Page 35 - Modul Engslish For Nursing

Miss Fatima : Well-noted, Nurse. I feel more prepared after listening your
explanation. Thank you.

Now, in pairs, write a dialogue between a nurse and a patient discussing about wound care
based on the patient log provided. Apply the expressions you have learned.

PATIENT LOG

Patient Information Medical Diagnosis:
Patient Name: Ida Safitri Suture on left forearm
DOB/ Age: 30 November 1994/ 30 years old
Gender: Female Nursing Diagnosis:
Room/ Bed Number: Fatimah/ 1A Impaired skin integrity related to the
sutures

Date Assessment Findings Nursing Care Plan Evaluation (SOAP)
Planning Intervention
16/10/2024, - Reduced swelling, - Reduced - Reduced - Reduced swelling,
08:00 AM mild redness remains swelling, mild swelling, mild mild redness
- Suture intact, no redness remains redness remains remains
drainage observed - Suture intact, no - Suture intact, - Suture intact, no
drainage no drainage drainage observed
observed observed

17/10/2024, Redness decreased; Redness Redness Redness decreased;
08:00 AM wound edges decreased; decreased; wound edges
approximated wound edges wound edges approximated
- Minimal clear approximated approximated - Minimal clear
exudate observed - Minimal clear - Minimal clear exudate observed
exudate observed exudate
observed

Nurse Name: Nurse Yuri
Signature: ___________
Date: 18 October 2024

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