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1.

SAMPOOING

A.Definition
Hair is part of the body that has the function of protection and temperature control.
Indications of changes in the health status of self can also be seen from the hair easy to fall
off as a result ofmalnutrition. Hair washing is to remove the dirt on the hair and scalp by
using soap or shampoo then rinse with clean water untilclean.

B.Purpose
1. Provide senan da fresh feeling to clients / patients

2. Stimulate blood peredara under the scalp

3. Hair kept clean neat and terpelihar

4. Clean lice and dandruff

C. Indications

1. if the client's hair dirty

2. In patients who will undergo surgery

3. Routinely five times a day, if the patient's condition allows

4. Once installed hood ticks

D. Preparation tool

1. Two comb
2. Two towels
3. One fruit washcloth
4. Net gloves
5. Cotton and place
6. Soap or shampoo
7. Alas (towel / perlak)
8. Gutter
9. Kom small (magkok) and the gauze in place 2-3 pieces
10. Crooked lisol contains a solution of 2-3%
11. Net gloves
E. Procedure execution

1. Bring the device to the front of the patient

2. Describe the purpose and procedure that will be done

3. Wash your hands

4. Wear apron

5. Wear gloves

6. Adjust the position of Tidus patients as comfortable as possible with the head near the

head side of the bed

7. Install perlak and towels under the patient's head

8. Place the bucket in the mop pad on the floor, under the patient's head

9. Put the bucket in the mop pad on the floor under the patient's head

10. Install gutters and navigate to the empty bucket

11. Close the outer ear canal with cotton and cover the patient's eyes with a washcloth

12. Close the chest with a towel to the neck

13. Comb the hair then flush with warm water using the scoop

14. Rub the base of the hair with gauze that has been given shampoo kemudin sequence

with a fingertip. dirty gauze throw into crooked

15. Rinse hair thoroughly and then dry with a dry towel

16. Lift the lid ear with eyes

17. Lift tlang, input into the bucket and put a towel in the tray

18. Return the patient in the position seula by lifting the head and base and
meletakaannya on the pillow

19. Comb the hair back with a comb patient clean and let dry or dry with a hair dryer and

comb to tidy.

20. Trim the patient

21. Remove gloves and input into bebgkok

22. Remove the apron and input into the empty bucket

23. Organize and clean the tool

24. Return the tool to the same place

25. Wash your hands

26. Document actions

2. INJECTION

A. Stage PraInteraksi
1. To verify the data before when there
2. Wash hands
3. Setting up the medicine correctly
4. Placing the tool near the client correctly
B. Orientation Phase
1. Provide regards as a therapeutic approach
2. Describe the purpose and procedure of action on the family / client
3. Asking the client's readiness before the activities carried out
C. Work Phase
1. Adjust the position of the client, in accordance injection site
2. Install perlak and bases
3. Freeing the area to be injected
4. Wearing gloves
5. Determining the correct injection site (palpation of the injection area for the presence
of edema, mass, tenderness. Avoid the area of scarring, bruising, abrasion or infection)
6. Clean the skin with an alcohol swab (circular from the inside to the outside diameter
5cm)
7. Using the thumb and forefinger for skin mereganggkan
8. Insert the syringe at a 90 degree angle, the needle enters 2/3
9. aspirations and make sure blood does not enter the syringe
10. Entering the drug slowly (rate of 0.1 cc / sec)
11. Repeal of a needle pricking
12. Pressing the puncture area with disinfectant cotton
13. Throw away the syringe into crooked

D. Phase Termination
1. Evaluate the action
2. contract for the next activity
3. to Leave with clients
4. Clearing tools
5. Washing hands
6. Take note of the activities in the nursing record sheet.

3. ORAL CARE

How to oral hygiene care in patients with a decreased level of consciousness


According to Perry (2005), while the oral hygiene care in patients with a decreased level of
consciousness, as follows:

A. Equipment
1. Fresh water
2. a tongue blade with pads or sponges
3. face towels, paper towels
4. small Kom
5. Crooked
6. glass with cold water
7. Spuit air-small bulb
8. The catheter is connected to a vacuum suction
9. Disposable gloves
10. Tweezers
11. Depper
B. Procedures action
1. Make sure the program a doctor if necessary particulars
2. Make sure the patient's identity
3. If possible, explain the procedure and grounds be taken to the patient's family
4. Bring tools
5. Wash hands and use gloves
6. Test the gag reflex by placing a tongue blade on the back of the tongue (patients
with impaired swallowing reflex require special treatment)
7. Inspection of the oral cavity
8. Position the client closer to the side of the bed, behind the patient's head toward the
mat, if necessary blamed suction machine and connect the hose to the suction
catheter.
9. Place a towel under the patient's face and bent under the chin.
10. Carefully stretch the patient's upper and lower teeth with a tongue blade b
inserting the barrel spatula quickly but gently, between the rear molars. Enter
when the patient relaxes. (Do not force).
11. Clean the patient's mouth using a tongue blade moistened with fresh water. Sip
as needed during cleaning. Clean the surface and the inner surface of the first
penguyah. Clean the roof of the mouth and the inside of the cheeks and lips. Rub
the tongue but avoidcausing vomiting reflex if any. Dampen a clean applicator
with water and rub the mouth to wash.
12. suction secretions when it accumulates.
13. Explain to the family that the action has been completed.
14. Remove the gloves.
15. Return the patient in a comfortable position.
16. Clean the equipment and return it to its place.
17. Document the procedure and the patient's condition
18. Check the back when needed.
4. ENEMA
A. Phase Pre-Interaction:

1. Check the maintenance records and review of medical records of patients.2.


2. Assess the needs of the patient.
3. Exploration and falidasi feelings of patients.

B. Phase Orientation:
1. Greet and call the patient by name.
2. Explain to the patient the action to be performed.
3. Give the client a chance to ask.
4. Ask the complaints and review specific symptoms in patients, post sampiran.

C. Implementation Phase:

1. Wash hands.
2. Set the room, close the windows and doors, use sampiran if the patient is in a general
ward or room door closed when the patient is in a special room.
3. Adjust the position of the patient with sim position tilted to the right.
4. Place the gluteal pengalas below.
5. Irigator warm liquid filled in accordance with the temperature of the body and
connect the intestine cannula, then check the flow by opening the cannula and bent to
remove water and give jelly on the tip of the cannula.
6. Use gloves.
7. Insert the cannula into the rectum toward the ascending colon approximately 15-20
cm while the patient is asked a deep breath and hold irigator as high as 30 cm from
the bed and open the clamp so that the water flow in the patient's rectum to indicate a
desire to defecate.
8. Instruct the patient to hold briefly when would defecate and install a bedpan or
suggest to the toilet. If the patient is unable to toilet, wash thoroughly with water and
pat dry with paper towels.
9. Open the glove.
E. Phase Termination:
1. Ask the patient feeling after the action.
2. Conclude the procedure performed.
3. Trim the equipment and hand washing.
TUGAS

NURSING III

NAMA : I WAYAN HENDRA WIJAYA

NIM : 14.321.2102

SEKOLAH TINGGI ILMU KESEHATAN WIRAMEDIKA

PPNI BALI