N Day/Date Time Dx Evaluations

o
4 Monday, 12.45 pm IV S: Clients mother said that on
January the client mouth there are
12nd 2015 many oral ulceration.
O: There are oral ulceration on
the client mouth.
A: Problem impaired tissue
integrity was not solved yet.
P: Continue Intervention
1. Assess the clients mouth
2. Assess wide and deppuness
of condition of the oral
ulceration.
3. Give oral care
4. Suggest client to always
keep oral care.
5. Collaboration to give the
drugs.

5 Monday, 12.45 pm V S: -
January O: - There are many pathice on
12nd 2015 clients skin.
- Trombosit : 18
- Hb : 6.0
- Leucocyte : 0.8
A: Risk for bleeding was not
happen.
P: Continue Intervention
1. Monitor clients vital sign.
2. Monitor blood examination
3. Avoid factor that can make
bleeding
4. Suggest client do daily
activity carefully
 5. Collaboration to laboratory
to check examination
regularly
6 Monday, 01.00 pm VI S: -
January O: Hb : 6.0
12nd 2015 Trombocyte : 18
Leucocyte : 0.8
A: Risk For Infection was not
happen.
P: Continued Intervention
1. Monitor client Vital Sign
2. Help client to do personal
Hygiene
3. Teach client family to do
oral care
4. Give client high calcium
and protein food
5. Collaboration

PROGRESS NOTE

No Day/Date Time Dx Implementation Evaluation

1 Tuesday, 02.30 I 1. Assessing scale of S: Client said that the
January 13rd pm the pain. pain was decrease.
P: Increase of
2015 O: client looked can sit
kidney acid.
Q: Stubbing Pain on the bad and
R: Right, left,
drawing boon.
upper abdomen
S: A: Acute pain problem
was solved partly.
Hurt even P: Continued
more.
Intervention
- Moderate.
T: Sometime and
Suddenly.
 2. Providing semi
fowler position.
- Client looked
comfort with
the position
3. Observing Vital
Sign.
P: 90 bites/minutes
R: 22
times/minutes
T: 37.1oC

4. Doing distraction
technique.
- The pain was
decrease
5. Collaborating to
giving Ranitine.
- Client said that
the pain was
decrease.

2 Tuesday, 02.35 II 1. Assessing dietary S: clients mother said

January 13rd pm intake. that client refuse to
- Client get
2015 eat, if she it, she just
forage as
ate food.
dietary.
O: BW: 18 kg
2. Measuring clients
BH : 135 cm
BW
-BW :18 kg CDC 2000 : 31 Kg
3. Collaboration with
A: Imbalance Nutrition
nutrition.
less then body
- Filled gradually
requirement not
per day
- Callory : 600 solved yet.
 kkal P: Continued
- Fluid : 800
Intervention
ml/kg
- Protein : 7.2 g

3 Tuesday, 02.40 III 1. Checking vital sign S: Client mother said

January 13rd pm before and after that client weak and
2015 doing activiy. just lie down on the
- P:90
bed.
98x/minute
O: client looked weak
- R: 22 32x/
and lie down on the
minute
- T: 37.1 bad.
37.1oC A: Activity intolerance
2. Assessing scale
was not solved yet.
activity.
P: Continued
- Activity scale 2
Intervention
(help by other).
3. Assessing scale
muscle.
- 4444 4444
4444 4444
4. Suggesting to
badrest regularly
- Client looked
bedrest
everyday.
4 Tuesday, 02.45 IV 1. Assessing the S: client said on her
January 13rd pm clients mouth. mouth many oral
- There were
2015 ulcuration.
many oral
O: oral ulcuration was
ulcuration on
still on the clients
the mouth.
mouth.
2. Giving oral care.
- Client said that A: Impaired tissue
feel fress and integrity problem
comport. was not solved yet.
 3. Suggesting client P: continued
to always keep oral Intervention
care. 1. Assess the
- Clients family
clients mouth
doing oral care 2. Assess wide and
to client. deppuness of
4. Collaboration to
condition of the
give the drugs.
oral ulceration.
-
3. Give oral care
4. Suggest client to
always keep oral
care.
5. Collaboration to
give the drugs.

