CLINICAL PRACTICE REPORT NURSING

MANAGEMENT IN THE OTAK KOKOK

ROOM RSUD PROVINSI NTB
MARCH 19 – 29, 2024
GROUP 2
GROUP I NURSING MANAGEMENT:
1. ARIF RAHMAN (NIM. P0720523003)
2. BAIQ IGA DWI ERDIANA (NIM. P0720523048)
3. NI MADE NONIK KARSANI (NIM. P0720523063)
4. SYAIDATUL ISLAMIAH (NIM. P0720523040)
5. DEWA MADE SIKAN (NIM. P0720523007)
6. DESQIA QATRUNNADA (NIM. P0720523026)
7. NOFITA AFIANI ARSIH (NIM. P0720523049)
8. TIFA DESYANA (NIM. P0720523064)
9. DITA DARA PERTIWI (NIM. P0720523050)
10. NUR AINI MUFIDA (NIM.P07120523065)
11. TIRTAYANI (NIM.P07120523077)
ACTIVITY PLAN
PLANNING OF ACTION (POA)
GROUP 2 NURSING MANAGEMENT
NO PROBLEM PURPOSE PROGRAM/ SUCCESS INDICATORS TIME PERSON IN
ACTIVITIES CHARGE

1. Handover There is 1. Role play of 1. Students are able to weigh March Group 2
Some good handover and receive by paying 25-27,
procedures 2024
cooperation attention to time efficiency
are not yet
optimal between so that shifts can be
nurses in carried out optimally
order to
improve
health
services.
NO PROBLEM PURPOSE PROGRAMS/ SUCCESS TIME PERSON
ACTIVITIES INDICATORS IN
CHARGE

2. Discharge Maximizing the Role-playing The use of media Monday, 25 Group 2

Planing use of media in release during discharge March 2024
include discharge planning
planning can be
leaflets and planning to 1. Modify the
lack of make it easier done optimally
leaflet
information for patients and
related to families to
how to care understand the
for patients education
while at provided
home
NO PROBLEM PURPOSE PROGRAMS/ACTIVITIES SUCCESS INDICATORS TIME PERSON IN
CHARGE

3. Nursing Round Reviewing patients Determine the patient for The patient expressed Wednesday Group 2
according to the nursing round satisfaction with the services 27 March
Nursing rounds are
Ronde criteria 1. Prepare for the provided by the nurse and in
2024
never conducted in 1. Doing Nursing nursing round overcoming the nursing
Rounds (strategies and problems experienced by
the room.
materials) the patient.
1. The nursing round can
be carried out according
to a predetermined
schedule.

4. Supervisi Creation Assign activities Supervision activities Tuesday, 26 Group 2

Supervision Work Program who will be supervised become the main activity March 2024
and the description and set clear goals for and are routinely carried out
only
that each in the room
performed by clearly appropriate Supervision. There is a standard
Management The standard 1. Propose a standard supervision format in the
nursing and there is has been assigned supervision format to room for each action
no standard Nursing
the head of the room
supervision
evaluation format.
IMPLEMENTATION AND EVALUATION
 IMPLEMENTATION EVALUATION
No ISSUE PRIORITIZATION

Developing a patient handover Handover carried out on Monday, March 25, 2024 – Wednesday,
1 Handover March 27, 2024.
format and technical instructions for The first weigh-in is done at the nurse station, then in the patient's
Handover has been done filling it emphasizes more on the room and back again at the nurse station.
care aspect. The weighing process is led by the head of the room and carried
well but not optimally: out by all nurses on duty and who change shifts.
Carry out handover for every shift
The primary nurse passes on to the next primary nurse who will
Some nurses do not change at the nurse station and change shifts.
visits to the patient room The content of the weigh-in includes the number of admissions,
mention the patient's the number of discharged patients and the total number of
1. Document patient handover patients, medical diagnoses, nursing diagnoses, subjective
medical diagnosis, some complaints, interventions that are or have been carried out and
do not mention the interventions that will be continued.
Weighing can be carried out every shift change.
patient's subjective and Every nurse can know the progress of the patient.
1. Communication between nurses went well.
objective complaints,
some do not mention
nursing problems that still
arise.
 ISSUE IMPLEMENTATION EVALUATION
No
PRIORITIZATION

Conducting socialization and Discharge planning carried out on Wednesday,

2 Discharge
simulation of discharge planning Monday, 25 March 2024
Planning in the room Patients have been given leaflets and counseling
Sharing socialization media in the about diseases, how to take medicine at home
Does not include leaflets form of leaflets about patients' and how to treat them.
diseases and how to care at home
and lack of information to families and patients. 1. Documenting discharge planning activities,
related to how to care 1. Documenting extension activities
for patients while at
home.
 ISSUE IMPLEMENTATION EVALUATION
No
PRIORITIZATION

Establish the activities to be Supervision carried out on Tuesday, 26 March 2024.

