english ganeshaa

NURSING CARE OF THE PATIENT WR

WITH ACKD (Acquired Cystic Kidney Disease) IN GANESHA HOSPITALDATE 1 - 12 JUNE 2015I. ASSESSMENTA. Identity Of The PatientsPatients came to the Ganesha Hospital on May 18, 2015. For the assessment started on Monday , June 1 2015 at 9 oclock and the ward of the inpatient for patient is at third floor in Cempaka Ward number 311 E. Information obtained through a method of an interview with the patient's family, physical examination, and observation . `

1. Identity Of The Patients

Name : WR

Gender : Male

Age : 77 years old

Marital Status : Married

Religion : Hindu

Nation : Indonesia

Last educational : Elementary School (SD)

Occupation : Not Working

Address : Br. Gelumpang SukawatiMedical Diagnostics: ACKD + PNA + Batu Ginjal + HHDCost Sources : JKBM

The Relationts with the patients :

Number of Medical Record : 064696B. The Reasons is in Hospital1. The Main ComplaintWhen the Hospitalized: The complaint of the patient is about abdominal pain.When to do the assessment : The complaint of the patient is about shortness.2. Disease HistoryThe patient came to the Ganesha Hospital on the may 18 2015 with his family.The patient came conscious with the complaints abdominal pain , after examination by a doctor ,patient are diagnose with PNA, a Kidney Stone and Hipertentiont Heart Disease (HHD). In Emergency room patients get therapy:

IVFD Nacl 3% 20 tpm makro

Farmadol fles 1000mg

Cefosubactam 1g

Metronidazole 1000mg

Captropil 25mg

Amlodipin

The ward of the inpatient for patient is at third floor in Cempaka Ward number 311 E: and patients get therapy ~ IVFD Futrolit 20 tpm makro

Farmadol fles 1000mg k/p

Captropil tablet 2 x 50mg

Metylpredysolon injeksi 3 x 20 mg

Furosemide injeksi 2 x 20 mg

Cefo sulbactam injeksi 2 x 1 g

Nucral syr 3 x 1 CI

Omeprazole injeksi 2 x 40 mg

Asam traneksamat injeksi 3 x 500 mg

C. The History of Previous HealthThe patient said that he has high blood pressure since 10 years ago .D. The History of Family HealtThe son of patients said in his family said there is no one to have the same disease suffered by patientsE. The Necessity of Bio-Psiko-Sosial-Spiritual

1. BreathingWhen to do the assessment the patient complain about feel shortness.2. Eat and DrinkWhen to do the assessment patients get a diet sonde 2000 calories 40 gr protein .The family said when the patient get sonde patients can only spend sonde that given from the hospital. The family also said patients refused to eat and given sonde .3. Elimination ( BAB, BAK )When to do the assessment patient had been chapter 1x with a mushy consistency colored black with a little fishy smell. As well as tubs patients 1100 cc , with a yellow color , a distinctive odor urine .

4. ActivityWhen to do the assessment the activity of the patient can help by his son, the patients only capable of sloping left and right oblique , patients more be active in bed because they felt weak .5. RecreationWhen to do the assessment the patient said that he cant go anywhere and he just stay in his room, and sometimes to talk with families and other people that who come to see .6. Rest and sleepWhen do the assessment the patients said he doesnt got a disturbed in his sleep , even in the hospital patient often sleep , For a night patien slept statr from 21.00-06.00 oclock and during the daytime patient slept start from 13.00-15.00 oclock .7. Personal HygieneWhen do the assessment The patients only wipe course twice a day with the help patients son to cleanliness self patient awake .Patients look clean and after in a wipe course by the family8. Body TemperatureWhen do the assessment the patient said he doesnt feel cold or warm in his body, the temperature is 36,1 0C.9. Comfortable FeltWhen do the assessment the patient said patient doesnt complaint about his pain.10. Safe FeltWhen do the assessment patients feel axious about his condition of disease and that had happened to him now.11. StudyWhen do the assessment the families of patients want to know and want to learn about the ways to cure diseases suffered by patients. Family always following therapy of the patient that advocated by doctors . 12. OccupationWhen do the assessment the families of patient said about patient doesnt work after he got hospitalized. 13. Socialitatoni and CommunicationWhen do the assessment the families of the patien said , patients want to interact with anyone good nurses and families inclined to the hospital. And he doesnt has a problem in communication.

