nursing academy of east kotawaringin timur task english admitting patients siti aisyah and yemima thalia

1. Admitting patients
Group Siti Aisyah & Yemima Thalia
Class IIB

2. One day nurse find patients complaint
patients with indication CHF (congestif
heart failure).
The patient name is Mr. ’’F” . He come
clinic with complaint dyspnea.

3. Assassment
Patient name : Mr.F
Hospital number : 36756346
Date of birth : 15 january 1987
Age : 29
Patient gender : male
Patient address : sari gading st 187
Prefers to be called : mr.F
Admitted from : home
Patient’s phone number : 085678986787
Civil status : married
Language : indonesia
Patient’s religion : muslim
Occupation : home wife

4. Patient contact 1 : Mr. G
 Relationship : uncle
 Address : muchran ali st.
 Phone street : 085243567486
Patient contact 2 : Mr. D
 Relationship : husband
 Address : cilik riwut 45 st.
 Phone street : 08524358798

5.  Date of admission : today’s date
 Time : 6 p.m
 Diagnosis/reason for admission : congestif
heart failure
 Significant health history:where has
patient not yet same sick before that.
 Allergies : -

6. Vital inspections
 Respiration : 30 per minute
 Pulse : 98 beats per minute
 Blood pressure : 140/90mmhg
 SPO2 : 94 %
 Temperature : 36,9 C
 CRT : back in 2s
 patient use O2 mask 6 L per minute
 Patient dyspnea

7. PHYSICAL EXAMINATION
a. Awareness : Compos Mentis E4M6V5 GCS.
b. Chief : no injury, no stitches, shape mesochepalus.
c. Eyes : no icterus sclera, conjunctiva pallor.
d. Nose : No secretions, not attached NGT, no polyps, no nostril
breath.
e. Mouth : no secretions, dirty teeth, mucous membranes moist.
f. Ears : symmetrical, clean, do not seem cerumen.
g. Neck : no enlargement of the thyroid gland
h. Thorax : I: breasts symmetrical shape no wound, no retraction of the
chest wall, use a respirator muscles.
P: No pulmonary edema
P: no tenderness
A: heart sounds S1, S2 normal, lung sounds crekcels
i. Abdomen : I: no lesions, no injuries heat, no acites
A: bowel 12 x / minute
P: the sound of timpani
P: no enlargement of the liver, no tenderness

8. DATA ANALYSIS
Data Subject :Patients say claustrophobic
Data Object :RR 26 x / m Looks
retraction of the chest wall .Use of a
respirator muscles .Lung sounds creckles
pulmonary edema.
Ineffectiveness hyperventilation breathing
pattern
DIAGNOSIS

9. implementation
- Observation blood pressure, pulse, and temperature
- Observation Frequency.
- Observation Oxygen flow
- Auscultation Breath sounds
- Give client Semifowler position.
- Collaboration give drug .

10. evaluation
 Client relax
 Respiration rate 22x/minutes
 Client say feel out of breath
 Heart rate 88 beats per minute

11. Thank you….