Kelompok 1

Kelompok 1Admiting Patient

Rofi Sekar Achida UtamaShultonAchmad SuhailiM. GufronFrengkyCollecting DataNameAgeSexReligionJobAddressNo. RegistrationRoomDx. medicalDate of entryDate of assessment

Vital SignsBody Temperature Pulse Breathing Blood pressureCheck LABPhotos chestUltrasound Abdomen & Gynecology OrganEye examination by an ophthalmologistPulmonary function tests (spirometry)ECG and TreadmillPhysical Examination for DoctorsContinue & Consulting MCU ResultsAssesmentGrouping of data divided into 2: Objective data is data that can be observed and measured. Ex: objective data: respiratory rate, blood pressure, edema and weight gain no nitty - nitty tan.2. Subjective the data is in getting data from the client as an opinion on the situation and events. Such information can not be independently determined by the nurse, but through an interaction or communication Ex: an explanation of the client's pain, weakness, frustration, nauseaDiagnosisStep - step determines the diagnosis:Classification and analysis of dataInterpretation of the dataValidation of dataNursing diagnosis FormulationPlanning for PatientsEvaluation of readiness to return. Factors studied were as follows:Respiratory status is stablePut adequate nutrition and growingNeeds a stable drugMedical treatment plan that is realistic for the homeImplementation

After planning the author refers to the implementation phase. At this stage the authors implement nursing care in accordance with the plans that have been prepared beforehand.

EvaluationFrom the diagnosis results obtained turned out to be a gap between theory and practice, this can be seen from the comparison between the diagnosis and the diagnosis of existing theories in the field.DocumentationNursing documentation is defined as everything that is written or printed as a reliable record of the evidence for authorized individuals.

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