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English task

Task 1 for the case study

1. Search and explain the patient's medical records

Medical records are records and documentation brisi file that contains the state of the
patient's condition, inspection, engobatan, actions and other services. but if examined
more deeply medical records have a meaning more complex, not just the usual record,
because the record is already reflected all the information regarding a patient who will
serve as the basis in determining further action in an attempt to service or other medical
action that is provided to a patient who came to the hospital.
2. Take the conversation or the setting of health care dirs.
One day a patient came to the hospital brought by his family and received by the clerk:
Patient: Good morning mba
Doctor: am also a mother, how can I help you?
Patient: yes my mba fever, headache since 5 days ago
Doctor: Who mother's name?
Patient: nurhalimah bias in the call imah
doctors: a mother from?
Patient: I am from Mantang, central Lombok
doctor: can I ask for number hpnya mother
Patient: 081732100234
Doctor: either the mother's number queue number 45 mothers can sit and wait in front of
Patient: Well mba thanks
Doctor: yes mother later sama2 clerk will call the appropriate number queue mother.
Patient: yes mba
Doctor: Please enter the number queue 45
Patient: mba iba thanks
Doctor: well then my mother used to Iyaa .Please Check mother climbed to the top
Patient: yes dock.
Doctor: Excuse me my mother would check the mother's body temperature before yes,
can lift my mother's armpit a little bet on the thermometer in the armpit good mother
mothers wait> 15 minutes, it thud.
Patient: yes mba
Doctor: mother's body temperature 38c
Patient: yes dock
Doctor: My mother either prescribe the medicine was yes, I love this mother the same
fever medication medicine mother mencretnya iya.silahkan take the medicine at the
pharmacy buk
Patient: Thank you dock
Doker: yes equally as may cepet healed.
3. Nursing care in patients with DHF
A. Patient identity
Name : ny. A
Age : 25 year
Religion : Islam
Profession : housewife
Gender : female

B. Data Pokus
1. Main complaint
Fever since five days ago, headache, no nosebleed, gums do not bleed
a. Airway : the patient's airway either no airway obstruction
b. Breathing
 Insfeksi: chest symmetrical shape
 Palpation: no lumps
 Percussion: normal voice
 Auscultation: no additional sound tersengar.
c. Circulation
 Public awareness: the patient was pale, decreased skin turgor, the eyes
appear sunken
 Blood pressure: 90/60 mmHg
 Temperature: 38 ° C
 Nadi: 80 x / minute
 RR: 18 x / minute
d. Disability
Examination of neurological status (GCS
E: 4 v: 5 m: 6
e. Exposure: no injury to the patient's body looked limp, body temperature: 38 C
f. Definity therapy: patients previously taking the drug paracetamol
2. History of present illness
Patients present with her husband at 11: 25 pm 8th april to ugd clinics rock
promontory patient complained of fever five days ago and headache, BAK
CHAPTER normal.
3. Past medical history
New patients were first treated this way.
C. assessment
1. lood: Blood pressure: 90/60 mmHg, Nadi: 80 x / min, RR: 18 x / min, temperature: 38
° C mucosa dry lips, decreased skin turgor
2. Breathing: normal breathing, there is no blockage, irregular breathing pattern
symmetrical chest wall movement.
3. Blater: patients do not experience an interruption in urination and defecation.
D. medical therapy
1. RL infusion
2. Inj. ranitidine
3. Pct 3x1
4. Dehaf 2x1
E. Data analysis

No Data Problem Cause

1. Ds: the client says they fever Hyperthermia associated Aedes agefty,
with dengue fever Antybody antigen
Do: s: 38 C infection process response,
N: 8O x / m Menosit stimulate cells,
RR: 18 x / m increased body cells,
increased body
temperature, increased
Tubu temperature

F. perioritas problem
Hyperthermia associated with dengue fever infection process.

G. nursing interventions

No Diagnose Objectives and expected Intervention

. outcomes
1. Hyperthermia associated After done action expected  observation TTV
with dengue fever 1x6O minutes at body  Encourage warm
infection process temperature with kritesia compresses
results:  Encourage lots of
 The body temperature drinking water
returned to normal 37 C  Collaboration in
 Impalpable patient's emberian
body heat antiseptic medicine
and intravenous

H. notes development

No. Diagnose Implementation Evaluation

Hyperthermia  mengopservasi TTV S: patients say fever
associated with dengue  recommends applying and headache to 5
fever infection process warm compresses nonexistent
 recommends drinking lots nosebleed, gums do
of water not bleed
 Collaboration in emberian O: body heat
antiseptic medicine and palpable, the patient
intravenous fluids was pale, looked
frail patients,
patients seem to
want to drink, the
patient looked at
compress, the
patient appears
inserted infusion.
A: the problem is
not resolved
P: interventions