NAMA : Said Ahmad Farid Rahman

NIM : P07220419041

PRODI : Sarjana Terapan Keperawatan & Profesi Ners Tk. 2

MATA KULIAH : Bahasa Inggris

DOSEN : Amiruddin, SS., M.Hum

1. Bacalah dengan cermat narasi catatan tindakan keperawatan (case study) berikut ini dan
buat nursing report sesuai format (tabel 5).

Case : 11/26/2019

Pt 4 hr post op; awakens easily, oriented X3, incision site in front of I ear extending down
and around the ear and into neck – approximately 6” inch length—without dressing. No
swelling or bleeding, bluish discolorization below I ear noted, sutures intact. Jackson-Pratt
drain in I neck below ear with 20 ml bloody drainage measured. Drain remains secure in
place with suture

and anchored to I anterior chest wall with tape. Pt denied pain but stated

she felt nauseated and promptly vomited 100 ml clear fluid. Pt attempted to get oob to
ambulate to bathroom with assistance, but feel dizzy uponstanding. Assissted to lie down in
bed, and help pt to void in bed. voided 200ml clear, yellow urine in bedpan. Pt encourages to
deep breath and coughqhr, and turn frequently in bed. Lungs sound clear bilaterally, anti
embolisme

stocking applied to both lower extremities. Explanation has given regarding these preventive
measures. Pt verbalized understanding _____ Ns. Monika

23.00. Pt continuous to feel nauseates. Compazine 1 mg IV___ Ns Larasati.

23.35. Pt states she’s no longer nauseated. No further vomiting, rating pain incisional area as
7/10; on scale 1-10, Medicated with morphin 2mg IV ___ Ns Larasati

23.55. Pt states pain as 1/10. Demonstrated taking deep breath and coughing effectively. ___
Ns Larasati
Date DX Implementation Response Signature

11/26/2019 Pain and S: Ns Larasati

nauseate
 23.00 d  giving Compazine 1 mg  Pt continuous
because Intra Vena to feel
of 4 hour nauseates
post
operation

 23.35  Medicated with morphin  Pt states she’s

2 mg Intra Vena no longer
nauseated

 Pt states pain
 23.55
as 1/10

O:

rating pain
incisional area
as 7/10; on
scale 1-10

A: No further
vomiting

P:Demonstrate
d taking deep
breath and
coughing
effectively