ENGLISH LANGUAGE II

“NURSING CARE PLAN”

CLASS: 1 A

GROUP 5:

1. Hania Safiira 2011312068

2. Fitrah aini rahman 2011313005
3. Mila Gustia 2011312065
4. Fitri Rahmayani Asnur 2011312071
5. Rizka Noviola Hardita 2011313008
6. Nazhifa fauziyah 2011317001
7. Atikah Salsabila Deyra 2011312080
8. Diyan R. Kurnia 2011312074
9. Resty Noer Syafitri 2011313002

FACULTY OF NURSING
ANDALAS UNIVERSITY
2020 / 2021
CASE :
Mrs S, 57 years old, was admitted to the hospital with the main complaint of pain when swallowing. The
patient said he could not sleep because the mouth felt very dry and hot and painful when swallowing. The
patient also complains of nausea, has no appetite, feels like vomiting, and feels tight in the stomach. The patient
appears weak, dry oral mucosa, moderate skin turgor, appears painful when swallowing. When checked the
throat looks red. The result of body weight before getting sick is 70 kg, currently 60 kg. Blood laboratory tests
obtained Hb 11 g / dl and albumin 3.5 mg / 100 ml.

ASSESMENT DIAGNOSIS INTERVENTION IMPLEMENTATION

Subjective data : - Acute pain associated with  To deal with pain 1. The patient is
- The patient not being able to swallow in sufferers, then given a warm
can't sleep food, and the throat looks
- The mouth do a warm compress on the
red.
feels very dry - Nutritional imbalance less compress on the throat area to
and hot than the need associated with relieve pain
throat area, and it
- Pain when the inability to enter, digest,
swallowing will be advisable 2. Patients are
and absorb food due to
- Nausea biological factors, to drink water instructed to
- No appetite characterized by nausea, regularly gargle with salt
- Feels like vomiting, and no appetite
accompanied by water to relieve
throwing up - Risk of electrolyte imbalance
- Stomach feels gargling with salt sore throat
tight water to deal with 3. Patients are given
Objective data pain. food in portions
- Looks weak
 For nutritional that are not too
- Dry oral
mucosa imbalances, the much, but given
- Medium skin enough time
patient will be
Turgor
- Looks pain given food that is intensity
when 4. The patient is
soft, easy to
swallowing
- The throat digest, and is given soft
looks reddish structured foods
given in portions
- Body weight
before sickness that are not too such as porridge,
70 kg, currently banana, chicken
much, but with
60 kg
- Hb 11 gr / dl enough time soup, and eggs
(Low) 5. The patient is
intensity, and will
Normally 12-16
gr / dl be guided to drink given a nutritious
- Albumin 3.5 diet, and is rich in
water regularly.
mg / 100ml.
 For nausea, the iron, vitamin B12
patient is advised and folate such as
 to eat slowly, red pickled pulp
breathe using deep and soy milk to
breaths to force increase the
the nausea reflex, hemoglobin value
limit drinking 1
hour before, 1
hour after dam
during meals,
avoiding pungent
food odors.

evaluation
 S: The client said it no longer hurts when swallowing, can sleep because the mouth is no longer dry and
hot, and the appetite will return, no longer feel nauseous or the stomach feels tight, no longer felt
 O: The patient's Hb is 15 g / dl, body weight has increased to 68 kg
 A: Problem is resolved overall
 P: Instruct the patient to drink water frequently, and avoid foods that are too spicy, hot, and too sweet.