NAMA : Juwita Puspita Sari

NIM : 041STYC17
TUGAS 1
BHS. INGGRIS
1. Cari dan jelaskan catatan medis (record) dalam bhs inggris
In the explanation of Article 46 paragraph (1) of the Medical Practice
Law, what is meant by medical records is a file containing records and
documents about the patient's identity, examination, treatment, actions and
other services that have been provided to the patient.

2. Buat percakapan atau setting tentang pelayanan kesehatan di rumah sakit dalam
bhs. inggris
Patient : Mr.. Erik, I have a headache
Nurse : Yes, are you okay? Do you need me to call the doctor?
Patient : It’s just felt so dizzy and I barely can’t see it clear since
everything circle around.
Nurse : Did you take your medicine yet?
Patient : Not yet. I just finished eating.
Nurse : Here, let me help you. Take the medicine first, and I’ll call the
doctor. Patient : Thanks Mr. Erik. I think I need a rest, could you help me
please I wanna lie?
Nurse : Yes, here let me help you. Do you feel comfortable now?
Patient : Yes, it’s much much better. The headache slowly getting better.
Nurse : Okay then, I need to go now. I’ll inform the doctor right away.
And where is your family?
Patient : My mom is in the cafeteria and she will be back in a minute. It’s
okay you can leave me.
Nurse : Okay Mr.jon . Don’t hesitate to push the buzzer whenever you
need me okay? I’ll be here in no time. Now take a rest and get well soon.
Patient : Thanks a lot Mr. Erik
 NURSING CARE
NEED SECURITY AND COMFORTABLE

A. PENGAKAJIAN
I. Identification of patients
Name                                       : ny "N"
Age                                         : thirty seven years
Family                                     : five people
Last education                                    : elementary school
Occupation                              : housewife
Address                                   : jln.T.A.Gani
Hospital admission date          : 16 December 2014
Diagnostic medic                    : effusion fleura

II. Family history

1. The main complaint : tightness
Trigger factor                          : due to accumulation of fluid in the cavity fleura
Nature of complaint                : settle
Location anddistribution        : chest
Scale complaint                       : severe (6-10)
Start and duration of pain       : from entering the hospital
Things that ease / burden        : break / tightness

2. Past health history

Patients say the illness / complaint that is often experienced shortness
Patients say never hospitalized earlier
The patient said he had never had surgery
Patients say no allergies

III. Vital signs:
a. Blood pressure        : 100 / 70mmHg
b. Pulse                        : 70x / i
c. Body temperature   : 37 C
d. Respiratory             : 32x / i
IV. History needs comfort
 Patients say never suffered trauma resulting in pain
 Location of pain: chest area
 The nature of pain: sedentary
Patients say never impaired body temperature changes
 Patients say the disease is often experienced shortness
 Patients say never experienced flatulence
Physical examination
1. Inspection
a. Vocal: wince
b. Facial expressions: grimacing
2. Palpation
a. Pain scale: severe (6-10)
b. Quality of pain: sharp
3. Percussion
a. Beep: timpani
4. Auscultation
a. Bowel sounds: wheezing

DATA FOCUS

Name: ny "N"                                               needs: security and comfort

Age: 37 years old                               room: surgical treatment
Gender: female                                  date: 8 January 2015

Subjective data Objective data

The patient said congested while Patient appears pale
sleeping on their backs
Patients seems weak 
 The patient said chest pain
Grimacing facial expressions
Patients say often cough
Observation of vital signs:
Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i

DATA ANALYSIS
 Name: ny "N"                                   needs: security and comfort
Age: 37 years old                               room: surgical treatment
Gender: female                                  date: 8 January 2015
DATA ETIOLOGY PROBLEM
Subjective Data permeability changes fleura Impaired sense of comfort
1. The patient said congested while
sleeping on their backs Decreased plasma osmotic
pressure
2. Patients report pain in the chest area

3. Patients say often cough Increased systemic capillary

hydrostatic pressure
Objective data
1. The patient appears pale Reduced dranaise limfatif

2. Patients seems weak Pulmonary edema fluid

movement and passing
3. grimacing facial expression
through the pleural lining
4. Observation of vital signs viselaris
Blood pressure: 100/70 mmHg
Temperature: 37 c Increased peritoneal fluid
Nadi: 70x / i
Respiratory: 32x / i

V. DIAGNOOSA NURSING
 Impaired sense of comfort associated with shortness
Objective: after the act of nursing 2x24 hours expected of patients showed
comfort with criteria results:
a. Shortness bekurang
b. Pain is reduced
c. Cheerful facial expressions

VI. INTERVENTION NURSING

1. Assess breathing pattern
Rational: to determine the pattern of breathing
2. Observation of vital signs
Rational: to recognize and facilitate action
3. Give a comfortable position
Rational: to reduce pain with semi-Fowler's position
4. Create a quiet neighborhood
Rational: to improve comfort
 5. Collaboration with other nurses and other medical team in delivering drugs
Rational: to reduce the complaints

VII. IMPLEMENTATION OF NURSING
1.      Assess breathing pattern
Results: Respiratory 32x / i
2. Observe vital signs
Results: vital signs
 Blood pressure: 100/70 mmHg
 Temperature: 37 c
 Breathing: 70x / i
3. Provide a comfortable position possible (semi-Fowler)
Results: The patient can perform semi-Fowler's position
4. Creating an environment that is quiet
Results: The patients can calm
5. Treatment with nurses and other medical team in delivering drugs
Results: The administration of analgesic drugs

VIII. EVALUATION OF NURSING

Ø  Subjective:
 patients say claustrophobic when sleeping on their backs
 Clients say pain in the chest
 Clients say often cough

Ø    Objective:
 patient appears pale
 patients seems weak
 grimacing facial expressions
 observation of vital signs
Blood pressure: 100 / 70mmHg
temperature: 37 C
Pulse: 70x / i
Respiratory: 32x / i
Ø  Asesmennt: Issues not resolved interference comfort

Ø  Planning: continue intervention

1. examine the pattern of breathing
2. The observation of vital signs
3. give a comfortable position
4. create a calm environment
5. collaboration with nurses and medical teams provide drug