Session I at Nurse Station

On Thursday (September 25th, 2018) at 07.00 am all nurses (PN and AN) morning and
night shifts and Nurse Unit Manager (NUM) gathered at the nurse station.
NUM (Aldi): Good morning everyone (Sit at the nurse station)
(All morning and night shift teams enter the nurse station)
Ners: Good morning sir!
NUM (Aldi) : Have everyone gathered?
Ners : Yes, sir.

NUM (Aldi) : Good, then let's start right away. Assalamualaikum wr. wb. Before starting
handover the shift in this morning, let start by praying together. Pray begins
(prayer). Enough. Please NIC / AN of night shift to convey the condition and
progresses of the patient while on duty to the PN / AN who will carry out the
shift on this time (morning).
PA1 (Dhinar) : Good morning everyone, thank you for the opportunity. Before Ners Selly
and Ners Lilis conveyed the condition of the patient, I am going to report the
M1-M5 first.

M1 (Workforce) : The number of nurses with a night shift was 3 nurses, I am as AN1, Ners
Selly as PN, and Ners Lilis as AN2. Room Nurse 3 people, 3 professional
students, 1 Nurse Aide Team (NAT). Everyone was present and have carried
out their duties well.
M2 (Facilities and Infrastructure) : Facilities for patients have no problems, both beds, patient
desks, wheelchairs, wall clocks, scales, bathrooms and toilets and sinks are
still in good condition. Likewise, medical equipment in the room B is also in
good condition.
M3 (Nursing Care Method): for M3 there is no problem
M4 (Cost) : all patients use BPJS

M5 (Quality) : no patients with phlebitis, one patient with decubitus. That’s all i can report,
then I leave it to Selly and Ners Lilis.

PP (night shift) (Selly): Thank you, now I am going to continue the night shift report. The
number of patients under management currently reported is 12 people, with
a minimum dependency level of ...... people, partial dependence as much as
...... people and a total dependency level of ....... people.
 Bed SBAR
Situation: Mr. Warimin, age 64, admitted to hospital on day 11, with a medical
diagnosis of Sepsis + Hipoalbumin + PJK OMI
Background: GC (General Conditions) are weak; GCS 456; BP 105/75 mmHg;
P (Pulse): 92x / minute; RR: 20; T: 36.4 C. Attached IV line on left hand Day 2
(20G) Aminofluid 21 dpm (drops/minute) IV Line on right hand Day 3 (20G) Road
Norepinephrine speed 5.0 nano / minute, O2 nasal 3 Lpm. The last defecation of last
night was soft (09/26/2018), Installed DC (+) Day 9 output 1000 ml / 24 hours, the
B3
portion of the meal did not run out, the patient complained his body felt weak.
Therapy that has been given 100 nanogram NE
There are no oral and injection drugs given at night shift
Assessment: Impaired cardiac output loss
Recommendation:
Monitoring Vital Sign and fluid balance
Check Lab KK (Creatinine, BUN, SGOT, SGPT)
Situation: Mr. Tan King Sing, aged 73 years, Decubitus Ulcer Gr.II Sakrum +
Sepsis Encephalopathy + Anemia (9.0) MRS day 4
Background: GC is weak; GCS 433; TD 120 / 60mmHg; P: 88x / minute; RR: 32
is attached to 8 lpm of NRM O2, ronkhi secret breath sounds (+), T: 37,1. Attached
IV line left hand (20G) day 3, Attached, NGT day 10 production of black color
20ml / 24 hours, Sonde milk 200 cc, Attached catheter Day 4 production of urine
1000 ml / 24 hours, the last defecation date 25/09 / 2018 soft, patient decreased
B4 consciousness
Therapy that has been given are ventolin and combivent nebul
Assessment: ineffective airway clearance
Recommendation:
TTV monitoring
Management of oxygenation and airway clearance (nebul and respiratory
physiotherapy), plan for treating ulcer decubitus sacrum wounds
Right-left tilt every 2 hours

