REPORT ADULT NURSING CARE

NURSING CARE FOR Mr. J WITH PNEUMONIA IN AGAPE ROOM

KEDIRI BAPTIST HOSPITAL

Arranged by:

Celia Kristiana Putri

01.2.22.00805

STIKES RUMAH SAKIT BAPTIS KEDIRI

GRADUATE NURSING STUDY PROGRAM (CHANGE LEVEL)
ACADEMIC YEAR 2022/2023
 STIKES RS. BAPTIS KEDIRI
NURSING STUDY PROGRAM GRADUATE PROGRAM (CHANGE LEVEL)
MEDICAL SURGICAL NURSING CARE

NAME : CELIA KRISTIANA PUTRI

NIM : 01.2.22.00805
ROOM : AGAPE
DATE : December 16, 2022

1. BIODATA:
Name : Mr. J No.Reg : 010143
Age : 83 years old
Gender : Male
Religion : Christian
Adress : Semampir, Kediri City
Education : APRO
Occupation : Retired
Opname date : December 15, 2022
Assesment date : December 16, 2022
Blood Type :O
Medical Diagnosis : Pneumonia + CHD

2. CHIEFT COMPLAIN
The patient complains of cough. He said the phlegm was difficult to come out
and he also felt shortness of breath. Shortness of breath increased when the
patient cough for expel the phlegm and decreased when he was resting with
semi-fowler position.

3. PRESENT DISEASE HISTORY

The patient came to the Kediri Baptist Hospital on December 15 2022. The
patient complains he had been coughing since 2 weeks ago, the cough has been
getting worse about 3 days ago. He said the phlegm was difficult to come out
accompanied by shortness of breath. Shortness of breath also appeared but
disappeared. The patient also had a high fever since 3 days ago and oedem on
both of his legs. After being examined by the medical team, the patient was
diagnosed with pneumonia

4. PAST DISEASE HISTORY

The patient said that he had a history of Coronary Heart Disease (CHD), and
routin control to the dr.Yoseph Sp.J, and He also had cataract surgery 3 months
ago. History of drug use : Aspilet, CPG, Furosemid, ISDN, Atorvastatin,
Ibersartan, Fluimucyl.
 5. FAMILY HEALTH HISTORY
The client says that no one in his family has the same illness
Genogram :

Keterangan :
: Man

: Woman

: Marry

: Descendant

: Patient

: Dead

: Live in one house

6. PSYCHOS SOCIAL AND SPIRITUAL HISTORY

The patient says he go to Church every Sunday and believes that God will help
him, heal him from his illness. The patient also has a good relationship with his
family and close to his grandchildren.

7. PATTERNS OF DAILY ACTIVITIES (eat, rest, sleep, elimination, activity)

No Activity Daily Before Sick After Pain

Living (ADL)
1. Fulfillment of Eating and drinking Eating and drinking Amount :
nutritional and Amount : Type :
fluid needs Type : 1) Rice : 1/2 (portion)
1) Rice : 1/2 (portion) 2) Side dishes: there are
2) Side dishes: there are vegetable, low salt, and fish
vegetable, low salt, and dishes
fish dishes 3) Vegetables: yes
3) Vegetables: yes 4) Drinking: 600 cc / day
4) Drink: 600 cc / day
Abstinence:
Abstinence: There isn't any
There isn't any
Difficulty eating/drinking:
Difficulty eating/drinking: There isn't any
There isn't any
Attempts to overcome
Attempts to overcome difficulties:
difficulties: There isn't any
There isn't any

2. Elimination Pattern BAK: 4-5 x/day BAK: 5-6 x/day

Quantity: 600 cc Quantity : 1000 cc

CHAPTER: 1x/day CHAPTER: 1x/day

Consistency : dense Consistency : dense

Problems and how to solve: Problems and how to solve:

 There isn't any There isn't any

3. Sleep break pattern Afternoon: 3 hour Afternoon: 2 hours

Evening: 8 hours Evening: 8 hours

Sleep Disorders : None Sleep Disorders : None

Use of sleeping pills: Use of sleeping pills:

