NURSING CARE AND NURSING ASSESSMENT WITH A DIAGNOSIS

“CORONARY HEART DISEASE”

Lecture:
Dwi Priyantini, S.Kep.,Ns., M.Si

Group’s Name:

1. Aida Berlian (151.0002)

2. Mahkda Anjani Putri (151.0030)
3. Ratnasari Hardiyanti (151.0044)
4. Riska Utama (151.0047)
5. Selvia Kumaala Dewi (151.0049)

HANGTUAH SURABAYA HEALTH SCIENCES INSTITUTE

PERIODE 2016-2017
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015

HANDOVER OF PATIENTS
Has accepted new patients
Name : Tn.Hariyono (62th) Sex : Male/Female
No.Reg : Date :10 February 2016
Medical Diagnosis : Time : 06.00
Doctor who cure :
Originally room : IGD In to the room : Rubby

1. Client Condition :
Awareness : Composmentis GCS : 456
TTV : 140/80 mmHg , pulse : 93 bpm , reg/irreg , strong /weak , temp : 373 oC , RR :
20x/minuts, Rhonchi : / , Wheezing : / , retr : , Type :
KU : pain in the gut
Medical devices used : -infusion: (date & time , residue: cc)
-
2. Handover of Drugs
The List of Drugs Received
No Drugs name Dosage Total

3. Data Investigations Carried ( and total)

1.) …………………………………………. 4.)…………………………………………
2.)………………………………………….. 5.)…………………………………………
3.)………………………………………….. 6.)…………………………………………

4. Special Note

Surabaya, 10 February 2016

Nurse room proveniance Primary nurse room

(……………..………..) (……………….…)
 PROGRAM PENDIDIKAN PROFESI NERS
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2015

SHEET ADMISSION OF NEW PATIENTS

Full name/ Age : Tn.Hariyanto / 62 th

No. RM :
Date MRS/ Time : 10 February 2016
Medical Diagnosis :
Address/ No.Telp :
1. Introduce self
2. Introduce the headroom and nurses responsible
3. Introduce Doctor responsible
4. Explanation the rule of Hospital :
a. Facilities Room
b. Visiting Hours
c. Eating Time
d. Watchman
1.) Watcher is a client family
2.) Each patient can only wait one person
5. Introduce the room/ Environtment
a. Kitchen
b. Toilet
c. Doctor Consultation Room
d. Nurses Counter
e. Preyer rooms and Qibla direction
f. Lobby Room
g. Lift (Exit)
6. Explanation will be acentralized system and its drug with inform conssent
7. Don’t bring valuables
8. Introduce new patient to other patients in same room (if there)
9. To ask again about the clarity of theinformation that has been submitted
10.. Drugs are brought, information:…………………………
11. The examination are brought,information :…………..
This information with (√) if you have done

Surabaya, 10 February 2016

Nurse Patient/Family

(Sutrisno) ( )
 PROGRAM PENDIDIKAN PROFESI NERS
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2015

Patient name /Age: Sex:L/P

No.RM :
Medical Diagnosis :

APPROVAL OF MEDICAL ACTION

I undersigned bellow :
Name :
Age : Sex : L/P
Proof of identity / KTP :
Hereby declares that the realhas given :

APPROVAL
Medical form for action**
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
To myself*/Wife*/Husband*/Children*/Father*/Mother*/My siblings* with :
Name :
Age : Sex : L/P
Address :
Proof of identity/ KTP :
Treat at :
I understand the need and benefits of measures as necessary as above to me, including the
risks and complications that may arise. I also realized that doctors and nurse have done a best
effort. However it is dependent on almighty God permits one to the success of medical measures.
The statement I made this agreement full awareness andwithout coercion.

Surabaya,
…………………………..
Witness Doctor Maker a statement
(………………….) (………….………..) (……………..…………..)
(………………….)

**Fill with the kind of medical treatmeant due

* Cirle selected
 PROGRAM PENDIDIKAN PROFESI NERS
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2015

CONSULTATION SHEET

To Yth: Prof./DR/Dr……………………………………………
Consult Date…………………………………………………….
Dear Prof./DR/Dr,
Please helpcolleagues to (*) (*) Circle appropriate
1. Consultation/ an action problem medic today
2. Caring together for further
3. Expert care case for further
On this patient, we will care with……………………………………….......................................
……………………………………………………………………………………………………..
Information Clinic are important currently :

Thanks for your attention and your participation.

Greeting Colleagues,
Prof./DR/Dr…………………………………….
If you need, use the back page.

CONSULTATON ANSWER

Date : Time :

Dear, Prof./DR/Dr…………………………..
After consultation request our colleagues in the evaluation of patient currently get.
Suggestions Medical action/ curing :

Thanks for your attention and your partisipation

Greeting Colleagues
Prof./DR/Dr………………………………..
NB: If you need, use the back page.
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016

FORMAT NURSING ASSESSMENT

Date/Time assessment : 10 February 2016 Room/Class : Rubby

Date/ Time MRS : No.room :
No.RM : Medical Diagnosis :

I. IDENTITY
1. Name : Hariyanto
2. Age : 62 th
3. Sex : Male
4. Religion : Islam
5. Tribes : Java
6. Status married : Married
7. Education :
8. Work : Superrannuation
9. Address and no.telp :
10. Person in change :

II. HISTORY OF PAIN AND HEALTH

1. Main Complain
Painfull
2. History of present illness
Patients come to the PHC hospital withpressure pain, pain is going on since June ,
intermittent pain that is felt when on the move.
3. Previous medical history
DM (-) , Hypertensive (-) , Ashtma (-) , Heart pain (-) , Lung pain(-) , etc (
mention,…………………………………………..)
4. Family history of disease
DM (-) , Hypertensive (-) , Ashtma (-) , Heart pain (-) , Lung pain(-) , etc (
mention,…………………………………………..)
 5. Genogram

6. History of alergy
Food ( - ), Type…..
Drugs ( - ), Type…..

III. THE PATTERN OF HEALTH FUNCTIONS

1. Perseption of Health (Confidence of Health & Illness)
According to the patient’s illness was a trial of God ( ), punishment of God ( ), others
(………………………………………………………………………………….)
Patients can receive disease, yes (√), no ( )
Patients believe that the disease will be cured, yes (√), no ( )

