Name : Mega Veronika / Class : IIB / St. # : 30.01.12.0032 / Patients Illness : Hepatitis

Five Phase Points Description / Elaboration

Assessment Phase1. The patients identifications2. General condition of the patient3. Medical data : subjective and objective

1. Patients identificationsName : Mrs. MAge : 59 years oldSeks : FemaleMarital status : MarriedNumberof children : 7Religion : IslamicOccupation : SalesmanHome address : Srikatun Street

2. General conditionThe patient looksmedium sick, layingweak and installedinfusion AS 15 dropsperminute in her lefthand

3. Medical data : SD : patients say, she

felt pain in the abdomenand her body was limp.

OD :- The patient looks

laying weak- The patient looks

uncomfortable- The vital sign :

- BP : 110/80 mmhg- T : 36,5o C-RR : 18 x/ minute-P : 80x/minute

Diagnosing Phase 1. The results of the medical checkup2. The most problem of the patient 1. The results of the medical checkup : Hepatitis 2. The most problem of the patient : Pain in abdomen

Intervention / Planning Phase

1. The preparation of the medicaltreatment

2. The medicine that will be given3. The goal of each planning item based

on the diagnose

1. The preparation of the medical treatment- monitoring the scale and location of pain- Observe vital sign- Give warm compresses in abdomen feel pain- Teach relaxation techniques- Involve the family in meeting the needs of patients- collaboration with medical team for drug therapy

2. The medicinethat will be given- Lesichol 3x/dayforHepatitis- Lasic 2X/ dayforpain inabdomen

3. The goal of each planningitem based on the diagnose:The long term goal- The pain DisappearShort-term goals-Condition patients improved-The pain inpatients diminish

Implementing Phase 1. The time schedule of the treatment2. The treatment given each day

1. The time schedule of the treatment- 08.00 a.m- 08.30 a.m- 08.50 a.m- 10.30 a.m- 11.00 a.m- 12.00 a.m- 12.30 a.m

2. The treatment given each day- look general condition of the patient- give eat to the patient- give oral medicineto the patient- measure the vital sign patient- give warm compresses- advise the patient to rest- observe of the general condition of the patient

Evaluating Phase

1. S = Subjective data after theintervention

2. O = Objective data after theintervention

3. A = Last Assessment4. P = Planning ( before patient leave )

S = The patient said the pain diminishedO = - The patient looks bed rest in bed

- Patient looks relax in bed- The vital sign : BP : 110/80 mmHg

T : 37o CRR : 22x/ minuteP : 80x/ minute

A = Pain is still feltP = Intervention 1-6 to be continued