EVALUATION

Name No.Reg Space Diagnosis : Mrs. N : 1428202 : Anggrek : Gastritis

No 1

Date 20th November 2011 04:00 am

Note The Development S : Patient said that left abdominal pain for 2 days O : - Scale pain 6 from scale ranges 1 to 10 - T: 110/80 mmHg - N: 90 x / minute - S: 36oC - Rr: 24 x/ minute A: The problem of abdominal pain and inadequate nutrition partially resolved, that is: - Pain was reduced - Patient want to eat even though 2-3 tablespoons P: Plan continued - Give a warm compress on the abdomen field - Invite patient to talk so the pain disappeared shortly S: Patient said that the pain still felt and not reduced O: - The state of general weakness - Scale pain 6 A: The problem of abdominal pain is has not been resolved, that is: Scale pain still 6 from scale ranges 1 to 10 P: Plan continued - Give a warm compress on the abdomen field - Collaboration with the medical team in giving analgesic drugs S: Patient said that abdominal pain had decreased O: - The state of general weakness - Scale pain 5 A: The problem of abdominal pain is partially resolved, that is: Scale pain 5 P: Plan continued Give a warm compress on the abdomen field S: - The patient said that the pain still remains - Patient said that decreased appetite and didnt vomiting after eating - Patient said that her weight still 54 kg O: - The state of general weakness

09:00 am

14:00 pm

19:00 pm

21th November 2011 01:00 am

- weight before illness 55 kg, weight when sick 54 kg - The mucosa of the mouth and lips are dry A: The problem of abdominal pain and inadequate nutrition partially resolved, that is: - Scale pain 5 - The patient didnt vomit after eating P: Plan continued - Give a warm compress on the abdomen field - Give an interesting and warm food - Give food to fit and does not stimulate S: Patient said that the pain more intense O: - The state of general weakness - Scale pain 6 A: The problem of abdominal pain and inadequate nutrition has not been resolved, that is: Scale pain 6 from scale ranges 1 to 10 P: Plan continued Give a warm compress on the abdomen field S : Patient said that abdominal pain had decreased O: - The state of general weakness - Patients can relax A: The problem of abdominal pain partially resolved, that is: Scale pain 4 P: Plan continued Give a warm compress on the abdomen field S: - Patient said there was no change of abdominal pain - Patient said that appetite was improved and vomit was reduced - Patient said that her weight still 54 kg O: - The state of general weakness - Scale pain 4 - Eating out servings - Weight before illness 55 kg, weight when sick 54 kg - The mucosa of the mouth are dry A: The problem of abdominal pain and inadequate nutrition partially resolved,that is: - Improved appetite - The patient didnt vomit after eating - Abdominal pain was reduced P: Plan continued - Give a warm compress on the abdomen field - Give an interesting food and warm - Give food to fit and does not stimulate S: Patients said that the pain become better O: The state of general weakness A: The problem of abdominal pain partially resolved,that is:

06:00 am

11:00 am

16:00 pm

21:00 pm

Scale pain 3 P: Plan continued Give a warm compress on the abdomen field S : Patient said that the pain disappeared and appetite abnormal O: - General condition is quite - T: 120/80 mmHg - S: 36oC - N: 82 x / minute - Eating out 2/3 servings A: The problem of abdominal pain is resolved, that is: - Scale pain 0 - Patient can relax and rest in peace P: Plan continued Observation of nutrient intake S: - Patient said that appetite was not stable - The patient said that her weight still 54 kg O: - General condition is quite - T: 120/80 mmHg - S: 36oC - N: 82 x / minute - Eating out 2/3 servings - Weight before illness 55 kg, weight when sick 54 kg - The mucosa of the mouth and lips are dry A: The problem of inadequate nutrition partially resolved,that is:, Patient doesnt vomit after eating P: Plan continued - Give an interesting food and warm - Give food to fit and does not stimulate S: - Patient said that the pain has not incurred - Patient said that appetite had improved - Patient said that the body was fresh O: - General condition was good - T: 120/80 mmHg - S: 36oC - N: 84 x / minute A: The problem of abdominal pain and inadequate nutrition was resolved, that is: - Pain has not incurred - Vomiting disappeared - Eating out P: Plan terminated Patient was be permitted to go home

22 th November 2011 02:00 am

07:00 am