2. Activity and exercise pattern

a. Self care Ability
Activity SMRS MRS
0 1 2 3 4 0 1 2 3 4
Take a bath √ √
Dress up/primp √ √
Elimination/toileting √ √
Mobility in bed √ √
Moving √ √
Walking √ √
Up the stairs √ √
Shoping √ √
Cooking √ √
Home maintenance √ √

Skor : 0 = Be autonomous 3 = Assisted by others and kit

1 = Help kit 4 = Dependent /disability
2 = Assisted by others
Help Kit : ( √ ) No ( ) Crutch ( ) Stick
( ) Bedpan bedside ( ) Wheel Chair

b. Personal Hygiene
At Home At the Hospital
Take a bath: 2 x/days Take a bath /swabbed: 2 x/days
 Brush your teeth : 2 x/day Brush your teeth : 2 x/day
Hair wash : 3 x/week Hair wash : 3x/day
Cut nails: 1 x/week Cut nails: 1x/day
c.activity everyday
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………
d.Recreation
Watching TV (√) , listening to music / video (-) , reading books/newspapers (√) , take a
walk(√) , etc,mention …………………………………………………………………………
e. sports : (-) not (√) yes , kind : take a walk (√) . running/jogging (√) ,etc mention………
3. Sleep and Rest Patterns
At home In the hospital
Sleep time : Afternoon ……..,……… Sleep time : Afternoon ……..,………
Night……,…….. Night……,……..
Sleep hours total : Sleep our total:
Problems in hospital : (√) Nothing ( ) wake up early ( ) nightmare
( ) insomnia etc, ………………..
1. Metabolic – Nutrition Patterns
a. Eat patterns
At home In Hospital
Frequency : Often ( ),rarely ( ) Frequency : often ( ), rarely ( )
Type : Type :
Total : Total :
Prohibition :
Favorite food :
Appetite : (√) normal ( ) Increased ( ) decreased
( ) Nausea ( ) vomit ... .. cc ( ) stomatitis
Difficulty swallowing : () Yes (√) not
Dentures : () Yes (√) not
NG Tube : () Yes (√) not
b. drinking patterns
At home in the hospital
c. Frequency: frequent (), rarely () Frequency: frequent (), rarely ()
d. Types : Types :
e. Total : Total :
f. abstinence :
g. Favorite food:
2. Elimination pattern
a. Defecate
At home in the hospital
Frequency : Frequency :
Consistency : Consistency :
Color : Color :
 ( ) yellow
( ) mix with blood
( ) etc,…………..
Problem in the hospital : ( ) constipation ( ) diarrhea ( ) incontinence
Colostomy :( ) Yes ( ) No
b. Urination
At Home In the Hospital
Frequency : ………x/days Frequency : ……..x/days
Total : …………..cc Total : …………..cc
Color : …………… Color : ……………
Problems in the Hospital : ( ) disuria ( ) aucturia ( ) hematuria
( ) retensi ( ) ickontinen
Cateter : Yes,Cateter…………………….

6. Patterns of cognitive perceptual

Speak :( ) Normal ( ) Stutter ( ) Slurred speech
Everyday Language : ( ) Indonesia ( ) Java ( ) etc,………………….
Ability to read :( ) Can ( ) Csn’t
The level of anxiety : ( ) Mild ( ) Moderate ( ) Severe ( ) Panic
Cause,…………………………………………………………..
Interaction skills :( ) Corresponding ( ) No,………………………………….
Vertigo :( ) Yes ( ) No
Painful :( ) Yes ( ) No
If, yes P : ………………………………………………………………….
Q :…………………………………………………………………..
R : ………………………………………………………………….
S :………………………………………………………………….
T :…………………………………………………………………..
7. Pattern of self-concept
Picture of yourself :……………………………………………………………….....
Identity :………………………………………………………………….
Role :………………………………………………………………….
Ideal self :………………………………………………………………….
Pride :………………………………………………………………….
8. Coping patterns
The main problem for MRS (disease, costs, personal care)
…………………………………………………………………………………………….
Moving problem will happen, because
……………………………………………………………………………………………..
 9. Sexual Patterns - Reproduction
Last menstrual period : -
Menstrual problems : -
Last Pap smears : -
Breast examination / testis itself each month : ( ) yes ( ) no
The problems associated with the disease : ……………………….

10. Role Patterns - Relationships

Occupation : Retired
Quality of work : working frequency - x/week
From at……………… - …………….
Relationships with others : (√ ) both ( ) unfavorable
Support system : ( ) pair ( ) eighbor / friend ( ) does not exist
( ) others………………………………………….
Family problems regarding treatment in hospital:
……………………………………...

11. Patterns Value - Faith

Religion : Islam
Implementation of Worship : prayer
Abstinence Religion : (√ ) no ( ) yes …………………………
Request a visit rohaniawan: (√ ) no ( ) yes

I. ASSESSMENT PERSISTEM (Preview of system)

1. Vital sign
a. Temperature : 373 ℃ Location : Axillary
b. Nadi : 93 x/min Rhythm : ……… Pulse : ……….
c. Blood pressure : 140 / 50 mmHg Location : …………………………
d. Breath frequency : 20 x/min Rhythm: …………………………
2. Respiratory system (Breath) or BI
Shape chest : (√ ) Symmetrical ( ) Asymmetric
( ) Barrel chest/Funnel chest/Pigeon chest
Cough : ( ) Yes (√ ) no
Productive : ( ) Yes (√ ) No Color spontaneous:
Pain when breathing : ( ) Yes (√ ) No
Breathing patterns : ……… x/min
Frequency of breath : (√ ) Regular ( ) Hypoventilation ( ) Kussmaul
( ) Irregular ( ) Cheyne stokes ( ) Apnea
( ) Hyperventilation ( ) Biot ( ) others ……
breath sounds
Normal : (√ ) Vesikuler ( ) Bronchial ( ) Bronchovesikuler
Abnormal : ( ) Stridor ( ) Wheezing ( ) Rales
( ) Ronchi ( ) Krepitasi
Fremitus vocal : ( v ) Palpable ( ) No palpable
Spontaneous breathing : ( v ) yes ( ) no
Contained breathing apparatus : ( ) Nasal ( ) Bag and Mask ( )
tracheostomy ( ) mask ( ) Respirator
Nursing problems : …………………………………………………………….
3. The Cardiovasculer System (Blood) or B2

