TUGAS BAHASA INGGRIS

DISUSUN OLEH:
KELOMPOK III
1. FLORINDA BLEGUR
2. GERALD RIHI DO
3. GILBERT MANUKULE
4. HAJI.P.A.S. AZIS
5. INA VONI .Y.2.DJULA

JURUSAN DIII KEPERAWATAN TK.1 REGULAR A

POLTEKES KEMENKES KUPANG
2020/2021

 
  

NURSING CARE REPORT

I. Patient’s identity
• Name : Chester Bennington
• Age : Thirty Six Years Old
• Sex : Male
• Address : Los Angeles - California
• Nationality : Unites States of America
• Education : High School
• Occupation : Singets
• Marital Status : Married
• Religion : -
• Date of Assessment : Sunday, 19 December 2012
• Source of Information : Patiens
• Date of Admission : Sunday, 19 December 2012

II. Patient’s history

1. Patient’s chief complaint on admission:
Patient’s chief complaint: have a some hurt in his lungs
2. Patient’s current medical case history:
gastric infection
3. Patient’s past medical case history:
gastric infection
4. Patent’s family medical history:

5. Medical diagnosis:
Gastritis
6. Intervention:
Taking medication

III. Current Assessment (Before and after admission)

1. Perception and health maintenance:
Stay away from acidic and spicy foods, and Reduce Your Intake of Fatty Foods

2. Nutritional metabolic pattern:

a. Hospital dietary
Must eat some porridage
b. Food intake
White rice
c. Liquid intake
Water

 
3. Elimination Pattern
a. Bowel movement
Bowel obstruction
b. Bladder
Can

4. Activity and exercise pattern:

Self Care 0 1 2 3 4
Eat / Drink ✓,
Take a bath ✓,
Toileting ✓,
Get Dress ✓,
Bed mobilization ✓,
Movement ✓,
Body Alignment and Range of Motion ✓,
*Note: 0: independent, 1: using aid, 2: dependent, 3: dependent and using aid, 4: depend
on oxygen

5. Sleeping and Resting Pattern

Fully bedrest
6. Perceptual Pattern
1. Vision
Good
2. Hearing
Good
3. Taste
Bad
4. Sensation
Good

7. Relationship Pattern
(Communication, relationship with others, financial support)
patients can relate well to everyone

8. Stress Management
(Changes have happened in patients’ life recently)

the patient has stable emotions

9. Norms and Believe

(Patients’ view about religion and religious activities, etc)
the patient is not diverse, but is kind
DATA ANALYSIS

No Data Etiology Problems

NURSING DIAGNOSIS
1.
2.
3.

NURSING PLAN

No. Diagnosis Purpose Intervention plan Rationale

IMPLEMENTATION

No. Date Preparation Implementation Signature

EVALUATION

No. Date Nursing Evaluation

diagnosis Subjective Objective Analysis Planning