BE Name Ag Doctor Medical Diagnosa Diet treatment

D e History
 8 hours
observation
 Monitor intake
fever , T:
/ output
38.5 C, HB TETP  Monitor sign
: 14 mg/dl, Dengue High of lock of
Ms.Shell Dr.
1 24 Ht : 55% , Hemoragi energy fluids
y john
Trombosite c Fever and high  Giving
: 100.000 protein Antipyretic
sel/mm3  Compress the
forehead
 Oral feeding
with porridge
BP : 140/
100 mmhg,  Observation
Pulse : 95 Low salt vital sign
times/minut , liquid  Speech
Dr. Stroke therapy
Mam e diet, and
2 62 stevan Hemoragi  ROM
Dominic Respiratory milk
y c  Giving
: 23 peptiber antihypertensi
times/minut n on
e  NGT Feeding
GCS : 9
 Observation
vital sign
BP : 130/90
 Observation
mmHg, intake / output
Blood sugar  Giving insulin
Dr. low
Mrs. : 490 , Hb / day IV unit
3 55 khatan Diabetic sugar ,
Betty :13 mg/dl,  Giving
a low salt
Nail antihypertensi
wounds fir 5 on
days  Giving
metformin
 Oral feeding

Group 5 : 7B

Dina Hafizhah

Habibah Nuriyah
Latiefah Bayu Yusril

Syifa Hifziatu Rahmah

1. Ms. Shelly, 24 years old, Dr. John

- Medical History : fever, T: 38.5°C, Hb: 14 mg/dl

Ht: 55%, Trombosite: 100.000 sel/mm3

- Diagnose : Dengue Hemoragic Fever

- Treatment : * 8 hours Observation

* Monitor intake/output

* Monitor sign of lock of fluids

* Giving Antipyretic

* Compress the forehead

* Oral feeding with porridge

- Diet : TETP High energy and high protein

2. Madam Dominic, 62 years old, dr. Stevany

- Medical History : BP: 140/100 mmhg, Pulse: 95 times/minute

Respiratory rate: 23 times/minute, GCS: 9

- Diagnose : Stroke Hemoragic

- Treatment : * Observation vital sign

* Speech Therapy

* ROM

* Giving antihypertension

* NGT Feeding

- Diet : Low salt, liquid diet, and milk peptibern

3. Mrs. Betty, 55 years old, dr. Khatana

- Medical History : BP: 130/90 mmhg, blood sugar: 490, Hb: 13 mg/dl,

Nail wounds fir 5 days

- Diagnose : Diabetic

- Treatment : * Observation vital sign

* Observation Intake/output

* Giving insulin/day IV unit

* Giving antihypertension

* Giving Metformin

* Oral feeding

- Diet : Low Sugar, low salt

Dina : Assalamualaikum, good morning everyon. Alhamdulillah we were still given

health this morning. Before we hand over let’s pray firs, pray begin……….”

Latiefah : Okay, first patients is ms. Shelly 24 yeart out, dr. john she is DHF. Last

condition is fever temperature; 38,5 C, HB : 14mg/dl improving already,

hematocrit : 55%, trombosit: 100.000sel/mm. the trombosit haven’t returned to

normal.

Treatment already given:

 Monitor intake/output

 Moniter sign of lock of fluids

 Giving antipyretic

 Compress her forhead

Diet : higt energy and higt protein

Latiefah : next is madamdominic,62 yo, dr stevany. Las conditional is Bp : 140/100

mmHg, pulse : 95 time/ minute RR : 23 time/minute, GCS : 9 her diagnose is

stroke hemoragic treatment already given :

 Observation vital sign every 4 hours

 Speech therapy every Friday

 ROM every Monday, Thursday, and Friday

 Giving anti hypertension

  NGT feeding

Diet : low salt, liquid diet, amd milk peptibern.

Dina : last patiens is mrs. Betty, 55 years old, dr khatana las condition is

Bp : 130/90 mmHg, blood sugar : 490, Hb : 13mg/dl nail wounds for day . her

diagnose is diabetic treatment already given :

 Observation blood sugar and vital sign

 Observation intake/output

 Giving insulin/ day IV unit

 Giving metformin

Diet : low sugar, low salt

 MORNING HANDOVER

Dina : is there anything undear?

Syifa : the latest laboratory result is already? For ms shelly

Dina : not yet, the analist said she wiil ushered the result leter.

Syifa : well, is doctor john planning a new therapy?

Dina : No, the massage just went through yesterday.

Habibah : Has, the family been given education about hemorrhagic stroke?

Latiefah : Not yet, her husband told his son will come to nurse.

Habibah : How many time do you change the dressing in patient B?

Latiefah : every day we change he dressing, that’s clear?

If that’s okay, let’s finish and say alhamdulilah to next shift happy working!
 A DAY ON THE WARD

Habibah : Assalamualaikum, I’m habibah and my patner is syifa will be your nurse today

from 08.00 to 14.00 did you ring the bell?

Can I help you ?

Latiefah : walaikumsalam, yes nurse I’m ring the bell.

I have a sore stomach.

Syifa : where’s the pain?

Latiefah : here

Dina : after eating I hour ago, she is getting sick to her stomach nurse.

Habibah : can you describe the pain latiefah?

Latiefah : it’s stabbing pain

Dina : she is always in pain like this at home

Syifa : okay, it must be really painful. I have number to describe the pain I is no pain

and 10 is very worse. What number it’s your pain?

Latiefah : it’s around 8

Habibah : okay latiefah, my friend will give you freatment to make you feel better. It is a

technique of deep breath.

Syifa : oke you can follow me.

Let your body is relax

Firs, deep breath, hold three second then exthale slowly

Repeat it 5 times

What do you feel now?

Latiefah : it’s better but still pain

Habibah : we will cull dr Roman to give you pain reliever, if you need help you can

press the button here.

Dina : okay thank you nurse