PA2 (shift malam) (Lilis) : i continue the night shift report

Bed SBAR
Situation: Mr. Ali Fatnan, age 33 years, MRS day 3, with a medical diagnosis of
Regular HD ESRD + Ascites permagna + HHD
Background: GC Good; GCS 456; TD 130 / 80mmHg; P: 96x / minute; RR: 24
installed 02 nasal 4 lpm; T: 37. Attached IV line right hand (20G) venflon, left hand
AV Shunt, spontaneous Urination minimal (<50ml) IWL: 15 x 77 = 1155, intake to
B11
drink 400 ml, Last defecation 19/11 soft, Edema Extremity second leg pitting edema
( -), Ascites (+), the client complains of an enlarged stomach
Therapy that has been given
Oral medication for folic acid and amlodipine 10 mg
Assessment: Excess fluid volume
 Bed SBAR
Recommendation:
TTV monitoring and fluid balance
Plan regular HD programs
Ascites evacuation plan
Situation: Mr. Bruri Andaru, age 27 years, MRS day 8, medical diagnosis ALL
Leukemia phase limphoma post melena
Background: I have enough, GCS 456, TTV: BP 120/100 mmHg, P 90 / minute,
RR 18 / minute, temperature 39.9 C shivering (+), attached IV left hand (20G) day
3, spontaneous urination, post open biopsy on the 3rd day of the wound seeping (-)
, bleeding (-), defecation 1x a day, eating 3/4 portion, Hb (9.3) Platelets (9000), the
client complained of his temperature which is increasing and decreasing.
Therapy that has been given
Inj Tranexamic acid 500 mg
B12 Inj Metoclopramid 10 mg
Oral medication for Paracetamol 500 mg, Paracetamol drip 100 ml.
Assessment: Hyperthermia and risk of bleeding
Recommendation:
TTV monitoring and signs of bleeding
Observation and treatment of post biopsy wounds
Minimizes movement to prevent post biopsy bleeding
PRC 2 kolf transfusion plan and TC 10 bag
Advise to compress if the temperature is more than 37 C
Clinical chemistry laboratory check and complete blood transfusion (Hb, Plt, WBC)

PA2 (night shift) (Lilis): That's the report of night shift.

NUM (Aldi) : Thank you for night service colleagues. Is there any questions or
clarification? (talk to All team). Okay, morning shift team, please.
PP1 (morning shift) (Roziqin): For today's program from primary 1
1st B3 Mr. Warimin monitors hemodynamics, there is no event
2nd B4 Mr. Tan King Sing with decubitus ulcer care
PP2 (morning shift) (Rini): For today's program from primary 2
1st B11 Mr. Ali plans a regular HD program
2nd B12 Mr. Bruri plans to transfer PRC and TC
NUM (Aldi) : Well, any else need to be clarified?
PA2 morning (Mario) : Is there a blood sample request and delivery for Mr. Bruri B12?
PA2 (night shift) Lilis : yes already, yesterday the sample and blank request for blood was 2
colf PRC and 10 bags of TC. Later we can call the bank to the blood supply.
Morning PA2 (mario) : good
NUM (Aldi) : any other else to be clarified?
All : No sir.

NUM (Aldi) : Thank you for the night team who have report the condition of all patients
at this time. If there are no additions and nothing else is discussed, before we
validate the patient, let's wash hands first, Ns. Yumi please led by 5 moments
of washing hands and let’s wash hands together

PA1 morning (Yumi) : 5 moments of hand washing (before contact with patient, before aseptic
action, after contact with body fluids, after contact with patients, after contact
with the patient's surroundings)

All : (Practicing washing hands 6 steps, face down 2 hands alternately, close and
lock and turn thumb, last rubbing fingertips)

NUM (Aldi) : Let's have come to the patient, later if there is a secret thing we want to talk
about can be discussed again at the nurse station

Session II in the Treatment Room / Patient Bed

Morning and night shift nurses validated back at the night nurse patient introducing morning
service nurses.

