NAME : Indriyani Eka Lani Oematan

NIM : 01.2 17.00609

ENGLISH TASK: ASKEP IN ENGLISH

STIKES RS. BAPTIS KEDIRI

NURSING STRATA 1
NURSING FORMAT

NAME OF STUDENT : Indriyani Eka Lani Oematan

NIM : 01.2.17.00609
ROOM : Wijaya Kusuma
DATE : June 02, 2020

1. Assessment
1.1 Patient Identity
Name : Ms. J
Age : 14 years
Religion : Islam
Gender : Female gender
Marital Status : Not Married
Education : Middle School
Profession :-
Insurance : BPJS
Ethnic groups : Indonesia
Address : Ward
Date of Entry : June 1 2020
Date of Assessment : June 2, April 2020
Registration Number : 808743
Medical Diagnosis : Scabies

1.2 Medical History

Main complaint :
The patient said pain, pain like burning, pain in the neck area, pain scale 5, pain
persisted since 4 days ago.

Current medical history:

On April 21 2020 the patient was taken to the emergency room, previously 4 days
ago the patient complained of itching, until pain, burning pain, pain in the neck
area, pain scale 5, persistent pain, the patient's face grimaced in pain, the patient
complained that the body felt warm, by the doctor is then examined and diagnosed
with scabies, the patient is advised to be hospitalized so that it gets the right
treatment, the patient and family agree, finally being taken to the wijaya kusuma
room.

Past Medical History:

The patient said he did not have a history of scabies or a history of other diseases.
Family Health History:
the patient said he had a history of diabetes from his mother.

GENOGRAM

: Male : Line of descent

: Women : Only one house left
: Marriage Line : Patient
X : Dead

Sociocultural History:
Before getting sick: Pasin has good relations with family and community, often
playing with his peers.
When sick: the patient has good relations with family and community as
evidenced by family and neighbors who are visiting, responsive and cooperative
with medical actions.

Review the Pattern of Healthy Pain

The patient said that if the patient or sick family were immediately taken to the
nearest health center or health clinic

Gordon's health function pattern

1. Pattern of Perception and Health Management
Clients often eat colored foods, and are ready to serve.
2. Nutrition and metabolic patterns
When healthy: eat 3 times a day (rice, side dishes, vegetables) portions out
Drink 7-8 glasses / day ± 800 cc
When sick: eat 3 times a day (rice, side dishes, vegetables)
 Drink 7-8 glasses / day ± 800 cc
3. Elimination Pattern
When healthy: CHAPTER 1x / day normal consistency
BAK 4-5 x / day
When sick: CHAPTER 2x / day
BAK 3 times / day
4. Activity and Exercise Pattern
When healthy: Patients say patients go to school and play
When sick: patients cannot go to school and play only lying on a hospital
bed.
5. Cognitive patterns and perceptions
Patients can communicate well, able to understand questions and answer
questions given by nurses properly, it's just that patients look embarrassed
by the state of pain in front of the nurse.
6. Self-Concept Perception Patterns
The patient says a child is still in school.
7. Sleep and rest patterns
When healthy: noon: Patient rest 2 hours
Night: Patient sleeps 8 hours
When sick: noon: the patient has difficulty sleeping due to itching
Night: the patient sleeps briefly and is easily awakened due to pain and
itching
8. Patterns of roles and relationships
The patient said he was a child born of mother and father
9. Sexual-Reproductive Pattern
Patients are male.
10. Stress-coping Tolerance Pattern
Patients say if problems that are felt to bother the patient always talk about
it to mom and dad
11. Value-Trust Pattern
When healthy: patients diligently pray 5 times, diligently following the
activities in the mosque
When sick: patients only pray on the hospital bed.

