A. IDENTITY PATIENT
Name : Ny. S
Address : Bhayangkara Purwodadi RT 04 RW 09
Age : 70 Years
Sex / status : Women / widows
Job : Retired civil servant
Number of children : 5 people; 3 men, 2 women
Number of grandchildren : 10 people
Sign RS : July 13, 2005
B. MEDICAL HISTORY PHYSICAL EVALUATION
I. Medical History
1. The main complaint of patients
Family / guardian says "eat drink still difficult, ngobrok, over the rest should be helped"
2. History of surgery / operation
Never before
3. History of hospitalization at Hospital
Has been Had lodgings in RS Yakkum Purwodadi, because hypertension and asthma
4. Other medical history
Already less than 5 years suffer from diabetes, HT
5. History of allergy
There is no
6. Habit
Families say the client had never smoked, drank alcohol, exercise participate in gymnastics elderly elderly neighborhood health, eating 3 meals a day, do not like to drink coffee
7. The drugs currently
With a doctor's prescription
Ceftriaxon 1 x 2 g
Metronidazole 3 x 500 mg
Diflucan 1 x 300 mg (PO)
Euterax 1 x 25 mg (morning on an empty stomach)
Actrapid 4 - 4-4
Na Cl 3 x 100 mg
Plet oral 1 x 100 mg
Asetosal 1 x 100 mg
Without a prescription
Ø Catheter care
Ø Treatment of genital and perineal area
Ø Oral hygiene
Ø Maintenance infusion
8. Summary symptoms
a. Assessment of patients over their own health
Not to be assessed subjectively
b. Summary of typical symptoms
There is a weakness, dysphagia
9. Screening for depression
Can not be assessed
10. Functional status
a. Basic and instrumental ADL
Bathing, ambulation, dressing, dressing, bladder / bowel movement, eating and drinking, drugs set to be "completely dependent on others" Patients ngobrok, BAK with Douwer tool cateter
b. Functional limitations
Before the illness, the client still can work like a mild way to the bathroom, ADL and others. But since the pain to unconsciousness, the client was just lying in bed.
II. Physical examination
1. Vital Signs
Date: 25/07/05 at 12:00 pm
Blood pressure : 190/110 mmHg, pulse: 80 x / min,
RR : 20 x / min
Temperature : 36.8 0 C
BB : 70 Kg, earlier:
TB : 160 cm
2. Skin
Looks wrinkled, damp, there is hematoma at the infusion former right foot, net
No pressure sores.
3. Hearing
Paien can hear the intonation a bit harsh, do not wear aids.
4. Vision
Patients can see clearly, when read using tools such as glasses.
5. Mouth
Clean mouth, teeth already dated, lower teeth stay number 5, not wearing dentures, there are no lesions / blisters on the gums and oral mucosa.
6. Neck
There is no enlargement of lymph
7. Chest
There are no physical abnormalities, there are no mass, chest expansion normal, regular rhythm of breath (20 x / min), does not seem the use of auxiliary muscles of breath.