5 Tuesday, 02.50 V 1. Monitoring clients S: -

January 13rd pm vital sign. O: - Trombosit : 18
- P: 90x/ minute
2015 - Hb : 6.0
- R: 22x/minute
- Leucocyte : 0.8
- 37,1oC
2. Monitoring blood A: Risk for bleeding
examination was not happen.
- Hb : 6.0
P: Continue
- Leucocyte :0.8
- Trombocyte : Intervention
18 1. Monitor clients
3. Suggesting client
vital sign.
do daily activity 2. Monitor blood
carefully. examination
- Scale activity 2 3. Avoid factor that
(help by other) can make
4. Avoiding factor
bleeding
that can make 4. Suggest client do
bleeding. daily activity
- Client looked
carefully
just lie down on 5. Collaboration to
 the bad. laboratory to
check
examination
regularly

6 Tuesday, 02.55 VI 1. Monitoring client S: -

January 13rd pm Vital Sign. O: Hb : 6.0
- P: 90x/ minute
2015 Trombocyte : 18
- R: 22x/minute
- 37,1oC Leucocyte : 0.8
2. Helping client to
A: Risk For Infection
do personal
was not
Hygiene.
happen.
- Client take oral
P: Continued
care and wiping
Intervention
and change her
1. Monitor client
clotes.
3. Giving client high Vital Sign
2. Help client to
calcium and
do personal
protein food.
- Client get Hygiene
3. Teach client
forece, fish,
family to do
fruid and
oral care
vegetables.
4. Give client high
calcium and
protein food
5. Collaboration

7 Wednesday, 02.40 I 1. Assessing scale of S: Client said that the

January 14th pm the pain. pain was decrease.
P: Increase of
2015 O: client looked can sit
kidney acid.
Q: Stubbing Pain And drawing again.
R: Right, left,
A: Acute pain problem
upper abdomen
S: was solved partly.
 P: Continued
Hurt little Intervention
more.
- Moderate.
T: Sometime

2. Providing semi
fowler position.
- Client looked
comfort
3. Observing Vital
Sign.
P: 98 bites/minutes
R: 24
times/minutes
T: 37.3oC

4. Collaborating to
giving Ranitine.
- Client said that
the pain was
decrease.

8 Wednesday, 02.45 II 1. Assessing dietary S: clients mother said

January 14th pm intake. that client ate half of
- Client get
2015 food.
forage as menu
O: BW: 18,4 kg
2. Measuring clients
BH : 135 cm
BW
-BW :18 kg CDC 2000 : 31 Kg
3. Collaboration with
Client looked half of
nutrition.
food.
- Filled gradually
A: Imbalance Nutrition
per day
- Callory : 600 less then body
kkal requirement not
- Fluid : 800
solved yet.
 ml/kg P: Continued
- Protein : 7.2 g
Intervention
9 Wednesday, 02.50 III 1. Checking vital sign S: Client mother said
January 14th pm before and after that client weak.
2015 doing activiy. O: client looked weak
- P:90
and lie down on the
100x/minute
bad.
- R: 24 32x/
A: Activity intolerance
minute
- T: 37.3 was not solved yet.
37.0oC P: Continued
2. Assessing scale
Intervention
activity.
- Activity scale 2
(help by other).
3. Assessing scale
muscle.
- 4444 4444
4444 4444
4. Suggesting to
badrest regularly
- Client looked
bedrest
10 Wednesday, 02.55 IV 1. Assessing the S: client said that oral
January 14th pm clients mouth. Ulcuration was
- The oral
2015 Decrease.
ulcuration still
O: oral ulcuration
was decrease.
looked decease little
2. Giving oral care.
- Client said that bit.
feel fress A: Impaired tissue
3. Suggesting client
integrity problem
to always keep oral
was solved partl.
care.
P: continued
- Client always
Intervention
keep and oral
 ulcuration was 1. Assess the
decrease. clients mouth
4. Collaboration to 2. Assess wide and
give the drugs. deppuness of
-
condition of the
oral ulceration.
3. Give oral care
4. Suggest client to
always keep oral
care.
5. Collaboration to
give the drugs.

11 Wednesday, 03.00 V 1. Monitoring clients S: -

January 14th pm vital sign. O: - Trombosit : 18
- P: 98x/ minute
2015 - Hb : 6.0
- R: 24x/minute
- Leucocyte : 0.8
- T: 37,3oC
2. Monitoring A: Risk for bleeding
blood was not happen.
examination P: Continue
- Hb : 7.2
Intervention
- Leucocyte :1.5
- Trombocyte : 1. Monitor clients
29 vital sign.
3. Suggesting client 2. Monitor blood
do daily activity examination
3. Avoid factor that
carefully.
- Client activity can make
always helping bleeding
4. Suggest client do
by her mother
daily activity
in father.
carefully
5. Collaboration to
laboratory to
check
 examination
regularly

