ENGLISH NURSING ASSIGNMENTS
DISUSUN OLEH :
NAMA : ETI JUNIA ASTUTI
NIM : 029STYC 17
YAYASAN RUMAH SAKIT ISLAM NUSA TENGGARA BARAT
SEKOLAH TINGGI ILMU KESEHATAN YARSI MATARAM
PROGRAM STUDI ILMU KEPERAWATAN JENJANG S1
MATARAM 2019/2020
1. explanation of medical records
a. understanding of medical records
Permenkes Number 269/MenKes/Per / III / 2008, regarding
Medical Records states Medical records are files containing records
and documents about patients that contain identity, examination,
treatment, other medical actions in health care facilities for outpatients,
hospitalization both managed by the government or private
b. the purpose of medical records
to support the achievement of orderly administration in efforts to
improve the quality of health services in hospitals. The filling or
recording of medical records at a hospital is carried out by doctors and
nurses.
c. medical record function
1) Basic maintenance of health and treatment of patients
2) Proof material in the Humum case
3) Materials for research and education purposes
4) Basic payment for health service costs
5) Material for preparing health statistics
d. benefits of medical records
1) As a communication tool between doctors and other health workers
who take part in providing services, treatment, care for patients.
2) As a basis for planning treatment / care given to patients.
3) As written evidence of all acts of service, disease progression and
treatment during the patient's visit / treatment.
4) As material for analysis, research and evaluation of the quality of
services provided to patients.
5) Protect the legal interests of patients, hospitals and also doctors and
other health professionals.
6) Provides special data that is very useful for research and education
purposes. As a basis in calculating the cost of paying patient
medical services.
7) Become a source of memory that must be documented, as well as
material for accountability and reports.
e. fill in the medical record
1) outpatient medical record
a) patient identity
b) date and time
c) history results, including at least complaints and history of
disease
d) physical examination and medical support results
e) diagnosis
f) management plan
g) treatment and / or action
h) other services that have been provided to patients
i) for dental case patients equipped with a clinical odontogram
and
j) approval of actions when needed.
2) inpatient medical record
a) patient identity
b) date and time
c) history results, including at least complaints and history of the
disease
d) results of physical examination and medical support;
e) the diagnosis
f) management plan
g) treatment and / or action
h) approval of actions when needed
i) clinical observation records and treatment results.
j) discharge summary
k) names and signatures of doctors, dentists, or certain health
professionals who provide health services
l) other services performed by certain health workers
m) for dental case patients equipped with a clinical odontogram.
2. conversations about hospital services in English
Mr. F is a 62 year old father, currently he is being treated in one of the
rooms in the hospital. K because this morning he felt shortness of breath
and pain in his chest accompanied by coughing up phlegm and dizziness.
Nurse : Assalamu’alaikum ma’am and sir ?
Family and clients : wa’alaikumsalam nurse.
Nurse : Excuse me, my nurse Nurse Eti Junia Astuti, just call Sister Eti.
I'm a nurse in charge of this room. I was on duty from 07.00 am to 14.00
noon later. Mom, if anything, you can call me in the nurse's office.
Previously was this true with mr. F.
Patient's family: yeah right miss. Now my father wants to do with the
nurse.
Nurse : I now want to check the condition of the father, How is ma’am?
Client's family: oh yes, please nurse.
Nurse : how is your condition now?
Client: I feel congested since 3 days ago accompanied by cough with
phlegm.
Nurse : What did you drink before?
Client: I used to drink neo napacin and comics from 2 years ago but I can't
get lost so go straight to the hospital
Nurse : o yes sir now I will install the nebulizer here the goal is to relieve
the narrowed respiratory tract due to a blockage in your respiratory cavity.
Client's family: approximately what causes constriction?
Nurse: so the cause of the narrowing is due to an increase in excess
secretions so that the father can cough up phlegm and find it difficult to
breathe. .(While taking action)
Client's family: Yes, thank you for the explanation
Nurse: Yes, you're welcome, I have finished the installation later if there
are complaints, call me in the nurse's office. (smiling)
Client: Yes, nurse
3. Nursing Care In The Emergency Department
Nursing Care With Asthma Cases In The Hospital Emergency Room
A. Assessment
1. Client identity:
Name : Mrs. F
Age : 62 years old
Address : kr. Taliwang
Religion : Islam
Gender : male
Marital status : married
Education : primary school
Profession : laborer
Person in charge
Name : Mis. M
Age : 34 years
Gender : Female
Hub. With clients: client's child
Profession : Housewife
2. Main complaint: clients complain of tightness.
3. Current disease history :
The client came to the emergency room on March 12, 2020 at 11:00
WITA, the client said that it was congested since 3 days ago
accompanied by coughing up phlegm, the client had previously taken
Neo napacin and comic medicine, the client worked as a feather
plucker without wearing a mask and had never been in control to the
puskesmas.
4. Past medical history :
The client said that he had never experienced a disease like this, but
before that he often had a flu, got dizzy.
