You are on page 1of 3

Perawat pagi : (indah inzi)

Perawat malam : (eva ciken)

Pagi pukul 7.00 wib, tiba lah perawat Sift Pagi


inzi : Good morning,,
All : Good morning
inzi : (look at the watches) okay, it’s a 07.00 am, it’s time for offering shift. Night
shift with morning shift.
inzi : okay nurse eva and nurse kriss. Lets we start this offering shift
inzi :Before we start this offering shift, lets pray together with according to each
belief… begin…
inzi : okay, nurse Indah and me will be present the report. Nurse indah, please
indah : thank you nurse inzi. Let me start. For this morning shift, we have 4 patient.
there are 2 old patient and 2 new patient. the new patient are in the room 3 and room 4

First patient (Person in charge is Indah)


With:
S (situation) -: Mr. F (49 years old)
- Room 1
- Diagnosis: asthma
- Conscious: compos mentis
- The patient is out of breath
- Breath with the nostril
- The breathing is fast
- There is a mucus

B (background) - : Has been given 2 liters of O2 therapy


- Has been given nebulizer therapy
A (Assessment) - : Check up the vital sign
o Blood Pressure : 130/90 mmHg
o Pulse : 80 x/m
o Respiratory Rate : 30 x/m
o Temperature : 37 oC
20 drops
IVFD (intra vennes fluid drip) therapy: /m

R (Recommendation) - : Checked the vital sign every 5 hours


- Giving nebulizer therapy 12x/hours -
Monitoring O2 therapy

Eva : I want asking the question. Still Mr.F often out of breath?
Indah : Mr. F often out of breath. So, you must monitoring his O2 therapy
Eva : Okay nurse indah thank you
Indah : you’re welcome

Second Patient (Person in charge is Indah)


S (situation - : Mr. B (40 Years old)
- Room 2
- Diagnosis: Gastroentritis (GE)
- The patient said his body is still weak
- The skin turgor is bad

B (background) - : Lack of fluids


- Has been given IVFD RL (intra vennes fluid drip ringer
laktat) therapy 20drops/m

A (Assessment) - : Check up the vital sign


o Blood Pressure : 130/80 mmHg
o Pulse : 80 x/m
o Respiratory Rate : 22 x/m
o Temperature : 36 oC
-
R (recommendation) - : Continue IVFD RL therapy 20drops/m
-

Kris : is Mr.B have a vomit?


Indah : yes sure. In the last night. So, you must monitoring his intake and output,
okay?
Kriss : okay Nurse Indah thank you
Indah : yes, you’re welcome

Inzi : okay next I will report for a new patient in the room 3 and room 4
Third Patient (Person in charge is Inzi)
S (situation) - : Mr. I (48 Tahun)
- Room 3
Diagnosis : Post Operation Debridemen et DM
(diabetikum) + cellulitis on the left upper arm.

B (Background) -: Hb 10
- Blood Sugar Level 145

A (assessment) -: Check up the vital sign


Blood Presure : 120/90 mmHg
o Pulse : 70 x/m
o Respiratory Rate : 22 x/m
o Temperature : 37 oC
- Diet M2
- Urine is dense

R (recommendation) -: Checked the Hb


- Controling intake & output
- Controling vital sign every 3 hours
Checked the Blood Sugar Level every 2 jam

Eva : what is the last patient’s Hb?


Inzi : The last patient’s Hb is 10. Don’t forget to checked the patient’s Hb again,
Eva : Okay nurse inzi
Forth patient (person in charge is Inzi)
S (situation) -: Mr. S (35 Tahun)
- Room 4
- Diagnosis: Hepatitis
- Patient is weak, lack of appetite, and
- it looks yellow

B (background) -: Bilirubin is 2,1 mg/dl (milligram/deciliters) (Normal is=


0,1 – 1,2 mg/dl)
- The patient has not history of allergies

A (assessment) - : Check up the vital sign:


o Blood Pressure : 110/90 mmHg
o Pulse : 60 x/m
o Respiratory Rate : 24 x/m
o Temperature : 36,7 oC
- IVFD RL Theraphy 20 drop/m

R (recommendation) -: Checked the Bilirubin


- Checked the Hb

Kris : nurse Inzi, I want to ask you. What is Hb of patient?


Inzi : the result have not come yet. Please take the result in the laboratory. Okay I
think is enough. Any questions?
Kriss : I think no
Inzi : what about you nurse eva?
Eva : No
Indah : okay I think is enough too. When meet the patient, don’t forget to bring the
patient’s medical record
Inzi & eva :.. okay nurse
Indah : okay, it’s finish. Let’s go back to the nurse room
All : okay
Inzi :okay, the offering shift is done. Make sure everything is complete. For the
morning shift, enjoy your duty. And for the night shift can go back to home
All : okay nurse inzi
Inzi : to ending this offering shift, let’s we pray with according to each belief…
begin…
Inzi : okay thank you for your attention