ENGLISH ASSIGNMENT IN NURSING
“NURSING CARE FOR Mr. J WITH PNEUMONIA IN FLAMBOYAN
ROOM KEDIRI HOSPITAL”
Lecturer : Ipan Dwi Nata, S.Pd., M.Pd
Arranged by :
Group 5
Noor Hidayati
Listra
Metri Agusni
Novella Vevilaya Putri
Pepelia
CASE STUDY DESCRIPTION
Mr. J, 83 years old, came to the Kediri Hospital on December 15,
2022. The patient complains of cough. He said the phlegm was
difficult to come out and he also felt shortness of breath. The patient
also had a high fever since 3 days ago and oedem on both of his legs.
NURSING CARE
1. Patient’s Identity
Name : Mr. J
Age : 83 years old
Gender : Male
Religion : Christian
Adress : Semampir, Kediri City
Education : Senior high school
Occupation : Retired
Opname date : December 15, 2022
Assesment date : December 16, 2022
Blood Type :O
Medical Diagnosis : Pneumonia + Coronary Heart Disease (CHD)
2. CHIEFT COMPLAIN
The patient complains of cough. He said the phlegm was difficult to come out and he
also felt shortness of breath. Shortness of breath increased when the patient cough for
expel the phlegm and decreased when he was resting with semi-fowler position.
3. PRESENT DISEASE HISTORY
The patient came to the Kediri Hospital on December 15, 2022. The patient complains he had
been coughs since 2 week ago, the cough has been getting worse about 3 days ago. He said
the phlegm was difficult to come out accompanied by shortness of breath. Shortness of
breath also appeared but disappeared. The patient also had a high fever since 3 days ago and
oedem on both of his legs. After being examined by the medical team, the patient was
diagnosed with pneumonia.
4. PAST DISEASE HISTORY
The patient said that he had a history of Coronary Heart Disease (CHD), and routine control to
the dr. Yoseph, Sp.J, and he also had cataract surgery 3 months ago. History of drug use :
Aspilet, CPG, Furosemid, ISDN, Atorvastatin, Ibersartan, Fluimucyl.
5. PSYCHOS SOCIAL AND SPIRITUAL HISTORY
The patient says he go to church every Sunday and believes that god will help him, heal him
from his illness. The patient also has a good relationship with his family and close to his
grandchildren.
6. PATTERNS OF DAILY ACTIVITIES (eat, rest, sleep, elimination, activity)
7. PATIENT’S CONDITION / APPEARANCE / GENERAL IMPRESSION
The patient looks weak, rest in bed with semi-fowler position, the consciousness is
composmentis, GCS 4-5-6 (15), the body feels hot and dry, gets 5 lpm oxygen nasal canul, and
gets 500cc NS infusion therapy in the right hand.
8. VITAL SIGN
Body temperature : 38,5 ◦C
Pulse : 66 x/minute
Blood pressure : 120/70 mmHg
Respiration rate : 28 x/minute
SpO2 : 95%
Weight / Height : 72 kg / 155 cm
9. PHYSICAL EXAMINATION
A. Head and neck examination
Head: white hair, no wounds or lesions on the patient’s scalp. There is no lump on
the head and there is no tenderness
Eyes: right and left eyes symmetrical, concave, isochoric pupils
Nose: no sores or lesions, no polyps, clean, no tenderness, anosmia (-)
Mouth: clean mouth, no stomatitis, no caries, dry lip mucosa
Ears: symmetrical shape, no lesions, clean ears, no wax, no lumps, no tenderness
Neck: clean, no lesions, no enlargement of the thyroid and lymph glands
B. Skin and nail integument examination
Skin: clean skin, normal skin turgor, skin looks red and feels hot
Nails: short and dirty nails, no cyanosis, CRT < 2 seconds
C. Breast and armpit examination (if needed)
Breast: normal, there is no lump
Armpits: clean, no enlarged lymph nodes
D. Examination of the chest / thorax
Thorax inspection: chest movement during inspiration and expiration symmetrical
Lungs
Inspections: symmetrical chest expansion, there is chest wall retraction, no lesions
Palpation: there is tenderness, no palpable lump
Percussion: muffed sound
Auscultation: vesikuler, there are additional sound rhonchi +/+, wheezing -/-, basal
minimum, respiration rate 28 x/minute
E. Heart examination
Inspection: there is no visible enlargement of the jugular vein and the shape of the
chest is symmetrical between left and right and there is no cyanosis
Palpation: there is no tenderness and palpable ictus cordis on the 5th ICS mid
clavicle left
Percussion: deafening percussion sound on 4th and 5th ICS in the left mid clavicle
Auscultation: no additional heart sounds heard, S1 and S2 normal (lub-dub),
murmur (-), gallop (-)
F. Abdomen examination
Inspection: the shape of the abdomen is convex, no lesions
Auscultation: bowel sounds heard 10 x/minute
Palpation: no abdominal tenderness, there is abdominal distension
Percussion: a tympanic sound is heard
G. Examination of genitals and the surrounding area (if needed)
Genitals: normal, no wounds or lesions
Anus: normal, no wounds or lesions
H. Musculoskeletal examination
Lower extremity: oedema +/+, with pitting oedema ± 2 mm
I. Neurological examination
Level of consciousness: Composmentis GCS: 4-5-6, 4: patient can open eyes spontaneously
5: good environmental orientation 6: patient can follow orders well
J. Examination of mental status
Patient is well aware, orientation to time, place and atmosphere is good. He believes that god
Will help him, heal him from his illness.
10. X-Ray Result
DATA ANALYSIS
NURSING DIAGNOSIS
NURSING INTERVENTION
NURSING IMPLEMENTATION
EVALUATION
- Terima Kasih -