1.3 Physical Examination

a. General Conditions
Compositional awareness, the patient looks grimaced in pain, the patient
often scratches a lump in the neck, there is a lesion that is scratched on the
neck of the skin, the patient looks covered and the skin is reddish.
b. Vital sign
Temperature: 37.5º C
Pulse: 92 times / minute
Breath: 21 times / minute
Blood Pressure: 110/90 mmHg
c. Head
I: black hair, clean. There are no lumps
P: There is no tenderness
d. Eye
 I: isochorism, red conjunctiva, red sclera,
P: palpebral edema is not palpable
e. Nose
I: no injuries, no bleeding
P: No palpable lumps, no tenderness
f. Ear
I: dirty ears, no injuries
P: No palpable lumps, no tenderness
g. Mouth
I: pale lip mucosa, no lesions
h. Neck
I: There are lumps, red bumps spread to the right neck, there are scratch
marks.
P: No palpable swelling of the thyroid gland, no tenderness
i. Integumentary / skin and nail examination:
Skin: skin appears reddish, there are bumps, there are lesions scratched
with lumps.
Nails: long, dirty nails
j. Chest and back Chest
I: symmetrical, no abnormalities in the chest
A: vesicular breath sounds in all of the chest
Per: left and right sonor
P: not felt benjoan, no tenderness
Back: no back abnormalities (such as skleois, kyphosis and lordosis)
k. Abdomen
I: symmetrical, no lesions, no lumps
A: Normal bowel sounds
P: There is no enlargement of the liver or spleen
Per: tympani
l. Extremities
RL Q 24 hour infusion was placed in the right hand
MMT : 5 5
5 5
Can withstand maximum weight and is able to resist gravity
m. Genetalia
Catheter not installed
n. Anus
Not reviewed

1.4 Medical Support Data (Diagnostic Examination)

Laborat date: June 2 2020
WBC 22,62 K/ul 1.1– 10.9 K/ul
RBC 4.79 K/ul 4.20 – 6.30 M/ul
HGB 11.9 g/dl 12.0 – 18.0 g/dl
HCT 35.1 % 37.0 – 51.0 %
 MCV 73.3 fl 80.0 – 97.0 fl
MCH 24.8 pg 26.0 – 32.0 pg
MCHC 33.9 g/dl 31.0 – 36.0 pg
PLT 441 k/ul 140. – 440 K/ul
LYM 2.3 % 0.6 – 4.1 %
MID 0.5 % 1.0– 1.8 %
GRAN 3.6 % 20. – 7.8 %
K+ 3.23 ME q/L 3.6 – 5.0 ME q/L
Na+ 131 Me q/L 136 – 145 Me q/L
Glukose sesaat 113 <200 mg/dl
Cl- 109 95 – 105 Mmol/L
Calsium 9.5 8.8 – 10.0 mg/dl

1.5 Additional Data (Management)

Ranitidine 150 mg BID PO
Sanmol 1 gram Q 6 hours if 38ºC IV
Dermazin Zalf BID PO
Tramadol 50 mg IV Q 8 Hours PRN sick PO
Cefriaxone 2 x 1 gr IV

Kediri, 02 June 2020

Collage student

(Indriyani Eka Lani Oematan)

 DATA ANALYSIS

PATIENT'S NAME : Ms. J

AGE : 14 years
NO. REGISTER : 808743

NO SOFT DATA RELATED FACTORS / NURSING

OBJECTIVE DATA RISK (E) (NANDA)
SUBJECTIVE DATA PROBLEMS

1. DS: The patient said Inflammatory response and Acute pain

pain, burning pain, increased local pressure due
neck pain, pain scale 5, to biological injury agents
persistent pain.
 
DO: - There are lumps,
lesions with neck
scratches
- the patient's face
grimaces in pain Pain
scale 5

2. Ds: The patient said to Immunodeficiency Damage to skin

feel itchy integrity

Do:
- Itching - gatakl necked
- Frequently scratching
the neck
- There are lumps and
lesions in the neck
 LIST OF NURSING DIAGNOSIS PATIENT'S

NAME: Ms. J
AGE: 14 years
NO. REGISTER: 808743

NO DATE NURSING DIAGNOSES THE DATE SIGNATURE

APPEAR LIMITED
1. 02 june 2020 Acute pain associated with O2 June 2020
inflammatory responses
and biological injury
agents characterized by
patients saying pain, pain
such as burning, pain in
the neck area, pain scale 5,
persistent pain. There are
lumps, lesions with neck
scratches. the patient's face
grimaced in pain

2. 02 june 2020 Damage to skin integrity 02 June 2020

associated with
immunodeficiency is
indicated by the patient
saying feeling itchy,
itching - neck pain,
frequent scratching on the
neck.
There are lumps and
lesions in the neck
 NURSING PLANNING