There isn't any There isn't any

4. Personal Hygiene 1. Bathing Frequency : 2 x/day Bathing Frequency : 2 x/day

(Personal
Hygiene) 2. Hair washing frequency : 3 x/ 2. Hair washing frequency : 3
weeks x/ weeks

3. Tooth brushing frequency : 3. Tooth brushing frequency :

2x/day 2x/day

4. Nail Condition : Clean 4. Nail Condition : Clean

5. Change clothes : every 5. Change clothes : every

shower shower

5. Other activities Routine activities : Routine activities :

Watching TV Rest in bed

Activities done in spare time : Activities done in spare time :

Play with his grandchildren Watching TV

8. PATIENT'S CONDITION/ APPEARANCE/ GENERAL IMPRESSION

The patient looks weak and tight, rest in bed with semi-fowler position, the
consciousness is composmentis, GCS 4-5-6 (15), the body feels hot and dry, gets
5 lpm oxygen nasal canul, and gets 500 cc NS infusion therapy in the right hand.

9. VITAL SIGN
Body Temperature : 38.5 ºC
Pulse : 66 x/minute
Blood Pressure : 120/70 mmHg
Breathing : 28 x/minute
SpO2 : 95%
BB / TB : 72 Kg, 155 cm
10. PHYSICAL EXAMINATION
A. Head and Neck Examination
Head: Black and white hair, no wounds or lesions on the patient's
scalp. There is no lump on the head and there is no
tenderness.
Eyes: Right and left eyes symmetrical, concave, isochoric pupils
Nose: No sores or lesions, no polyps, clean, no tenderness anosmia (-)
Mouth: Clean mouth, no stomatitis, no caries, dry lip mucosa
Ears: Symmetrical shape, no lesions, clean ears, no wax, no
lumps, no tenderness
Neck: Clean, no lesions, no enlargement of the thyroid and lymph
glands.

B. Skin and Nail Integument Examination:

Skin: clean skin, normal skin turgor, skin looks red and feels hot.
Nails: short and dirty nails, no cyanosis, CRT <2 seconds.

C. Breast and Armpit Examination (If needed):

Breast: normal, there is no lump.
Armpits: Clean, no enlarged lymph nodes.

D. Examination of the Chest / Thorax

Thorax inspection: chest movement during inspiration and expiration
symmetrical, there is hair growth
Lungs:
Inspection: symmetrical chest expansion, there is chest wall retraction, no lesions
Palpation: there is tenderness, no palpable lump
Percussion: muffled sound
Auscultation: vesikuler, there are additional sound rhonchi +/+, wheezing -/-, basal
minimum, RR : 28x/minute

E. Heart Examination:
Inspection: There is no visible enlargement of the jugular vein and the shape
of the chest is symmetrical between left and right and there is no
cyanosis.
Palpation: There is no tenderness and palpable ictus cordis on the 5th ICS mid
clavicle left, CRT < 2 seconds, and jugular venous pressure (JVP)
7 cmH2O.
Percussion: Deafening percussion sound on 4th and 5th ICS in the left mid
clavicle.
Auscultation: No additional heart sounds heard, S1 and S2 normal (lub-dub).
murmur (-), gallop (-), sound coincides with a palpable pulse on
the carotis artery.

F. Abdomen Examination:
Inspection: the shape of the abdomen is convex, no lesions
Auscultation: bowel sounds heard 10x/minute
Palpation: no abdominal tenderness, there is abdominal distension
Percussion: a tympanic sound is heard, sopel BU (+)

G. Examination of genitals and the surrounding area (if needed):

Genetically : Normal, no wounds or lesions
Anus : Normal, no wounds or lesions
 H. Musculoskeletal Examination:
5 5
5 5

Lower Extremity: oedema +/+, with pitting eodema ± 2mm

I. Neurological Examination:
Level of consciousness: Composmetis
GCS: 4-5-6
4: patient can open eyes spontaneously
5: good environmental orientation
6: patient can follow orders well

J. Examination of Mental Status: Patient is well aware, orientation to time, place

and atmosphere is good. He believes that God will help him, heal him from his
illness.