14. SpiritualWhen do the assessment patients said during in hospital patients do prayer on the bed.F. Physical Examination1. General State Of the Patient

The general impression: WeakAwareness

: Compos Mentis GCS (E=4, M=5, V=6)Posture

: ErectWeight

: 62 kgHeight

:165 cmTurgor the skin

: not elastisSkin Colour

: Sapodilla ripe2. Cardinal SymptomBlood Pressure: 170/90 mmHg

Temperature: 36,1 0C

Pulse

: 90 x/minuteRespirations: 12 x/minute3. Physical Condition1) Head:

Inspection: Cleanliness good , the spread of hair evenly , there is no lesions , looked listless the face , of hair color partially white.

Palpasi: There is no pain pressure.2) Eyes:

Inspection:Symmetrical forms, white of the sclera, pale the conjunctiva, pupil isokor, no lesions.

Palpasi: There is no pain pressure.3) Nose:

Inspection: Attached NGT in the nostrils right, symmetrical forms, there is no lesions, cleanliness enough, there are the breath of the nostrils, patients with attached o2 kanulanasal 3 l / minutes.

Palpasi: There is no pain pressure4) Ears: Inspection: Symmetrical forms, cleanliness enough, there is no lesions, there was no swelling. Of hearing fine. Palpasi: There is no pain pressure, good hearing.5) Mouth and tooth :

Inspection: Cleanliness enough , looked bleeding in the area of the mouth and gums , the colour of lips is pale , mucous lips dry .6) Neck:

Inspection: There is no lesions

Palpasi:There is no dam the jugular vein , not there is enlargement of the thyroid gland , there is no pain pressure.7) Thorax:

Inspection: Symmetrical forms, there is no lesions, there are retraction help respiratory muscles.

Palpasi: There is no pain pressure

Percussion: Resonant voice sounded the part of the thorax right , and sound dalnes in ICS 3 , 4.5 , 6 left

Auskultasi: A vesicular breathing8) Abdomen:

Inspection:Symmetrical form, there is no distention , there is no lesions, umbilical is clean.

Auskultasi: Noisy intestines x / 20 minutes

Percussion: Audible of tympanic

Palpasi : There is no pain pressure9) The extremities

Top

: Symmetrical forms , there is no cyanosis , on the right hand attachead IVFD fluktrolit infusion of 20 tpm. CRT < 2 seconds. Bottom

: Symetrical forms, there is no cyanosis, there is no lesions and there is no pain pressure.G. InvestigationsThe results of the examination of the pathology lab clinic on May 31, 2015NoIndicatorResultUnitA reference value

12

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20WBC

LYM%MID%GRA%LYMMIDGRANRBCHGBHCTMCVMCH

MCHCRDW%RDWaPLTMPV

PDW

PCT

LPCR14.711.1

7.0

81.9

1.6

1.1

12.0

2.73

8.2

23.1

84.6

30.2

35.7

15.4

84.4

106

9.0

13.8

0.09

24.0109/l%

%

%

109/l

109/l

109/l

1012/l

g/dl

%

Fl

Pg

g/dl

%

fl

109/l

fl

fl

%

%4.8-10.820.0-40.0

3.0-9.0

50.0-70.0

0.8-4.80.1-7.0

2.0-7.0

4.7-6.1

15.4-18.0

42.0-52.0

79.0-99.0

27.0-31.0

33.0-37.0

11.5-14.5

30.0-47.0

150.0-450.0

7.2-11.1

10.0-17.0

0.2-0.4

0.1-99.9

The results of laboratory examination on June 2, 2015NoIndikatorResultUnitA reference value

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20WBC

LYM%

MID%

GRA%

LYM

MID

GRAN

RBC

HGB

HCT

MCV

MCH

MCHC

RDW%

RDWa

PLT

MPV

PDW

PCT

LPCR15.9

12.1

5.3

82.6

1.9

0.9

13.1

3.09

9.1

26.4

85.4

29.5

34.5

15.7

88.7

123

7.9

12.2

0.09

15.5109/l

%

%

%

109/l

109/l

109/l

1012/l

g/dl

%

Fl

Pg

g/dl

%

fl

109/l

fl

fl

%

%4.8-10.8

20.0-40.0

3.0-9.0

50.0-70.0

0.8-4.8

0.1-7.0

2.0-7.0

4.7-6.1

15.4-18.0

42.0-52.0

79.0-99.0

27.0-31.0

33.0-37.0

11.5-14.5

30.0-47.0

150.0-450.0

7.2-11.1

10.0-17.0

0.2-0.4

0.1-99.9

The results of laboratory examination on May 31, 2015ParameterHasilRujukanSatuanSpecimenketerangan

