I.

EVALUATION
Name : Mr.A Registration Number : 25609
Age : 53 years old Room : IRNA III
Date Time Diagnose Evaluation Initials

1
Thursday S:
30/08/2018 - The patient said the
headache was decrease
- The patient said that he’s
more relaxed

O:

- The patient looks more

relaxed
- Vital sign :
 BP: 140/80 mmHg
 T: 36,5 oC
 R: 20x/menit
 P: 78 x/menit
- The patient points to the
pain scale in number 4

A:

- The problems is partially

resolved

P:

- Continue the intervention

 2 S:
Thursday,
- The patient said that he
30/08/2018
can do activities without
any help from his family
nor nurses
- The patient said that he
can toileting by himself
without any help from
his family nor nurses.

O:

- The patient seems

capable of carrying out
activities without any
help from others.
- Muscle strength
4 4
4 4

A : The problems is solved

P : Stop the intervention

3 S:
Kamis,
- The patient said they
30/08/2018
were able to create an
adequate sleep patern 6-8
hours per day.
- The patient said that he was
 fresher because he can sleep
well.
-
- O:
- The patient seems able to
rest adequately.
- Ananemis conjunctiva.
- Vital sign :
 BP : 140/80 mmHg
 T : 36,5 ˚C
 R : 20 x/menit
 P : 78 x/menit

A : The problems is partially

resolved

P : Continue the intervention