NURSING CARE

SUMMARY IN MRS.J WITH

THE CASES OF DISPEPSIA

PUTRI DWI DIANI

1420119023
Date No DF Evaluation initials
24 1 S = osb came with complaints of nausea,
February vomiting, dizziness
2021 O = T: 120/80 mmHg P: 76 R: 24 S: 36.5 So:
98% Warm akral, attached RL infusion,
08.00 smooth droplets, no phlebitis
A: the problem has not been resolved
P: continue the intervention

Date No DF Evaluation Initials

24 2 S : client said still nausea vomiting and no
February appetite
2021 O : the client looks limp
A : the problem is not resolved
14.00 P : proceed intervention
Date No DF Evalution Initials
25 1 S: os said I was still nauseous, dizziness
Februay lessened, already wanted to eat little by
2021 little
O: T: 120/80 mmHg P: 76 R: 24 S: 36.5
06.00 So: 97% The client still looks limp
A: The problem is partially resolved
P: continue the intervention

25 2 S : client said it was not nausea, vomiting,

February however masoh no appetite
2021 O : the client looks limp
The portion of eating out ½ servings
14.00 A : the issue is resolved in Part
P : lanjutkan intervensi
 
I : recommend eating the food in a warm state
and encourage them to eat little but often
Date No DF Evalution Initials
26 1 S: os said that she was no longer
February nauseous, vomited, already wanted to eat,
2021 was able to sleep, no dizziness
O: T: 120/80 mmHg P: 76 R: 24 S: 36.5 So:
08.00 98% The client seemed more excited and
refreshed
A: problem is resolved
P: go home
THANK YOU