8. Lungs
Inspection : Symmetric, Static, Dynamic
Palpation : Right = left fremitus Steam
Percussion : Resonant to the entire lung field
Auscultation: vesicular in all areas of the lung
9. Cardiovascular
Inspection : IC invisible
Palpation : IC palpable 2 cm in SIC V LMCS
Percussion : Heart Configuration within normal limits
Auscultation: heart sounds I - II pure, gallops (-), murmur (-)
10. Abdomen
Inspection : Flat, venektasi (-)
Auscultation: Noisy Intestine (+) Normal
Percussion : Tympani
Palpation : Supple, liver / limpe not palpable
11. Rectum / anus
There was no interference
12. Genital
Appear normal, attached Douwer cateter No. 16
13. Musculoskeletal
No deformities and inflammation / bumps, the limitations of motion in the lower extremities and upper
14. Neurological / psychological
a. Mental status
Disorientation occurs where (sometimes), time, memory loss
b. Mood / affective
Not to be assessed subjectively
c. General
Motor movements: minimum strength, no prisoners when cornered elbow
15. Extremity
a. Above
No edema, infusion mounted on the left hand
b. Under
No edema, no infusion needle puncture marks on the right foot (hematoma)
16. Back
No injuries decubitus
C. LABORATORY DATA
Blood Laboratories dated July 22, 2005
Examination
|
Result
|
Unit
|
Normal Price
|
Hb
|
12.10
|
g%
|
13-16
|
Ht
|
35.8
|
%
|
35-47
|
Erythrocytes
|
4,05
|
Million / mmk
|
3.9 to 5.6
|
MCH
|
29.9
|
Pg
|
27-32
|
MCV
|
88.4
|
Fl
|
76-96
|
MCHC
|
33.9
|
g / dl
|
29-36
|
Leucocytes
|
9.3
|
Thousand / mmk
|
4-11
|
Eosinophils
|
0
|
%
|
1-3
|
Basophils
|
0
|
%
|
0-2
|
Rod
|
0
|
%
|
2-5
|
Segment
|
89
|
%
|
47-80
|
Lymphocytes
|
5
|
%
|
20-45
|
Monocytes
|
6
|
%
|
2-10
|
Platelets
|
305
|
Thousand / mmk
|
150-400
|
And reduction of blood sugar
Fasting glucose 134 mg / dl
Management of DM: 80-109: good
110-125: medium
> 126: bad
Impaired fasting blood sugar when 110 <GDP <126 & GTT 2 hours <140
Reduction I
Sugar 2 PP + reduction
PP sugar 2 hours 156.0 mg / dl
DM Management: 80-140: good
145-179: medium
> 180: bad
Reduction II
Blood Laboratories dated July 22, 2005
Examination
|
Result
|
Unit
|
Normal Price
|
Urea
|
45
|
Mg / dl
|
15-39
|
Creatinine
|
0.92
|
Mg / dl
|
0.60 to 1.30
|
Sodium
|
131
|
Mmol / L
|
136-145
|
Potassium
|
5.3
|
Mmol / L
|
3.5 to 5.1
|
Chloride
|
97
|
Mmol / L
|
98-107
|
Blood Laboratories dated July 26, 2005
Examination
|
Result
|
Unit
|
Normal Price
|
Sodium
|
131
|
Mmol / L
|
136-145
|
Potassium
|
4.1
|
Mmol / L
|
3.5 to 5.1
|
Chloride
|
94
|
Mmol / L
|
98-107
|
Urinalisa dated July 21, 2005
The results: amber, clear, pH 5.0, BJ 1.015, protein 75 mg / dl, sediment: epithelial 2/3, erythrocyte, leukocyte 8/10, LL dbn, urine culture candida> 100,000
Urine culture (July 23, 2005)
Yellow, clear, PH 6, prot. 25 mg / dl, sed (-), sed. Epithelial third, Leko 3/5, erit 7/10
Blood culture: sterile
Peripheral blood picture dated July 18, 2005
Hit. Type: E0, B0, Bt0, sg 91, L n, M0
E: anisocytosis, mild poikelositosis
Tr: JML normal, large bt (+), Leko: number appeared normal
D. OTHER ADDITIONAL EXAMINATION RESULTS
Head CT scan without contrast dated July 19, 2005
· Sulcus and fissure widens
· Sist. Ventricular and cisterna partially dilated
· Hypodense lesions seem not expressly limit the left caudate nucleus, left thalamus and right corona radiata
· Invisible mid line shiffing
· Cerebellum and brainstem good
· Impression: infarction left caudate nucleus, thalamus, left and right corona radius
· Radiology:
· Results: cardiomegali impression, elangatio aorta, less good photo
ECG:
Results: sinus rhythm reg.
Freq. 66 x / min
Axis: N. axis
Position: intermed
Gel. P: 0.06 sec
PR : 0.16 dt
QRS : 0.08 dt
Impression: NSR, ischemic, ami anterior
E. PROBLEM LIST OF NURSING
1. Physical immobility
2. Changes in patterns of nutrient
3. Self-care deficit
4. Changes in the pattern of elimination
5. Resti infection
F. REPORT CONTINUED
1. Pem. Nutrient : Sonde diet, 1900 kcal, 40 g protein
2. Rehabilitation : Rather recline / 2 hours
G. PSYCHOSOCIAL
Not to be assessed subjectively
Functional status
KATZ Index of AKS : G
Norton Scores : 11
Depression scores : -
Level of consciousness : Compos mentis
Socio-Economic Issues
The patient was a widow, retired civil servant / teacher, the late husband retired civil servants / principal, retiring every month approximately 1.5 million. Clients staying at home alone, accompanied by nephew 1 female (working), the size of 15 x 20 m2, 2 bathrooms, toilet seat, 5 bedroom, house walls, tiled floor, not slippery, the distance to the shower room 10 meters .
