1.

DATA ANALYSIS
Name Px : Tn. AH
Age : 62 tahun
Medical Dx : CVA Infark + PJK + Illeum perforasi
No. RM : 345600

NO. DATA (Symptom) CAUSE (Etiologi) PROBLEM (Problem)

1. DS : Px say “fatigue, 1. Put nutrient 1. The risk of

nausea and vomiting” inadequate changes in
nutrition lack of
2. DO : Lack of demand
- Vital sign: information about
a. Temperature: 37OC food
b. Nadi : 86x/mnt
c. Blood pressure:
140/90mmHg
d. Frequency of breath : Intake of food intake
28x/menit less
- level Consciousness:
composmentis
-Px Experienced dysuria Lack of nutrients
- Pupil Px looked isokor
(pupils equal)

2. PRIORITY ISSUE
 Nausea and vomiting

Nursing diagnose :
1. The risk of changes in nutrition lack of demand related to
nutrient inputs are inadequate.
 3. PLANNING

NO Nursing Objectives and Results Intervensi

diagnoses Criteria
1. The risk of After nursing actions during 1. Record of
changes in 2x24 hours reduced the complaints of nausea
nutrition lack of expected complaints / vomiting, anorexia
demand b / d of 2. Advise the client to
nutrient inputs are KH. modify diir (posi eat
inadequate  The patient did not look little by little tp
weak and nausea reduced often)
 Curiosity vomiting 3. Plan diit
reduced arrangements with
 Px want to eat clients engage and
 k / u stable nutrition (calorie
 intake increases needs, varied menu)
 observation TTV within 4. Monitor the client's
normal limits 1. Record nutritional intake
of complaints of nausea / 5. Observation TTV
vomiting, anorexia
 4. IMPLEMENTASI

Tgl/Jam Implementasi Diagnose TTD

21-02-2016 Diagnosis 1
13.45 Weigh received by agencies morning

15.30 Px coming from poly muah neurological

complaints, diarrhea and vomiting.
16.30 Assessing new px on behalf of Mr. Aryono
Haryato. initial anamnesis

16.40 observing Vital Sign

Tension: 140/90 mmHg RR: 28 x / minute
Nadi: 86 x / min S: 37  C

16.45 Notes the complaints of nausea / vomiting,

anorexia.

19.30 Giving intravenous fluid therapy Asering -

14tpm.

19.45 Participate in a blood sample to check DL px,

SE, Albumin

20.00 Advise the client to modify diir (posi eat little

by little but often)
Px satisfied for interrogation tomorrow
Endoskepi already in puasakan started at 17:00

21-02-2016 Diagnosis 1
21.00 Weigh received the official lunch

21.30 Planning a diet arrangement involving clients

and nutrition (calorie needs, varied menu)

22.10 Helping ADL'S Px urinary elimination

24.00 Giving injection therapy Alinamir Px 1,

kelmeco 1x1
24.10 Provide oxygenation nasal ....

05.00 Observation TTV

BP: 100/60 mmHg S: 36 ° C
N: 80x / min RR: 20 x / min
Monitor the client's nutritional intake

23-02-2016 Diagnosis 1
 07.00 Weigh received the night shift
Advise the client to modify diir (posi eat little
by little but often)

07.30 GDA 80g / dl

Consul in medicine

08.00 Provide therapy cepsi, prosta

Inform the patient to fast

10.00 TTV observations:

TD; 180/70 ......

5. EVALUATION FORMATIVE

Tgl/jam Evaluasi TTD

3-2-2016 S : Px said “Px saying "they felt weak and wanted to vomit"
20.00 O : Px looked limp and needed help for her ADL
TD: 80/70mmHg S: 36ºC N: 84x/mnt
RR: 22x/mnt
A : Nausea and vomiting
P : Intervention 1,2,3,4 and 5 continued

4-2-2016 S : Px said “a sense of weakness reduced but did not vomit"

05.00 O : Px looked limp
TD: 100/80mmHg S: 37ºC N: 92x/mnt
RR: 20x/mnt
A : The issue is resolved in part
P : Intervention 1,2,3,4 and 5 continued
 4-2-2016 S : Px saying "it did not limp and no nausea or vomiting"
12.00 O : Px looks better than ever
A : The problem is resolved
P : Intervention 1,2,3,4,5 completed

SUMMATIVE EVALUATION

Tgl/Jam Nursing Problem Evaluation TTD

03-02-2016 The risk of changes in S : Px saying "still

nutrition lack of demand          feels limp and wanted
b / d of nutrient inputs
        gag "
are inadequate.
O : Px looked limp and need
help for his ADL
TD: 80/70mmHg S: 36ºC
N: 84x/mnt
RR: 22x/mnt
A : Nausea and vomiting

P : Intervention 1,2,3,4 dan 5

continued

The risk of changes in S : The risk of changes in

nutrition lack of demand nutrition lack of demand
b / d of nutrient inputs
b / d of nutrient inputs are
04-02-2016 are inadequate.
inadequate.
O : Px looks better than
       Previous
A : The problem is resolved
P : Intervention 1,2,3,4,5
completed