Nama : Laila Az-Zahra

Nim : 3019041075
Kelas : 2C DIII Keperawatan
Mata Kuliah : Bahasa Inggris

NURSING DOCUMENTATION

I. Patient’s Identity
Name : Salma Ayu Amalia

Sex : Female Address : Rangkasbitung

Age : 19 Years Old
Occupation : Student in college Phone number : +(62) 876-2587-9067
Marital status : Single Next of kin : Her Mother
Religion : Islam Health insurance : Insurance BPJS
(Health Social Security Administering
Bodies)
II. Health History
Disease history : Diabetes Mellitus

Immunization history :
Vaccine Yes No Not sure When
Covid-19 - ✓ - -
DPT - ✓ - 3 month of age
Polio - ✓ - 6 month of age
Measles - ✓ - -
Rubella - ✓ - -
Allergy history : She allergy see food
III. Assessment Results
Head : Face :
 Normal  Symmetrical
 No lesions  No lumps
 No lumps  He has lesion
 Size normal Skin :
Hair :  Colour Brown
 Thick  He has simple
 Soft Cheeks :
 Normal  Symmetrical
Scalp : Lymph Nodes :
 Normal  No felt
 No dandruff  Normal
Skull :
 Normal
Neck : Nose and sinuses :
 Normal  Infection
 Mucus
Mouth : Pharynx :
 Teeth  Symmetrical
 Not lessions
 It’s color white
 Symmetry
 Gumy
 It’s color pink
 Not lessions
 Symmetry
 Tongue
 Not leesions
 It’s color pink
 Moist
 Soft Palate
 Not lessions
 It’s color pink
 Moist
Eyes : Ears :
 Visual acuity normal  No lesions in he ears
 Extra ocular movement normal  Tenderness normal
 He the conjunctiva is clear  The ears is clean
 He the sclera is white  Response positif
 He had no lesions

IV. Patient’s Hygiene

Body: Oral:

The patient able to help but cooperative The patient is unable to perform proper
with turning. No complaints of severe oral hygiene by himself. Mucous
itching. The patient's body is in good membranes and lips are moist, pink and
condition because the patient says that intact. No dental plaque. Teeth clean. No
nothing feels painful when touched. and wounds. No gag reflex elicited. The Patient
the patient's skin looks healthy and not responsive. The patient does not have any
dry serious problems in his mouth including
his gum. other than that all is normal
V. Elimination pattern
Defecation: Urination:
Defecation loose, light brown on the potty. The patient is unable to urination. Urine
after completion the patient said much normal. Urine color is pale yellow
better.
VI. Injection Therapy
injection therapy is the drug cefotaxime. The injection is given only once because this is
only to see whether the patient has a drug allergy or not
VII. IV Therapy
IV therapy access is used to administer medications and fluid replacement which must
be distributed throughout the body.
VIII. Lab Samples Results
Blood: Urine:
Erythrocytes (red blood cells) : 4,5 /pl Colorless; ketones-negative; pH 7.
hemoglobin (hg) : 13,0 g/dL Specific gravity-1.019
hematocrit : 45 % Protein-negative for occult blood
basophils : 0,0 % Bile-negative.
eosinophils : 1,0 %
rod1 : 2,0 %
segment1 : 50,0 %
lymphocytes : 20,0%
monocytes 2,0%
sedimentation rate (LED) : < 10 mm
leukocytes (white blood cells) : 50,0 ul
MCH / HER : 27 pg
MCHC / kHER : 32 g/dL
MCV / VER : 80 fl
Platelets : 150 ul
Feces: Sputum:
Guaiac Test : Positive ------