"Take Off Patient/ Operan Jaga": Tugas Bahasa Inggris [PDF]

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TUGAS BAHASA INGGRIS



“TAKE OFF PATIENT/ OPERAN JAGA”



Disusun Oleh :



Nama



: 1. TATA YULIA D. S 2. SAMIATUL ALIYAH



Tingkat



(P1337420418026) (P1337420418092)



: 2B



PRODI DIII KEPERAWATAN BLORA POLTEKKES KEMENKES SEMARANG TA 2020/2021



At the main clinic, a noble image, at 8:00 a.m. WIB, was carried out between nurses Karu



: “Assalamualaikum, good morning, today the same as the previous days in accordance with the activities of the early morning shift will be preceded by operands between nurses who stand guard last night with nurses who shift this morning. Please the nurse who is late at night to report the patient's condition”



Nurse (Night) : “Thank you for the time given, good morning colleagues, I will today report the condition of the patient last night. Consisting of 3 patients.” 1. Patient bed 1 a / n S, age 38 with dx: COB (post op). K / U px coma, the patient is still unconscious with GCS 1 1 1. Earlier this morning at 05.00 WIB, TD: 90/60 mmHg, N: 80x / minute, RR: 20x / minute, and S: 37. The patient was attached with infusion ns 0 , 9% 20 tpm, catheter, NGT and 4 lpm oxygenation. Last night the injection that had entered mannitol 100 cc, Ceftriaxone 2 gr, Phenitoin 10 mg, and Cimetidin 2 gr. DL checks have been made earlier 06.00 WIB results later this afternoon. Head CT scan plan and re-insert infusion because it has plebitis. Intervention continued 2. Bed 2 a / n Mrs. S, age 34 with dx: Ca Cervix. Last night the patient complained of pain, nausea and no appetite. K / U cm, Face grimacing, px bleeding, Gcs 4,5,6, TTV this morning TD: 110/70 mmhg, N: 90x / minute, RR: 20x / minute, S: 36.5. RL of 20 tpm was installed, last night was given Vitamin A 50,000 iu and Mirabion 1 capsule, Kalnex 500 mg, mefenamic acid 500 mg orally. Yesterday night I was given a blood transfusion 1 PRC runs out. This morning I had done a DL check and a complete urine examination, the results haven't been. PRC plan for further blood transfusion if the hemoglobin has not been ≥ 10gr / dl according to doctor's advice, the intervention is continued. 3. Bed 3 a / n Mr H, age 50 years with dx: Appendixitis (Post op). K / U cm, GCS 4 5 6, the patient did not complain of pain, this morning TD: 120 / 80mmHg, N: 80x / minute, RR: 20x / minute, S: 36.60C. The patient was placed with a 20 tpm NS infusion, had been given ranitidine injection 2 ml and 500 mg antrain. Plan to continue intervention. Done sir Karu



: “Good thanks to the night watch nurse, for the report. Is there anything unclear?”



Nurse



: “Clearly ma'am”



OPERAN JAGA Di suatu klinik utama citra mulia, pagi pukul 08.00 WIB, dilakukan operan antar perawat Karu



:Assalamualaikum, selamat pagi rekan-rekan, hari ini sama seperti hari-hari sebelumnya sesuai dengan kegiatan awal shift pagi akan didahului oleh operan antara perawat yang berjaga malam kemarin dengan perawat yang shift pagi hari ini. Silahkan kepada perawat yang sift malam melaporkan kondisi pasien



Perawat (Malam)



: Terima kasih atas waktu yang telah diberikan, selamat pagi rekanrekan, saya hari ini akan melaporkan kondisi pasien tadi malam. Terdiri dari 3 pasien.



1. Pasien bed 1 a/n Tn. S , umur 38 th dengan dx: COB (post op). K/U px coma, pasien masih tidak sadar dengan GCS 1 1 1. Tadi pagi 05.00 WIB,TD : 90/60 mmHg, N : 80x/menit, RR :20x/menit, dan S : 37. Pasien terpasang infus ns 0,9% 20 tpm, kateter, NGT dan oksigenasi 4 lpm. Tadi malam injeksi yang sudah masuk manitol 100 cc, Ceftriaxone 2 gr, Phenitoin 10 mg, dan Cimetidin 2 gr. Cek DL sudah dilakukan tadi 06.00 WIB hasil nanti siang. Rencana CT Scan Kepala dan pasang ulang infus karena sudah plebitis. Intervensi dilanjutkan 2. Bed 2 a/n Ny. S , umur 34 th dengan dx : Ca Serviks. Tadi malam pasien mengeluh nyeri, mual dan tidak nafsu makan. K/U cm, Wajah tampak meringis, px mengalami perdarahan, Gcs 4,5,6, TTV pagi ini TD : 110/70 mmhg , N : 90x/menit, RR : 20x/menit, S : 36,5. Terpasang infus RL 20 tpm, kemarin malam sudah diberikan Vitamin A 50.000 iu dan Mirabion 1 capsul, Kalnex 500 mg, Asam mefenamat 500 mg per oral. Kemarin malam sudah diberikan transfusi darah 1 PRC habis. Tadi pagi sudah dilakukan cek DL dan pemeriksaan urine lengkap, hasil belum. Rencana transfusi darah PRC lanjut jika Hb belum ≥ 10gr/dl sesuai advice dokter, intervensi dilanjutkan. 3. Bed 3 a/n Tn H, umur 50 th dengan dx: Apendiksitis (Post op). K/U cm, GCS 4 5 6, pasien tidak mengeluh nyeri, pagi ini TD: 120/80mmHg, N: 80x/menit, RR: 20x/menit, S: 36,60C. Pasien terpasang infus NS 20 tpm, sudah diberikan injeksi ranitidin 2ml dan antrain 500 mg. Rencana lanjutkan intervensi. Selesai pak. Karu



:Baik terimakasih kepada perawat jaga malam, atas laporannya. Baik apa ada yang kurang jelas?



Perawat



: Jelas bu (serentak)