Pulse : Frequency 93 x/min

( ) Regular ( ) Irreguler ( ) Strong ( ) Weak
Blood pressure : 140/50 mmHg
Heart sounds : ( ) S1 S2 single ( ) Murmurs ( ) S3/S4 ( ) Gallops
CRT : ( ) < 2 second ( ) > 2second
Chest pain : ( √ ) Yes ( ) No
Others :………………………………………………………….
The problemof nursing : -

4. Nerves system (Brain) or B3

The level of awareness : (√ ) Compos Mentis ( ) Delirium ( ) Apathy ( ) Somnolen

( ) Sopor ( ) Coma
GCS : Eye (4) Verbal (5) Motoric (6) Total (15)
Reflex : ( √ ) Normal ( ) Parese ( ) Hemiparese ( ) Kernig
( ) Babinsky ( ) Paraplegi ( ) stiff neck
Motor coordination : ( √ ) Yes ( ) no
convulsions : ( ) Yes ( √ ) no
The probems of nursing : no problems nursing

5. Urinary system (Bladder) or B4

Complaint : ( √ ) No problems ( ) Incontinensia ( ) Retension

( ) Oliguria ( ) Disuria ( ) pain ( ) Poliguria
( ) Poliuria ( ) Nokturis ( ) hot ( ) Hematuria
Urine output : 3600ml/days Frequency: 5x/days
Colour : jernih, Smell: ammonia, others………………………...
Tools Cateter : ( ) Yes ( √ ) no
The problem ofnursing :no problems nursing

6. Sistem Pencernaan (Bowel) atau B5

TB: 165 cm BB: 74 kg

Mucosa of the mouth : lembab kering merah stomatitis
Throat nyeri telan sulit menelan
Abdomen supel tegang nyeri tekan, lokasi :
luka operasi jejas lokasi :
Enlarged liver yes no
Enlarged spleen yes no
Ascites yes no
Nausea yes no
Vomating yes no frequency : -
Attached NGT yes tno
Bowel: 15x/min
BAB : 1x/days, consistency : soft liquid
Mucus/blood incontinensia colostomy

The problemof nursing :noproblems nursing

7. Muskuluskeletal System (Bone) or B6 and Intergumen

Motion free limited

Limb abnormalities yes no
Spinal abnormalities yes no
Fractures yes no
Traction/spalk/gips yes no
Compartement syndrome yes no
Skin ikterik sianosis redness hiperpigmentasi
Akral warm hot cold dry wet
Turgor good less bad
Injuries :- type : - large : - : clear dirty
Muscle strength :5555,5555,5555,5555
Others
The problem of nursing :…………………………………………………………………………..

8. Sensing system

Vision (Eye)
Shape : ( √ ) Normal ( ) Eksoptalmus ( ) Endoftalmus
( ) others ………………….
Pupil : ( √ ) Isokor ( ) anisokor
( ) Miosis ( ) Midriasis
Light reflex : …./…..
Sclera : (√ ) clear ( ) cloudy ( ) others
Eye movement : ( √ ) Normal ( ) Abnormal info………………
Color blindness : ( ) yes, type ( ) parcial ( ) total (√ )no
Smell (Nose)
Shape : (√ ) Normal ( ) Deviasi
Disturbance smell : ( ) yes (√ ) no
Hearing( Ear )
Auricle : (√ ) Normal ( ) Abnormal Info ………………..
Tympanic Membrane : ( ) bright ( ) redness ( ) cloudy
Otorrhoea (bleeding) : ( ) yes (√ ) no
Hearing loss : ( ) yes ( √ ) no
Tinnitus : ( ) yes (√ ) no
Taste : (√ ) Normal ( ) no feel
( ) others
Touch : (√ ) Normal ( ) abnormal, mention …………………….

9. Reproductive system dan Genetalia

Male
Sex ( shape ) : (√ ) Normal ( ) Anormal, Info ………………
Keep genetalia : (√) Clear ( ) No clear, Info ………………..
Disfunction : ………………………………………………………………
Others : ………………………………………………………………

Female
Breast :
Shape : ( ) symmetrical ( ) asymmetrical
abnormal : ( ) yes,type….. ( ) no
Sex :
shape : ( ) Normal ( ) no
vaginal discharge: ( ) yes ( ) no
Menstrual cycle : ……….days
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
INTERVENSI KEPERAWATAN
No. Nursing Objectives and Criteria Results Intervention
diagnoses
15/0 Anxiety about Having performed for 1x24
2/20 the procedure hour nursing care is expected
16 execution to decrease anxiety and the
patient and family understand
the procedures for
implementing the DLA,
marked by KH:
 Not able to identify and
express the anxiety that is felt.
 vital signs within normal
limits.
 middle excretion showed
reduced anxiety
 Clients say know and
understand the procedures for
implementing the DLA
16/0 Acute pain by
2/20 surgery
16 After nursing care during the
expected 3x24jam reduced pain,
KH:
17/0 Acute pain by  The patient was calm
2/20 surgery
 Patients say no pain
16
After nursing care during
3x24jam reduced pain, KH:
 Patients appear calm
 Patients say no pain
TTD
1. Use BHSP approach
2. Explain all procedures,
what is felt during the
procedure, and objective
procedures performed
DCA
3. Listen attentively.
4. Make a back / neck rub to
relieve anxiety.
5. Teach relaxation
techniques to reduce
anxiety
6. Collaborate to reduce
anxiety by drug delivery.
1. Assess the patient's pain
scale
2. Teach pain management
3. Collaboration with
physicians to analgesic
administration
1. Assess the patient's pain
scale
2. Teach pain managemet
3. Observation TTV
4. Collaboration with
physicians to analgesic
administration
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016