3 Supervisi
supervised and set clear The head of the room supervises primary nurse and
Supervision is only goals for each supervision. primary nurse supervises associate nurses.
carried out by 1. Propose a standard 1. The supervision used a standard supervision
supervision nursing supervision format for format.
management and the each primary and
head of the room does associate nurse.
not yet have a standard
format.
 ISSUE IMPLEMENTATION EVALUATION
No
PRIORITIZATION

Nursing Round Determining the patient for

A round of nursing has been conducted on Friday, March 15,
4 Nursing rounds the round 2024 at 9.00 WITA. Patients on behalf of Nn "I" with medical
are never Preparing for a nursing diagnosis of pulmonary TB, CKD (Chronic Kidney Disease) On
conducted in the round HD, SLE (Systemic Lupus Erythematosus), have been treated
room. for almost 1 month. The nursing round was attended by the
1. Conduct nursing rounds
nurse, the Head of the otak kokok room represented by Ners
Dian, the supervisor of the Crowed Brain room. Results of
nursing diagnosis Ineffective breathing patterns, hypervolemia
and impaired skin integrity. The last result of the round is to
monitor oxygen saturation if the patient is off the nasal canul,
maintain the semifowler position, teach deep breath relaxation
techniques, change the left/right tilt position every 2 hours to
prevent pressure sores from forming, provide education to limit
fluid and salt intake.
1. Patients and families understand the explanations given,
cooperate and re-practice what has been taught.
CONCLUSION
• Otak kokok it is one of the isolation treatment rooms located at ntb provincial hospital. otak kokok

rsup has 20 rooms, 10 rooms in the front with a total of 20 beds and 10 rooms in the interior

(isolation room) with a total of 16 beds, so that the total bed or bed is 36 beds. personnel consist

of s-1 nursing + nursing which is 17 people, diploma vi nursing is 1 person, diploma iii nursing is 7

people, diploma iii midwifery is 1 person, and non-nursing personnel consists of nutritionists 1

person, cleaning service which is 6 people and central administration which is 1 person,

pharmacist 1 person, tranporter 1 person, and waiter 1 person. the nursing care method applied in

the crowed brain space is a modified primary model.

• The need for nursing personnel in the otak kokok room rsup to calculate the need for nursing

personnel in the otak kokok room we use gillies formula. when calculated with the gillies formula,

it was found that the results of the division of energy were 13 people / day.
The documentation system in otak kokok is based on sop (standard operating
procedure) and sak (standard nursing care), the availability of documentation
facilities and infrastructure for health workers (supporting administrative facilities).
there is already a nursing care format, as well as nurses awareness of
responsibilities and responsibilities.
 Nursing Rounds

The implementation of the nursing round carried out by nursing practice students
accompanied by land supervisors went well. some input from the land supervisor becomes a
lesson for the student.

Discharge Planning

Discharge planning is carried out by practical students using leaflet media and discharge
planning’s format
Weigh and Accept

Role play handover carried out every shift change starting with the pre-conference by
mentioning the patient's name, medical diagnosis, complaints, nursing diagnosis, and follow-
up plan, conducted at the nurse station for morning and for the afternoon duty, then continued
validation to the patient's room and returned to the nurse station room for post conference and
documentation by practical students.

Supervision

the supervision role play has been carried out on march 26, 2024 related to the supervision of
the head of the room to primary nurse and primary nurse to associate nurse. the results of the
supervision obtained a value of 79% for primary nurses and 91% for associate nurses. input
for primary care is to involve associate nurse in decision making and remind associate nurse
to take action according to sop.
DOCUMENTATI
ON
DESIMINASI AWAL
TIMBANG TERIMA
DISCHARGE PLANNING
SUPERVISI
RONDE KEPERAWATAN
THANK YOU