11. Medical Examination

Date : December 15,
2022

No Inspection Results Normal Value Interpretation

of Results

1. Hemoglobin 12.3 g/dL 11.6 – 16.3 Normal

WBC 16.86 4.50 – 11.30 High
HCT 38.4 40.0 – 52.0 Normal
PLT 339 139 – 335 High
GDS 188mg/dL < 200 Normal

2. Clinical chemistry
SGOT 38u/L 8 – 33 High
SGPT 62u/L 4 – 36 High
BUN 33mg/dL 7 – 22 High
Urea 70mg/dL 10 – 50 High
Creatine 2.03mg/dL 0.67 – 1.17 High
Natrium 139mmol/L 135 – 148 Normal
Kalium 4.01mmol/L 3.5 – 5.3 Normal
Ca++ 1.15mmol/L 1.13 – 1.32 Normal
Klorida (CI-) 102mmol/L 101 – 110 Normal

3. Total Protein 6.55 g/dL 6.6 – 8.7 Low

Albumin 3.75 g/dL 3.5 – 5.0 Normal
Globulin 2.80 g/dL 1.5 – 3 Normal

4. Uric Acid 13.4mg/dL 4.3 – 7.6 High

Cholesterol Total 128mg/dL <200 Normal
Cholesterol HDL 27mg/dL 45 – 60 Low
Cholesterol LDL 75mg/dL < 100 Normal
Triglycerid 135mg/dL < 150 Normal

5. Thorax Impression: Abnormal

Pneumonia
Sinistra Basal
Cardiomegali and
Aorta Sclerosis
12. Therapy:
1) Drip Levofloxacine 500mg IV / day
2) Inj. Ondansentron 8mg IV / 12 hours
3) Ambroxol 3 x 1 tab PO
4) Prorenal 3 x 2 tab PO
5) Asam Folat 2 x 1 tab PO
6) CPG 1 x 75mg PO
7) Atorvastatin 1 x 40mg PO in night
8) Sucralfat syrup3 x 10cc PO
9) Paracetamol 3 x 500mg PO
10) Allopurinol 1 x 300mg PO
11) Nabic 3 x 2 tab PO
12) Nebule farbivent 1 amp + NS 1cc + Bisolvon 2,5cc / 8 hours
13) Aspilet 1 x 1 tab PO in the night
14) ISDN 2 x 1 tab PO
15) Furosemid 1 x 1 tab PO in the morning
16) Tiaryt 1 x 200mg PO
17) Opilac 3 x 15cc PO until the patient can defecate
18) Ardium 2 x 500mg PO

13. Client / family expectations regarding the disease:

The patients hope to recover from his illness and come back home.

Kediri, December 16 2022

(Celia Kristiana Putri)

 ANALISA DATA

Name : Mr. J
Age : 83 years old
No.Reg : 010143

DATA OBYEKTIF (DO) FAKTOR YANG MASALAH

DATA SUBYEKTIF (DS) BERHUBUNGAN/RISI KEPERAWATAN
KO (E) (P)
Subjective Data: Restrained Ineffective Airway
The patient complains of cough. secretions Clearance
He said the phlegm was difficult (D.0149)
to come out and he also felt
shortness of breath.

Objective data:
 The Patient looks weak
and tight, rest in bed with
semi-fowler position,
 GCS 4-5-6 (15),
Composmentis.
 The Patient gets 5 lpm
oxygen nasal canul, and
gets 500 cc NS infusion
therapy in the right hand
 There are additional
sounds: Rhonchi +/+
 Thorax Impression:
Pneumonia Sinistra Basal
 Vital Sign:
T: 38.5 ºC
P: 66 x/minute
BP: 120/70 mmHg
RR: 28 x/minute
SpO2: 95%

Subjective data: Disease process Hypertermia

The patient said he had a high (D.00130)
fever since 3 days ago.