PATIENT'S NAME: Ms. J

AGE: 14 years
NO. REGISTER: 808743

1.NURSING DIAGNOSIS: Acute pain associated with biological injury agents

1. NOC: Pain Level
a. Reported pain is increased in 4
b. Facial pain expression is increased at 4
c. Breath frequency is increased at 4
d. The radial pulse rate is increased at 4
e. Blood pressure is increased at 4
2. NOC: Pain: disturbing effect
a. Discomfort is increased at 4
b. Impaired role appearance improved at 4
c. Disruption in routine is increased at 4
d. Disturbances in activities of daily living are increased at 4
e. Difficulty in maintaining employment is increased at 4
f. Disorders enjoy life enhanced at 4
g. Disruption of physical activity is increased at 4

Note: (retained / enhanced) cross out on

2.Nursing Diagnosis: Damage to skin integrity
1. NOC: tissue integrity: skin & mucous membranes
a. Skin temperature is increased at 4
b. Sensation is increased at 4
c. Texture improved on 4
d. Tissue perfusion is increased at 4
e. Skin integrity is enhanced at 4
f. Lesions on the skin are improved at 4
g. Necrosis is increased at 4
2. NOC: allergic response: systemic
a. The itching of the whole body is improved at 4
b. Itchy skin edema that is enhanced in 4
c. The increase in skin temperature is increased at 4
d. Fever is increased at 4
e. Muscle aches are increased at 4
f. Joint pain is improved at 4

Note: (retained / enhanced) cross out one

 NURSING PLANNING

PATIENT'S NAME : Ms. J

AGE : 14 years
NO. REGISTER : 808743

NURSING
NO INTERVENTION RATIONAL
DIAGNOSES
1. Acute pain is Pain Management 1. To assist in the
related to the 1. Investigate pain assessment of
inflammatory complaints, note patients and to
response and location, pain intensity, determine
biological injury and scale interventions that
agents are 2. Instruct the patient can be carried out
characterized by to report pain 2. Early
the patient saying immediately upon intervention in pain
pain, pain such starting control facilitates
as burning, pain 3. Monitor vital signs muscle recovery by
in the neck 4. Explain the causes decreasing muscle
region, pain scale and consequences of tension
5, persistent pain. pain to the client and 3. Autonomic
There are lumps, his family responses include,
lesions with neck 5. Encourage rest changes in BP,
scratches. the during the acute phase pulse, RR, which
patient's face 6. Encourage the are associated with
grimaced in pain techniques of pain relief
construction and 4. With the cause
relaxation and effect of pain
7. Give a conducive the client is
environmental expected to
situation participate in
Collaboration with the treatments to
medical team in giving reduce pain
medication as 5. Reducing pain
indicated aggravated by
movement
6. Reduces muscle
tension, increases
relaxation, and
enhances your
sense of control and
coping abilities
7. Providing
support (physical,
emotional,
increasing sense of
control, and coping
abilities)
 Eliminating or
reducing client pain
complaints
2. Kerusakan Skin care 1. Shirt / bandage
intergritas kulit 1. Encourage the
pressure minimizes
berhubungan patient to wear loose
dengan clothing scarring by keeping it
imunodefisiensi 2. Avoid wrinkles on
flat, soft and soft.
ditandai dengan the bed
Pasien 3. Keep the skin clean 2. Avoid long-term
mengatakan to keep it clean and dry
pressure on the
merasa gatal, 4. Monitor the skin for
Gatal – gatal redness tissue, reduce the
dileher, Sering 5. Bathe the patient
potential for tissue
mengaruk di with soap and warm
bagaian leher water ischemia / necrosis
Terdapat
and the formation
benjolan dan lesi
di bagian leher of pressure sores
3.Clients who
experience skin
disorders that must
always be cleaned.
If not, the skin can
become a medium
so bacteria can
enter
4.Shows the
inflammatory
process.
5. If not cleaned,
the skin can
become a medium
so bacteria can
enter. Antiseptic
soap is
recommended
.
 NURSING ACTIONS

PATIENT'S NAME: Ms. J

AGE: 14 years
NO. REGISTER: 808743

NO NO.DX DATE / NURSING ACTIONS SIGN

HOUR HAND
1. 1 02 June 20
14.00 1. Ask for complaints of
pain, pay attention to
location, pain intensity,
and scale
• Pain like burning
sharp objects, in the
14.05
bump area, scale 5

2. Monitor vital signs

• Temperature: 37.5º C
14.10 Pulse: 92 times / minute
Breath: 21 times /
minute
Blood Pressure: 110/90
14.15 mmHg

3. Explain the causes

and consequences of
14.20
pain to the client and
his family
• Due to pain from the
effects of inflammation
14.00