Entering Room B3 Approaching Mr. "Warimin"

PP night shift (Selly) : Assalamu'alaikum Wr Wb. As usual, we are here willing to carry out
handover activities every shift, so that the official shift know the condition,
and later who will be in charge of caring for you. And this is Ns. Roziqin and
Ns. Yumi who are both taking care of you today.
PA1 (morning shift) (Yumi) : How do you do Mr. Warimin? What do you feel now?
B3 patient (Mr. W) : Still feeling weak.

PP1 (morning shift) (Roziqin) : be patient, sir. Your treatment program is still the same as
yesterday, and we are still monitoring your condition. Mr. warimin must also
help us by improve eating, drink enough water, and always praying, if anyone
complains can contact me.
B3 patient (Mr. W): Yes, thanks.
PA1 (morning shift) (Yumi) : Then we excuse us, sir, have a good rest.
NUM (Aldi) : let's go to another patient. Please father rest again.
All : see you later, Mr. Warimin.
B3 patient (Mr. W) : see you

Approaching B4 patient Mr. Tan King Sing

NUM (Aldi) : Good morning, Mr. Tan King Sing and Mrs. Tan, this morning will be treated
by Ns. Roziqin and Ns Yumi.
Patient's family (Mrs. Tan): Good morning sir.
PP1 (Roziqin) : Mrs. Tan, is there any complain about Mr. Tan's current condition?
Patient's family (Mrs. Tan): no nurses, Mr. Tan is still the same as yesterday.

PP1 (Roziqin) : Yes, ma'am, we keep observing awareness, cleaning mucus which is risky in
inhibiting the airways, and plans to treat Mr. Tan's wounds. Mrs. Tan must still
be convinced of healing and help with prayer.

PA1 (Yumi) : Yes, Mrs. Tan. We are ready to take care of Mr. Tan and if there are
complaints with Mr. Tan, please call us to take care of him this morning.

Approaching B11 patients Ali

NUM (Aldi) : Good morning sir?

PA2 (Night Shift) Lilis: sir, nurse will be in charge for caring your father this morning are Ns.
Rini and Ns. Mario.
PA2 (morning shift) (Mario): Hello Mr. Ali, what do you feel now?
Patient B11 Mr. Ali: I had sleeping problems last night, my stomach was bulging

PP2 (morning shift) (Rini): Yes sir, we have told the doctor for the liquid evacuation program
in your stomach, while still waiting for the laboratory results to determine the
right action. You also planned to continuing dialysis program, sir. Do not
forget to drink limited to 2 glasses per day and the amount of urine that comes
out is still calculated.
Patient B11 (Mr. Ali): Yes Ms. Thank you.

Approaching B12 patients Bruri

PA2 (Lilis) : Good morning Mr. Bruri, Nurse will be in charge for caring you this
morning are Ns. Bellani and Ns. Leni huh
PP2 (morning shift) (Rini): Good morning sir? How was this morning? did you sleep well
overnight sir?
Patient B12 (Mr. Bruri): Yes, bro, it was hard to sleep because of the heat and my body
shivered.

PA2 (night shift) Lilis: Mr. Bruri’s temperature was 39.9 C and given 100 ml paracetamol drip,
this morning it was checked down to 37.2 C.

PP2 (Morning Shift) (Rini): Okay, then we keep monitoring the temperature, sir. If there is a
complaint or an increase in temperature until shivering, immediately report
it to the nurse. Today will also be planned to replace the wound on your post
biopsy sir.
B12 patient (Mr. Bruri): yes nurse, thank you
NUM (Aldi) : have a good rest, sir

Narrator: When finished, NUM and the nurse returned to the station to clarify whether there
was anything need to be discussed again

After turning away from the patient

NUM (Aldi) : Okay let's go back to the Nurse Station
All : yes sir
NUM (Aldi) : nurse, is there anything else need to be clarified?
All : enough, Sir.

NUM : I thank the night shift team, and have a good morning duty for you all
morning shift team. let's pray, hopefully the morning shift team can carry out
the task well and the night shift team can get home safely. Start praying.
Thank you, Wassalamualaikum, Wr.Wb.