Objective data:
 Body temperature: 38.5 C
 The skin looks red and
feels hot
 Dry lip mucosa
 WBC : 16.86
 Thorax Impression:
Pneumonia Sinistra Basal
 LIST OF NURSING DIAGNOSES

Name : Mr. J
Age : 83 years old
No.Reg : 010143

NO THE DATE NURSING DIAGNOSIS OVERCOME STD

APPEARED (SDKI) DATE
1. December 16, Ineffective airway clearance December 17,
2022 related to retained secretions as 2022
evidenced by the patient The problem
is partially Celia
complains of cough. He said the
resolved
phlegm was difficult to come out
and he also felt shortness of
breath, the Patient looks weak
and tight, rest in bed with semi-
fowler position, GCS 4-5-6 (15),
Composmentis, the patient gets 5
lpm oxygen nasal canul, and gets
500 cc NS infusion therapy in
the right hand, there are
additional sounds: Rhonchi +/+,
Thorax Impression: Pneumonia
Sinistra Basal, Vital Sign:
 T: 38.5 ºC
 P: 66 x/minute
 BP: 120/70 mmHg
 RR: 28 x/minute
 SpO2: 95%

2. December 16, Hyperthermia associated with a December 17,

2022 disease process as evidenced by 2022
the patient said he had a high
fever since 3 days ago, body Celia
temperature: 38.5 C, the skin
looks red and feels hot, dry lip
mucosa, WBC: 16.86, Thorax
Impression: Pneumonia Sinistra
Basal
 NURSING CARE PLAN

