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    The nursing documentation summarizes the assessment of a 67-year-old male patient named Ron Jones who presented with a cough for 1 week. The cough was productive with yellow and sometimes green sputum. He reported feeling tired but no fever or chills. His past medical history included smoking 2 packs per day for 35 years and a recent course of antibiotics for his cough that provided no relief. His vital signs were stable. On examination, his respiratory rate was 16 breaths per minute with yellow and green sputum. The doctor advised inhaler therapy and a new course of antibiotics, and the patient was instructed to return in 10 days.

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    The nursing documentation summarizes the assessment of a 67-year-old male patient named Ron Jones who presented with a cough for 1 week. The cough was productive with yellow and sometimes green sputum. He reported feeling tired but no fever or chills. His past medical history included smoking 2 packs per day for 35 years and a recent course of antibiotics for his cough that provided no relief. His vital signs were stable. On examination, his respiratory rate was 16 breaths per minute with yellow and green sputum. The doctor advised inhaler therapy and a new course of antibiotics, and the patient was instructed to return in 10 days.

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    The nursing documentation summarizes the assessment of a 67-year-old male patient named Ron Jones who presented with a cough for 1 week. The cough was productive with yellow and sometimes green sputum. He reported feeling tired but no fever or chills. His past medical history included smoking 2 packs per day for 35 years and a recent course of antibiotics for his cough that provided no relief. His vital signs were stable. On examination, his respiratory rate was 16 breaths per minute with yellow and green sputum. The doctor advised inhaler therapy and a new course of antibiotics, and the patient was instructed to return in 10 days.

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    22 views3 pages

    Form KMB

    Uploaded by

    Jihan
    The nursing documentation summarizes the assessment of a 67-year-old male patient named Ron Jones who presented with a cough for 1 week. The cough was productive with yellow and sometimes green sputum. He reported feeling tired but no fever or chills. His past medical history included smoking 2 packs per day for 35 years and a recent course of antibiotics for his cough that provided no relief. His vital signs were stable. On examination, his respiratory rate was 16 breaths per minute with yellow and green sputum. The doctor advised inhaler therapy and a new course of antibiotics, and the patient was instructed to return in 10 days.

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    of 3

    NURSING DOCUMENTATION AND REPORTING

    Untuk memenuhi tugas matakuliah


    Praktik Bahasa Inggris dalam Keperawatan
    Yang dibimbing oleh Dr. Ns. Retno Lestari S.Kep., M.Nurs.

    By
    Name : Jihan salsabila
    NIM : 225070209111042

    PROGRAM STUDI ILMU KEPERAWATAN


    DAPARTEMEN KEPERAWATAN FAKULTAS ILMU KESEHATAN
    UNIVERSITAS BRAWIJAYA
    MALANG
    2022
    NURSING ASSESSMENT FORM
    MRS Date :- Entry Hours :-
    Date of Assessment : October 21, 2022 No. RM : 084448xx
    Assessment Hours : 08.00 Nurse Name : Jihan Salsabila
    Day of care to :1

    IDENTITY
    1. Patient Name : Ron Jones
    2. Age : 67 y.o
    3. Date of birth : December 15th 1955
    4. Sex : Male
    CURRENT HEALTH STATUS
    Chief complaint: feels well but sometimes he feels a bit tired all the time
    HISTORY OF NOW DISEASE
    The client suddenly complains of had a cough, the cough was getting worse since 1 week. He said the
    cough was productive and the colour of sputum was yellow, but sometimes it was green. The patient felt a
    little bit tired all the time, and he said didn’t have a fever or chills. The patient has taken antibiotics
    PAST MEDICAL HISTORY
    1. Ever been treated : yes no when: diagnosis:
    2. History of chronic and communicable diseases
    Control history : ..........................
    History of drug use: The patient has taken antibiotics
    3. Allergy history : -
    Etc:
    FAMILY HEALTH HISTORY
    Yes No
    - Type : …………………
    - Genograms :

    BEHAVIOR THAT AFFECTS HEALTH


    Behavior before illness that affects health :
    1. Alcohol Yes No Description ……………………………
    2. Smoking Yes No
    3. Information : The patient has smoked since 35 year ago (2 pack a day)
    4. Medication Yes No
    5. Description : The patient has taken antibiotics, but he said it can’t reduce his cough, so he stopped
    taking those antibiotic medication.
    6. Exercise Yes No
    information ...................................

    PHYSICAL OBSERVATION AND EXAMINATION


    1. Vital sign
    Temperature : 37 ⁰C HR : 88x/minute Blood pressure : 150/84 mmHg RR : 16x/minute
    Awareness Compos Mentis Apathy Somnolen Sopor Koma
    2. Respiratory System (B1)
    a. RR: 16x/minute
    b. Complaints: shortness breath pain orthopnea
    cough productive not productive
    Secretion: yes Consistency:...............
    Color: yellow sometimes green Smell:...........
    c. Use of accessory muscles for breathing:
    d. Breathing Irregular Reguler
    e. Pleural Friction rub :
    f. Pattern Breating dyspnea Kusmaul Cheyne Stokes Biot
    g. Breath sound Cracles Ronki Wheezing
    h. Breathing apparatus yes no
    Type ............................................... ..Flow _ ..............lpm
    i. WSD Usage:
    j. Tracheostomy: yes no
    k. Etc:

    THERAPY
    Based on the doctor's advice, the client gets :
    1. Inhaler therapy
    2. Antibiotics

    OTHER ADDITIONAL DATA:


    Discharge Planning : The patient should return about 10 days to take a prescription for antibiotics

    Malang, October’21 2022


    Nurse

    (Jihan Salsabila)

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