NURSING PROGRESS

Room : RPD
No. RM : 72635
Doctor : dr. Didik
Name : Ny. I
Doctor Team : 1. dr. Didik
Date of Birth : 5 -29-1990
2. Ns. Refi S.Tr. Kep
Sex : Female 3. Ns. Cici S.Tr.Kep

Date/Time Doctors Health Team Signature

S; 1. dr. Didik
- Stated she's "Fever still exist " 2. Ns. Refi
- She's complain of weakness S.Tr.Kep

O:
- Skin warm and dry, pale but without pallor
and cyanosis
- Temperature 39.6 °C
- BP 90/70
- patient looks weak

A: Hipertermia related to Infection proces

P:
- - Give antipiretik Paracetamol 3 x 500 mg
- - Monitor temperature / 8 hours
- - Monitor of vital sign.
- - Obs. respiration status / 8 hours
- - Give intruction to the patient drink 2 L of
water per day.
- -Give intruction to tell nurse about symptoms
of hipertermia.
-
-

Medical Diagnosis : DHF

Nurse Diagnosis : Hipertermia related to infection process