12 Wednesday, 03.05 VI 1. Monitoring client S: -

January 14th pm Vital Sign. O: Hb : 6.0
- P: 98x/ minute
2015 Trombocyte : 18
- R: 24x/minute
- 37,3oC Leucocyte : 0.8
2. Helping client to
A: Risk For Infection
do personal
was not happen.
Hygiene.
P: Continued
- Client said feel
Intervention
clean, fress and
1. Monitor client
comfort after
Vital Sign
doing personal
2. Help client to
hygiene.
do personal
3. Giving client high
Hygiene
calcium and
3. Teach client
protein food.
family to do
- Client ate half
oral care
the food
4. Give client high
calcium and
protein food
5. Collaboration

13 Thrusday, 09.00 I 1. Assessing scale of S: Client said that the

January 15th pm the pain. pain was decrease.
P: Increase of
2015 O: client looked
kidney acid.
Q: Stubbing Pain playing game on
R: Right, left,
her gadget with
upper abdomen
S: fowler position.
A: Acute pain
Hurt little bit. was solved partly.
- Mild.
P: Continued
 T: Sometime and Intervention
Suddenly.

2. Providing semi
fowler position.
- Clients pain
was decrease.
3. Observing Vital
Sign.
P: 90 bites/minutes
R:24 times/minutes
T: 37.1oC

4. Collaborating to
giving Ranitine.
- Clients pain was
decrease.
14 Thrusday, 09.05 II 1. Assessing dietary S: clients appetite was
January 15th pm intake. little bit increase.
- Client get rice,
2015 O: BW: 19 kg
fish, fruid and
BH : 135 cm
vegetable as
CDC 2000 : 31 Kg
menu
A: Imbalance Nutrition
2. Measuring clients
less then body
BW
-BW :19 kg requirement was not
3. Collaboration with
solved yet.
nutrition.
P: Continued
- Callory : 600
Intervention
kkal
- Fluid : 800
ml/kg
- Protein : 7.2 g

15 Thrusday, 09.10 III 1. Checking vital sign S: Client mother said

January 15th pm before and after that client start to
2015 doing activiy. walking to urinate.
 - P:90 O: client looked sit and
100x/minute stand up to take
- R: 24 28x/
fruid.
minute
A: Activity intolerance
- T: 37.1
was not solved yet.
37.1oC
2. Assessing scale P: Continued
activity. Intervention
- Activity scale 2
(help by other).
3. Assessing scale
muscle.
- 4444 4444
4444 4444
4. Suggesting to
badrest regularly
- Client looked
bedrest and
sometime
walking to
take
something.
16 Thrusday, 09.15 IV 1. Assessing the S: clients mother said
January 15th pm clients mouth. that the oral
- The oral
2015 ulcuration was
ulcuration was
decrease.
decrease.
O: oral ulcuration
2. Giving oral care.
- Client said feel looked decrease.
fress and clean. A: Impaired tissue
3. Suggesting client
integrity problem
to always keep oral
was solved partly.
care.
P: continued
4. Client always keep
Intervention
oral ulcuration and
1. Assess the
was decrease.
 5. Collaboration to clients mouth
2. Assess wide and
give spred the
deppuness of
drugs.
- condition of the
oral ulceration.
3. Give oral care
4. Suggest client to
always keep oral
care.
5. Collaboration to
give the drugs.

17 Thrusday, 09.15 V 1. Monitoring clients S: -

January 15th pm vital sign. O: - Trombosit : 18
- P: 90x/ minute
2015 - Hb : 6.0
- R: 24x/minute
- Leucocyte : 0.8
- 37,1oC
2. Monitoring blood A: Risk for bleeding
examination was not happen.
- Hb : 9.0
P: Continue
- Leucocyte :3.8
- Trombocyte : Intervention
120 1. Monitor clients
3. Suggesting client
vital sign.
do daily activity 2. Monitor blood
carefully. examination
- Scale activity 3. Avoid factor that
always doing by can make
her mother bleeding
4. Suggest client do
daily activity
carefully
5. Collaboration to
laboratory to
check
examination
 regularly

18 Thrusday, 09.20 VI 1. Monitoring client S: -

January 15th pm Vital Sign. O: Hb : 6.0
- P: 90x/ minute
2015 Trombocyte : 18
- R: 24x/minute
- 37,1oC Leucocyte : 0.8
2. Helping client to
A: Risk For Infection
do personal
was not
Hygiene.
happen.
- Client said feel
P: Continued
clean after doing
Intervention
personal
1. Monitor client
hygiene.
3. Giving client high Vital Sign
2. Help client to
calcium and
do personal
protein food.
- Client can ate Hygiene
3. Teach client
often to ate
family to do
oral care
4. Give client high
calcium and
protein food
5. Collaboration

