Name:Sukma Asri

NIM :P07120216027
Class :DIV Keperawatan 5A
Daily report
Nursing documentataion

Date(dd/mm/yy) ward/room:internal disease room/melati 1

22 may 2018 Code status:12345xxx
I.Personal detail
Patient identity Next of kin identity
Surname:Mrs.A Surname: mr.A
Date of birth:Yogyakarta,1st june 1992 Age:30 th
Age:27 years old Sex:male
Sex: female Addres:yogyakarta
Religion:moslem Relathionship with the patient: husband
Addres:yogyakarta Phone number:082345678xx
Ocupation:teacher
Civil state:married
Phone number:081215888xxx
Name of GP:dr.mikha

II.Medical information
Chief complain:
fever,muscle pain,headache,vomit since 5 days ago
Sign and symptoms:nose bleed, decreased apetite and petekie
Allergy:-
Medication:oral medicine paracetamol
Past history:-
Last meal:yesterday at 4 pm eating meatballs
Event leading: fever,muscle pain,headache,vomit since 5 days ago and nose bleed,decreased
apetite,petekie
Vital sign:
BP:90/60 mmhg
PULSE:80 x/mnt
RR:20 x/mnt
BODY TEMPERATURE:39 C
Doctor’s diagnostic: dengue hemorrogic fever
Comment/recomendation: checking blood and give a medicine ranitidin and paracetamol

Medication history:
Name Dosage/frequency Purpose
Ranitidin Iv 8x50 mg lessen the nauseous and vomit
Paracetamol Oral 4x120mg decrease the fever
RL Iv 20 tetes/mnt substitute the body fluids

III.Care Plan
N Identity Time Diagnose and Nursing Plan that Plan that
O patient patient’s condition problem have been have not
done done yet
1. Mrs.a Mornin Diagnose: dengue Pain, 1.monitor 1.complete
Yogyakarta, g shift hemorrogic fever Hiperterm TTV blood check
1 st june 22 may General condition i, 2.relaxatio 2.collaborati
1992, 2018 :good Fluid n and on with
27 years 07 am ,composmentis deficit distraction nutritionists
old, Complaint: patient 3.warm
dr.mikha stilll fever ,still feel comoress
muscle pain 4.give
,vomit2x,headache paracetam
scale 5,nosebleeding ol Oral
,petekie and 4x120mg
decreased apetite. 5.injection
Vital sign: ranitidin
BP:90/60 mmhg Iv 8x50
PULSE:80 x/mnt mg
RR:20 x/mnt
BODY
TEMPERATURE:3
9C

2. Mrs.a afternoo Diagnose : dengue pain, 1.monitor 1.monitor

Yogyakarta, n hemorrogic fever Hiperterm TTV nutrition
1 st june Shift General condition i, 2.relaxatio status
1992, 22 may :good, Fluid n and dan 2.monitor
27 years 2018 composmentis deficit distraction degree of hb
old, 14 pm Complaint : patient 3. warm and ht
dr.mikha still feel muscle comoress 3.give
pain,vomit 1 x, 4.complete paracetamol
headache scale 4, blood Oral
the nose unbleeding check is 4x120mg
and The meal is not done 4.injection
finished ranitidin Iv
Vital sign: 8x50 mg
BP:90/60 mmhg 5. consulted
PULSE:82 x/mnt to the
RR:20 x/mnt nutritionsist
BODY
TEMPERATURE:3
9,2 C
 Trombosit :
112000/mm

3. Mrs.a evening Diagnose : dengue pain , 1.has been 1.give the

Yogyakarta, Shift hemorrogic fever Hiperterm consulted information
1 st june 22 may General condition i to the to still
1992, 2018 :good nutritionsi bedrest
27 years 7 pm ,composmentis st 2.monitor
old, Complaint :patient TTV
dr.mikha still fever , still feel 3.relaxation
muscle pain,not and
vomit,headache distraction
scale 3 and nose 4. warm
unbleeding comoress
Vital sign: 5.give
BP:100/60 mmhg paracetamol
PULSE:84 x/mnt 4x120mg
RR:20 x/mnt 6.injection
BODY ranitidin Iv
TEMPERATURE:3 8x50 mg
8C