YAYASAN BIDARA MUKTI

AKADEMI KEPERAWATAN BIDARA MUKTI GARUT

IZIN MENDIKNAS NO : 1420/D/T/2007-12/D/O/2010
JL.Pembangunan No.112 Tarogong Kidul- Garut, Telp.(0262) 9144454

MIDTERM EXAM
Odd Semester, 2020-2021

Study Program : Nursing Diploma III Course : ENGLISH FOR

NURSING
Grade/ Semester : 3 (three)/ 5st Semester Lecturer : Nita Yuanita, S.Pd., M.Si.
Day & Date : Irsyad Nugraha, M.Pd.
Time Allocation : 90 minutes

I. Make a report using nursing process (assessing, diagnosing , planning, implementing and
evaluating ). Your report should be at least 4 paragraphs, your report should be complete and
comprehensive!)

Answer :

Assesing

Nurse : Good morning

Patient : Morning
Nurse : How your feeling?
Patient : actually i'm not good, last night my body wash hot
Nurse : ok, ill check the blood pressure, then I chek the mother temperatur. Can you just lay down your
hand?
Patient : oke
Nurse : well, you have a high blood pressure. Do you have serious health problem in the past?
Patient : hmm, not actually, but two years ago I head high blood sugar because I often drink sweet ready to
eat drink.
Nurse : that muat be stopped mom, cause it Will ruint your health.
Patient : oke
Nurse : Try stretching hits ganda!
I'll Goong to a thermometer in your urmpit. After that your hand close together again by playcing
your hands on your chest.
Patient : oke
Nurse : I wanted three minutes to get the result
Patient : ok

Diagnosing

The patient experienced serious health problems, namely kidney failure for 1 month ago, always dizzy and
could not walk properly and took deep breaths of about 22 times / minute. he has a high blood pressure of
around 160/90 mmHg. he has a fast pulse rate of about 100x / minute. on the other hand, the patient looks
fine.
Name : Risna
Health status : feel back pain, dizziness and rarely dialysis to the hospital
Breath : 20 x / minute
Blood pressure : 160/90 mmHg
Pulse rate : 92 x/ minute
 YAYASAN BIDARA MUKTI
AKADEMI KEPERAWATAN BIDARA MUKTI GARUT
IZIN MENDIKNAS NO : 1420/D/T/2007-12/D/O/2010
JL.Pembangunan No.112 Tarogong Kidul- Garut, Telp.(0262) 9144454

the patient is named Risna. she had kidney failure about 1 month ago, dizzy, and she rarely dialed blood to
the hospital. he took about 20 breaths / minute. she has high blood pressure around 160/90 mmHg and she
also has a pulse rate of about 92 x / minute.

Patient: good morning, nurse

Please help me?
Nurse: Morning, please.
What is wrong with you?
Patient: My stomach hurts, it's been 2 days
Nurse: You said you have a stomachache?
patient: Yes nurse, lower right abdominal pain has been 2 days, bloating, my pain is like being pressed by
heavy heavy objects will get worse if my stomach is pressed and too much activity
Nurse: Fine, I will report your condition to the doctor
Patient: good nurse

Doctor: OK, what is the patient nurse complaining about?

Nurse: She complained of lower right abdominal pain
Doctor: What are the symptoms experienced by the patient
nurse: She has pain like a heavy pressure in her lower right abdomen and it gets worse when her stomach is
pressed and too much activity, she has acute appendicitis in her medical history
Doctor: Fine, I will check the condition
Please welcome the patient to the medical room
Nurse: Yes, doc

Nurse: Please enter the medical room, let me take you

Patient: Good nurse, thank you
Nurse: you're welcome

Planning and Implementing

1. The risk of reduced fluid associated with acute kidney

▪ monitor fluid status (skin turgor, mucous membranes, urine output)
▪ auscultate td and weigh body weight
▪ assess skin color, temperature, cyanosis, peripheral pulse and diaphoresis regularly
▪ program for dialysis

2.High risk of arrhythmias associated with electrical conduction secondary to hyperkalemia

▪ assess the causative factors of the individual condition and hyperkalemic factors
▪ give a low-potassium diet
▪ TV monitor every 4 hours
▪ monitors clients who are receiving rapid potassium infusions

3. Changes in nutrition less than body requirements associated with anorexia, vomiting, nausea.
▪ Observation of client status and diet effectiveness.
▪ Encourage good oral hygiene before and after eating.
▪ Give low salt food
 YAYASAN BIDARA MUKTI
AKADEMI KEPERAWATAN BIDARA MUKTI GARUT
IZIN MENDIKNAS NO : 1420/D/T/2007-12/D/O/2010
JL.Pembangunan No.112 Tarogong Kidul- Garut, Telp.(0262) 9144454
▪ Provide small, frequent meals.
▪ Collaboration of anti-emetic drugs.

Evaluating

Nurse: Ma'am, how have there been any changes?

Patient: Alhamdulillah, Ma'am is getting better.
Nurse: are there any other complaints?
Patient: there is a nurse
Nurse: what?
Pasient: there is still a little more nausea
Nurse: well I will tell the doctor
Patient: good nurse. Thank you
Nurse: same

Nurse: doc, so far the client has experienced changes for the better.
Doctor: No more complaints?
Nurse: there is a dock only a little less nausea
Doctor: good nurse, you can go home tomorrow
Nurse: good doctor