19 Friday, 08.00 I 1. Assessing scale of S: Client said that the

january 16th pm the pain. pain was decrease
- Client said that
2015 with scale pain.
her abdomen
pain was
reduce.
O: client looked more
2. Providing semi
coordinate with
fowler position.
- Client looked other people and she
comfort in semi can drawing with
 fowler position sitting position.
3. Observing Vital
A: Acute pain
Sign.
was solved.
P: 96 bites/minutes
R:26times/minutes P: Continued
T: 36.9oC
is stopped
4. Collaborating to
giving Ranitine.
- Client said that
pain was
decrease.
20 Friday, 08.05 II 1. Assessing dietary S: clients father said
january 16th pm intake. that the client ate
- Client get rice as
2015 rice half of food and
a menu that
she ate other food
given by
like cracker.
hospital.
O: BW: 19.5 kg
2. Measuring clients
BH : 135 cm
BW
-BW :19 kg CDC 2000 : 31 Kg
3. Collaboration with
Client looked ate
nutrition.
food and cracker.
- Callory : 600
A: Imbalance Nutrition
kkal
- Fluid : 800 less then body
ml/kg requirement was not
- Protein : 7.2 g
solved yet.
P: Continued
Intervention
21 Friday, 08.10 III 1. Checking vital S: Clients family said
january 16th pm sign before and that client still
2015 after doing weak.
activiy. O: client still looked
- P:96
weak and justlie
100x/minute
down and
 - R: 26 30x/ sometimes with
minute semifowler position.
- T:36.9
A: Activity intolerance
o
37.1 C
was not solved yet.
2. Assessing scale
P: Continued
activity.
- Activity scale 2 Intervention
(help by other).
3. Assessing scale
muscle.
- 4444 4444
4444 4444
4. Suggesting to
badrest regularly
- Client looked
bedrest with
semifowler
position
22 Friday, 08.15 IV 1. Assessing the S: client said
january 16th pm clients mouth. that oral
- Oral ulculation
2015 ulcuration was
was decrease and
decrease and just
clients lips
got on the side of
looked moist.
lips.
2. Giving oral care.
- Clients mother O: oral ulcuration
help client to looked decrease and
keep and doing clients lips looked
aoral care. moist.
3. Suggesting client
A: Impaired tissue
to always keep oral
integrity problem
care.
was solved.
- Client keep
P: Intervention is
cleaning of her
Stopped
mouth and her
oral ulculation
 was decrease.
4. Collaboration to
give spred the
drugs.
-

23 Friday, 08.20 V 1. Monitoring clients S: -

january 16th pm vital sign. O: - Trombosit : 18
- P: 96x/ minute
2015 - Hb : 6.0
- R: 26x/minute
- Leucocyte : 0.8
- 36.9oC
2. Monitoring blood A: Risk for bleeding
examination was not happen.
- Hb : 10
P: Continue
- Leucocyte :4.0
- Trombocyte : Intervention
139 1. Monitor clients
3. Suggesting client
vital sign.
do daily activity 2. Monitor blood
carefully. examination
- Scale activity are 3. Avoid factor that
doing and can make
helping by her bleeding
4. Suggest client do
family.
- Activity scale are daily activity
2 (help by other). carefully
5. Collaboration to
laboratory to
check
examination
regularly

24 Friday, 08.25 VI 1. Monitoring client S: -

january 16th pm Vital Sign. O: Hb : 6.0
- P: 96x/ minute
2015 Trombocyte : 18
- R: 26x/minute
- 36.9oC Leucocyte : 0.8
 2. Helping client to A: Risk For Infection
do personal was not
Hygiene. happen.
- Client said feel
P: Continued
comfort after her
Intervention
mother wiped
1. Monitor client
her body
Vital Sign
hygiene. 2. Help client to
3. Giving client high
do personal
calcium and
Hygiene
protein food. 3. Teach client
- Client can ate
family to do
often to aet and
oral care
eat regularly 4. Give client high
calcium and
protein food
5. Collaboration

