Name : Devi Sintia Dewi Br S

NIM : 01.2.17.00597
Undergraduate Nursing Program of Study
S1 Tingkat IV
Individual Course Assignment “English II”
Make Implementations and Evaluation based on nursing diagnoses below!
Individual Course Assignment
Diagnose 1 : Hipervolemia
No. Time Implementation & Patient Response Sign
1. 9th October 2020 Checking Vital sign
07.15 am RR : 36,5 C N : 90 beats/minute Ns. M
P : 24 beats/minute TD : 110/70 mmHg

09.00 am check for signs and symptoms of hypervolemia Ns. M

result: the patient had edema and dyspnea

11.00 am monitors fluid intake and output Ns. M

result : intake :1800 cc , output : 1300cc
11.30.am Infusion rate monitor Ns. M
Result: Fluid intake
12.30 – 13.30 am Limit fluid intake Ns. M
Result: Liquid balance
No. Time Implementation & Patient Response Sign
th
1. 10 October 2020 Checking Vital sign
16.05 am RR : 37,3 C N : 96 beats/minute Ns. M
P : 23 beats/minute TD : 120/70 mmHg

16.45 am Check for signs and symptoms of hypervolemia Ns. M

result: Edema and dyspnea appear to be reduced

19.00 pm Monitors fluid intake and output Ns. M

result : intake :1500 cc , output : 1000cc
19.30.pm Infusion rate monitor Ns. M
Result: Fluid intake
20.30-21.00 pm Limit fluid intake Ns. M
Result: Liquid balance
Evaluation :

Collaborative
Date / Time Development Notes Sign
nursing problems
Hipervolemia 9th October S : The patient said she still felt swelling and dyspnea Ns. M
2020 O : 1. Swelling
14.00 WIB 2. RR : 36,5 C N : 90 beats/minute
P : 24 beats/minute TD : 110/70 mmHg
3. There is increased chest wall retraction
A : Nursing problem have not been resolved
P : The intervention was continued
1. Checking vital sign
2. Check for signs and symptoms of hypervolemia
3. Monitors fluid intake and output
4. Infusion rate monitor
5. Limit fluid intake
Evaluation :

Collaborative
Date / Time Development Notes Sign
nursing problems
Hipervolemia 10th October S : The patient said swelling and dyspnea has decreased Ns. M
2020 O : 1. Swelling decreased
21.00 WIB 2. RR : 37,3 C N : 96 beats/minute
P : 23 beats/minute TD : 120/70 mmHg
A : Nursing problem resolved
P : The intervention was stopped
Diagnose 2 Impaired skin integrity
No. Time Implementation & Patient Respon Sign
1. October Checking Mrs B body temperature Ns. R
9th, 2020 S : 37 C
8.00 am P : 24 beats/minute
N : 86 beats/minute
TD : 130/80 mmhg
Look at the causes of skin integrity disorders:
redness and abration skin, uremic frost skin 

10.00 am Change position every 2 hours if bed rest Ns. R

R /: the patient looks comfortable
10.30 am Encourage patients to increase nutritional intake Ns. R
R /: consume fruits and vegetables
11.20 am Collaboration with nutritionists to pay attention to the nutrition Ns. R
of patients with 4 healthy 5 perfect
2. October Identify the causes of impaired skin integrity Ns. R
10th, 2020 Itchy skin
8.00 am
09.00 am Use petroleum / oil based products on dry skin Ns. R
Use products made from mild / natural and hypoallergic on
sensitive skin
skin becomes moist
10.00 am Recommend using a moisturizer (eg, lotion, serum) Ns. R
The patient's skin becomes moist
Evaluation
Collaborative
Date /
nursing Development Notes Sign
Time
problems
Impaired skin 9th S : He said that he feels itchy in his skin and can’t Ns. R
integrity October stop scratching all over his body
2020 O : redness and abration skin, uremic frost skin
14.00 WIB A : Impaired skin integrity partly resolved
P : The intervention was continued
1. Checking vital sign
2. Change position every 2 hours if bed rest
3. Identify the causes of impaired skin
integrity
4. Recommend using a moisturizer (eg,
lotion, serum)
Impaired skin 10th S : The patient said that her ithcy has increased Ns. R
integrity October O : 1. Don’t Seem redness and abration in her skin
2020 1. RR : 36,7 C N : 92
14.00 WIB beats/minute
P : 22 beats/minute TD : 110/80
mmHg
A : The problem is resolved
P : The intervention was stopped
Diagnose 3
Implementation: Impaired Gas Exchange (D.0003) Wednesday, 9th October 2020
Time Implemntation & Patien Response Sign.
09.00-09.15 am - Identify the effect of changing Ns. D
position on respiratory status
- Identify the weakness of the breath
aids muscles
R /: The patient feels dyspnea,
cyanosis, Vital Signs: BP: 110/70
mmHg, HR: 95 bpm, T: 36.5 C, RR:
26 x / minute, irregular breathing
patterns, nasal breathing, additional
muscle breathing, lung wheezing
sound
10.00-10.15 am - Give the patient the semi-Fowler Ns. D
position
- Facilitates changing positions as
comfortable as possible
- Provide oxygenation as needed
R /: The patient is still a bit dyspnea,
there is still additional breath sounds
effectively
10.20-10.50 am - Teaches deep breath relaxation Ns. D
techniques
R /: The patient understands and
practices deep breath relaxation
techniques
11.00 - Collaborating with doctors in Ns. D
administering bronchodilators
Evaluation: Impaired Gas Exchange (D.0003) Wednesday, 9th October 2020
Time EVALUATION
12.00 am S: He said that he feels dyspnea
O:
- cyanosis,
- Vital Signs: BP: 110/70 mmHg, HR: 95 bpm, T: 36.5 C,
RR: 26 x / minute
- irregular breathing patterns, nasal breathing
- lung wheezing sound

A: Impaired gas exchange problem has not been resolved

P: The intervention was continued
- Identify the weakness of the breath aids muscles
- Provide oxygenation as needed
- Give the patient the semi-Fowler position
- Teaches deep breath relaxation techniques

Implementation: Impaired Gas Exchange (D.0003) Wednesday, 10th October 2020

Time Implemntation & Patien Response Sign.
09.00-09.15 am - Identify the weakness of the breath Ns. D
aids muscles
R /: The patient feels dyspnea,
cyanosis, Vital Signs: BP: 110/70
mmHg, HR: 90 bpm, T: 36.9 C, RR:
24 x / minute, irregular breathing
patterns, nasal breathing, additional
muscle breathing, lung wheezing
sound
10.00-10.15 am - Provide oxygenation as needed Ns. D
R /: The patient is still a bit dyspnea,
there is still additional breath sounds
effectively
- Give the patient the semi-Fowler
position
10.20-10.50 am - Teaches deep breath relaxation Ns. D
 techniques
R /: The patient understands and
practices deep breath relaxation
techniques

Evaluation: Impaired Gas Exchange (D.0003) Wednesday, 10th October 2020

Time EVALUATION
12.00 am S: The patient is still a bit dyspnea, there is still additional breath
sounds effectively

O:
- The patient feels dyspnea, cyanosis,
- Vital Signs: BP: 110/70 mmHg, HR: 90 bpm, T: 36.9 C,
RR: 24 x / minute,
- lung wheezing sound

A: The problem of interrupted gas exchange is partially resolved

P: The intervention was continued
- Identify the weakness of the breath aids muscles
- Provide oxygenation as needed
- Give the patient the semi-Fowler position
- Teaches deep breath relaxation techniques