INDIVIDUAL TASK

ENGLISH SUBJECT

FIND DIFFICULT VOCABULARY AND MAKE A NURSING CARE

Student Name : Aulia Tavian

Student ID Number : 616080717005

Lecturer Name : Ns. Masitoh Tampubolon, S.Kep

Study Program : Sarjana Keperawatan dan Pendidikan Profesi Ners

Date of Assignment : Thursday, 30 April 2020, at 06.00 PM

Due Date : Wednesday, 06 May 2020, at 01.00 PM

Program Studi Sarjana Keperawatan dan Pendidikan Profesi Ners

Institut Kesehatan Mitra Bunda Batam

T.A 2019/2020
 FOREWORD

Bismillahirahmanirrahim,

Assalamualaikum warohmatullahi wabarokatuh

In the name of Allah, the Most Compassionate, the Most Prayerful, we pray and give thanks for His
presence, who has bestowed His mercy, guidance, and inayah to us, so that I can complete this
individual task.

I have arranged this individual task to the maximum and received help from various parties so that it
can facilitate the making of this individual task. For that I express many thanks to Mrs. Ns. Masitoh
Tampubolon, S.Kep. As a supporting lecturer and all parties who have contributed in making this
Individual Task.

Despite all that, I fully realize that there are still many short comings both in terms of sentence
structure and grammar. Therefore, with open arms I accept all suggestions and criticisms from
readers so that I can improve on this task.

That's all and thank you for the attention, I hope that this individual task can provide benefits and
inspiration to readers, especially writers.

Wassalamualaikum warohmatullahi wabarokatuh

Batam, 01 May 2020

Author
Find difficult word!

No. English Indonesia

1 Chest pain Nyeri dada
2 Severity Kerasnya
3 Neck vein distention Distensi vena leher
4 Pacemaker Alat pacu jantung
5 Congestion Kemampetan
6 Nausea Mual
7 Hydration Hidrasi
8 Gravida kehamilan
9 Breast lump Benjolan pada payudara
10 Vagina Discharge keputihan
11 Sexually transmitted disease Penyakit menular seksual
12 Last menses Menstruasi terakhir
13 Seizures kejang
14 Tics Berkedut
15 Weakness Kelemahan
16 Spinal cord injury Cedera tulang belakang
17 Head injury Cedera kepala
18 Tremor getaran
19 Syncope Sinkop (keadaan pingsan)
20 Equal grip strength Kekuatan pegangan yang sama
21 Difficulty swallowing Kesulitan menelan
22 Paralysis Kelumpuhan
23 Clammy Basah,lembab,dingin
24 Integrity Integritas
25 Bruising Memar
26 Pallor Muka pucat
27 Jaundice Penyakit kuning
28 Worse Lebih buruk
29 Flat datar
30 Blunt Tumpul
31 Hopeless Putus asa
32 Helpless Tidak berdaya
33 Inappropriate Tidak pantas
34 Neat Bersih,rapi
35 Disheveled Kumal, lusuh, tidak rapi
36 Agitated, anxious Gelisah
37 Appropriate Sesuai
38 Combative Agresif
39 Guarded Berhati-hati
40 Hostile Berseteru
41 Somber Muram
42 Silly Bodoh
43 Sullen Cemberut
44 Tearful Menangis
45 Threatening Mengancam
46 Violent Kasar
47 Withdrawn Ditarik
48 Wound Luka
49 Bruise Memar
50 Blister Lepuh
Patient Name: Mr. D Date: 14 January 2020 Time: 01.08 PM MR : 90.54.42

B/P Sit Standing Lying Temp 37,9oC Radial Pulse 90x/minute Ht 170 cm Wt 58kg
R
L Lab Collected___________________________________________________

Review of Systems Nursing Assessment Check, circle or fill in the blank as

applicable_____________

Cardiovascular Severity ______________ ___Hypotension

___Arrhythmia _______ Pitting ___Hx of MI

___Chest pain _______Non-Pitting ___Palpitations

___Neck vein distension ___Peripheral pulse ___Pacemaker

___Edema – ___Wt gain

Location___________ ___Hypertension
 ___Hematuria ___Syncope
___Incontinent ___Equal grip strength
Respiratory
___Hx prostrate problems ___PERLA
√Rales/Wheeze
___Frequency/Urgency ___Vertigo
√ Cough
___Catheter ___Difficulty swallowing
___Congestion
___Distension ___Paralysis
___Trach
Skin
___COPD √ Warm /dry
√Dyspnea/SOB ___Cool
___Orthopnea √Clammy
√ Sputum color Reproductive
___Integrity (* body
√ Oxygen Gravida/Para _____________ audit)