5. History of hereditary diseases
The client's family says the client has no history of hereditary disease
from a previous family.
6. Genogram
X ////
////
Informatio :
/// : A sick family member
: in one family
X : man who died
: female
: male
7. primary assessment
a. airway
There is a secretion of the sputum of the client having difficulty
breathing, coughing, sounding wheezing.
b. Breathing
visible development of the right, left and symmetrical chest, the
client has difficulty breathing RR: 36 x / m, irregular rhythm, seen
using a breathing aid nebulizer.
c. Circulation :
TD : 130 /80 mmhg S : 36,0.C
N : 80x/m RR : 36 x/m
CRT : 2 detik
d. Disability :
client awareness composmentis with GCS (E4, V5, M6), the client
says it is difficult to breathe.
e. Exposurure :
hair slightly graying, scalp looks clean, no hematoma, no wounds,
brown skin and skin turgor both because the skin returns in about 1
second when pinched.
8. secondary assessment
a. level of awareness : hair slightly graying, scalp looks clean no
hematoma.
b. GCS : E4V5M6
c. Vital sign
TD : 130 /80 mmhg S : 36,0.C
N : 80x/m RR : 36 x/m
CRT : 2 detik
d. physical examination
1) Head: hair slightly gray, scalp looks clean, no hematoma.
2) Eyes: normal pupillary size, right / left pupillary light
stimulation (++)
3) Mouth: Dry lip mucosa
4) Nose: no plip, clean.
5) Ears: symmetrically clean, no cerumen
6) Neck: no enlarged teroid glands
7) Chest:
Inspection: symmetrical chest development, visible use of
muscle nebulizer breathing aids.
Palpation: vocal, right-left fremitus
Percussion: sonor
Auscultation : sounds wheezing.
e. Esktermitas: acral cold
Upper extremity: CRT 2 seconds no edema
Lower extremity: no edema.
9. AMPEL Assesment :
a. Allergy : no allergies
b. Medication : the client had previously taken the drug neo napacin
to relieve cough.
c. Postillness : client said before he had experienced flu, dizziness.
d. Environvment : client lives with his child the client lives near the
road and the client's environment is quite densely populated.
e. Lastmal : client said, it would be 2 hours before this morning
before being taken to the last health center to consume rice with
side dishes and drink water.
f. elimination status
Date elimination Frekuens color Incontinence
i and
constipation
12/042020 Urin 3x Yellow -
12/04/2020 Fekal 1x Yellow Solid
nutritional status
Date Days to Amount
12/042020 This 1 plate
morning
Fluids: clients drink 6-8 glasses a day every day
10. Therapy
Numbe Date type of Dose Indication
r therapy
1 12/03/2020 Combivent 3 ampul Bronchodilators
for asthma
2 12/03/2020 Salbutamol 4 mg Asthma and
other
conditions
related to
shortness of
breath.
B. Analysis data
No Data Etiologi Problem
Ds : Asthma cleaning the
client said tightness airway is not
accompanied by cough Increased secretion effective
with phlegm production
TD : 130 /80 mmhg
S:36,0.C
N:80x/m obstuction
RR:36x/m
CRT : 2 detik
client seemed
claustrophobic
Wheezing sounds
Cold acral
Dry lip mucosa is a
muscle aid for
breathing nebulizer
C. Nursing plan
No Dx Goals and results Plan SIKI Rational
. criteria
1 After taking nursing 1. Assess client's 1. To find out
actions for 1x30 condition the state of
minutes is expected : 2. Effective cough the client
The client breathes training 2. To remove
effectively a. Identification of excess
There is no secret coughing abilities secretions
Breathing aids are b. Assess for 3. To measure
not installed sputum retention the
no coughing c. Adjust the frequency
tightness position of the of breath
vital signs stable spring fowler- sounds
TD : 130/80 mmhg fowler
N : 60-70 d. Explain the
S: 36,6 purpose of an
RR: 16-20x/m effective cough
e. Encourage deep
inhalation
through the nose
for 4 seconds and
then hold it out
3. Respiration
monitoring
a. Assess the
rhythm
frequency
inside
b. Assess for
blockages
c. Palpate
pulmonary
expansion
d. Auskutsi
breath sounds
D. Implementation
date and Implementation response to results
time
12/03/2020 Assessing the state of Ds:
11: 10 the client client said the tightness
began to decrease after
being treated
11: 05 Pairing inhalation Do:
A nebulizer with a dose
of 1 ampoule combivent
dioplos 2cc nacl
11:20 Assessing vital signs TD : 13/60 mmhg
N : 75x/m
RR: 22x/m
S 36,0.C
11:25 Examine the sound of No breathing sounds
breath
E. Evaluation
Date and dx progress note
time
12/03/2020 1 Subjective :
11:30 The client says the tightness starts to take
medication after being treated
Objective:
TD: 13/60 mmhg
N : 75x/m
RR: 22x/m
S 36,0.C
Assesment: Destination partially resolved
Plan : The intervention continued at home with
Administration of salbutamol 3x1 / 4mg