BUN192.66 - 20mg/dlH

Creatinin6.10.8 1.3mg/dlH

II. NURSING DIAGNOSISA. Data AnalysisNoFocus DataEtiologyNursing Problem

1DS :

The patien said he is felt shortnessDO :

Respiratory : 12 x/minute There is a retraction breathing muscle There is the breath of the nostrils

Attached with kanulanasal 3 l/minuteChronic Renal FailureGFR decreasedMetabolic AcidosisHyperventilationIneffective Breathing PatternIneffective Breathing Pattern

2

DS : Patient said that he felt weakDO :

The face of patient looked languid and pale. HGB : 8.2 RBC : 2.73

Pulse: 90 x/minute Respiratory: 12 x/minuteLevel of Hb, Ht, Erytrocytes decliningHypoxia

An imbalance of supply with consumption O2

WearinessActivity Intolerance

Activity Intolerance

3

DS :

Patient said that he felt weakDO : The colour of lips and conjungtiva is pale HB : 8,2

Chronic renal failureDisorders of the acid balanceGastric Acid Increasing

Irritation in the gastricHematemesei Melena

Anemia

Coaboratif problem of anemia

Colaboratif Problem of Anemia

4DS : Patient said that he felt weakDO :

Blood Preassure : 170/90 mmHg

Retention Na

JG stimulated so that renin out

Renin +angiotensisnogen= angiotensinogen 1

Angiotensinogen 1+PCE = Angiotensinogen II

Entered tunika media

Suffered kontriksi faseColaboratif problem of HipertentionColaboratif problem of Hipertention

5DS :

The family of the patient said that when the patient give sonde only able to spend sonde that given from the hospital . The family of the patient also said patients sometimes refuse to given sonde that get from the hospital.DO :

Looks bleedings in the mouth and gums. The colour of his lips is pale Lips of the mucous is dry Attached NGT

HB : 8,2Disorder of the acid balance

Gastric Acid production increasingIrritation in the gastricGastritis

Nausea and VomitingNutrition, Altered: Less than Body RequirementsNutrition, Altered: Less than Body Requirements

B. Diagnosa Keperawatan1. Ineffective Breathing Pattern related to hiperventilation as evidenced by the patient felt shortness, respiratory 12 x/ minute, there is a retraction breathing muscle, there is the breath of the nostrils, attached with kanulanasal 3 l/minute2. Activity Intolerance related to an imbalance of supply with consumption O2 as evidenced by patient said that he felt weak, the face of patient looked languid and pale, HGB : 8.2, RBC : 2.73, pulse: 90 x/minute, respiratory: 12 x/minute3. Colaboratif Problem of Anemia related to hematemesis melena as evidenced by patient said that he felt weak, the colour of lips and conjungtiva is pale, HB : 8,2.4. Colaboratif problem of Hipertention related to angiotensin hormone increases as evidenced by patient said that he felt weak, blood preassure : 170/90 mmHg5. Nutrition, Altered: Less than Body Requirements related to irritation in the gastric as evidenced by the family of the patient said that when the patient give sonde only able to spend sonde that given from the hospital, the family of the patient also said patients sometimes refuse to given sonde that get from the hospital, looks bleedings in the mouth and gums. the colour of his lips is pale, lips of the mucous is dry, attached NGT, HB : 8,2III. INTERVENTIONSA. The diagnosis of priority

1. Ineffective Breathing Pattern related to hiperventilation as evidenced by the patient felt shortness, respiratory 12 x/ minute, there is a retraction breathing muscle, there is the breath of the nostrils, attached with kanulanasal 3 l/minute2. Colaboratif Problem of Anemia related to hematemesis melena as evidenced by patient said that he felt weak, the colour of lips and conjungtiva is pale, HB : 8,2.3. Colaboratif problem of Hipertention related to angiotensin hormone increases as evidenced by patient said that he felt weak, blood preassure : 170/90 mmHg4. Nutrition, Altered: Less than Body Requirements related to irritation in the gastric as evidenced by the family of the patient said that when the patient give sonde only able to spend sonde that given from the hospital, the family of the patient also said patients sometimes refuse to given sonde that get from the hospital, looks bleedings in the mouth and gums. the colour of his lips is pale, lips of the mucous is dry, attached NGT, HB : 8,2

5. Activity Intolerance related to an imbalance of supply with consumption O2 as evidenced by patient said that he felt weak, the face of patient looked languid and pale, HGB : 8.2, RBC : 2.73, pulse: 90 x/minute, respiratory: 12 x/minute3. Nursing InterventionsNoDate DxPatient OutcomesInterventionsRationale

1.Monday, June 1st 2015

09.00 am1After 3 x 24 hours of nursing care , expected patients breathing pattern back to normal / stable with outcomes: The rhythm of breath, respiratory frequency in the normal range, no additional sound.

