NURSING CARE PLAN FOR PATIENT WITH DIARHEA IN

MELATI ROOM PELNI HOSPITAL JAKARTA

Nama : Putri Budy Utami

Nirm : (15046)

AKADEMI KEPERAWATAN PELNI JAKARTA

Jl.AIPDA K.S. Tubun 92-94 Jakarta 11410
Telp (021)548 0608 psw 1313/1314
fax Akper PELNI (021)548 5709 E-mail :akper.pelni@gmail.com
Website :http://www.akper-rsPELNI.ac.id
 CHAPTER III
CASE REVIEW

A. Nursing Assesment

1. Client Identity

My Client’s name is Mr. R. He is 55 years old . He is not married. He is a

Moslem. He is a Javanese. His last education is senior highschool. He
lives at Jl. H soleh 1 Rt 009/ Rw 006, Kebon Jeruk, West Jakarta. He
speaks in Indonesian language. He entered Pelni hospital,in Melati room
on 13 september 2016. His registration number is 653241. His medical
diagnosis is Diarhea. His Financial source is from BPJS. Personal
information is from hisself and his family.

2. Resume

My Client’s name is Mr R. She is 55 years old. At night on 22 Mei 2017,

he came with his daughter to Emergency room of Pelni’s Hospital. he is
feel a breathless. He is got a cough for 1 month ago. Her vital signs is
Blood Pressure : 130/90 mmHg, Respiration Rate : 26x/minute,
Temperature : 380c, and Pulse : 85x/minute. She’s condition is compos
mentis. The medical diagnosis is Tuberculosis of lungs. She is got
medicine Rifampisin, Ethambutol, and Streptomisin. She is got oxygen
kanul nasal 2 liters. She is got inhalation therapy with bisolvon 10 drops.
Give her a semi fowler position for reduce shortness of breath.
Observation of vital sign if there is a change. She is moved to Cempaka
Dewasa room at 02:00 am.