Page 29 - Modul English Communication In Nursing

PATIENT LOG
Patient Information Medical Diagnosis:
Patient Name: Anwar Hidayat Chronic Diabetic Foot Ulcer
DOB/ Age: 3 May 1976/ 58 years old
Gender: Male Nursing Diagnosis:
Room/ Bed Number: Khalid Bin Walid/ 2B Impaired skin integrity related to diabetes
mellitus and poor circulation

Date Assessment Findings Nursing Care Plan Evaluation (SOAP)
Planning Intervention
18/10/2024 Vital Signs: BP 135/90 Wound care and Clean wound Patient reports less pain
(09:00 am) mmHg, HR 82 bpm, RR infection daily and apply and some reduction in
18 breaths/min. Wound prevention dressing swelling. Wound size
is red with some has slightly decreased.
discharge (3 cm). Warn patient of the
Patient reports mild possible skin irritation
pain and stinging due to the dressings.
around the wound.
Patient has diabetes for Improve blood Teach patient Patient understands
12 years and poor blood sugar control for about blood and agrees to follow-up
sugar control. better healing sugar with the diabetic clinic.
management
Wound has not healed Promote Teach foot care Patient is following foot
well in 3 weeks. circulation and and proper care instructions but
reduce pressure footwear needs written
reminders.
Patient shows mild Reduce anxiety Offer emotional Patient feels calmer and
anxiety about wound support and is more confident in
healing. suggest joining a continuing care.
diabetes
support group
Nurse Name: Nurse Zainab
Signature: ___________
Date: 18 October 2024

Nurse Zainab : "Assalammu’alaikum. Good morning, Mr. Anwar. How are you today?"
Mr. Anwar : "Wa’alaikumsalam. Good morning, Nurse. I’m feeling better, but my foot still hurts a
bit. The wound seems to be taking a long time to heal."
Nurse Zainab : "I see. I am here to assess your wound. Let’s take a look at your wound. The wound
looks a bit red and has some discharge. It's about 3 cm in size. How would you rate
the pain today?”
Mr. Anwar : “It’s not too bad, just a mild pain and a stinging feeling around the wound.”

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