Vital signs in normal range1. Measure the vital signs every 8 hours2. Give semi-Fowler position3. Instruct the patient to deep breathing or breath lips slowly according to patients ability

4. Collaboration to give oxygen therapy1. To facilitate the provision of appropriate interventions

2. To maximize ventilation

3. To facilitate breathing so more O2 that entered

4. Supply O2 is enough to reduce the work of breathing

2Monday, June 1st 2015

09.00 am2After 3 x 24 hours of nursing care , expected expected to minimize the occurrence of sustained anemia with outcomes :

Patients do not look pallor Results of laboratory hematology (Hb, RBC) within normal range1. Monitor for signs of anemia such as pallor, dyspnea when breathing

2. Monitor of laboratory hematology like Hb, RBC

3. Instruct how to prevent bleeding, such as using a soft brush to brush his teeth.

4. Give HE to the family to give patients food that containing of iron

5. Collaboration in giving blood transfusions as indicated

1. To facilitate the provision of appropriate interventions

2. To determine the effectiveness of treatment programs

3. Bleeding in any place in the body can aggravate anemia

4. Iron is one of the ingredients in the formation of blood cells.

5. To increase the levels of Hb, RBC, HCT, PLT.


09.00 am3After 3 x 24 hours of nursing care , expected patient's blood pressure is controlled with outcomes:

Vital signs in normal range1. Observation of patient's blood pressure2. provide advice to adhere to dietary and fluid restrictions.3. Instruct the patient to report signs of fluid overload, headache, edema or seizures.4. Give antihypertensive medications according to doctor instructions.1. Blood pressure measurements provide objective data for monitoring patients condition..

2. Compliance with dietary restriction and dialysis fluid prevents the buildup of excess fluid and sodium.

3. indication for inadequate control of hypertension and the need for change the therapy4. antihypertensive medications has important role in the treatment of hypertension due to CKD.


09.00 am4After 3 x 24 hours of nursing care , expected the problem of inbalanced Nutrition, Less Than Body Requirements is resolved with outcomes :

An increase in the arm circumference

There were no significant weight loss

Shows the tasting and swallowing function1. Assess etiologic factors from reduced nutritional intake. (anorexia, nausea, vomiting, an unpleasant diet, depression, lack of understanding of diet restriction, stomatitis).

2. Provide appropriate food diet prescribed by a physician nutrition and installation

3. Increase protein intake containing high biological value such as eggs, dairy products, meat.

4. Encourage low-protein, high-calorie and low sodium snack between meals.

5. Change the medication schedule so the medication is not given immediately before a meal.

6. Explain the rationale and relation dietary restrictions with kidney disease and an increase in urea and creatinine.

7. Create a pleasant environment in mealtime.

8. Observation evidence of inadequate protein intake (edema, slow healing, decreased serum albumin)1. Providing information on other factors can be changed or removed to improve dietary input.

2. Encouraging increased dietary inputs.

3. Complete proteins are used to achieve nitrogen balance necessary for growth and healing.

4. Reduce food and protein restricted and provide calories for energy.

5. Ingestion of medication before meals causes anorexia and satiety.

6. Improve the patient's understanding of the relation between diet, urea and creatinine with dietary restrictions.

7. Unpleasant factors in meal times important to causing anorexia eliminated

8. Put inadequate protein that causes a decrease in albumin and other proteins, edema and slowing healing.


09.00 am5After 3 x 24 hours of nursing care , expected patients reported an increase exercise tolerance with outcomes: Vital signs in normal range Do not complain weak and fatigue

1. Measure the vital signs every 8 hours

2. Observe signs of fatigue (tachycardia, palpitation, dyspnea, dizziness, blurred - firefly, limp, lackluster posture, slow movements and tense.

3. Provide ROM training4. Give the HE to the family to assist patients in activities beyond the limits of tolerance.1. Cardiopulmonary manifestations of heart and lung efforts to bring an adequate amount of oxygen to the tissues

2. Helps determine appropriate interventions.

3. To prevent contractures

4. To prevent fatigue.

IV. IMPLEMENTATION

Date/TimeNo Dx.ImplementationFormatif evaluationSign

Monday, June 1st 2015 06.00 amDelegative administration of drugs:

Asam tranexasamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction

09.00 am1,2

assess the patient's general condition and vital signs Weak patients general condition

T : 37 c

P : 80 x/minuteBP : 170/00 mmHg

RR : 24x/minute

09.30 am4Assess etiologic factors from reduced nutritional intake.Patient said that he could not swallow

10.00 am1Adjust the semifowler position.