INTERVENSI KEPERAWATAN
No. Nurses Purpose and Criteria Result Intervention TTD
Diagnosis
18/0 Acute pain by After 3x24 hours of nursing 1. Assess the patient’s pain
2/20 surgery care for the expected reduced scale
16 pain, KH : 2. Teach pain management
 Patient seemed calm 3. Observation TTV
 Patient said it wasn’t 4. Collaboration with
painfull medical team
Painfull After 3x24 hours of nursing 1. Assess the patient’s pain
19/0 care for the expected reduced scale
2/20 pain, KH : 2. Teach pain management
16  Patient seemed calm 3. Observation TTV
 Patient said it wasn’t 4. Collaboration with
painfull medical team
 IMPLEMENTATION & EVALUATION
Date Nurses Time Implemention Paraf Formative Evaluation
Diagnosis SOAPIE/ Notes
Development
14/0 Intolerance 06.30 Switch to night shift S = patients expressed
2/20 Activity 07.00 Good general state, akral no pain
16 HKM, spontaneous O = patient seemed calm
breath A = the issue isnot
08.00 Educationn to patients resolved
11.30 Observation TTV : TD= P = interventions
110/80, pulse= 60, RR= continued
30, temp= 36 ̊ R/observastionTTV,
13.45 Switch to morning shift education activity
14/0 Intolerance 14.00 Conscious general state, S = patients expressed
2/20 Activity akral HKM,spontaneous no pain
16 breath, GCS 456 O = patient seemed calm
16.00 Observation TTV: TD = A = problems resolved
120/80, pulse =68, RR = partially
18, tenp = 36 ̊ P = interventions
continued at this night
1. ObservationTTV
2. Education to limit the
activity
3. BC
14/0 Intolerance 20.45 Afternoon shift S = patients expressed
2/20 Activity 04.00 Help ADC patient no pain
16 05.00 Obs TTV : TD= 120/80, O = patient seemed calm
N/S = 63/36 and RR= 18 A = problems resolved
05.50 Assess the patient’s pain partially
scale P = interventions
P= post CPAG continued
Q= throbbing pain 1. Observation TTV
R= chest middle 2. Pain scale
S= - 3. Teach management of
T= residential wane pain
06.00 Teach management of
pain
 IMPLEMENTATION & EVALUATION
Date Nurses Time Implemention Paraf Formative Evaluation
Diagnosis SOAPIE/ Notes
Development
15/0 Acute pain 13.30 Change to morning S = patients expressed no
2/20 shift pain
16 15.30 Observation TTV : Good general state, akral
TD= 140/80, pulse= 76, HKM, GCS=456
RR= 30, Temp= 36 ̊ Asses the pain
15.30 Good general state, P= post CABG
akral HKM, GCS=456 Q= throbbing pain
16.00 Assess the patient’s R= chest middle
pain scale S= scale 3
P= post CABG T= residential wane
Q= throbbing pain Patient seems touch the
R= chest middle chest when the pain come
S= 3 A = problems not resolved
T= residential wane P = intervention continued
17.30 Teach management of  Educatin the patient to
pain bedrest
19.00 Give the terapy  Teach the managemet
including the doctor’s of pain
advise  Observation TTV
 Assess the pain scale
 Help ADL
15/0 Intolerance Change to afternoon S = The patient asks that
2/20 Activity shift no pain
16 Keadaan umum baik, O = the patient seems
DCS= 456, Akral calm GCS= 456
HKM A = the problem not
Memberikan edukasi resolved
kepada pasien untuk P = intervention continued
membatasi mobilitasi R/ observation Hv
Observasi TTV : TD= Education the patient to
130/70, S= 36, N= 72, limit the activity and
RR= 20 don’t strong to close
BAB, helpADL pattient
 IMPLEMENTION & EVALUATION