Name : Mr. J
Age : 83 years old
No.Reg : 010143

Nursing diagnoses: Ineffective airway clearance related to retained secretions

1. SLKI : Airway Clearance Code L.01001

a. Effective Cough Defended/increased on 1/5

b. Sputum Production Defended/increased on 1/5

c. Dyspnea Defended/increased on 1/5

d. Breath Frequency Defended/increased on 2/5

e. Breath Pattern Defended/increased on 5/5

f. Nervous Defended/increased on 5/5

g. Wheezing Defended/increased on 5/5

h. Hard to talk Defended/increased on 5/5

i. Cyanosis Defended/increased on 5/5

2. SLKI : Breath Pattern Code L.01004

a. Minute ventilation Defended/increased on 4/5

b. Inspiratory pressure Defended/increased on 4/5

c. Expiratory pressure Defended/increased on 4/5

d. Breathing frequency Defended/increased on 2/5

e. Breath depth Defended/increased on 2/5

f. Defended/increased on

g. Defended/increased on

h. Defended/increased on

i. Defended/increased on
 NURSING CARE PLAN

Name : Mr. J
Age : 83 years old
No.Reg : 010143

Nursing diagnoses: Hyperthermia related to disease process

1. SLKI :Thermoregulation Code L.04034

a. Red Skin Defended/increased on 3/5

b. Pale Defended/increased on 3/5

c. Tachypnea Defended/increased on 5/5

d. Body temperature Defended/increased on 3/5

e. Skin temperature Defended/increased on 3/5

f. Blood pressure Defended/increased on 5/5

g. Shivers Defended/increased on 3/5

h. Oxygen consumption Defended/increased on 2/5

i. Hypoxia Defended/increased on 4/5

2. SLKI : Neurological Status Code L.06053

a. Seizure frequency Defended/increased on 4/5

b. Hyperthermia Defended/increased on 4/5

c. Diaphoresis Defended/increased on 4/5

d. Pale Defended/increased on 3/5

e. Sistolik blood pressure Defended/increased on 5/5

f. Pulse frequency Defended/increased on 5/5

g. Level of consciousness Defended/increased on 5/5

h. Defended/increased on

i. Defended/increased on

Name : Mr. J
Age : 83 years old
No.Reg : 010143
No. Nursing Diagnosis
1. Ineffective airway clearance
related to retained secretions as
evidenced by the patient
complains of cough. He said the
phlegm was difficult to come
out and he also felt shortness of
breath, the Patient looks weak
and tight, rest in bed with semi-
fowler position, GCS 4-5-6
(15),Composmentis, the patient
gets 5 lpm oxygen nasal canul,
and gets 500 cc NS infusion
therapy in the right hand, there
are additional sounds: Rhonchi
+/+, Thorax Impression:
Pneumonia Sinistra Basal, Vital
Sign:
 T: 38.5 ºC
 P: 66 x/minute
 BP: 120/70 mmHg
 RR: 28 x/minute
 SpO2: 95%
NURSING INTERVENTION
Goal/Outcome Interventions Rationals Sign
After nursing intervention Respiratory Monitoring (I.01014) 1. Tachypnea, shallow respirations and
for 1 x 24 hours, then 1. Monitor rate, rhythm, depth, and effort asymmetric chest movement are frequently
Respiratory Monitoring of respirations present because of the discomfort of moving
(I.01014) and Airway 2. Monitor breathing patterns the chest wall and fluid in the lung due to a Celia
Clearance (L.01001) 3. Monitor patient’s ability to cough compensatory response to airway obstruction
improved with the effectively 2. Altered breathing patterns may occur together
outcome criteria : 4. Monitor patient’s respiratory secretions with accessory muscles to increase chest
1. Sputum production 5. Auscultate breath sounds excursion to facilitate effective breathing.
decreased 6. Monitor oxygen saturation, x-ray 3. Coughing is the most effective way to remove
2. Dyauspnea decreased thoraks, and BGA secretions.
3. Breath sounds (mengi, 4. Pneumonia may cause thick and tenacious
wheezing, ronchi) Airway Manajement (I.01011) secretions in patients.
decreased. 7. Position patient to maximize ventilation 5. Crackles, rhonchi, and wheezes are heard on
4. Breathing rate potential (Semi Fowler / Fowler) inspiration, expiration due to fluid
improves 8. Instruct how to cough effectively accumulation, thick secretions, and airway
5. Breathing pattern 9. Give oxygen, as appropriate spasms and obstruction.
improves 10. Maintain adequate hydration by forcing 6. Follows progress and effects and extent of
fluids to at least 3000 mL/day unless pneumonia. A therapeutic regimen may
contraindicated (e.g., heart failure). facilitate necessary alterations in therapy.
11. Collaboration for therapy treatments : Oxygen saturation should be maintained at
bronchodilators, expectorants, 90% or greater. Imbalances in PaCO2 and
mucolitic as needed. PaO2 may indicate respiratory fatigue.
7. Doing so would lower the diaphragm and
promote chest expansion, aeration of lung
segments, mobilization, and expectoration of
secretions.
8. Coughing is the most effective way to remove
secretions.

2. Hyperthermia associated with
a disease process as evidenced
by the patient said he had a high
fever since 3 days ago, body
temperature: 38.5 C, the skin
looks red and feels hot, dry lip
mucosa, WBC: 16.86, Thorax
Impression: Pneumonia Sinistra
Basal
9. These measures are needed to correct the
hypoxemia
10. Fluids, especially warm liquids, aid in the
mobilization and expectoration of secretions.
Fluids help maintain hydration and increase
ciliary action to remove secretions and reduce
viscosity. Thinner secretions are easier to
cough out.
11. Mucolitic increase or liquefy respiratory
secretions, expectorants increase productive
cough to clear the airways by liquefying
lower respiratory tract secretions and
reducing their viscosity, bronchodilators are
medications used to facilitate respiration by
dilating the airways.
After nursing intervention Management of Hyperthermia (I.15506) 1. To determine the body temperature of the
for 1 x 24 hours, then 1. Monitor body temperature patient
Management of 2. Identification of the cause of the 2. To find out what causes the problem of
Hyperthermia (I.15506) hyperthermia (eg, dehydration, hyperthermia
improved with the exposure to hot environments, use of 3. To prevent dehydration in patients Celia
outcome criteria: incubators) 4. To prevent complications of hyperthermia
1. The skin is no 3. Monitor electrolyte levels 5. To reduce excessive sweating
longer reddish 4. Monitor complications due to 6. Avoid dehydration in patients
2. Decreased pallor hyperthermia 7. To improve the cleanliness of the patient
of the skin 5. Loosen or undress environment
3. Absence of 6. Give oral fluids 8. To reduce humidity that causes hypothermia
tachypnea 7. Change linen daily or more frequently 9. To increase the patient's oxygenation
4. Body if you have hyperhidrosis (excessive requirements
temperature sweating) 10. To reduce excessive sweating
normalizes 8. Apply external cooling (eg, 11. To meet the patient's hydration needs and
5. Skin temperature hypothermic blankets or cold
balance fluids in the patient's body
normalizes compresses to forehead, neck, chest,
abdomen, axillae).
9. Give oxygen, if necessary
10. Suggest bed rest
11. Collaborative administration of
intravenous fluids and electrolytes
 IMPLEMENTATION