Semifowler position has been given by nurses

10.15 am4Provide the patient drink milk as much as 100cc through NGT (sonde)the patient was only able to spend 100 cc

10.30 am1Teach patients to do deep breathing or breath lips slowly according to abilityPatient cooperative, but has not been able to do well

10.45 am1Provide oxygen therapy 3 lpmoxygen therapy has been given through nasal canule

12.00 am1,4Delegative administration of drugs:

Cefo Sulbactam 2 gram Nucral 5 m1 (1 teaspoon)

The drug was administered through Intra Venous and oral , no allergic reaction

01.30 pm1,2

Assess the patient's general condition and vital signsWeak general condition

T : 37c

P :80x/ minuteBP : 170/100mmHgRR : 24x/ minute

02.00 pm5Provide range of motion training

Range of motion training has been given by the nurse , patient cooperative

02.15 pm4Provide the patient drink milk as much as 100cc through NGT ( sonde)the patient wasv only able to spend 100 cc

03.30 pm3Advise families to assist patients in activities beyond the limits of tolerance Patients families cooperative

04.00 pmDelegative administration of drugs:

Asam tranexamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction

04.05 pm2 Provide 1 kolf packed RBCs (PRCs) packed RBCs (PRCs) has been given, no alergic reaction


Omeprazole 4 mgThe drug was administered through Intra Venous, no allergic reaction

06.15 pm4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 100 cc

07.30 pm1,2assess the patient's general condition Weak general condition




12.00 pmDelegative administration of drugs :

Cefo Sulbactam 2 gram Asam tranexamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction

Tuesday, June 2nd 2015

05.15 amDelegative administration of drugsOmeprazole 4 mgThe drug was administered through Intra Venous, no allergic reaction

05.30 am1Monitor of results laboratory:

RBCs, Hb and Hct, PLTThe results are

Hb : 9.1 g/dl

RBC : 3.09 1012/l

HCT : 26.4 %

PLT : 123 109/l

05.45 am1,2,3,4assess the patient's general condition and vital signsWeak general condition

T : 37c

P : 80x/ minuteBP : 160/90 mmHgRR : 24x/ minute

06.15 am4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 100 cc

08.00 amDelegative administration of drugs:

Asam traneksamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction

09.00 am1Provide patients position as comfortable as possible.

semifowler position has been given by nurses

09.15 am2Maintining oxygen therapy 3 liter per minuteoxygen therapy has been given through nasal canule

09.20 am2Teach patient effective coughing and deep brfoodhing.Patient cooperative

09.30 am 2 Provide 2 kolf packed RBCs (PRCs) packed RBCs (PRCs) has been given, no alergic reaction



Cefo Sulbactam 2 gram Nucral 5 ml (1 teaspoon)

The drug was administered through Intra Venous and oral, no allergic reaction

01.30 pm1,2,3,4,5Assess the patient's general condition and vital signsWeak general condition

T : 37c

P : 80x/minuteBP: 150/90mmHgRR : 24x/minute



03.30 pm5Advise families to assist patients in activities beyond the limits of tolerancePatients families cooperative


Asam tranexamat 250 mg (5ml)The drug was administered through Intra Venous, no allergic reaction

04.05 pm2Provide 1 kolf packed RBCs (PRCs)Packed RBCs (PRCs) has been given, no alergic reaction




07.30 PM1,2,3,4assess the patient's general condition Weak general condition





Cefo Sulbactam 2 gram Asam tranexamat 250 mg (5ml)The drug was administered through Intra Venous, no allergic reaction

Wednesday, June 3 rd 2015





Hb : 10.8 g/dl

RBC : 3.76 1012/l

HCT : 31.7 %

PLT : 147 109/l


T : 36c

P : 74x/minuteBP : 170/90 mmHgRR : 24x/minute


08.00 amDelegativeadministration of drugs:





09.20 am1Teach patient effective coughing and deep brfoodhing.Patient cooperative, but has not been able to do well





01.30 pm1,2,3,4Assess the patient's general condition and vital signsWeak general condition

T : 36,7c

P :80x/minuteBP160/100mmHgRR : 20x/minute





Asam tranexamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction



07.30 pm1,2,3,4assess the patient's general condition Weak general condition






Cefo Sulbactam 2 gram Asam tranexamat 250 mg (5ml)The drug was administered through Intra Venous, no allergic reaction

