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LABORATORY SCHEDULE

No Day Time Activity Lecturer

1. Monday 10.00-11.40 Learning about how to inject, Mr. Damon


NGT (Naso Gastric Tube), Wicaksi
Catheter, Infusion.

2. Tuesday 11.00-12.40 Learning about Manegement of Mr. Rismawan


Patients Saveness Adi

3. Wednesday 08.00-09.40 Learning about how to NGT Mr. Dafid


(Naso Gastric Tube).

4. Thursday 09.00-10.40 Learning about how to Chateter. Mrs Yuana

5. Friday 13.00-14.40 Learning about how to Mrs. Leni


oxygenation

6. Saturday 07.00-08.40 Learning about how to Bathe the Mr. Rismawan


Patient
COMPREHENSIVE NURSING ASSESMET

Resident Name: M Samsul Arifin

Nim : 16037140947

Allergies : Nausea and vomiting, high heat, and reduced appetite

Diagnoses: Typhoid Fever

1. NUTRITION
Diet: Purred
Recent weight changes: Yes
Supplements: Yes
Conditions affecting eating, chewing, or swallowing: No
Monitoring required at mealtimes: No
Fluids Monitoring: Yes Restricted
Mocous membranes: Moist
Skin turgor: Fair
Coment:
Food is better cooked until tender and served at temperatures that are neither too hot
nor cold so as not to stimulate the imposition
Better food is provided often but in small portions
When given for long periods or in special circumstances, it should be accompanied
by vitamin and mineral supplements, or formula foods.

2. ELIMINATION
Bladder Incotinence : Occasional (less than daily)
Bowel Incotinence: Occasional (less than daily)
Incotinence management techniques: Yes
Bowel sounds present: Yes
Constipation: Yes
Ostomies:
Coment: Elimination of alvi. Clients may experience constipation due to prolonged
bed rest. While urine elimination is not disturbed, only the color of urine into brownish
yellow. Clients with typhoid fever occur an increase in body temperature resulting in a
lot of sweat out and feel thirsty, so it can increase the body fluids.

3. SENSORY
Vision: Normal
Hearing: Normal
4. MUSCULOSKELETAL
Mobility: Normal Assistive Devices: No
ROM: Limited
Motor Development: Tremor
ADLS:
Eating: S, Bathing: S, Dressing: S

5. SKIN
Rash
Skin Intact: Yes
Special Care or Monitoring: Yes

6. NEURO
Sensation: Intact
Pain: Daily
Vebal Response: Confused
Aphasia: Expressive
Memory Deficits: No
Impaired Desision-making:
Sleep Aids: No
Sleep Pattern: Sleep not well
Seizures: No

7. CIRCULATION
History:
Pulse: Regular
Skin: Pink
Edema: Yes Pitting: Yes

8. RESPIRATION
Respirations: Irregular
Breath Sound: Right (clear), Left: (clear)
Shortness of Breath:
Respiratory Treatments: None

9. DENTAL
Own Teeth
Dental Hygiene: Good
10. PSYCHOSOCIAL
Self Injurious Behavior: No
Agressive Behavior: No
Behavior: Calm
Answer Question: Slowly
Delusions and/or Hallucination: No

11. MEDICATION & TREATMENTS


Has a 3-way check (orders,medications, and MAR) been conducted for all of the
residents medications and treatments, including OTCs and PRNs?: Yes
Were any discrepancies identified?: Yes
Are medications stored aproriately?: Yes
Has the caregiver been instructed on monitoring the effectiveness of drug therapy,drug
reactions,side effects,and how and when to report problems that may occur?: Yes
Are vital signs required related to a medications or diagnosis?: Yes
Is lab monitoring required related to a medication or diagnosis
(hypoglycemic,anticoagulant,psychotropic,seizure,etc.)?: No
Have arrangements been made to obtain these labs?: Yes

12. HIGH RISK MEDICATIONS


Is the resident taking any high risk drugs?: No
Has the caregiver received instruction on special preacutions for all high risk
medications (such as hypoglycemic,anticoagulants,etc.) and how when to report
problems that may occur?: Yes

13. SAFETY NEEDS


Is the environment safe for the resident?: No