type : 2
Eosinofil
0
Basofil
0
Stab
45
Segmen
45
Limfosit
8
Monosit
Special : Eritrocit/ 4,66 4,18 3.00 – 6.00 M/UL
RBC
Thrombo/ 281 234 150 – 450 K/UL
PLT
Reticulosit
PCV / HCT 41,3 39,6 37.0 – 47.00 %
Malaria
Bleeding Time 2,00 1,30 N : < 3’
Clotting Time 10,00 11,00 N : < 12’
P.P.T 12,3 12,1 (N different control 2)
Lekosit
Epitel sel
Kristal :
Ca Oxalat
Asam Urat
Tri. Phos
Amorbh
Silinder :
Granulair
Hyaline
Lekosit
Erythrosit
Other
Special : Specific Gravity
Reaction/ PH
Aceton
Esbach
Other
Pregnancy test : Plano Test
GM
Test
GM
Titrasi
FACES :
Consistency
Blood
Mucus
Leukocyte
Erythrocytes
Ova
Flyblow
Benzidine Test
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
NURSING RESUME
NAME : SEX :
NO.RM : ROOM :
(...........................)
PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
SHEETS DISCHARGE PLANNING
DISCHARGE PLANNING No.Reg :
Name :
Sex :
Part : Part :
Control :
a. Time :
b. Place :
Diet rules :
Other :
Surabaya,
Patient/Family Nurse
(.......................) (.......................)
A. DATE ANALYSIS
Patient's Name : Tn. Hariyono
Age : 62 year
Dx.Medical : PJK Post CABG
MRS's Date : 10 February 2016
Studying Date : 10 February 2016
1. acute Pain b/d After be done bring up 1. Build Connection R/ to easy it client
agens accident of treatment as long as Mutual Believe to in to controlled the
physical 3x24 time to be patient behavior,to close it
expected the pain that body to patient
to be felt patient 2. Study patient's skala R/ to to know as far
lessen,with Result pain as which level pain
Criteria : and to can action
Patient appear mmberikan next
calm 3. Observation of the R/to to know public
Patient tell not signs patient's vital condition
pain 4. Collaboration with R/ to to controlled
pain Skala to medical team in or to lessen the pain
lessen medicine giving feel
analgesic
2. Risk its happen As long as be done 1. Build Connection R/to to close it body
descendant of action of treatment mutual Believe to patient to patient
network fusioner doesn't happen 2. Study existence R/to evaluation
b/pressure d network fusioner changing of consciousness condition
descendant blood descendant, with 3. Inspeksi existence pale,
Result Criteria: sianosis. R/ to to know
a. TTV in normal limit turgor's condition
b. Input and output 4. Study sign sign vital patient
normal
c. full Consciousness 5. intake's Monitor and R/to to evaluation
output patient's breath
rhythm
R/ Untukmengetahui
body balance
liquefying
3. Intoleransi After be done bring up 1. Build connection mutual R/ to easy it client in
activity of treatment as long as believe in patient to controlled the
b/weakness d 3x24 dharapkan's time behavior,to close it
public able patient to do 2. TTV's Observation body to patient
activity stand alonely, patient
with Result Criteria: R/to to know public
a. Can to do activity 3. Give it condition
stand alonely knowledge/education to
b. TTV In Normal client R/ so that asien
Limit know limit in
activity
D. IMPLEMENTATION of TREATMENT