Thursday, June 4th 2015 02.15 am4Provide the patient drink milk as much as 100cc through NGT

the patient was only able to spend 100 cc



RBCs, Hb and Hct, PLTThe results were

Hb : 10.2 g/dl

RBC : 3.48 1012/l

HCT : 30.9 %

PLT : 152 109/l


S : 36CP : 80 x/minuteBP : 170/100 mmHgRR : 20 x/minute




09.00 am1Provide patients position as comfortable as possible.semifowler position has been given by nurses

09.15 am1Maintining oxygen therapy 3liter per minuteoxygen therapy has been given through nasal canule




Cefo Sulbactam 2 gram

Nucral 5 ml (1 teaspoon)The drug was administered through Intra Venous and oral, no allergic reaction


T : 36,5c

P : 80 x/minuteBP : 160/100 mmHgRR :20x/minute



02.15 pm4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 100cc


04.00 pm1,2,3,4Delegative administration of drugs:









Cefo Sulbactam 2 gram Asam tranexasamat 250 mg (5 ml)The drug was administered through Intra Venous, no allergic reaction

Friday, June 5th 2015




T : 37c














T : 37c

P : 80x/minuteBP : 160/100mmHgRR : 22x/minute















Saturday, June 6th 2015


02.15 am4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 100cc


T : 36c


06.15 am4Provide the patient drink milk as much as 100cc through NGTThe patient was only able to spend 100 cc











T : 36c

P : 80x/minuteBP 160/100mmHgRR : 20x/minute



03.30 pm5Advise families to assist patients in activities beyond the limits of toleranceFamilies,s patient cooperative

04.00 pm1,2,3,4,5Delegative administration of drugs:





07.30 pm1,2,3,4,5assess the patient's general condition Weak general condition






Sunday, June 7th 2015



05.45 am1,2,3,4assess the patients general condition and vital signsWeak general condition

T : 37c


06.15apm4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 100cc



09.00 am1Provide patients position as comfortable as possible.Semifowler position has been given by nurse





Cefo Sulbactam 2 gram Nucral 5 ml (1 teaspoon)The drug was administered through Intra Venous and oral, no allergic reaction

01.30 pm1,2,3,4,5Assess the patients general condition and vital signsWeak general condition

T : 37c











07.30 pm1,2,3,4assess the patients general condition Weak general condition






Monday, June 8th 2015




T : 37c



07.00 amWound care in decubitusThe wound is treated , the color pink wound

07.30Provide training tilt left - right oblique

patients cooperative



09.00 am1Provide patients position as comfortable as possible.Semifowler position has been given by nurses







01.30 pm1,2,3,4Assess the patients general condition and vital signsWeak general condition

T : 37c

P :80x/minuteBP : 150/100mmHgRR : 24x/minute




03.45 pm4Release NGT and dower cateter by doctors commandNGT and dower cateter has been released





06.30pm4provide patients food porridge strain appropriate diitthe patient was able to swallow soft food, and was only able to spend 1/2 portion of porridge strain






Tuesday, June 9th 2015



T : 37 oCP : 80x/minuteBP : 170/100 mmHgRR : 22x/minute

07.30am4provide patients food porridge strainthe patient was able to spend portion only of porridge strain




09.10 am5Wound care in decubitusThe wound is treated , the color pink wound

10.00 am5Provide training tilt left - right oblique


11.30 am1Teach patients to do deep breathing or breath lips slowly according to abilityPatient cooperative , but still a bit of trouble





01.00 pm4provide patients food porridge strainthe patient was only able to spend portion of porridge strain


T : 37,2 ocP : 80 x/minuteBP : 160/100

RR : 24x/minute




04.00 pm1,2,3,4,5Delegative administration of drugs:




06.30pm4provide patients food porridge strainthe patient was only able to spend portion of porridge strain






Wednesday, June 10th 2015



T : 36.9c

P : 74x/m

BP : 170/100 mmHgRR : 22x/m

07.30 am4provide patients food porridge strainthe patient was only able to spend portion of porridge strain


Asam traneksamat (250 mg) 5 mlThe drug was administered through Intra Venous, no allergic reaction



09.20 am1Teach patient effective coughing and deep breathingPasien kooperatif, namun masih sedikit kesulitan

09.30 am5Wound care in decubitusThe wound is treated , the color pink wound







T : 36,4c





03.45 pm4Removing NGT and Dower catheter patients on doctor's ordersNGT and Dower catheter has been removed