Date Nursing Problems Time Implementation Paraf Formative

Evaluation SOAPIE/
Notes Development
Acute pain 20.45 Change to afternoon S : patient said still
shift feel pain
21.50 Monitor the patient’s O : Grimacing feel
general condition good, pain
awareness P : PostCABC
composmentis, GCS Q : throbbing pain
24.00 456, spontaneous breath R:
, Akral HKM S: 3 scale
05.00 Change infusion PZ T : disappear arise
500 cc/24 hours
05.15 Observation TTV TD = A : problem solved
140/80 , 36.2 , 73 partially
Reviewing complaints P : next intervation
of pain  Instruct bedrest
P : PostCABC  Obsevation
Q : throbbing pain TTV
R:  Assesing pain
S: 3 scale scale
T : disappear arise
Acute pai 07.30 Change to morning S : patient said still
shift feel pain
11.00 Obs.TTV P : post CABC
TD: 140/80 RR: 18 Q :throbbing pain
12.00 Assesing pain scale R:
P: Post CABC S:4
Q : throbbing pain T : disappear arise
R: O : patient seemed to
S:3 show his wound
T : disappear arise A : problem solved
partially
P : next intervation
 IMPLEMENTATION & EVALUATION
Date Nursing Time Implementation Paraf Formative Evaluation
Problems SOAPIE/ Notes
Development
Acute pain 07.00 Change to night shift S = the patient ask that
Give the drugs after the operation, the
08.00 Education to the patient chest still pain
Assess the pain O = P= post CABC
09.30 P= post CABC Q= throbbing pain
Q= throbbing pain R=
R= right chest S= 3
S= 3 T= appear rise
T= disappear arise A = the problem
0.00 Teach the management of resolved partly
pain P = intervention
11.00 Observation TTV : TD= continued R/ afternoon
120/70, pulse= 84, RR=  Observation TTV
20, tempt= 36,8 ̊  Assessthe pain
13.00 Give the drugs  Teach the
management of pain
 Give the terapy
including the doctor’s
advise
Acute pain 14.00 Change to morning shift S = the patient ask that
Help ADL the patient after the operation, the
15.00 Observation TTV: TD = chest still pain
16.00 120/70, pulse =80, RR = O = the patient seems
18, tempt = 37,1 ̊ calm
Assessthe pain A = the problem
17.00 P= post CPAG resolved partly
Q= throbbing pain P = intervention
R= right chest continued k/night
S= -  Observation TTV
T= appear rise  Assess the pain scale
17.30 Teach the management of  Teach the
pain management of pain
19.00 Give a terapy to the  Give the terapy
patient including doctor’s
advise
 IMPLEMENTION & EVALUATION
Date Nursing Time Implementation Paraf Formative Evaluation
Problems SOAPIE/ Notes
Development
Ansietas 07.00 Change to nigt shift S = the patient ask that
The patient have been he still pain
09.00 coming from ICU,post O = P= post CABC, Q=
CABG throbbing pain, R= - ,S=
10.00 Observation TTV : TD= 3,T= appear rise
80/70, pulse= 33, tempt= A = the problem
36 ̊ resolved partly
11.00 Give the terapy including P = intervention
doctor’s advise continued R/ afternoon
Observation TTV,
Assess the pain, Teach
the management of pain,
Give the terapy
Pain 14.00 Chang to morning shift S = the patient ask that
14.50 k/u good, GCS 452 after the operation, the
15.00 Observation TTV: TD = chest still pain
120/80, pulse =72, tempt O = P= post CABC, Q=
= 36 ̊ throbbing pain, R= -,S=
16.00 Assess the pain 3,T= appear rise
P= post CPAG, Q= A = the problem
throbbing pain, R= -,S= resolved partly
3,T= appear rise P = intervention
16.15 Teach the managementof continued p/nigth
pain Observation TTV,
19.00 Give the terapy Assess the pain, Teach
the management of pain,
20.30 Change to night shift Give the terapy
Pain k/u good GCS 456 S= the chest still pain
Assess the pain Q= P= post CABC, Q=
P= post CABC,Q= throbbing pain, R= -,S=
throbbing pain,R= 3,T= appear rise
epigastrium,S= 3,T= A= the problem resolved
appear rise partly
TTV; TD : 120/70 , S: P= intervention
368 ,N : 90 , RR:20 continued
 IMPLEMENTATIONS & EVALUATIONS
Date Nursing Time Implementation Paraf Formative Evaluation
Problems SOAPIE/ Notes
Development
Ansietas 07.00 Change to night shift S = the patient says that
08.00 Observation the the pain come again
condition was good O = P= post CABC, Q=
11.00 Observation TTV : TD= throbbing pain, R= - ,S=
140/90, pulse= 33, 3,T= appear rise
Tempt= 36 ̊ A = the problem
12.00 Teach how to relax the resolved partly
breathing chest P = intervention
continued R/ afternoon
Observation TTV,
Assess the pain, Teach
the management of pain,
Give the therapy
including the doctor’s
advise
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015

CENTRALIZED APPROVAL LETTER DO DRUGS

The undersigned below:
Name : Sumarmiati
Age :
Sex :L/P
Address : Jember
Data : ( ) self ( ) wife ( ) husband ( ) parents ( ) etc
Name patient : Tn. Hariyono Room : Rubby 11.2
Age : 62 years Sex : L/P
Address : Jember No. Reg :
Declare ( deal / no deal*) to do drugs centralization, after get information about drugs
centralization , regulating the use of drugs regulated or coordinated by nurses in accordance with
the doses administered by doctors.
This drugs centralization to do procedure :
1. Patient/family filling the approval letter for cooperation in the management drugs
centralization
2. Each received a prescription from a doctor handed over to the nurse in charge at that
time.
3. Drugs from pharmacy handover to nurses
4. Dugs name,doses,amount received will be recorded in a received
5. Drugs will save in drugs room
6. Daily medication given by nurses appropriate doses.
7. If patient go home and still available then the rest of the drug will be given to patient or
famil. Thus the responsible on statements made and actions claim/lawsuit at a later date
for this action.
Surabaya,
The nurse who explains Which approved

( ……………………………. ) ( Sumarmiati)

Witness 1:……………………………(……………………)
Witness 2:……………………………(……………………)
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015

HANDOVER OF PRESCRIPTION DRUGS

Name of the patien : Tn. Hariyono Room : Rubby 11.2

Ages : 62 th No. Reg :

No. Day/Dat Name of the Dose Total Info Ttd/ Name of Ttd/ Name Info
e/Time drugs (received/submi submitting of
tted) receiving
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015

MEDICINE GIVING FORMAT ORAL

INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.

Name : Tn. Hariyono No.Reg :

Ages : Room :
DRUGS DATE
Name of Accept:
Drugs:
Dose:
Vaclo 75mg
1x1 Time Name Name Name Name Name Name Name Name

ESO:

Residu:
TT
Px/Family
Name Of Accept:
Drugs:
Dose:
Time Name Name Name Name Name Name Name Name

Residu:
TT
Px/Family
Name: No.Reg:
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2015
MEDICINE GIVING FORMAT ORAL

INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.

Name : Tn. No.Reg :

Ages : Room :
DRUGS DATE
Name of Accept:
Drugs: Dose:
Time Name Name Name Name Name Name Name Name
8

ESO:
Residu:
TT
Px/Family
Nama of Accept:
Drugs: Dose:
Time Name Name Name Name Name Name Name Name

ESO:
Residu:
TT
Px/Family

Name : No.Reg :
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
MEDICINE GIVING FORMAT ORAL

INFORMATION :
1. There is no hisself, 2. Patient doesn't want drink medicine, 3. the Medicine is stopped, 4. Patient patient
not to be allowed drink medicine.