Name : Mr. J
Age : 83 years old
No.Reg : 010143

NO NO.DX DATE/HOUR NURSING IMPLEMENTATIONS SIGN

1. DX I 16/12/2022
08.00 1. Observing patient’s Vital Sign
Result:
S : 38,5 ºC,
N : 66 x/minute,
RR : 28 x/minute
BP : 120/70mmHg Celia
08.15 2. Monitoring rate, rhythm, depth, and
effort of respirations
Result: RR: 28 x/minute, saturation of
oxygen 95% with nasal canul 5lpm,
there is chest wall retraction.
08.25 3. Monitoring breathing patterns
Result : dypsnea
08.30 4. Do Auscultation breath sounds
Result: additional breath sounds rhonchi
+/+, wheezing -/-
10.00 5. Collaborate with the doctors in therapy
Result: giving nebulizer with farbivent
1 amp + NS 1cc + Bisolvon 2,5cc/ 8
hours
10.05 6. Help the patient for semi fowler
position to maximize ventilation
Result : The patient rest in bed with
semi-fowler position and doing
nebulizer
10.10 7. Provide education on how to cough
effectively and giving clapping
Result : phlegm + yellow color
10.35 8. Giving the patient O2 nasal canul at 5lpm
11.30 Result : SpO2 : 97%
9. Observing patient’s Vital Sign
Result:
S : 38 ºC,
N : 70 x/minute,
RR : 26 x/minute,
BP : 120/80 mmHg

2. DX II 16/12/22
08.00 1. Monitoring body temperature every 4
hours with termometer
Result: 38.5 ºC
09.00 2. Identification of the cause of the
hyperthermia Celia
Result: WBC 16.86, Thorax Impression:
Pneumonia Sinistra Basal
09.15 3. Monitoring electrolyte levels
Result: normal
Natrium : 139mmol/L
Kalium : 4.01mmol/L
Ca++ : 1.15mmol/L
 Klorida (CI-) : 102mmol/L
10.00 4. Reduce excessive heat
Result: The patient wear clothes from
hospital and just wear thin blankets
10.15 5. Applying warm compresses to the
forehead, neck, chest, abdomen and
axillae.
Result : The patient looks relax
10.30 6. Collaborate with the doctors in therapy
Results: Giving paracetamol 500mg, and
infusion of NS 500 cc/24 hours
11.00 7. Change linen because the patient has
hyperhidrosis (excessive sweating) then
suggest the patient to bed rest and drink
enough
Result: The patient drink water
600cc/day because the complication
(CHD)
11.25 8. Giving the patient O2 nasal canul at 5lpm
11.30 9. Observing patient’s Vital Sign
Result:
S : 38 ºC,
N : 70 x/minute,
RR : 26 x/minute,
BP : 120/80 mmHg
 IMPLEMENTATION

Name : Mr. J
Age : 83 years old
No.Reg : 010143

NO NO.DX DATE/HOUR NURSING IMPLEMENTATIONS SIGN

1. DX I 17/12/22
08.00 1. Observing patient’s Vital Sign
Result:
S : 37,2 ºC, Celia
N : 72 x/minute,
RR : 24 x/minute
BP : 110/80mmHg
08.10 2. Monitoring rate, rhythm, depth, and
effort of respirations
Result: RR: 24 x/minute, saturation of
oxygen 99% with nasal canul 5lpm,
there is no chest wall retraction.
08.15 3. Monitoring breathing patterns
Result : normal
08.20 4. Do Auscultation breath sounds
Result: additional breath sounds rhonchi
is minimum +/+, wheezing -/-
10.00 5. Collaborate with internal doctors in
therapy
Result: giving nebulizer with farbivent
1 amp + NS 1cc + Bisolvon 2,5cc/ 8
hours
10.10 6. Help the patient for semi fowler
position to maximize ventilation
Result : The patient rest in bed with
semi-fowler position and doing
nebulizer
10.15 7. Monitoring patient’s respiratory
secretions and giving clapping
Result : phlegm + yellow color
10.40 8. Monitoring patient’s ability to cough
effectively
Result : The patient can do effective
cough technique independently.
10.45 9. Giving the patient O2 nasal canul at 5lpm
11.45 Result : SpO2 98%
10. Observing patient’s Vital Sign
Result:
S : 37 ºC,
N : 68 x/minute,
RR : 22 x/minute,
BP : 120/90 mmHg