___Hyst / Vasectomy ___Bruising (* body

Gastrointestinal audit)
___Breast lump / discharge
___Sexually transmitted disease ___Pallor
√ Nausea /vomiting
Last menses _____________ ___Jaundice
___Hydration
___Vag / Penile discharge ___Cyanosis
___Constipation /
Diarrhea
___B.S. present
Neurological Activity
___Hepatitis ___Ad-lib
___Headaches
___Incontinence ___Bed or chair bound
___Seizures
___Colostomy Equip for ambulation
___Tics _______
√Anorexia/Bulimia
___Weakness
Last BM _________________
___Hx CVA
-Skeletal
___Spinal cord injury
Genitourinary ___Balance / Gait
___Head injury
___Arthritis
Urine color yellow ___Parkinson
___Chronic Pain
√Urine odor ___Tremor
___Weakness
___UTI ___Posturing
___Muscle wasting
___Pain ___S/S EPS
___Restricted movement
(Circle) RA LA RL LL Eye Contact Sight
Fair Good Poor ___WNL (inc. correction)
Sleep Pattern
Hr per night ±5 hour ___Impaired
___Day sleeping Orientation
___Person
___Difficulty falling
asleep ___Place
Hearing
___Difficulty staying ___Time ___WNL (inc. correction)
asleep
___Event ___Impaired
___Dreams
___Early awakening
Nutrition Pain
___Insomnia Diet _____________ Level 1-10:
___Restless Meals per day 3 times Best___ Worse___ Now___
___Nightmares a quarter serving Onset ____________
Supplements______ Location ____________
LOC Appetite come down Quality ____________
___Alert
Anorexia / Bulimia Duration ____________
___Drowsy
___Wt loss + / - 10 lb in last 3 mo Caused by ____________
___Lethargic
Relieved by ____________

___Mute Hallucinations
Memory intact YES NO ___Auditory
___Obscenities
Remote ____ ____
___Visual/Lewy body
___Pressured
Recent ____ ____ symptoms
___Rambling
Immediate ___ ____ ___Tactile
___Rapid
___Olfactory
Speech / language ___Reserved
___Gustatory
___Blocking
___Word Salad
Mood
___Circumstantial ___Labile
√ Clear ___Elevated
___Content Appropriate ___Depressed
___Loud √ Pleasant
___ Angry
Affect ___Unworthy ___Combative
___Flat
___Homicidal √ Cooperative
___Blunt
___Suicidal ___Guarded
___Sad
___Injury/ self harm ___Hostile
___Hopeless/Helpless
___Irritable
____ Inappropriate
Grooming / Hygiene ___Isolative
____ Bright ___Appropriate dress
___Labile
√ Clean
___Manic
Thought Content ___Neat
___Manipulative
___Tangential
___Disheveled
___Pacing
___Confused
___Unclean
___Delusional ___Pleasant
___Depersonalization ___Sad
Behavior
___Disorganized ___Silly
___Aggressive
___Flight of ideas ___Somber
___Agitated
___Fragmented ___Sullen
___Angry
___Goal directed ___Tearful
___Anxious
___Grandiose ___Threatening
___Appropriate
___Obsessed ___Uncooperative
___Apathetic
___Paranoid ___Violent
√ Calm
___Perseveration ___Withdrawn
___Childlike
√ Religiosity

Allergies: (medication, foods, contact)

the patient has no history of allergies

Body Audit
Wound Assessment (Score by keys below)
W=Wound
B=Bruise S=Scar IV=IV site R=Rash Stage for Pressure ulcers
D=Decubitis
Undermining (4) ________________ I–
IV Non-blanching erythema
site
Surrounding tissue (5)________________ II –
#1 #2 #3 Blister, skin break
Location/# __________ Tunnel ________________ III –
Break exposing subcutaneous skin
Location Left side
IV
Insertion date 14 January 2020
– Break exposing muscle, bone or tendon
Stage -pressure ulcers (I-IV)________________
Preventative Skin Measures: Specialty bed,
Dressing date 14 January 2020
pressure relief device, other
Size ________________ _______________________________________________

Tubing date __________ Infectious Disease:________________________ *

Observe Universal precautions
Depth ________________
S/S infection __________
Purpose of Visit
Wound bed color (1) ________________
Patency __________
Skilled observation / Asmt/ Procedure
Drainage (2) ________________ Instruction Medication
Other __________ Other_________

Odor (3) ________________ R/T___________________

Wound edges ________________ √Discharge plan ___ Management
___Care Plan Update
___Teaching material ___ Response
√Discharge Planning
___Disease Process ___ Administration
___Psychological and behavioral assessment
___Diet
___ Compliance
___Initial assessment
√Intervention
Narrative report including head to toe summary of
problems:__________________________________________________