Name : Tn.Hariyono No.Reg :

Ages : 62 year Room : Roby

DRUGS DATE 10-2-2016 11-2-2016 12-2-2016

Name Of Accept:
Drugs: Dose:
Time Name Name Name Name Name Name Name Name
8

ESO:
Residu:
TT
Px/Fam
ily
Name Of Accept: 1x1
Drugs: Dose: 4 mg
Time Name Name Name Name Name Name Name Name
8

ESO:
Residu:
TT
Px/Fam
ily
Name : No.Reg :
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
MEDICINE OF DRUGS
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Tim Name Dos TTD Ti Na Dos TTD
Of e of Nurse e Of e of Nurse me me e of Nurse
Drug dru Drug dru Of dru
gs gs Dru gs
g
Date: 8 13. Flumo
11-2- 00 cyl
2016 Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dose TTD Tim Name Dos TTD Ti Na Dos TTD
Of of Nurs e Of e of Nurse me me e of Nurse
Drug drugs e Drug dru Of dru
gs Dru gs
g
Date: 08.0 Biso 1x1 Nita
12-2- 0 Prulul 3x1
2016 Flumo
cyl
Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Tim Name Dos TTD Ti Na Dos TTD
Of e of Nurse e Of e of Nurse me me e of Nurse
Drug dru Drug dru Of dru
gs gs Dru gs
g
Date:

Info : Info : Info :

TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Time Name Dos TTD Ti Na Dos TTD
Of e of Nurs Of e of Nurse me me e of Nurse
Drug dru e Drug dru Of dru
gs gs Dru gs
g
Date: 13.00 Flum
11-2- ocyl
2016 Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dose TTD Tim Name Dos TTD Ti Na Dos TTD
Of of Nurs e Of e of Nurse me me e of Nurse
Drug drugs e Drug dru Of dru
gs Dru gs
g
Date: 08.00 Biso 1x1 Nita
12-2- Prulul 3x1
2016 Flumo
cyl
Info : Info : Info :
TER DOSE AND THERAPY GIVING
APY MORNING AFTERNOON NIGHT
Time Name Dos TTD Tim Name Dos TTD Ti Na Dos TTD
Of e of Nurse e Of e of Nurse me me e of Nurse
Drug dru Drug dru Of dru
gs gs Dru gs
g
Date:

Info : Info : Info :

 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
GIVING FORMAT INJECTION
Name/Ages : Tn. Hariyono/62 year Sex :L/P
No.RM :
Date.MRS/Time :10 February 2016
Medical Diagnosis :
Name Way & Date of Giving
of Dose Info
drugs Giving
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
GIVING FORMAT INJECTION
Name/Ages : Tn.Hariyono / 62 year Sex :L/P
No.RM :
Date.MRS/Time :10 February 2016 / 06.00 WIB
Medical Diagnosis :
Date of giving : 13-02-2016
Time Intake Output
Drink Soade Lequefying Vomit Urine Blooding Retensi IWL Info
Infus
07.00
08.00
09.00 200 200
10.00
11.00
12.00 200 200
13.00
14.00
Balance
15.00 200 200
16.00
17.00
18.00 200 -
19.00
20.00
21.00 200 200
Balance
22.00
23.00
24.00 200 200
01.00
02.00
03.00 -
04.00
05.00
06.00 200 200
Balance
Total
Balance
Advice
Doctor

NB : IWL = (15 x BB)/ 24 hour =......cc/hour

IWL with temperature going up =

[(10% x Intake Lequefying) x (temperatur patient - 37C)] + IWL normal =......cc/hour
24 hour
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
GIVING FORMAT INJECTION

Name/Ages : Tn.Hariyono / 62 year Sex :L/P

No.RM :
Date.MRS/Time :10 February 2016 / 06.00 WIB
Medical Diagnosis :
Date of giving : 12-02-2016 (px 500 cc/ 24 hour)
Time Istake Output
Drink Soade Lequefying Vomit Urine Blooding Retensi IWL Info
Infus
07.00
08.00
09.00 50 100 100
10.00
11.00
12.00 100 100 100
13.00
14.00
Balance
15.00 150 90 100
16.00
17.00
18.00 700 200
19.00
20.00
21.00 200 400 200
Balance
22.00
23.00
24.00
01.00
02.00
03.00
04.00
05.00
06.00
Balance
Total
Balance
Advis
Doctor

NB : IWL = (15 x BB)/ 24 jam =......cc/hour

IWL with temperature going up =

[(10% x Intake Lequefying) x (temperatur patient - 37C)] + IWL normal =......cc/hour
24 hour
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
GIVING FORMAT INJECTION
Name/Ages : Tn.Hariyono / 62 year Sex :L/P
No.RM :
Date.MRS/Time :10 February 2016 / 06.00 WIB
Medical Diagnosis :
Date of giving : 11-02-2016
Time Istake Output
Drink Soade Balance Vomit Urine Blooding Retensi IWL Info
Infus
07.00
08.00
09.00 450 450 100
10.00
11.00
12.00 100 400 200
13.00
14.00
Balance
15.00 350 100
16.00
17.00
18.00 300 200
19.00
20.00
21.00 250 100
Balance
22.00
23.00
24.00 200 200
01.00
02.00
03.00 150
04.00
05.00
06.00 100
Balance
Total
Balance
Advis
Doctor

NB : IWL = (15 x BB)/ 24 jam =......cc/hour

IWL with temperature going up =

[(10% x Intake Lequefying) x (temperatur patient - 37C)] + IWL normal =......cc/hour
24 hour
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
GIVING FORMAT INJECTION
Name/Ages : Tn.Hariyono / 62 year Sex :L/P
No.RM :
Date.MRS/Time :10 February 2016 / 06.00 WIB
Medical Diagnosis :
Date of giving : 13-02-2016
Time Istake Output
Drink Soade Balance Vomit Urine Blooding Retensi IWL Info
Infus
07.00 100 50 100
08.00
09.00 200 100
10.00 250
11.00
12.00 150 100
13.00 200
14.00
Balance 450 250 500
15.00
16.00
17.00
18.00
19.00
20.00
21.00
Balance
22.00
23.00
24.00
01.00
02.00
03.00
04.00
05.00
06.00
Balance
Total
Balance
Advis
Doctor

NB : IWL = (15 x BB)/ 24 hour =......cc/hour

IWL with temperature going up =

[(10% x Intake Lequefying) x (temperatur patient - 37C)] + IWL normal =......cc/hour
24 hour
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
SHEETS VISITE DOKTER
NO.REG : .............................................................................................
NAME : Tn. Hariyono
SEX : Male
AGES : 62 thn
ROOM : Rubby
MEDICAL DIAGNOSIS :PJK

No. Date Infestigation TTD

1. 10-2-2016 S : To study breast pain Dr.BB
O: Chest Pain
A: PJK
P : Observation

2. 11-2-2016 Call dr.BB p/p

3. 13-2-2016 S : Chest pain

O: T 100/70 N 80x/minute
A: CAO,PRO CAPO
P : RR tetap
Infus H5
Help Mobility

4. 14-2-2016 - Pro CABG Prof.