2. DX II 17/12/22
08.00 1. Monitoring body temperature every 4
hours with termometer
Result: 37,2 ºC
08.10 2. Reduce excessive heat Celia
Result: The patient wear clothes from
hospital and just wear thin blankets
10.00 3. Collaborate with the doctors in therapy
Results: Giving paracetamol 500mg, and
 infusion of NS 500 cc/24 hours
11.00 4. Change linen because the patient has
hyperhidrosis (excessive sweating) then
suggest the patient to bed rest and drink
enough
Result: The patient drink water
600cc/day because the complication
(CHD)
11.25 5. Giving the patient O2 nasal canul at 5lpm
11.30 6. Observing patient’s Vital Sign
Result:
S : 37 ºC,
N : 68 x/minute,
RR : 22 x/minute,
BP : 120/90 mmHg
 EVALUATION

Name : Mr. J
Age : 83 years old
No.Reg : 010143

NO NO. DATE/ NURSING EVALUATION SIGN

DX HOUR
1. DX I 16/12/22 S : The Patient complains that he still cough
14.00 and the phlegm difficult to come out

O : The Patient looks dyspnea, rest in bed

with semi-fowler position, GCS 4-5-6 Celia
(15), additional breath sounds rhonchi
+/+, wheezing -/-, yellow phlegm (+)
Vital Sign :
S : 38 ºC,
N : 70 x/minute,
RR : 26 x/minute,
BP : 120/80 mmHg
SpO2 : 97% with O2 nasal canul 5lpm
there is chest wall retraction

A : The problem of ineffective airway

clearance is partially resolved

P : Intervention is continued :
number 1-11

2. DX II 16/12/22 S : The Patient complains that he still has

14.00 fever and his body feels weak

O : The Patient looks dyspnea, rest in bed

with semi-fowler position, GCS 4-5-6 Celia
(15), the skin looks red and feels hot,
moist lip mucosa
Vital Sign :
S : 38 ºC,
N : 70 x/minute,
RR : 26 x/minute,
BP : 120/80 mmHg
SpO2 : 97% with O2 nasal canul 5lpm

A : The problem of hypertemia is

partially resolved

P : Intervention is continued :
number 1-11
 EVALUATION

Name : Mr. J
Age : 83 years old
No.Reg : 010143

NO NO. DX DATE/HOUR NURSING EVALUATION SIGN

1. DX I 17/12/22 S : The Patient says the cough and

14.00 shortness of breath have decreased
after nebulizer and
Celia
O : The Patient looks dyspnea, rest in bed
with semi-fowler position, GCS 4-5-6
(15), additional breath sounds
minimum rhonchi +/+, wheezing -/-,
yellow phlegm (+)
The Patient can do effective cough
technique independently
Vital Sign :
S : 37 ºC,
N : 68 x/minute,
RR : 22 x/minute,
BP : 120/90 mmHg
SpO2 : 98% with O2 nasal canul
5lpm
there is no chest wall retraction

A : The problem of ineffective airway

clearance is partially resolved

P : Intervention is continued :
number 1-11

2. DX II 17/12/22 S : The Patient says that his body has no

14.00 fever

O : The Patient looks relax, rest in bed Celia

with semi-fowler position, GCS 4-5-6
(15), the skin looks and feels normal,
moist lip mucosa
Vital Sign :
S : 37 ºC,
N : 68 x/minute,
RR : 22 x/minute,
BP : 120/90 mmHg
SpO2 : 98% with O2 nasal canul
5lpm

A : The problem of hypertemia is

resolved

P : Intervention was stopped