English Leason Task Nursing Documentation

ENGLISH LEASON TASK
NURSING DOCUMENTATION
Created by :
Tuning Setiowati
NIM P07120216039
HEALTH POLYTECHNIC OF MINISTRY OF HEALTH YOGYAKARTA
NURSE DEPARTEMENT
2019
NURSING DOCUMENTATION
A. Patient Detail
1. Patient Identity
a. Name : Mrs.S
b. Date of Bith : 24 July 1963
c. Age : 55 years old
d. Sex : Female
e. Married Status : Widow
f. Civil state : Indonesia
g. Address : Yogyakarta
h. Occupation : Trander
i. Religion : Moslem
j. Last Education : Primary High School
k. Phone Number : -
l. Diagnoses : Dyspnue e.c suspec pneumonia, GEA
2. Next of Kin Identity

a. Name : Mr.Y
b. Date of Birt : 24 January 1984
c. Age : 26 years old
d. Sex : Male
e. Religion : Moslem
f. Occupation : Teacher of Senior High School
g. Relationship with the patient : Son
h. Phone Number : 089532932522
B. Medical Information
Primary health problem Patient has short breath since yesterday
Sign and Syntome Daughter of patient said patient has short breath and
also coughing sometimes since yesterday, patient
has diarrhea since four days ago, patient just ate for
two times a day. Patient has diarrhea 5x in a day
with liquid consistency.
Past Healthy Patient has been hypertension since 5 years ago

Last Meal Daughter of patient said patient ate something that
spicy before patient get diarrhea
Vital Sign - Blood Pleasure = 140/90 mmHg
- Respiration = 26 x/a minutes
- Pulse = 102 x/a minutes
- Body tempherature = 36,7oC
C. Peoblem of Patient
Assesment Problem
- Patient has short breath since Short breath
yesterday
- Vital Sign :
 Blood Pleasure = 140/90
mmHg
 Respiration = 26 x/a
minutes
 Pulse = 102 x/a
minutes
 Body tempherature =
o
36,7 C
- Daughter of patient said patient Diarrhea

ate something that spicy before
patient get diarrhea
- Patient has diarrhea 5x in a day
D. Invertation of Nurse
Diagnose Goal Implementation
Short Breathing After get treatment 2 days - Observation vital
short of breath of patient sign
can be recover with - Arrange half sitting
outcome : position of patient
- Respiration patient - Colabration with
16-20 x/minutes doctor about oxygen
therapy
Diarrhea After get treatment 3 days - Observation vital
short of breath patient can sign
ben recover with outcome : - Observation intake
- Patient not complain and output
diarrhea again - Colaboration with
nutritionist for diet
and fluid
- Colaboration with
doctor about IV
infusion
- Colaboration with
doctor about
antibiotik
E. Implementation
Date Implementation
18 July 2018 Patient visited in ward at 09.00 the condition of patient didn’t
At 14.00 connect during communication, she also has got short breath and
(Morning Shift) coughing sometimes, and she got diarrhea since four days ago and
she just eat for two times a day.
Vital sign :
- Blood Pleasure = 145/90 mmHg
- Pulse = 107 x/a minutes
- Body tempherature = 36,7oC
In emergency room at 08.15 o’clock with diagnoses dypsneu e.c

suspec pneumonia and GEA then doctor was give instructions to
put on IV infusion 20 drop a minutes and given 5 liters/minutes
oxygen therapy using nasal canul. Patient has diarrhea 5x in a day
Doctor instruct to give patient antibiotic cefotaxime 1gr/8 hours
with IV rute.
Nurse of ward
( Tuning)
18 July 2018 Patient said she still has short breath, patient looks pale and
At 20.00 patient also feel nauseous. Patient has still diarrhea 3x since
(Afternoon shift) afternoon with liquid consistency, food from hospital is not spent.
The vital sign :
- Pulse = 86x/a minutes
- Body Tempherature = 36,4oC
Patient has given antibiotic cefotaxime 1gr at 18.00 with IV rute,

IV infusion still put on 20 drop/minutes, patient has not allergic to
cefotaxime drug and continue the instruction from doctor to give
antibiotic cefotaxime.
Plan to take colaboration with nutritionist for diet and fluid
Take colaboration with doctor about antiemetik drug and give
motivation patient to eat a lillte but often
Nurse of ward
( Tuning)
19 July 2018 Patient has given cefotaxime drug 1 gr with IV rute, patient said
At 08.00 has still diarrhea 3x in the full night with liquid consistency and
(Night Shift) also still feel weak, and still feel short of breath.
The vital sign :``
- Respiration = 20x/ minutes
- Pulse = 85x/minutes
- Body temperature = 36.8oC
The IV infusion still put on 20 drop/minutes
The antibiotic cefotaxime 1 gr/8 hours and ranitidine drug 2 ml/8
hours is continue.
Doctor instruct to give ranitidin 1 ampuls/8 hours to treatmnet the
nauseous.
Nurse of ward
( Tuning)
20 July 2018 Patient has given ranitidine drug 2 ml and antibiotic cefotaxime 1
At 14.00 gr at 10.00 o’clock with IV rute,
(Morning Shift) Patient feel has not feel short of breath again and has diarrhea 4x
Vital sign :
- Respiration = 20x/menit
- Pulse = 84x/menit
- Body Temperatue = 36,7oC
Patient feel weak and not feel nauseous again, the IV infusion still
put on 20 drop/minutes.
Doctor give instruct to stop oxygen and loss the nasal canul.
Nurse of ward
( Tuning)
20 July 2018 Patient said not diarrhea again but patient still feel nauseous
At 20.00 Patient has given ranitidine drug 2 ml and antibiotic cefotaxime 1
(Afternoon Shift) gr at 18.00 o’clock. IV infusion still put on 20 drop/minutes.
Patiet feel more good than yesterday.
Vital sign :
- Blood pleasure = 130/80 mmHg
- Respiration = 20x/minutes
- Body temperture = 36,4oC
Doctor instruct to stop the cefotaxime drug and continue
ranitidine drug
Nurse of ward
( Tuning)
21 July 2018 Patient said not feel nauseous again and not diarrhea again.
At 08.00 Patient want to back home and patient has not problem health
(Night Shift) again. Patient has given ranitidine drug 2 ml and antibiotic
cefatoxime 1 gr at 06.00 o’clock.
Vital sign :
- Respiration = 20 x/minutes
- Body Temperature = 36,5oC
Doctor instruct to stop the drug and instruct to dischart planning.
Nurse of ward
( Tuning)
22 July 2018 Patient said has not problem health again. Patient was back home
At 11.00 at 11.00 o’clock.
(Morning Shift) Vital sign :
- Respiration = 20 x/minutes
- Body Temperature = 36,6oC
Stop Intervension
Nurse of ward
( Tuning)

English Leason Task Nursing Documentation

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ENGLISH LEASON TASK

HEALTH POLYTECHNIC OF MINISTRY OF HEALTH YOGYAKARTA

2. Next of Kin Identity

Primary health problem Patient has short breath since yesterday

Past Healthy Patient has been hypertension since 5 years ago

- Daughter of patient said patient Diarrhea

In emergency room at 08.15 o’clock with diagnoses dypsneu e.c

Patient has given antibiotic cefotaxime 1gr at 18.00 with IV rute,

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