Member:

1. Agatha Rifqia Marendra P (2111011125)

2. Rijal Maulana Juan A (2111011127)
3. Delita Mayasari (2111011138)
4. Ila Lailatul Komariyah (2111011145)
5. Agil Sapta Nugraha (2111011152)
6. Fikhih Wahyu Islamy (2111011155)
7. Indah Safitri (2111011161)

1. SBAR COMMUNICATION
a. Situation
Mr. D, 46 years old was admitted to the A and E department on July 5th 2023
after an accident. In A and E dapertement his BP is 130/82 mmHg, pulse 100x/min,
RR 26x/min. Client’s had a cyanotic lips, unconscious and there is a bruise on his
abdomen
b. Backgroud
In the emergency room patient was x rayed and found bleeding in the abdomen.
Lapaoroscopic surgery has been performed.
c. Assessment
The nurse reported that today the patient had an increase in temperature to
39,1oC. Blood transfusion have been carried ot as many as 8 PRC bags before the
temperature rises. The urine output has decreased and the acral feels warm.
d. Recommendation
Patients transferred to the ICU

2. FILL IN THE DISCHARGE PLANNING FORM BASED ON THE SITUATION

DISCHARGE PLANNING Resgitered Number: 696969

Admission date: 9 June 2023 Discharge date: 6 September 2023
Unit : Orthopaedic Unit : Orthopaedic
Patient’s condition when discharge from
hospital: ( ) Forced to go home
( ) Recover ( ) Runaway
(√ ) Ongoing care in out patients unit ( ) Died
( ) Move to another hospital
A. Control
1. Time: 18 june 2020
2. Place: Orthopaedic unit
B. Ongoing care at home (medication and walking exercises etc)
Take the antibiotic appropriately and walking exercises with crutches
C. Diet rules / nutrion)
A diet in lysine, including calcium for boe restoration, and intake of boron to reduce
urinary excretion of calcium and magnesium
D. Medication that still taken and the amount:
Antibiotics and analgetics
E. Activity and Rest:
walking exercises with crutches
F. Brought home (Laboratorium results, thorax photo, ECG, medication, etc)
Medication (antibiotics and analgetic) and walkig exercises with crutches.
G. Others: -
Jember, 6 September 2023
Patient / Family Nurse

(Mr. M.) (Agil Sapta Nugraha)