ENGLISH NURSING ASSIGNMENTS

DISUSUN OLEH :

NAMA : ELSA KARUNIATI

NIM : 024STYC 17

YAYASAN RUMAH SAKIT ISLAM NUSA TENGGARA BARAT

SEKOLAH TINGGI ILMU KESEHATAN YARSI MATARAM
PROGRAM STUDI ILMU KEPERAWATAN JENJANG S1
MATARAM 2019/2020
1. explanation of medical records
a. understanding of medical records
Medical records are those that contain records and documents
between the patient's identity, examination results, treatment that has
been given, as well as other actions and services provided to patients.
Notes are writings made by doctors regarding the actions taken on
patients in the context of health services.
Forms of Medical Records in the form of a manual that is
written completely and clearly and in electronic form according to the
provisions.
Medical Records consist of patient data records that are carried
out in health services. These records are very important for services for
patients because with complete data can provide information in
determining treatment decisions, treatment, medical treatment and
others.
Permenkes Number 269/MenKes/Per / III / 2008, regarding
Medical Records states Medical records are files containing records
and documents about patients that contain identity, examination,
treatment, other medical actions in health care facilities for outpatients,
hospitalization both managed by the government or private
b. the purpose of medical records
to support the achievement of orderly administration in efforts to
improve the quality of health services in hospitals. The filling or
recording of medical records at a hospital is carried out by doctors and
nurses.
c. medical record function
1) Basic maintenance of health and treatment of patients
2) Proof material in the Humum case
3) Materials for research and education purposes
4) Basic payment for health service costs
5) Material for preparing health statistics
d. benefits of medical records
 1) As a communication tool between doctors and other health workers
who take part in providing services, treatment, care for patients.
2) As a basis for planning treatment / care given to patients.
3) As written evidence of all acts of service, disease progression and
treatment during the patient's visit / treatment.
4) As material for analysis, research and evaluation of the quality of
services provided to patients.
5) Protect the legal interests of patients, hospitals and also doctors and
other health professionals.
6) Provides special data that is very useful for research and education
purposes. As a basis in calculating the cost of paying patient
medical services.
7) Become a source of memory that must be documented, as well as
material for accountability and reports.
e. fill in the medical record
1) outpatient medical record
a) patient identity
b) date and time
c) history results, including at least complaints and history of
disease
d) physical examination and medical support results
e) diagnosis
f) management plan
g) treatment and / or action
h) other services that have been provided to patients
i) for dental case patients equipped with a clinical odontogram
and
j) approval of actions when needed.
2) inpatient medical record
a) patient identity
b) date and time
 c) history results, including at least complaints and history of the
disease
d) results of physical examination and medical support;
e) the diagnosis
f) management plan
g) treatment and / or action
h) approval of actions when needed
i) clinical observation records and treatment results.
j) discharge summary
k) names and signatures of doctors, dentists, or certain health
professionals who provide health services
l) other services performed by certain health workers
m) for dental case patients equipped with a clinical odontogram.
2. conversations about hospital services in English
A man comes to health services delivered by his friend, complaining of
shortness of nafs after working as a construction worker.

friend: excuse me !
Nurse: Yes, can I help you?
Friend: Please help my friend nurs !
nurse: good sir, please wait here for a moment!
friend: yes nurs
Nurse: Excuse me, I will put on a nebulizer so that your breathing is better.
are you willing?.
patient: nod
nurse: well, i live first. Sir, please rest.

not long after, the nurse returned to the patient

nurse: good afternoon sir!

patient: good afternoon nurs
Nurse: Well, I'm Nurse Elsa Karuniati who is on duty this afternoon to
take care of you. Previously, what was your name?
 patient: Mr.J
nurse: how's the breath, is it better?
patient: already
Nurse: If so, I take off the device, then you go straight to the doctor to
prescribe medicine
patient: yes, thank you
nurse: You're welcome

3. Nursing Care In The Emergency Department

Nursing Care With Asthma Cases In The Hospital Emergency Room
A. Assessment
1. Client identity:
Name : Mr. J
Age : 44 years old
Address : kr. Taliwang
Religion : Islam
Gender : male
Marital status : married
Profession : laborer
Medical diagnosi : asthm
2. Main complaint: clients complain of tightness.
3. Current disease history :
the client came alone to the emergency services at the ampenan
puskesmas on March 10, 2020 with complaints of shortness of breath
suddenly since morning, wheezing, coughing, history of asthma.
4. Past medical history :
The client said before the client also had experienced the same disease
as the client experienced at this time.
5. History of hereditary diseases
The client says there is a family that has the same disease, the client's
mother.
 6. Genogram

///////
X ///

Informatio :