Children 5 people already independently
Children I : Men, junior high school teacher, elementary school teacher wife, 3 children, earning less than 2 million
Kids II : Men, Bappenas, the wife does not work, children 3 people, earning less than 2 million
Children III : Women, peg RSDK (Laborat) drug sales husband, 2 children, earning approximately 3 million
Children IV : Permpuan, housewives, drug sales husband, 2 children, earning less than 1 million
Child V : Men, private, not married, earning approximately 1 million
Good relationship with the family, the economy enough impression.
History of present illness
Five (5) days of clients ranging ngantukan and often weak, plenty of sleep, when woken up but still able to sleep again, coughing occasionally but now it does not exist, the client does not heat
2 weeks before admission in hospital RSDK mole clients Yakkum Purwodadi, because hypertension and asthma, have good home, 2 days in the home feels cold and taken to the hospital again.
Because there is no change or improvement then ask family refer to RSDK.
Past history of disease
Families said that the patient had a long (5 years) suffering from hypertension and diabetes
but controlled.
DATA ANALYSIS
NO
|
DATA
|
PROBLEM
|
1
|
DS: -
DO:
- The client looks weak
- Clients total bedrest
- KATZ Index: G
- Bed rest every 2 hours
- Clients can not walk
- All AKS assisted
|
Impaired physical mobility related to weakness
|
2
|
DS: -
DO:
- Clients total bed rest
- Clients weak
- All ADL assisted total
|
Self-care deficit related weakness, loss of coordination / control muscle
|
3
|
DS: -
DO:
- Installed NGT
- Liquid Diet 1900 kcal, 40 g protein
- Patients weak
- Swallowing reflex is weak
|
Changes in nutritional patterns associated weakness swallowing reflex
|
4
|
DS: -
DO:
- Installed DC
- Installed NGT
- Mounted Infusion
- The patient is weak
|
Resti infection associated with invasive
|
5
|
DS: -
DO:
- Installed DC No. 16
- Patients total bedrest
|
Elimination pattern changes associated with catheter placement
|
PRIORITY Nursing Diagnosis
1. Changes in nutritional patterns associated with swallowing reflex weakness
2. Impaired physical mobility related to weakness
3. Self-care deficit related to weakness, loss of coordination / control muscle
4. Elimination pattern changes associated with catheter placement
5. Resti infection associated with invasive
Nursing Plan
NO DP
|
OBJECTIVE - CRITERIA RESULTS
|
INTERVENTION
|
1
|
After nursing action for 5 x 24 hours the client is able to retain nutrients in accordance with their needs, with the result criteria:
Ø Adequate dietary intake personde
Ø Albumin in the range of 3.4 to 5 g / dl
|
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Ø Check the routine laboratory blood and protein
|
2
|
After nursing action for 5 x 24 hours the client is able to meet the physical needs, the outcome criteria:
Ø Can do light activity in bed
Ø Increased muscle strength
|
Ø Determine the client's functional abilities
Ø Plan activities with rest periods of strong
Ø Assist in transfer and ambulation
Ø Collaboration with physiotherapy in passive ROM exercises
|
3
|
After nursing action for 5 x 24 hour able to meet the client's self-care, with the result criteria:
Ø The client is able to perform self-care activities in their own ability level
Ø Requires only minimal assistance in self-care
|
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
|
4
|
After nursing action for 5 x 24 hours, no changes in the pattern of elimination, with the result criteria:
Ø Catheter remained patent in place
Ø Urine output exceeding 30 ml / hour
|
Ø Assess the patency of the catheter
Ø Assess the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Ø Record the urine comes out
Ø Encourage clients to drink enough
Ø Determine the normal voiding pattern
|
5
|
After nursing action for 5 x 24 hours there is no infection, the outcome criteria:
There does not appear any signs of infection (dolor, calor, rubor, pain, fungsiolaesa)
Vital signs within normal limits (BP: 120/80, N: 80-100, RR: 16-24, S: 36-37 0 C
|
Ø Assess TTV
Ø Perform daily catheter care
Ø Perform oral hygiene every day
Ø Perform vulvar hygiene every day
Ø Replace plaster NGT when it is dirty
Ø Maintain a state that did not happen infections
Ø Give antibiotics according to the program
|
IMPLEMENTATION OF NURSING
NO DP
|
WKT
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
07/25/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A:
Partially solved the problem, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
| |
2
|
07/25/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
Hours 13:45
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
