Dosen Pengajar : Risky Neguita Hanna

HAND OFF REPORT

OLEH :

MUHAMMAD DELLA NURWIANSYAH ODE

P201901079

PRODI. S1 KEPERAWATAN

UNIVERSITAS MANDALA WALUYA KENDARI

TA .2021
 HAND OFF REPORT

Case:

Mr. Kuly, 50 years old, a rubber worker came complaining of a cough with phlegm.
The patient has a cough more often at night than in the morning or during the day.
This complaint has been felt since 3 months ago. Initially a cough patient develops
when hoeing and gets heavier when spraying pesticides on his garden. The patient
also expressed fever, night sweats, decreased appetite, and weight loss from 50 kg
to 47 kg in one month. Patients have bad habits such as dumping sputum carelessly,
not wearing a mask when coughing, lack of knowledge of the patient's illness, lack of
family support for the patient, and the humid condition of the patient's home. The
patient also had a history of contact with a TB patient, namely his wife who had
passed away.
The physical examination that was carried out on the patient showed that the
patient's weight was 47 kg, height 163 cm, BMI 18.0 (underweight), he looked mildly
ill. Blood pressure 110/70 mmHg, pulse 80 x / minute, respiratory rate 17 x / minute,
body temperature
37.0oC. Anemic eye conjunctiva, sclera
anicteric. Ear and nose within normal limits. In the mouth, you can see that your
teeth and oral hygiene are sufficient. Throat, heart and abdomen within normal limits.
On examination of the lungs, inspection within normal limits, palpation within normal
limits, percussion within normal limits, auscultation for the presence of ronkhi sounds
in the right and left pulmonary limits. The superior and inferior limbs were within
normal limits, not cyanotic, edible, and acral warm. Neurological status: Normal
physiological reflex, pathological reflex (-).
In the hospital, the patient had an anterior posterior (AP) x-ray examination and it
was found that there were cavities in the right and left pulmonary.
After taking an X-ray, the patient comes to the Puskesmas to collect sputum. Sputum
collection was carried out twice with the first negative result then repeated and the
result was +2.
In this case, the patient is receiving treatment in the intensive phase, which is
treatment for 2 months, then the follow-up phase for 4 months

next. Based on the National TB Guidelines, it is stated that for the intensive phase
patients get treatment consisting of 2HRZE, namely the treatment obtained

for 2 months consisting of rifampin, isoniazid, pyrazinamid and ethambutol. Patients

get drugs that are included in the fixed dose combination group, namely in one drug,
including the four types of drugs above with each dose. Rifampin
150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg.4,15
Furthermore, the patient feels the treatment and does not feel bored quickly.
In TB treatment, it is necessary to have PMO (Drug Drinking Supervisor) whose
conditions consist of someone who is known and trusted by the patient, someone
who lives close to the patient, and is willing to help the patient voluntarily. In this
case the PMO for the patient is Mrs. J, who is the patient's grandson from the
patient's first child who lives in the same house and there is a health worker who
lives close to the patient's house to supervise and control taking medication and also
provide support to patients so they don't stop taking their medication.
Nurse Della conducts a handover report to other nurses with information such as the
following:
• Patient's name: Kuly
• PATIENT AGE: 50 years
• Medical Diagnosis: Pulmonary Tuberculosis (TB)
• Major Health Problems: Cough without phlegm
• Unusual events: Cough more frequently at night than in the morning
• Disposal Planning:
1 Use a mask and do not get rid of phlegm carelessly
2 Routine control if there are complaints
3. Immediately go to the puskesmas when the medicine runs out
4. Management is given in the form of pharmacological management, namely in the
form of 2HRZE and non-pharmacology in the form of education to patients and their
families about the disease.
• Significant changes Cough begins to subside
• STAT / Quick Reference: (No need)
• Care needed: take medication regularly
• Progress with intervention: Patients routinely take medication regularly, use a mask
and do not throw phlegm carelessly