///// : A sick family member

/////

: in one family

X : man who died

: female

: male

7. physical examination
 a. level of consciousness: composmetis GCS: 15, E: 4, V: 5, M: 6
b. Vital sign
TD : 110 /80 mmhg S : 36,8.C
N : 80x/m RR : 26 x/m
CRT : 2 detik
c. Head: symmetrical head, black hair, and no tenderness.
d. Eyes: left and right symmetrical eye shape, anemic conjunctiva,
isochoric pupils, light reflexes (+) / (+)
e. Nose: symmetrical nose shape, no secretions, no lesions and
tenderness, good olfactory function.
f. Ear: symmetrical shape, no tenderness, no lesions, no lumps, good
hearing function.
g. mouth: symmetrical shape, dry lip mucosa, no lesions, clean
tongue, yellow teeth, good taste function.
h. Neck: symmetrical shape, no lesions, no swelling, no tenderness,
no enlargement of the thyroid gland.
i. Chest:
Inspection: symmetrical shape, no lesions, no lumps, visible chest
wall traction, RR: 26x / m
Palpation: chest development inspiration and expiration are the
same, no tenderness, deep breathing rhythm and slow.
Percussion: sonor
Auscultation : ronchi sounds in the right lung of the superior lobe
and whezzing in the right bronchus.
j. abdomen
inspection: symmetrical shape, no lesions, no bumps.
auscultation: bowel sounds 5-20x / m
percussion: -
palpation: no abdominal tenderness
k. skin: brown skin color, good skin turgor, no lesions, CRT <2
seconds
8. therapy given
 - nebu combiven 1 resp
- salbutamol 3x4 mg
- deksametason 3x0,5 mg
- ambroxol 3x30 mg

B. Analysis data
No Data Etiologi Problem
Ds : trigger factor ineffective
The client says he has -allergens breath pattern
had shortness of breath -stress
since morning. -weather
Do:
- visible chest wall pull IGE-bound antigen
- there are whezzing on the surface of mast
and ronchi sounds cells or basophils
-TD : 110 /80 mmhg
S:36,8.C secrete histamine
N:80x/m meditor
RR:26x/m
CRT : 2 detik capillary permeability
increases

smooth muscle
contraction increases

increased bronchial
lymph secretion

narrowing of the
airway

increased work of
respiratory muscles
 ineffective breathing
pattern

C. diagnosis
ineffective / in effective breathing patterns associated with narrowing of
the airway that is characterized by shortness of breath, the tug of the chest
wall, and there are whezzing and ronkhi sounds.
D. Nursing plan

No Dx Goals and results Intervention Rational

. criteria
1 after taking nursing 1. monitor the 1. to find out the
actions for 1x24 hours frequency, rhythm rhythm and depth
the client is expected to and depth of of the client's
be able to regulate breathing breathing
effective breathing 2. Monitor the breath 2. to know the client's
patterns with the pattern breathing patterns
results: 3. monitor the ability to sooner or later
1. expiration partners cough effectively 3. can save energy so
increase 4. monitor for airway that it does not get
2. ventilation a obstruction tired easily and can
minute increases 5. auscultate breath expel phlegm to
3. inspiratory sounds the maximum
pressure increases 6. position the client in 4. makes it easy for
4. prolongation of the semi-fowler the client to
the expiratory position breathe
phase decreases 7. give oxygen therapy 5. to detect faint
5. breathing according to order breath sounds with
frequency 8. collaboration drug wheezing
improves delivery expiration or the
6. respiratory absence of breath
weakness sounds
 improves 6. help lung
expiration
7. maximizing
oxygen supply for
gas exchange
8. speed healing

E. Implementation
date and Implementation response to results
time
10/03/2020 monitor the Do:
11: 00 frequency, rhythm RR: 26x/m with slow and
and depth of deep rhythms
breathing
11: 05 monitor breathing Do:
patterns the client's breathing
pattern is slow and deep
11:10 monitor the existence Do :
of airway obstruction no secretions or other
airway obstruction
11:15 auscultate breath Do :
sounds faint breath sounds with
wheezing expiration
11 : 20 position the client in Do :
the semi-fowler the client looks easier to
position breathe
11:25 collaboration drug Do :
delivery the client feels easier to
breathe and is not
crowded anymore after
being nebu combiven 1
resp
F. Evaluation
Date and Dx progress note
time
12/03/2020 1 Subjective :
11:30 The client says it is not difficult to breathe again
and tightness is reduced
Objective:
- good client breath pattern
- the client looks calmer
- the general state of the client is good
- TD: 90-120 mmhg
N : 60-100x/m
RR: 12-24x/m
S 36,5-37,5.C
- no ronchi and wheezing noises
Assesment: the problem is resolved
Plan : intervention stopped