07/25/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
07/25/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine output of 900 cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted properly fixed dn
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
07/25/05
09:00
10:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Replacing plaster NGT when it is dirty
Response: NGT installed new, clean condition
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftraxon entry, no allergies
Ø Assessing TTV
Response: BP: 190/110 mmHg, N: 80 x / min, RR 20 x / min, S: 36.8 0 C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 190/110 mmHg, N: 80 x / min, RR 20 x / min, S: 36.8 0 C
A: Still attached NGT infusion and catheter
Q: Maintain intervention
|
IMPLEMENTATION OF NURSING
NO DP
|
WKT
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
07/26/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A: The problem is resolved in part, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
| |
2
|
07/26/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
Hours 13:45
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
07/26/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
07/26/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine production 1000cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted properly fixed dn
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
07/26/05
09:00
10:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Replacing plaster NGT when it is dirty
Response: NGT installed new, clean condition
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftraxon entry, no allergies
Ø Assessing TTV
Response: BP: 190/120 mmHg, N: 80 x / min, RR 20 x / min, S: 36.9 0 C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 190/120 mmHg, N: 80 x / min, RR 20 x / min, S: 36.9 0 C
A: clients still attached infusion, NGT and catheter
Q: Maintain intervention
|
IMPLEMENTATION OF NURSING
NO DP
|
TIME
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
27/07/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A:
Partially solved the problem, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Ø Check the routine laboratory blood and protein
| |
2
|
27/07/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
13.45 hours
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
27/07/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
27/07/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine output of 700 cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted and fixed with either
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
27/07/05
09:00
10:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Replacing plaster NGT when it is dirty
Response: NGT, clean condition
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftraxon entry, no allergies
Ø Assessing TTV
Response: BP: 130/90 mmHg, N: 72 x / min, RR 24 x / min, S: 36.5 0C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 130/90 mmHg, N: 72 x / min, RR 24 x / min, S: 36.50 C
A: Still attached NGT, and Infusion catheters
Q: Maintain intervention
|
IMPLEMENTATION OF NURSING
NO DP
|
TIME
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
07/28/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A:
Partially solved the problem, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Ø Check the routine laboratory blood and protein
| |
2
|
07/28/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
Hours 13:45
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
07/28/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
07/28/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine output of 800 cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted properly fixed dn
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
07/28/05
09:00
10:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftraxon entry, no allergies
Ø Assessing TTV
Response: BP: 140/90 mmHg, N: 80 x / min, RR 24 x / min, S: 36.8 0 C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 140/90 mmHg, N: 80 x / min, RR 24 x / min, S: 36.8 0 C
A: Still teerpasang NGT, and Infusion catheters
Q: Maintain intervention
|
IMPLEMENTATION OF NURSING
NO DP
|
TIME
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
29/07/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A:
Partially solved the problem, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Ø Check the routine laboratory blood and protein
| |
2
|
29/07/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
Hours 13:45
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
29/07/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
29/07/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine output of 700 cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted properly fixed dn
