ASSIGNMENT FOR 15TH MEETING ABOUT NURSING REPORT

NAMA : ANDI FARAMIDA

NIM : PO713201201155
KELAS: 2D
Here are three nursing cases in Indonesia, Please make a nursing report for each cases
belows. Use 6 (six) guidelines for good quality of your report based on the material related this
assignment. Here are the cases:
Case 1
Tn.B umur 34 tahun mengalami penurunan kesadaran. Tn.B membuka mata setelah diberi
perintah membuka mata. Saat ditanyakan tempat Tn.B sekarang berada Tn.B tampak bingung.
Saat diberi cubitan pada lengan tangan dekstra, Tn.B menarik tangannya menjauhi cubitan.
Perawat menilai GCS Tn.B E3V4M4 (somnolent).
Case 2
Seorang laki-laki umur 37 tahun, masuk di UGD dengan riwayat kecelakaan lalu lintas.
Terdapat bekas darah di mulut dan hidung klien, terdengar suara ronchi saat bernafas, terdapat
periorbital echimosis dan battle sign. Tanda tanda vital, TD 90/60 mmHg Nadi 115 kali permenit
(regular dan lemah) RR 32 kali permenit (irregular)
Case 3
Seorang perempuan umur 60 tahun dirawat di Rumah sakit dengan keluhan sesak nafas, batuk
disertai batuk produktif bercampur darah merah muda. Klien mengeluh sering merasa berdebar-
debar dan sulit tidur serta kencing sedikit. Hasil pemeriksaan fisik, tidak terjadi pitting edema,
TD 180/100 mmHg, HR 120 kali permenit, Nadi 32 kali permenit, BJ I meningkat, BJ II normal
dan irama gallop positif.

Answer:
Case 1:
Mr. B is 34 years old. During the examination, Mr. B opened his eyes after being given the order
to open his eyes. When asked where Mr. B is now Mr. B looks confused. When given a pinch on
the right arm, Mr. B pulled his hand away from the pinch. The nurse assesses Mr. B has
decreased consciousness with a GCS value of E3V4M4 (somnolent).
Case 2:
A 37-year-old man is admitted to the ED with a history of a traffic accident. There are traces of
blood in the client's mouth and nose, crackles are heard when breathing, there is periorbital
ecchymosis and battle sign. Vital signs, BP 90/60 mmHg Pulse 115 beats per minute (regular
and weak) RR 32 beats per minute (irregular)
Case 3:
A 60-year-old woman was admitted to the hospital with complaints of shortness of breath, cough
accompanied by a productive cough mixed with pink blood. The client complains of frequent
palpitations and difficulty sleeping and urinating a little. Physical examination results: BP
180/100 mmHg, HR 120 beats per minute, pulse 32 beats per minute, BJ I increased, BJ II was
normal and gallop rhythm was positive and there was no pitting edema.