- the patient said coughing for about a month, coughing up phlegm, and coughing up blood
twice, patients also experience fever, nausea, lack of appetite, dyspnea, dry lip mucosa

N DATA ANALYSIS NURSING DIAGNOSIS

o
DATA SOURCE Significant Findings Nursing DX : Write
all applicable in
PES Format
1 Problem :
Subjective Data
-the patient said coughing up phlegm cleaning the airway
accompanied by blood is not effective
-the patient said tightness

Physical Assesment
Etiology (related
- the patient looks crowded
vital sign : to)
- BP 130/80 mmHg hypersecretion in
- HR 90x/minute
the airway
- RR 24x/minute
- Temp 37,9oC
Physician’s Orders
- IVFD NaCl 0,9% + Carbazhucrome Signs &Symptoms
 1amp/ 8 hour (as evidence by)
- Inj. Ceftiazoxime 3x1 mg
cough with phlegm,
- Inj. tranexamic acid 3x500mg
coughing up blood,
- 1x4 tab anti-tuberculosis drug
shortness of breath,
initial phase
- 3x10 mg Codein
- 4 liter nasal cannula oxygen
therapy

2 Subjective Data Problem :

- the patient says nausea
- the patient says appetite decreased nutritional
imbalance is less
Objective Data than the body's
- patients only eat a quarter of the needs
food provided
Physical Assesment
- the patient looks weak
- dry lip mucosa Etiology (related
to)
vital sign :
- BP 130/80 mmHg anorexia, nausea
- HR 90x/minute
- RR 24x/minute
- Temp 37,9oC Signs &Symptoms
(as evidence by)
Physician’s Orders
- Inj. Ranitidine 2x1 amp nausea, decreased
appetite, dry lip
mucosa

3 Subjective Data Problem :

- the patient said fever
hyperthermia
Physical Assesment
- the patient looks weak
- dry lip mucosa Etiology (related
- the patient feels warm
to)
vital sign :
- BP 130/80 mmHg disease infection
- HR 90x/minute process
- RR 24x/minute
- Temp 37,9oC
 Signs &Symptoms
Physician’s Orders (as evidence by)
- encourage the patient to drink
plenty of mineral water Fever, skin feels
warm, dry lip
- encourage the patient to do a warm
mucosa
compress

NURSING CARE PLAN

No Nursing Diagnosis Expected Outcome & Nursing Actions

. Criteria for Measuring
1 Problem : -General good -observation of vital signs
-vital signs within normal -general state observations
cleaning the airway is not
limits -observation of breathing
effective
-shows the patent airway patterns
-not crowded -sputum monitor
-effective cough -position the patient as
Etiology (related to)
-not cyanosis comfortable as possible
hypersecretion in the -no additional breath (fowler, semifowler)
airway sounds -teach deep breathing
techniques
-teach effective cough
Signs &Symptoms (as -recommend drinking warm
evidence by) mineral water
-give oxygen therapy as
cough with phlegm, indicated
shortness of breath -give nebulizer therapy
-collaboration with the
medical team in providing
bronchodilator therapy
2 Problem : - general good - observation of vital signs
- vital signs within - general state observations
nutritional imbalance is
normal limits - monitor nausea vomiting
less than the body's needs
- ideal body weight - monitor nutrition input
 according to height and output
- there are no signs of - skin turgor monitor
Etiology (related to)
malnutrition - assess for food allergies
anorexia, nausea - no significant weight - weigh weight regularly
loss occurred - recommend eating a little
- spend the portion of but often
Signs &Symptoms (as food that has been - recommend eating while
evidence by) provided warm
- recommend eating foods
nausea, decreased appetite that are high in fiber
- collaboration with
nutritionists in nutrition
fulfillment
- collaboration with the
medical team in the
provision of medication
therapy
3 Problem : - general good - observation of vital signs
- vital signs within - general state observations
hyperthermia
normal limits color monitor and skin
- body temperature in temperature
the normal range - monitor fluid intake
Etiology (related to)
- no skin discoloration output
disease infection process - no dizziness - assess for signs of
- no sign of dehydration dehydration (dry skin, dry
- free from cold mucosa, cold acral, slow
Signs &Symptoms (as pulse, decreased skin
evidence by) turgor)
- encourage the patient to
Fever, skin feels warm drink plenty of mineral
water
- encourage the patient to
do a warm compress
- encourage the patient to
wear thin clothing and
absorb sweat easily
- collaboration with the
medical team by
providing antipyretic
therapy