03.50 pm5Provide training tilt left - right oblique











Thursday, June 11th 2015



T : 36,5c




Asam traneksamat 250 mg ( 5 ml)The drug was administered through Intra Venous, no allergic reaction









T : 37c




03.30 pm5Advise families to assist patients in activities beyond the limits of toleranceFamilies patient cooperative













T : 36,5c





09.00 am 1Provide patients position as comfortable as possible.Semifowler position has been given by nurses






T : 37c

















T : 36,5c






Date/TimeNo Dx.ImplementationFormatif evaluationSign

Monday, June 1st 2015 06.00 am1,2,3,4,5Discretionary administration of drugs:

Asam tranexasamat 3 x 5 mlThe drug was administered through Intra Venous, no allergic reaction

09.00 am1,2,3,4,5assess the patient's general condition and vital signs Weak patients general condition

T : 37 c

P : 80 x/m

BP : 170/00 mm/Hg

RR : 24x/m

09.30 am4Assess etiologic factors from reduced nutritional intake.Patient said that he could not swallow

10.00 am1Adjust the semifowler position.


10.15 am4Provide the patient drink milk as much as 100cc through NGT (sonde)the patient was only able to spend 50 cc


10.45 am1Provide oxygen therapy 3 lpmoxygen therapy has been given through nasal canule

12.00 am1,4Discretionary administration of drugs:

Cefo Sulbactam 2 x 2 gr

Nucral 3 x CI

The drug was administered through Intra Venous and oral , no allergic reaction


T : 37c

P :80x/m

BP : 170/100mm/Hg

RR : 24x/m



02.15 pm4Provide the patient drink milk as much as 100cc through NGT ( sonde)the patient wasv only able to spend 75 cc


04.00 pm1,2,3,4Discretionary administration of drugs:

Asam tranexamat 3 x 5 mlThe drug was administered through Intra Venous, no allergic reaction

04.30 pm2 Provide 1 kolf packed RBCs (PRCs) packed RBCs (PRCs) has been given, no alergic reaction

06.00 pmDiscretionary administration of drugs:

Omeprazole 2 x 4 mgThe drug was administered through Intra Venous, no allergic reaction






12.00 pmDiscretionary administration of drugs :

Cefo Sulbactam 2 x 2 gr Asam tranexamat 3 x 5 mlThe drug was administered through Intra Venous, no allergic reaction

Tuesday, June 2nd 2015

02.30 am4Provide the patient drink milk as much as 100cc through NGT


05.15 amDiscretionary administration of drugsOmeprazole 2 x 4 mgThe drug was administered through Intra Venous, no allergic reaction



Hb : 9.1 g/dl

RBC : 3.09 1012/l

HCT : 26.4 %

PLT : 123 109/l


T : 37c

P : 80x/m

BP : 160/90 mm/Hg

RR : 24x/m


08.00 amDiscretionary administration of drugs:

Asam traneksamat 3 x 5 mgThe drug was administered through Intra Venous, no allergic reaction



09.15 am2Maintining oxygen therapy 3l/moxygen therapy has been given through nasal canule


09.30 am 2 Provide 1 kolf packed RBCs (PRCs) packed RBCs (PRCs) has been given, no alergic reaction




Nucral 3 x CI



T : 37c

P : 80x/m

BP: 150/90mm/Hg

RR : 24x/m




04.00 pm1,2,3,4,5Discretionary administration of drugs:


04.05 pm2Provide 1 kolf packed RBCs (PRCs)Packed RBCs (PRCs) has been given, no alergic reaction









Wednesday, June 3 rd 2015





Hb : 10.8 g/dl

RBC : 3.76 1012/l

HCT : 31.7 %

PLT : 147 109/l


T : 36c

P : 74x/m

BP : 170/90 mm/Hg

RR : 24x/m











Nucral 3 x CI



T : 36,7c

P :80x/m

BP160/100mm/Hg

RR : 20x/m














Thursday, June 4th 2015 02.15 am4Provide the patient drink milk as much as 100cc through NGT




RBCs, Hb and Hct, PLTThe results were

Hb : 10.2 g/dl

RBC : 3.48 1012/l

HCT : 30.9 %

PLT : 152 109/l


T : 36,8

P : 80

BP : 170/100 mm/Hg

RR : 20










Nucral 3 x CIThe drug was administered through Intra Venous and oral, no allergic reaction