- Consul THT
- Consul Fm Cardiovaskular
-

5. 15-2-2016 - Pro CABG Dr.Y

-
-
a. PAC
b. T
c.
-
-
-
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
DOCTOR INSTRUCTION SHEETS

Name : Hariyono No.RM :

Date Tame Doctor Name Doctor Name Nurse

Intruction
10-2-2016 10.00 WIB -Tx Tetap Dr.Budi
-
-
-
-

11-2-2016 - Dr.Budi
-
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016

LABORATORIUM
NAME : Tn. Hariyono NO.RM :
AGES : 62 year ADRESS : Perum Bumi Margo Permata
SEX :L/P ROOM : Ruby II.2
DOCTOR : DATE MRS :
DATE :
DATE 10/02 13/02 VALUE NORMAL
BLOOD
Routine : B.B.S
Hemoglobin 13,8 13,8 11.5 – 16.0 g/dl
Lekosit/WBC 11,01 9,57 4.0 – 11.00 K/UL
Counting of type : 2
Eosinofil
0
Basofil
0
Stab
45
Segmen
45
Limfosit
8
Monosit
Special : Eritrocit/ 4,66 4,18 3.00 – 6.00 M/UL
RBC
Thrombo/ 281 234 150 – 450 K/UL
PLT
Reticulosit
PCV / HCT 41,3 39,6 37.0 – 47.00 %
Malaria
Bleeding Time 2,00 1,30 N : < 3’
Clotting Time 10,00 11,00 N : < 12’
P.P.T 12,3 12,1 (N different control 2)

K.P.T.T 25,4 25,4 (N different dengan

control 7)
Group blood
Rhesus Factor
Resinofil Count (N : 40-400/mm3)
CHEMISTRY
BLOOD
BLOOD SUGAR
DEGREE
Blood Sugar 94 126
Degree Acak
Blood Sugar 70 – 110 mg%
Degree Puasa
 Reduction Negative
Blood Sugar Degree 80 – 120 mg%
2 Hour PP
FALL HEART
Alkali Phosphatase <480 U/I
Children
L: 48-223 U/I ; P: 60-
Adult 223 U/I
S.G.O.T L: 1-25 U/I ; P: 1-21
U/I
S.G.P.T L: 1-29 U/I ; P: 1-22
U/I
Gross Titrasi 1.2 – 2.0 mi
T.T.T 1 – 5 U Mefagan
Billirubin : Direct <0.35 mg%
Total <1.00 Mg%
Gamma G.T L: 8-38 U/I ; P: 5-25
U/I
Total Protein 6.0 – 8.5 g%
Albumin 3.0 – 5.0 g%
Clobulin 0.7 – 1.7 g%
FAAL KIDNEY
BUN 8 – 20 mg%
Serun Creatin L: 0.8 – 1.7Mg% P:
0.6 – 1.2Mg%

Acid of Tendon L: 3.4 – 7.0Mg% P:

0.6 – 1.2Mg%
Clearence Creatinin
Natrium 3.6 – 5.5 mEg / I
Calium 94 – 111 m Mol/ I
Clorida 8.1 – 10.4 mg%
Calsium 2.0 – 5.0 mg%
Phospor (M 1.010 – 1.025)
Heavy of Type
Plasma
BLOOD FAT <10 mg%
Total Colesterol < 35 mg%
LDL – Colesterol < 200 mg%
HDL Colesterol
Trigleserida
Beta Lipoprotein Negative
IMUNOLOGI
HbsAg (Eliea) Negative
HbsAg (RPHA)
Anti HBc
Ig M Anti HBc
Ig M anti HAV
Ig E
ANA Test
Alfa Feto Protein
SEROLOGI
Widal Test : Thypus Negative
O
Thypus Negative
H
Pa. Typ Negative
A
Pa. Typ Negative
B
T.P.H.A
V.D.R.L
W.R
Ig. M Toxoplasma
Ig. G Toxoplasma
TIROID FT 4 Index
T3
T4
TBK
URINE
Rutin :Albumin
Reduksi
Urobilin
Billirubin
Sedimen :
Erythrosit

Lekosit

Epitel sel
Kristal :
Ca Oxalat

Asam Urat

Tri. Phos

Amorbh
Silinder :
Granulair

Hyaline

Lekosit

Erythrosit
Other
Special : Specific Gravity
Reaction/ PH
Aceton
Esbach
Other
Pregnancy test : Plano Test
GM
Test
GM
Titrasi
FACES :
Consistency
Blood
Mucus
Leukocyte
Erythrocytes
Ova
Flyblow

Benzidine Test
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
NURSING RESUME
NAME : SEX :

NO.RM : ROOM :

1. Date MRS :.................................................................................................................

Doctor who To take care :.....................................................................................................
Consultant's Doctor : .....................................................................................................
KRS Date : .....................................................................................................
2. Eras Treatment
a. Condition :
.....................................................................................................................................
b. Nursing problems for hospitalized :
.....................................................................................................................................
c. Action of given :
1. Action of nursing :
...............................................................................................................................
2. Action of medical :
...............................................................................................................................
3. Medical investigation :
...............................................................................................................................
4. The patient’s condition when return :
...............................................................................................................................
3. Patients go home
Nursing actions that need to be continued at home
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

Surabaya, February 2016

Head of thr room/Team duty

(...........................)
 PROGRAM PENDIDIKAN PROFESI NERS
STIKES HANG TUAH SURABAYA
2016
SHEETS DISCHARGE PLANNING
DISCHARGE PLANNING No.Reg :
Name :
Sex :

Date MRS : Date KRS :

Part : Part :

Dischanged from RS PHC Surabaya with state :

a. Heal
b. Continue outpatient
c. Move to other hospital
d. Forced return
e. Run
f. Died

Control :
a. Time :
b. Place :

Continue care in home : Lukaoperasi/instalation gift/Medication /Other (.................................)