25 Saturday, 08.30 II 1. Assessing dietary S: clients mother said

January 17th pm intake. that client ate the
- Client get rice,
2015 food that prepare by
fish, fruid, and
vegetable as hospital.
menu.
O: BW: 20 kg
2. Measuring clients
BH : 135 cm
BW
-BW :20 kg CDC 2000 : 31 Kg
3. Collaboration with
Clients body weigh
nutrition.
was increse.
- Callory : 600
A: Imbalance Nutrition
kkal
- Fluid : 800 less then body
ml/kg requirement was
- Protein : 7.2 g
solved partly.
P: Continued
Intervention
26 Saturday, 08.35 III 1. Checking vital sign S: Clients family said
January 17th pm before and after that the client like to
2015 doing activiy. drawing.
- P:90
O: client looked weak
98x/minute
and when drawing
- R: 24 30x/
her hand still weak.
minute
- T: 37.1oC A: Activity intolerance
2. Assessing scale
was not solved yet.
activity.
P: Continued
- Activity scale 2
Intervention
(help by other).
3. Assessing scale
muscle.

-4444 4444
4444 4444
4. Suggesting to
badrest regularly
- Client looked
bedrest and
drawing on the
bed.
27 Saturday, 08.40 V 1. Monitoring clients S: -
January 17th pm vital sign. O: - Trombosit : 18
- P: 90x/ minute
2015 - Hb : 6.0
- R: 24x/minute
- Leucocyte : 0.8
- 37.1OC
2. Monitoring blood A: Risk for bleeding
examination was not happen.
- Hb : 11
P: Continue
- Leucocyte :4.00
- Trombocyte : Intervention
145 1. Monitor clients
3. Suggesting client
vital sign.
do daily activity 2. Monitor blood
carefully. examination
- Client activity 3. Avoid factor that
 are helping by can make
her parent bleeding
4. Suggest client do
daily activity
carefully
5. Collaboration to
laboratory to
check
examination
regularly.
28 Saturday, 08.50 VI 1. Monitoring client S: -
January 17th pm Vital Sign. O: Hb : 6.0
- P: 90x/ minute
2015 Trombocyte : 18
- R: 24x/minute
- 37.1oC Leucocyte : 0.8
2. Helping client to
T: 37.1oC
do personal
A: Risk For Infection
Hygiene.
was not
- Client ask to her
happen.
mother to wipe
P: Continued
her body.
3. Giving client high Intervention
calcium and 1. Monitor client
protein food. Vital Sign
- Client ate often 2. Help client to
and regularly do personal
Hygiene
3. Teach client
family to do
oral care
4. Give client high
calcium and
protein food
5. Collaboration
Neuromuscular system

Other neurologic status is the levelof awareness of both qualitative and

quantitative studied a a reference in more intensive handling of patients, because
these factors may be a clue the damage (Vincent, 2005).

When damage to the frontal lobe in studying is the possibility of something, a

memory or higher intelectual functions. Cognitive impairement is the limited
lever of patients attention to something, it is difficult to understand something,
quickly forgotten, and lack of motivation. While psychological problems
characterized by lability, lability, frustation and lack of co-operative attitude.

Both laboratory investigation ECG and other vital because to determine the extent
of organ function impaired (Tjokronegoro & Henderson, 2002) and (Black &
Hawk, 2005).

Description of muscle strength:

5: Muscle contracts again full resistance

4: Strength reduced, but the contractions still able to move the joint against
resistance.

3: Strength further reduced but that joint can be moved only against gravity with
examiners resistance completely removed.

2: Muscle can only move if resistance of gravity is removed

1: Only a trace or flicker of movement is seen or left, or fasciculation are
observed.

0: No movement( totally paralysis)

Cardiovascular:

Physical examinatione of heart needs to be done because it is aims to obtain data

on the effectiveness of the heart pumps, the volume and filling pressure, cardiac
output, and cardiac compensatory mechanisms and blood vessles (Smeltzer &
Bare, 2005).

In this case there are signs and symptoms related to cardiovascular system which
changed. In physical examination there was no heart enlargement, heart sound is
single S1 and S2 regular, gallops (-), nuts (-), percussion dullness. Blood pressure
mmHg, Pulse 92 X/m regular, Temperature: 37,4 celcius, CRT >3 seconds.
Hematology laboratory results on January 10th, 2015; Hb: 6.0g/dl, Ht: 18.6%,
eritrocytes: 2.32milion/Ul, Leucocytes: 0.8/Ul, platelets: 18milion/Ul, MCV:
80.2g/dl, MCH: 25.8g/dl, MCHC: 32.2g/dl, Gran: 41.7%, Lymphocytes: 48.7%,
Lymphocyte #: 0.36 milion/Ul.