NASKAH RONDE KEPERAWATAN

NUM : Tiur Trihastutik., S.Kep

Primary Nurse 1 : Yohanes Pemandi Doka, S.Kep
Associate Nurse 1 : Evodia Lusia Meo Thena, S.Kep
Primary Nurse 2 : Heny Sulistiarini, S.Kep
Associate Nurse 2 : Ezra S. Sinaga, S.Kep
Doctor : Dwiko Nur Gunawan, S.Kep
Pharmacist : Simpliana Rosa , S.Kep
Nutritionist : Nindita D. Satiti, S.Kep
Patient : Liana O. Rompis, S.Kep
Patient’s family : Amanatul Firdaus, S.Kep
Documentation : Dwiko Nur Gunawan, S.Kep

NUM : Assalammualaikum wr.wb, Good morning everyone, thank you for your
attention and your time, according to the contract that we have been
agreed, today 16 November 2018 at 10.00 a.m, we will do nursing round.
Before that, I will introduce my team first, I am Tiur as the NUM, then Mr
Dwiko as the doctor, Ms. Simpliana as the pharmacy, Ms. Ninditha as the
nutritionist, Ns. Yohanes and Ns. Tiur as the primary nurse, Ns. Nina and
Ns Ezra as the associate nurse. This nursing round consists of case
presentation, continued patient validation, and back to ners station for
evaluation and recommendation. Our patient is An. F.Y,A 10 years old,
BPJS class 2 with medical diagnose Epilepsi State of epilepticus, With an
unresolved nursing problem is, Hipertermi and Mobility Impaired As for
the purpose of this round is to discuss the patient's problem to plan the
right intervention. For the next, please PN1 to explain the case or patient
problem.
PN1 : Thank you for the time given to me, and thanks to all the round teams that
have been present. Previously introduce my self my name is Yohanes as
PN in Room Bobo II, okay I will report the condition of patients in this
round, I start from the identity of patient ....
(Presentasi kasus)
This is a report of patient problems and the interventions we have done.
thank you
NUM : Well… the problems have been exposed by PN1, is there any question or
clarification? If no, then we just do the validation to the patient to match
the data with the patient problems .. lets go to room 2, to Farel’s room.. for
PN1 please prepare all the necessary medical equipment and patient status.
(the PN ask for help AN to prepare the equipments)
PN1 : Ners Nina please prepare tension and medical equipments, status and data
of the patients.
AN1 : Okay ners.
After the implementation of the nursing round at Ners Station, the round team visited
the patient's room for data validation
NUM : Good morning Mother ... how is the condition of Farel? Already getting
better?
Mawar’s family : Good morning. not yet . still cringing and crying
NUM : In accordance with the contract that we have agreed on, today there is a
nursing round. This nursing round is useful in order to solve the problem
of Farel’s situation so that his condition can improve faster. For the next
time please Ners Nina to do the assessment.

PN 2 : good morning mom, sir, Farel. What is the condition of Farel? Now How
about his temperature? Does he have a fever ?
Family : Farel…......... still have diferent temperature, sometimes he is fever dan
sometimes no.
AN 2 : Ners.. may I do the physical examination?
PN2 : yes.. of course
(AN do the physical examination)
(AN reports the data to the PN)
NUM : The examination has been completed by Mom, Mr .. after this we will
discuss it again for planning the action for Farel how to make him recover
quickly. thank you.

(Evaluation and recommendation)

NUM : Okay we have validated to the patient, and we already get the data but now
please come forward for Ns Heni to explain the Farah’s conditions from
the validation.
PN 2 : Ok.. I will explain about Farah’s condition, from the physical
examination.. we found the patient is bedridden,the eye view is empty,
GCS 3 x 5 the patient often grimaces, the temperature 37,9 0 C, he always
have siezure if the temperature is high
HR 124 times per minute.
NUM : Ok thank you Ns. Nina, now how about the doctor or counselor maybe you
can explain about the patient’s conditions and add the recommendation or
suggestion for the intervention?
(doctor or counselor explain the patients conditions )
Doctor : if the paracetamol in adequat, we must cek the blood cultur.
NUM : How about the team maybe you can add the recommendation or suggestion
for the intervention?
Pharmacist : This child complained of having high temperature so it was recomended to
administer paracetamol oral.
Nutritionist : from the start, Farel's child have seizure. Children get a child's diet and
have been replaced with diet sonde, pediasure milk recomended to farel
wit dosis 4 x 200 ml. Because he also have IMT 15kg/m2 underweight
NUM : Is there any clarification or question from PN and PA?
PN 1 : How many doses of paracetamol?
Doctor : Paracetamol 3 times a day 300 mg oral
AN 1 : then for the infusion, what is the doctor, is it still D5½ Ns 500 cc / 24
hours?
NUM : Ok.. team for the recommendation please write it in integration notes so
there is documentation and it can we do
Ok.. if its clear.. I will read back the results of the intervention and
recommendations earlier to clarify
(read the conclusion)
NUM : OK.. is there any left of recommendations?
Round team : nothing
NUM : Ok Good… please do all the interventions that have been planned and
recommended earlier each shift . If there’s any obstacles please may be
reported to me or to the relevant team ..
PN1 dan PN2 : Yes ners.
NUM : I close the round of nursing this morning, hopefully what we plan together
can be useful to solve the patient’s problems ... thank you very much for
the time and attentions ..wassalammualaikum WR Wb
Finally, the nursing round has been completed, the nurse executing the task.