Diet rules :

Medicines that are still drunk and numbers :

Aktivity and Rest :

Other :

Surabaya,
Patient/Family Nurse

(.......................) (.......................)
A. DATE ANALYSIS
Patient's Name : Tn. Hariyono
Age : 62 year
Dx.Medical : PJK Post CABG
MRS's Date : 10 February 2016
Studying Date : 10 February 2016

No Date Etiologi Problem

1. DS. Agens physical injury Pain
Patient tell “pain to left section breast.”
DO.
-Patient appear meringis
-TD :140/50 mmHg
-Artery : 120x/mnt
-RR : 33x/mnt
-Temperature : 37,3 ℃
- seted NG Tube (selang)
- appetite changing eat while in
hospital : 1 xhari don't finished
- operation wound 3cm
P= Post CABG
Q= cekot-cekot
R= breast beside left
S= 3
T= emerge while activity

2. DS Penurunan tekanan Resiko penurunan

DO. darah perfusi jaringan
TD: 80/70 mmHg
RR: 33x/menit
N:
Kesadaran: composmentis
Intake : 1000cc/hr
Output: 3600cc/hr
3 DS. Weekness Intolerance activity
Patient tell “limp to while operation
post.” DO.
- activity Pattern be assisted
other people
- Insomnia
- Pain
- Dispnea
- activity Ability always be
assisted other people
B. PRIORITY of PROBLEM (DIAGNOSIS of TREATMENT)
1. Feeling Disturbing comfort of pain b/d injury agens physical operation post
2. Risk its happen descendant of network fusioner b/d pressure descendant blood
3. Intolerance activity b/d weakness public
 C. PLANNING of TREATMENT

No Diagnosis of Aim And Criteria Intervention Constellational TTD

Treatment Result

1. acute Pain b/d After be done bring up
agens accident of treatment as long as
physical 3x24 time to be
expected the pain that
to be felt patient
lessen,with Result
Criteria :
 Patient appear
calm
 Patient tell not
pain
 pain Skala to
lessen
1. Build Connection R/ to easy it client
Mutual Believe to in to controlled the
patient behavior,to close it
body to patient
2. Study patient's skala R/ to to know as far
pain as which level pain
and to can action
mmberikan next
3. Observation of the R/to to know public
signs patient's vital condition
4. Collaboration with R/ to to controlled
medical team in or to lessen the pain
medicine giving feel
analgesic

2. Risk its happen As long as be done 1. Build Connection R/to to close it body
descendant of action of treatment mutual Believe to patient to patient
network fusioner doesn't happen 2. Study existence R/to evaluation
b/pressure d network fusioner changing of consciousness condition
descendant blood descendant, with 3. Inspeksi existence pale,
Result Criteria: sianosis. R/ to to know
a. TTV in normal limit turgor's condition
b. Input and output 4. Study sign sign vital patient
normal
c. full Consciousness 5. intake's Monitor and R/to to evaluation
output patient's breath
rhythm
R/ Untukmengetahui
body balance
liquefying
3. Intoleransi After be done bring up 1. Build connection mutual R/ to easy it client in
activity of treatment as long as believe in patient to controlled the
b/weakness d 3x24 dharapkan's time behavior,to close it
public able patient to do 2. TTV's Observation body to patient
activity stand alonely, patient
with Result Criteria: R/to to know public
a. Can to do activity 3. Give it condition
stand alonely knowledge/education to
b. TTV In Normal client R/ so that asien
Limit know limit in
activity
 D. IMPLEMENTATION of TREATMENT

Date Problem Time Implementation TTD formative Evaluation SOAPIE/

of Notes of development
Treatme
nt
14/02/20 feeling 06.30 feeling Disturbing comfort of S = patient state it still the pain
16 Disturbi
pain b/d agens cidera physical is breasted
ng
comfort 07.00 O = good public condition,
of pain
Weight accept with night shift GCS= 456, akral HKM. To
b/d
agens good public Condition, akral study patient's skala pain
cidera
08.00 HKM, spontaneous breath P= post CABG
physical
11.30 patient's Education Q= cekot-cekot
TTV's Observation : TD= R= middle breast
110/80, Artery= 60, RR= 30, S= skala 3
13.45 Temperature= 36 ̊ T= disappear emerge
Weight accept with morning Patient seen to hold his breast
while coming pain
14.00 shift
A = problem yet overcomed
conscious public Condition P = the intervention is
continued 1x24time
good, akral
1. Build Connection Mutual
15.30 HKM,spontaneous breath, Believe to patient
2. Study patient's skala pain
TTV's Observation: TD =
3. Observation of the signs
120/80, Artery =68, RR = 18, patient's vital
4. Collaboration with medical
Temperature =36 ̊C
team
Aspirin 500mg 3x1
Asetaminofen 30mg 2x1
15/02/20 Risk its 16.00 good public Condition, akral S= patient tell dizzy
16 happen
HKM, consciousness; O=taampak's patient calm
fusioner
of composmentis, A= the overcomed problem a
network
18.00 TD:80/90 part
b/pressu
re d RR:33x/minute P=the intervention is continued
descend
N:93x/minute 1. Build Connection mutual
ant
blood 20.30 Intake 1000cc/hr Believe to patient
Output 3600cc/hr 2. Study existence changing of
consciousness
3. Inspeksi existence pale,
sianosis.
4. Study sign sign vital
16/02/20 Intolera 06.00 good public Condition, DCS= 5. intake's Monitor and output
16 nce
456, Akral HKM S = patient tell pain there is no
activity
O = patient appear calm, GCS=
b/weakn 07.00 TTV's Observation : TD=
456
ess d
130/70, S= 36, N= 72, RR= A = problem yet overcomed
public
P = the intervention is
20
continued
10.00 1. Build connection mutual
believe in patient
To give it education to patient
2. TTV's Observation patient
to to limit 3. Give it knowledge/education
to patient
E. Sumatif's Evaluation

Patient's Name : Tn. Hariyono

Age : 62 year
Dx.Medical : PJK Post CABG

No Date and Time Notes of development TTD

1. 16 February 2016 S = patient tell pain there is no
O = patient appear calm, GCS= 456
A = problem yet overcomed
P = the intervention is continued
1. Build connection mutual believe in patient
2. TTV's Observation patient
3. Give it knowledge/education to patient