T : 36,5c

P : 80 x/m

BP : 160/100 mm/Hg

RR :20x/m



















T : 37c

P : 80x/m

BP : 170/100 mm/Hg

RR : 20x/m











Nucral 3 x CI



T : 37c

P : 80x/m

BP : 160/100mm/Hg

RR : 22x/m



















T : 36c

P : 80x/m

BP : 170/100 mm/Hg

RR : 20x/m

06.15 am4Provide the patient drink milk as much as 100cc through NGTThe patient was only able to spend 75 cc









Nucral 3 x CI



T : 36c

P : 80x/m

BP 160/100mm/Hg

RR : 20x/m















Sunday, June 7th 2015




T : 37c

P : 80x/m

BP : 170/100 mm/Hg

RR : 20x/m

06.15apm4Provide the patient drink milk as much as 100cc through NGTthe patient was only able to spend 75 cc



09.00 am1Provide patients position as comfortable as possible.Semifowler position has been given by nurse








T : 37c

P : 74x/m

BP : 160/100mm/Hg

RR : 20x/m










07.30 pm1,2,3,4assess the patients general condition Weak general condition






Monday, June 8th 2015




T : 37c

P : 80x/m

BP : 170/100 mm/Hg

RR : 22x/m










Nucral 3 x CI



T : 37c

P :80x/m

BP : 150/100mm/Hg

RR : 24x/m




03.45 pm4Release NGT and dower cateter by doctors commandNGT and dower cateter has been released





06.30pm4provide patients food porridge strain appropriate diitthe patient was able to swallow soft food, and was only able to spend portion of porridge strain






Tuesday, June 9th 2015



T : 37

P : 80

BP : 170/100 mm/Hg

RR : 24

07.30am4provide patients food porridge strainthe patient was able to spend portion only of porridge strain











T : 37,2

P : 80

BP : 160/100

RR : 24








06.30pm4provide patients food porridge strainthe patient was only able to spend portion of porridge strain






Wednesday, June 10th 2015



T : 36.9c

P : 74x/m

BP : 170/100 mm/Hg

RR : 22x/m





09.20 am1Teach patient effective coughing and deep brfoodhing.Pasien kooperatif, namun masih sedikit kesulitan





T : 36,4c

P : 80x/m

BP : 160/100mm/Hg

RR : 24x/m













Thursday, June 11th 2015



T : 36,5c

P : 74x/m

BP : 170/100 mm/Hg

RR : 24x/m








Nucral 3 x CI



T : 37c

P : 74x/m

BP : 150/90mm/Hg

RR : 20x/m



03.30 pm5Advise families to assist patients in activities beyond the limits of toleranceFamilies patient cooperative













T : 36,5c

P : 74x/m

BP : 170/100 mm/Hg

RR : 24x/m



09.00 am 1Provide patients position as comfortable as possible.Semifowler position has been given by nurses







T : 37c

P : 74x/m

BP : 150/90mm/Hg

RR : 20x/m
















T : 36,5c

P : 74x/m

BP : 170/100 mm/Hg

RR : 24x/m





V. EVALUATION

NoDateNo Dx Sumatif EvaluationSign

1 1Saturday, June 13th 2015

09.00 am1S : Patient said that he still felt shortness of breathO : Patients received oxygen therapy 3 l/m through nasal canule

A : The goal has not been achieved

Problem Ineffective Brfoodhing Pattern P : continue all interventions

2 2 Saturday, June 13th 2015

09.00 am2S : Patients families said that patient looked weak and pale

O : Hb: 10,8 g/dL, pallor conjungtivals

A : The goal has not been achieved

Problem collaborative anemiaP : continue all interventions

3Saturday, June 13th 2015

09.00 am3S : Patients families said that patient looked weak

O : Blood preasure : 170/100 mm/Hg

A : The goal has not been achievedProblem collaborative hypertension

P : continue all interventions


09.00 am

4S : Patients families said that the patient was able to swallow soft foods but only spend portion of food

O : Hb: 10,8 g/dL, NGT has been releasedA : The goal achieved in part

Problem Imbalanced Nutrition, Less Than Body RequirementsP : continue interventions number 2,3,8


09.00 am

4S : Patients families said that patient looked weak and patient just lay down on the bed

O : Hb: 10,8 g/dL, Patients looked paleA : The goal has not been achievedProblem -Intolerance activity

P : continue interventions all intervensions

Caretaker

NW

Male

43 years old

Married

Hindu

Indonesia

Senior High School

Private Employees

Son of the patient

english ganeshaa

Documents

assessment patients

patients family

sonde patients

patient wr

tubs patients

disease historythe patient

emergency room patients

cempaka ward number