4. Instruct techniques of
relaxation and
relaxation
 • Teach deep breathing
relaxation techniques

5. Give a conducive
environmental situation
• Set the room
temperature and keep
the environment calm

6. Collaboration with
the medical team in
giving medication as
indicated:
• Ranitidine 150 mg
BID
Sanmol 1 gr Q 6 hours
if 38ºC

Dermazin Zalf BID

Tramadol 50 mg IV Q 8
Hours PRN sick
Cefriaxone 2 x 1 gr

2 2 14.00 1. Explain to patients /

people closest to the
dosage rules, and the
effects of treatment and
restrictions on sexual
activity that can be done.
2. Explain the
importance of antiviral
treatment.
14.05 3. Improve healthy ways
of life such as good food
intake, balance between
16.10
activity and rest, monitor
health status and the
presence of infection.
4. Explain to patients
that they can infect
14.15 others.
Identification of
supporting sources that
make it possible to
maintain the necessary
home care.
 NURSING ACTIONS

PATIENT'S NAME: Ms. J

AGE: 14 years
NO. REGISTER: 808743

NO NO.DX DATE / NURSING ACTIONS SIGN

HOUR HAND
1. 1 02 June 20 1. Ask for complaints
14.00
of pain, pay attention
to location, pain
intensity, and scale
• Pain like burning, in
14.05
a lump area, scale 3

2. Monitor vital signs

Temperature: 37º C
Pulse: 88 times /
14.10
minute
Breath: 20 times /
minute
Blood Pressure:
14.15
110/80 mmHg

3. Asking the client

14.20
the cause and effect
of pain that was
explained yesterday
• The client is able to
14.00
explain the cause and
effect of pain

4. Ask the client how

the techniques of
construction and
 relaxation
• Clients can explain
deep breathing
relaxation techniques

5. Give a conducive
environmental
situation
• Set the room
temperature and keep
the environment calm

6. Collaboration with
the medical team in
giving medication as
indicated:
1. Ranitidine 150 mg
BID
2. Sanmol 1 gr Q 6
hours if 38ºC
3. Dermazin Zalf BID
4. Tramadol 50 mg
IV Q 8 Hours PRN
sick
Cefriaxone 2 x 1 gr
2 2 14.00 1. Ask the patient / closest
person about the dosage
rules, and the effects of
treatment and restrictions
on sexual activity that was
explained yesterday.
• The client is able to
explain the dosage rules,
 and the effects of
treatment and restrictions
14.05
on sexual activity

15.10
2. Ask about the
importance of antiviral
treatment that was
explained yesterday.
15.30 • The client is able to
explain the importance of
16.00
antiviral treatment.

3. Asking about healthy

ways of living such as
good food intake, balance
between activity and rest,
monitoring health status
and the presence of
infections that were
explained yesterday.
• Clients are able to
explain healthy ways of
life such as good food
intake, balance between
activity and rest, monitor
health status and the
presence of infection.

4. Ask the patient that

they can infect others.
• The client is able to
explain about
transmission

Inquire about supporting

sources that make it
possible to maintain care
at home.
 EVALUATION

PATIENT'S NAME: Ms. J

AGE: 14 years
NO. REGISTER: 808743

No Date DX Evaluation
1. 02 June 2020 1 S: The patient says it still hurts in the
lump area

O: There are scratch marks

      the patient's face grimaced in pain
      Pain scale: 5

A: the problem has not been resolved

P: Intervention is continued
     NOC: Pain level
                 Pain: irritating effects
      NIC: Pain management
2. 02 June 2020 2 S: The patient says itchy lumps are still
there
O: itchy, itchy neck, often scratching the
neck
There are lumps and lesions in the neck

A: the problem has not been resolved

P: Intervention is continued
      NOC: tissue integrity: skin &
mucous membranes
allergic response: systemic
      NIC: skin care
 NOTES OF DEVELOPMENT

PATIENT'S NAME: Ms. J

AGE: 14 years
NO. REGISTER: 808743

No Date DX Evaluation
1. 02 June 2020 1 S: The patient said that the pain from the lump was
reduced

O: There are scratch marks

      patient's face looks
      Pain scale: 3

A: the problem is partially resolved

P: The intervention is continued delegated to the

nurse

2. 02 June 2020 2 S: The patient said itching decreased

O: feel Itchy neck itchy, often scratched at the neck
There are lumps and lesions in the neck

A: the problem is partially resolved

P: The intervention is continued delegated to the
nurse