NURSING ENGLISH

ARRANGED BY :

NAME : M. BUSYAIRI PUTRA

NIM : 050STYC 17

ISLAMIC HOSPITAL FOUNDATION OF NUSA TENGGARA BARAT

HIGH SCHOOL OF HEALTH SCIENCE YARSI MATARAM
NURSING SCIENCE STUDY PROGRAM BACHELOR DEGREE
MATARAM 2019/2020
1. Medical Records
a. understanding of medical records
medical record is a record and document that contains the condition of
the patient's condition, but if examined in more depth the medical record
has a more complex meaning not just an ordinary note, because in that
note already reflected all information regarding a patient that will be used
as a basis in determining further actions in other services and medical
measures given to a patient who comes to the hospital.
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. Service conversation at the hospital
Nurse: Good afternoon, Anna. How are you feeling today?
Patient: It’s so cold in here! I think I have a fever
Nurse: Let me check your forehead.
Patient: Ok.
Nurse: You feel a bit warm. Let’s measure your body temperature, shall we?
Patient: Sure
Nurse: Here, put the thermometer under your armpit please.
Patient: Okay. (A minute later)
Patient: So, how is it?
Nurse: You have a bit of fever, but you don’t have to be worried about it. It is
normal to have a slight fever after a surgery like yours.
Patient: I’m glad to hear that.
Nurse: I think I will check your blood pressure as well.
Patient: Why? Is there something wrong?
Nurse: No, don’t worry. You are in good hands. Now would you please hold
out your arm so that I can wrap this cuff around it to read your blood pressure?
Patient: Ok.
Nurse: Your blood pressure is 100/70. It’s normal.
Patient: Thank you nurse.
Nurse : your welcome
3. Case Report

A. Assessment
1. Client identity:
Name : Mr. E
Age : 50 years old
Address : kr. Taliwang
Religion : Islam
Gender : male
Marital status : married
Education : primary school
Profession : Housewife
Person in charge
Name : Mis. M
Age : 34 years
Gender : Female
Hub. With clients : client's child
Profession : Housewife
2. Main complaint: clients complain of tightness
3. Current disease history:
Client came to the emergency room on March 2, 2020 at 10:00
WITA, the client said that it was congested since 4 days ago
accompanied by coughing up phlegm, the client had previously drank
vikcs formula 44, the client was an active smoker
4. Past medical history : Client says he has never experienced a disease
like this, but before
5. History of hereditary diseases
Client's family says the client has no history of hereditary disease
from a previous family.
 6. Genogram
**

Informatio :

** : A sick family member : in one family

: female

: male
7. primary assessment
a. airway
There is a secretion of the sputum of the client having difficulty
breathing, coughing, sounding wheezing.
b. Breathing
visible development of the right, left and symmetrical chest, the
client has difficulty breathing RR: 35 x / m, irregular rhythm, seen
using a breathing aid nebulizer.
c. Circulation :
TD : 120 /80 mmhg S : 36,6.C
N : 85x/m RR : 35 x/m
CRT : 2 detik
d. Disability :
Client awareness composmentis with GCS (E4, V5, M6), the client
says it is difficult to breathe.
e. Exposurure :
skin turgor is good because the skin returns in about 1 second
when it is pinched.
8. secondary assessment
a. level of awareness : hair slightly graying, scalp looks clean no
hematoma.
b. GCS : E4V5M6
c. Vital sign
TD : 120 /80 mmhg S : 36,6.C
N : 85x/m RR : 35 x/m
CRT : 2 detik
d. physical examination
1) Head: hair slightly gray, scalp looks clean, no hematoma.
2) Eyes: normal pupillary size, right / left pupillary light
stimulation (++)
3) Mouth: Dry lip mucosa
 4) Nose: no plip, clean.
5) Ears: symmetrically clean, no cerumen
6) Neck: no enlarged teroid glands
7) Chest:
Inspection: symmetrical chest development, visible use of
muscle nebulizer breathing aids.
Palpation: vocal, right-left fremitus
Percussion: sonor
Auscultation : sounds wheezing.
e. Esktermitas: acral cold
Upper extremity: CRT 2 seconds no edema
Lower extremity: no edema.
9. Assesment :
a. Allergy : no allergies
b. Medication : the client had previously taken the drug vicks formula
44 to relieve cough.
c. Postillness : client said before he had experienced flu, dizziness.
d. Environvment : client lives with his child the client lives near the
road and the client's environment is quite densely populated.
e. Lastmal : client said, it would be 2 hours before this morning
before being taken to the last health center to consume rice with
side dishes and drink water.
f. elimination status
defecate clients 1 time this morning and urinate 2 times this
morning
g. nutritional status
The client eats 3 times a day
 10. Therapy
Numbe Date type of Dose Indication
r therapy
1 March 2, Combivent 3 ampul Bronchodilators
2020 for asthma
2 March 2, Salbutamol 4 mg Asthma and
2020 other
conditions
related to
shortness of
breath.

B. Analysis data
N Data Etiologi Problem
o
Ds : Increased secretion cleaning the
clients complain of production airway is not
tightness effective
TD : 120 /85 mmhg
S:36,6.C
N:85x/m
RR:35x/m
CRT : 2 detik
client seemed
claustrophobic
Wheezing sounds
Cold acral
Dry lip mucosa is a
muscle aid for
breathing nebulizer
C. Nursing plan

No Dx Goals and results Plan SIKI Rational

. criteria
1 After taking 1. Assess client's 1. To find out
nursing actions for condition the state of
1x30 minutes is 2. Effective cough the client
expected : training 2. To remove
 The client a. Identification excess
breathes of coughing secretions
effectively abilities 3. To measure
 There is no b. Assess for the
secret sputum frequency
 Breathing aids retention of breath
are not c. Adjust the sounds
installed position of the
 no coughing spring fowler-
tightness fowler
 vital signs d. Explain the
stable purpose of an
TD : 130/80 effective
mmhg cough
N : 60-70 e. Encourage
S: 36,6 deep
RR: 16-20x/m inhalation
through the
nose for 4
seconds and
then hold it
 out
3. Respiration
monitoring
a. Assess the
rhythm
frequency
inside
b. Assess for
blockages
c. Palpate
pulmonary
expansion
d. Auskutsi
breath
sounds

D. Implementation
date and Implementation response to results
time
March 2, Assessing the state of Ds:
2020 the client client said the tightness
10:00 began to decrease after
being treated

10: 05 Pairing inhalation Do:

A nebulizer with a dose
of 1 ampoule combivent
dioplos 2cc nacl
 10:15 Assessing vital signs TD : 13/60 mmhg
N : 75x/m
RR: 22x/m
S 36,0.C

10:20 Teach efective cough DS : Client says

understanf and can do it

E. Evaluation
Date and dx progress note
time
March 1 Subjective :
2, 2020 The client says the tightness starts to take
medication after being treated
10:20 Objective:
TD: 13/60 mmhg
N : 75x/m
RR: 22x/m
S 36,0.C
Assesment: Destination partially resolved
Plan : intervention stopped