TUGAS BAHASA INGGRIS

NIM : 01.2016.132 NAMA : AMAL HAYATI

STIKES KURNIA JAYA PERSADA PALOPO

2017

NURSING CARE REPORT

A. Patients identitiy

1. Name : Mrs. S
2. Age : 42 th
3. Sex : Female
4. Addres : Kampiri
5. Nationality : Buiginese
6. Education : senior High School
7. Ocoipation : Hausewife
8. Marital Status : Married
9. Religion : Moeslim
10.Date of Assesment : 7 th April 2017
11.Source of Information : Child Patients
12.Date Of Adimission : 7 th April 2017

B.Patiens History

Patients Chief Complain on admission

Complains Of Abdominal Pain
Patients Current Medical Case History
Patients say tahat every morning after waking up the patients of ten feel pain
in his left abdomen. The pain was just as squeezing and feels the
heat.Patients complain of nausea and vomiting which make patients
decreased appetite.
The patients said this complaint occurred almost a week until finally taken to
the hospital

Patients past medical case history

Patients say that once admitted to the hospital with the same disease
(gastritis) 1 year ago and was given an antacid medicine.

Patients family medical history

In families that have no hereditary diseases such as diabetes and
hypertension as well as infectios diseases such as tuberculosis.

Medical diagnosis
Gastritis

Intervention
1. Give Small meals but often
2. Serve food in warm and varied
3. Encourage you to avoid foods that are spicy and gassy, and caffeine
4. Give Intravensa therapy
5. Assess the leved of pain
6. TTV Observation on the client
7. Create a Comfortable environment.
C.Current Assessment ( Before and After Admission )

Perception and helath

Before entering hospital : The patient assumes that the illness is often
recurrent and will also heal it self
After admission : Diseases suffered by the patient
should be trated immediately so as not to cause bleeding in the
stomach.
Nutritional metabolic pattern
Hospital dietary
Before entering hospital : The patient is not on a diet foods
After admission : Patients do spicy food taboss, gassy
Food Intake
Before entering hospital : Irregular eating 1 -2 x a day
Eat always runs in one portion
Said patients do not have a challenge to
food

After admission : Patiens say the morning just to eat

porridge run out potion because the patients felt sick
every time I want to eat and frequently vomited after eating the
patients
Liquid intake
At Home : Patients drink 6 -7 glasses ( 1500 1700 cc ) every
day
In The Hospital : The Patienss drinking water runs out 4 -5 glasses
( 1000 1100 cc ) every day and assited with intravensa fluid
administration.

D.Elimination Pattern

Bowel Movenment
Before entering the Hospital : patients defecation 1 x a day
After entering the hospital : new patients 1 x defecation since entering
hospital
Bladder
Before entering the Hospital : patients urinate 5 6 x a day 100 ml
every time urinate
After entering the hospital : patients urinate 3 4 x a day 75 ml
every time urinate