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BELAJAR BAHASA INGGRIS: NURSING DOCUMENTATION

After the nurse has obtained the health resources and problems of the patients, she can establish the nursing objectives. The nurse records key elements of the nursing database for every patient.

Nursing database includes these entry guidelines:

1.      health history information
2.      physical examination and diagnostic test information
3.      functional health pattern
4.      analysis of data
5.      summary of patient problems
6.      formulation of nursing diagnosis based on information for database.

Every day, the nurse writes nursing report on the patient’s care.  This report concerns the progress and effect of nursing and the change in the health status of the patient.

A.     Questions

·         Could you tell me your complete name?
·         What is your chief complaint?
·         What’s your religion?
·         Do you smoke?
·         Are you feverish?
·         Do you drink alcohol?
·         Have you stopped smoking?
·         Could you tell me about my family?
·         How many brothers and sisters do you have?
·         Are you married?
·         What is your father’s name?
·         Have you ever suffered from a certain diseases?
·         Are you allergic to certain food?
·         How are your bowel habits?
·         What about your bladder habits?
·         Do you pass water frequently?
·         Are you pregnant?

B.      Vocabulary

·         Antibiotic
·         Antifungal
·         Antivirus
·         Antispasmodic
·         Antidiuretic
·         Antidespresant
·         Antipyretic
·         Antipruritic
·         Antihelmintic
·         Bronchodilator
·         Cough medicine

C.     Practice

·         Practice the questions above with your partner.

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