V.

EVALUATION
Name: Mrs. K No. RM : 682112
Age : 51 years Room : Gili Gede

DATE HOUR DX EVALUATION PARAF

23/04/2020 09.30 1 S : The patient still feels dizzy
O : - the patient seems to be doing small
activities such as walking but is
helped by his family
-TD : 110/90 mmhg
- crt<2 seconds
- warm akral
A : the problem is not resolved
P : continued intervention
1. Assess the patients conditoin
2. Advise the patient to keep on
mobilizing
3. Keep chekhing blood sugar

23/04/2020 10.00 2

S : patient says his wound smells

O : - there is edema

- there is a diabetic ulcer on the heel

 of the left foot
- there is redness around the wound
- the patient looks grimacing in pain
- necrosis around the wound
- there is a mixed pussy blood
A : the problem is not resolved
P : intervention continues
1.Treat wounds properly
2.Collaboration of insulin
medication
3.Monitoring vital sign
4.Give the current elevation
position the patient is resting
23/04/2020 10.35 3 S : the patient said there was still pain
in the wound on the heel of the left
foot
P : the patient says that he feels pain
during activity and even though
he is not active
Q : the patient said the pain was
stabbing
R : the patient said pain in the wound
on the left leg on the heel

T : pain comes and goes

O : - necrosis around the wound
- S : pain scale 2 (0-10)
- the patient looks grimace pain
when moving his legs

- Vital sign
 TD : 110/90 mmHg

N : 80x/menit
RR : 20X/menit

S : 36,1oC

A : the problem is not resolved

P : intervation is continued
1. Study the cause of pain
2. Encourage keep doing deep breath
relaxation moments pain arises
3. Collaboration of during
administrasion analgesic
4. Monitoring vital sign