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
29/07/05
09:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftraxon entry, no allergies
Ø Assessing TTV
Response: BP: 130/70 mmHg, N: 80 x / min, RR 20 x / min, S: 36.9 0 C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 130/70 mmHg, N: 80 x / min, RR 20 x / min, S: 36.9 0 C
A: Still attached infusion, NGT and catheter
Q: Maintain intervention
|
IMPLEMENTATION OF NURSING
NO DP
|
TIME
|
IMPLEMENTATION - RESPONSE
|
EVALUATION
|
TTD
|
1
|
07/30/05
08:00
08:00
12:00
|
Ø Assessing the nutritional status of the client
Response: 70 Kg BB, TB 160, enough turgor, wrinkled skin, oral mucosa moist
Ø Collaboration on the nutritional needs of the body or nutrition team collaboration
Response: liquid diet, 1900 kcal, 40 g protein
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
Response: diet sonde entry
|
Hours 13:45
S: -
O:
Ø Diet sonde entered about 1000 cc to 2 times giving
Ø Start learning sip
Ø Moist oral mucosa
A:
Partially solved the problem, still attached NGT
P:
Continue intervention
Ø Assess the nutritional status of the client
Ø Calculate the nutritional needs of the body or nutrition team collaboration
Ø Maintain calorie intake by eating per sonde or parenteral nutrition as indicated
| |
2
|
07/30/05
09:00
09:30
09:45
09:50
|
Ø Determining the client's functional abilities
Response: The client still has the muscle strength 2-3
Ø Planning for robust activity with periods of rest
Response: bed rest every 2 hours, right oblique, and left lateral recumbent
Ø Assist in the transfer and ambulation
Response: The client still feel lazy to bed rest, clients often sleep on
Ø Physiotherapy with officers in passive ROM exercises
Response: The client was taught to sit, raise their hands and move it
|
Hours 13:45
S:
Clients say bad sleep than exercise motion
O:
Ø Clients looking sleepy
Ø Clients weak
Ø Clients are trained to sit and move his hands
Ø Muscle strength 2-3
A:
Problem is resolved in part
P:
Continue intervention: a patient to exercise ambulation aids, give encouragement to the client and family to move lightly
| |
3
|
07/30/05
10:30
12:30
12:45
08:30
|
Ø Assessing the capability and level of deficiencies to perform daily needs
Response: all the needs of clients assisted by a nurse or family
Ø Provide minimal assistance when the patient is able to do so
Response: give clients the opportunity to wipe the mouth with his hands
Ø Provide positive feedback to every effort made
Response: when the client motivated
Ø Assist patients in self-care (oral hygiene, vulvar hygiene and catheter care)
Response: cooperative clients
|
Hours 13:45
S: -
O:
Ø The client looks neat
Ø Dry lips
Ø Catheter net
Ø Vulvar hygiene maintained
A: The issue is resolved in part
Q: Continue intervention
Ø Assess the capability and level of deficiency to perform daily needs
Ø Provide minimal assistance when the patient is able to do so
Ø Give the patient sufficient time to perform tasks
Ø Give positive feedback for any work done
Ø Assist patients in self-care
| |
4
|
07/30/05
09:00
12:00
12:30
|
Ø Assessing the patency of the catheter
Response: catheter still attached
Ø Examines the color, character and flow of urine and the presence of a clot through the catheter every 2 hours
Response: clear yellow color, no clots, flowing smoothly
Ø Noting the urine comes out
Response: urine output of 700 cc / 6 hours
Ø Encourage clients to drink enough
Response: The client agreed
|
Hours 13:45
S: -
O:
Ø Catheter was inserted properly fixed dn
Ø Clear yellow urine color
Ø Urine flows smoothly
A: urinary catheter was inserted
Q: Continue intervention: observation of catheter patency
| |
5
|
07/30/05
09:00
10:00
10:00
11:30
|
Ø Catheter treatment
Response: cooperative clients
Ø Perform oral hygiene
Response: The client would cooperate, mucosa moist lips
Ø Doing vulvar hygiene
Response: the client feel more comfortable
Ø Perform maintenance infusion
Response: replacing infusion
Ø Maintaining a state that did not happen infections
Response: there is no sign of infection
Ø Giving antibiotics according to the program
Response: injection of metronidazole 500 mg and 2 g ceftriaxon entry, no allergies
Ø Assessing TTV
Response: BP: 150/80 mmHg, N: 84 x / min, RR 20 x / min, S: 36.8 0 C
|
Hours 13:45
S: -
O:
Ø Mucosa of the mouth clean
Ø The state of the vulva clean
Ø Catheter inserted either dg
Ø NGT is still attached
Ø There is no sign of infection
Ø The drugs have entered and no allergies
Ø BP: 150/80 mmHg, N: 84 x / min, RR 20 x / min, S: 36.8 0 C
A: Still attached infusion, NGT and catheter
Q: Maintain intervention
|
No comments:
Post a Comment