Lesson : ENGLISH VI

Lecturer : Framita Rahman, S.Kep.,M.Sc.

NURSING DOCUMENTATION

BY: GROUP II
IMMA AYU RIANI (19.01.058)
INDAH SARI (19.01.059)
JUMRIANI (19.01.060)
MELDA SANNY PM (19.01.061)
MILY INDIYANA (19.01.062)
NASMA (19.01.063)

SEKOLAH TINGGI ILMU KESEHATAN PANAKKUKANG MAKASSAR

PROGRAM STUDI S1 KEPERAWATAN (KONVERSI)
TAHUN AJARAN 2020

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 SURNAME : - FIRST NAME : -
AGE : 78 years old SEX : Male MARITAL STATUS : Married
OCCUPATION : -
PRESENT/CHIEF COMPLAINT :
A fever accompanied by coughing. The results of the temperature assessment
were 39 ° C, felt warm, and looked coughing, breathing 16 x / min, TD 110/70
mmHg, dry lips, and the client looked thin. Coughing up phlegm, since 4 days
ago, heard the sound of Rhonchi.
O/E
GENERAL CONDITION :
 Temperature were 39 ° C, felt warm, and looked coughing, breathing
16 x / min, TD 110/70 mmHg, dry lips, and the client looked thin.
EENT :
SUBJECTIVE DATA :
 The client's wife said that the client had not been given medication
 Cough with phlegm, since 4 days ago
OBJECTIVE DATA :
 The client looks coughing
 The body feels warm, with a temperature of 39o C
 Breathing 16 times / minute
 TD 110/70 mmHg
 lips appear dry
 the client looks thin
RS : Cough
CVS : -
GIS & NUTRITION : -
GUS: -
CNS : -
MSS & SKIN : -
PAIN : -
IMMEDIATE PAST HISTORY :
 There is no history of the patient's disease and no family has suffered

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 from the same disease
POINTS OF NOTE : -
INVESTIGATIONS : -
THERAPY/MEDICATION : -
NURSING DIAGNOSIS :
1. Ineffective walking cleaning associated with coughing
2. Lack of fluid volume associated with dry lip mucosa
3. Hyperthermia associated with the presence of disease
NIC :
NURSING DIAGNOSIS 1 :
1. Confirm the need for oral / tracheal suctioning
2. Instruct patient to rest and breathe deeply
3. Position the patient to maximize ventilation
4. Remove secretions by coughing or suction
5. Auscultate breath sounds, note any additional sounds
NURSING DIAGNOSIS 2 :
1. Maintain accurate intake and output records
2. Monitor hydration status (mucous membrane moisture, adequate pulse,
orthostatic blood pressure), if needed
3. Monitor vital signs every 15 minutes - 1 hour
4. Collaboration of IV fluids
5. Monitor nutritional status
6. Give oral fluids
NURSING DIAGNOSIS 3 :
1. Monitor temperature frequently
2. Monitor skin color and temperature
3. Monitor blood pressure, pulse and RR
4. Increase fluid and nutrient intake
5. Monitor hydration such as skin turgor, mucous membrane moisture
6. Compress the patient on the groin and axilla
EVALUATION
NURSING DIAGNOSIS 1 :

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 S:- The client's wife said that the client had not been given medication
- Coughing up phlegm, since 4 days ago
O : - The client looks coughing
- Heard the sound of Rhonchi.
A : Problem not resolved
P : Continue intervening
NURSING DIAGNOSIS 2 :
S:-
O :- Lips look dry
- The client looks thin
A : Problem not resolved
P : Continue intervening
NURSING DIAGNOSIS 3 :
S:-
O : The body feels warm, with a temperature of 39o C
A : Problem not resolved
P : Continue intervening

DATE/TIME NURSING REPORT

19-12-2020 / 09.00 a.m Monitor Vital Signs
19-12-2020 / 09.15 a.m Provide a comfortable position for the patient to maximize
ventilation
19-12-2020 / 10.00 a.m Compress the groin and axillary of the patient

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