PATIENT CARE PLAN

Patients name
Jhon swift

Action to be taken
o
o
o
o
o
o
o
o
o
o
o

.
o
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anamnesis
physical examination
laboratory examination
free the airway and mouth to
avoid asphyxia ,
if necessary, give oxygen .
improve the general state of the
patient
(give fluids and general
maintenance ) .
monitor vital signs
(general condition, conscious ,
breathing
, blood pressure , temperature
and
pulse every 30 minutes )
The blood pressure monitor ,
color and temperature . when
hypotension did
Tredenlenburg 's position .
thick do blood tests to confirm
the diagnosis

Reason for admission

Body Temperature Too High MAKE Patients Being seizures

Syimptoms
Initial malaria infection generally have
the following signs and symptoms :
1. shiver High fever Excessive sweating body
2. with decreasing temperature Experiencing
3. discomfort and uneasiness ( malaise ).
Other signs and symptoms include:
1. Headache
2. Nausea
3. Gag
4. Diarrhea

Taks 3

When i start a new shift, i lesten to the nursing report from the previous shift. The report is
about the patients condition and nursing interventions that has been done for each patient. I
observed a case of Mr. Swift then Mr. swift experiencing malaria illness with the following
symptoms:
the following signs and symptoms:
1. High fever Shiver Excessive sweating body
2. Experiencing with decreasing temperature
3. discomfort and uneasiness (malaise).
Other signs and symptoms include:
1. Headache
2. Nausea
3. Gag
4. Diarrhea
and when on leave too long it will be bad for Mr. swift. therefore we do medical Action as
follows:
A. General Measures
Before the diagnosis is confirmed by blood tests, some action needs to be performed on
patients with suspected severe malaria in the form of action intensive care (ICU), namely,
1. The release of the airway and mouth to avoid asphyxia, if necessary, give oxygen.
2. improve the general state of the patient (give fluids and general maintenance).
3. monitor vital signs (general condition, conscious, breathing, blood pressure, temperature
and pulse every 30 minutes)
4. The blood pressure monitor, color and temperature. when hypotension did Tredenlenburg's
position.
5. thick do blood tests to confirm the diagnosis
7. When did the principle CAB comatose patients (Circulation, Airway, Breathing)
Sirculation (circulation): check your pulse, blood pressure, skin turgor assessment, JVP. Keep
the balance of fluid and electrolyte balance by monitoring cairana record intake and output
adequately.
Airway (airway): keep the airway to keep it clean, without barriers, by: - clearing the
airway, flat bed with no pillow and prevent aspiration of gastric fluid entrance to the airway
by adjusting the position of the patient laterally and mounting NGT to suck gastric contents.
Breathing (breathing): when tachypnea or respiratory acidosis give oksiggen and refer to ICU
after performing the acts for several days we monitor the progress of patients. and the
patient's condition has improved.

PAPERS
ENGLISH LEANGUAGE
PATIENT CARE PLAN"

SUPERVISOR :
Melinda Puteri., M.Pd

ARRANGED BY :
Nova Hijjah suryani
NIM: 5120316 P0 030

D IV NURSING DEPARTMENT 2016/2017

POLTEKKES KEMENKES BENGKULU

FOREWORD
We extend gratitude for the presence of God Almighty, where mercy and grace we have been
able to compile this paper entitled patient care plan.
In the process of preparation of this paper, the author experienced a lot of problems. But
thanks to the guidance and support from various parties finally this paper can be completed
on time. On this occasion, with all humility, the author would like to thank the Coordinator of
English language courses, maam Melinda Puteri., M.Pd which has guided us in the process
of preparation of this paper.
The author, aware of this paper is not perfect, either from the content and systematics of
writing, therefore the authors are grateful if any criticism and constructive suggestions for the
perfection of this paper.
Finally, I hope this paper can be useful for compatriots and especially the readers.
Bengkulu, 13 August 2016
composer