ENGLISH PRACTICE

"Nursing Documentation and Reporting”

Facilitator : Dr. Ns. Retno Lestari, S.Kep., M.Nurs

BY :

ZAKIA

NIM. 225070209111032

NURSING SCIENCE STUDY PROGRAM

DEPARTMENT OF NURSING

FACULTY OF HEALTH SCIENCE

BRAWIJAYA UNIVERSITY
2022
PA 1 : Good morning Mr. Agus? Introduce me Ners Zakia. Here I
will take care of you today with my friend Ners Nia. How
are you?

Mrs. Agus : Wow, there's no change Ners. I still feel sick and can't
sleep, the food given is also not eaten

PA 2 : Oh, I see, sir. Okay, we are here, we will do an assessment

on you, to find out what problem you have.

Mr. Agus : Oh yes please sister

PA 1 and PA 2 also conducted an assessment of Mr. Agus. It was found that Mr.
Agus experienced severe pain in the area around the abdomen, nausea, insomnia,
lack of nutrition, anxiety about his illness, ascites and pleural effusion. BP: 90/60
mmHg, RR: 30x/min, sodium 100 meq/dl, albumin 2.8 g/dl. Now the patient is
placed in a 0.9% NaCl infusion. After getting the data that is deemed sufficient,
then PA 1 and PA 2 report the results of their assessment to the PP.

At the Nurse Station

PA 2 : Ma'am, we have done the study.

PP : Oh, how did it go?

PA 1 : It turned out that the problem with Mr. Agus is

experiencing severe pain in the area around the stomach,
nausea, insomnia, lack of nutrition, anxiety about his
illness, ascites and pleural effusion.

PP : Alright then, let's do data validation, directly to the patient,

okay?

PA 1 & PA 2 : Okay ma'am..

PP and PA 1 and PA 2 validate the data. After completing data validation, PP

will contract the next day for the nursing round.

In the patient room.

 PP : Alright, thanks for the co-operation. We'll meet again
tomorrow, sir, ma'am, for a nursing round.

Mrs. Agus : Oh yes. Thank you sis..

PP : Yes, you're welcome, sir.. Ma'am.. We'll excuse you first

Mrs. Agus : Wa'alaikumsalam.

At the Nurse Station

Karu : Assalamu'alaikum, good morning ladies and gentlemen. as

previously scheduled. I introduce first. This is PP as the
head of the team in this room, Nurses Regina and Nurse
Utin.. Immediately, please PP read out Mr. Agus' data.

Nurse 1 : Okay, thank you..

Good morning everyone... the patient in our nursing round

this time is Pak Agus, age 50. The patient was diagnosed
with CA. Colon stage II, bowel resection and adjuvant
chemotherapy were performed. The patient complains of
severe pain and nausea. He also had ascites and pleural
effusion. Patients limit eating and drinking because they
feel uncomfortable. Nursing problems that need to be
considered are excess fluid volume as well as fluid volume
deficiency. Where the signs of excess fluid volume from
the presence of pleural effusion and ascites, and signs of
lack of fluid volume or dehydration are blood pressure
90/60 mmHg, low sodium, low albumin, drinking less.
And there is a problem of nutrition less than the body's
needs. The patient had anorexia kaketsia syndrome.

Karu : Until here, is there anything that Ners Regina and Ners
Utin want to add..?

PA 1 : I would like to add a little ma'am.. from the results of the

patient's BMI assessment of 14.3. Today's blood pressure
 is 90/60 mmHg, RR 30x/minute, Sodium 100 meq/dl,
albumin 2.8 gr/dl. Now the patient has a 0.9% NaCl
infusion fluid.

Doctor : How about the temperature?

PP : The temperature is 38°C. We would like to intervene with

a diuretic to reduce ascites, but we are concerned that the
client's dehydration will worsen. For nutritional problems,
nutritionists have given TKTP (High Carbohydrate High
Protein).

Karu : What do you think you would like to add?

All : No ma'am..

Karu : Alright, if there's nothing to add, we'll just go straight to

the patient room to validate the data.