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#1 Nursing Process N Sharing Observation

This document discusses the nursing process and its five steps: assessing, diagnosing, planning, implementing, and evaluating. It provides details on each step, including how to conduct an assessment, formulate nursing diagnoses, develop plans of care, implement plans, and evaluate outcomes. Specific components of each step are defined, such as components of a nursing diagnosis and principles of planning. Communication techniques for sharing observations with patients are also reviewed. The document aims to guide nurses in properly applying the nursing process to provide quality nursing care.

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Erlangga Pratama
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445 views13 pages

#1 Nursing Process N Sharing Observation

This document discusses the nursing process and its five steps: assessing, diagnosing, planning, implementing, and evaluating. It provides details on each step, including how to conduct an assessment, formulate nursing diagnoses, develop plans of care, implement plans, and evaluate outcomes. Specific components of each step are defined, such as components of a nursing diagnosis and principles of planning. Communication techniques for sharing observations with patients are also reviewed. The document aims to guide nurses in properly applying the nursing process to provide quality nursing care.

Uploaded by

Erlangga Pratama
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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BAHASA

INGGRIS III
Lectured by:
Mrs. Nita Yuanita, S.Pd., M.Si.
Mrs. Lusiana Lesari, S.S., M.M.

1. THE NURSING
PROCESS
Prodi S1 Keperawatan, Tk. 3/ Sem. VI
STIKes Karsa Husada Garut, Tahun Akademik 2019/ 2020
STEPS ON THE NURSING PROCESS
To achieve the goal of Nursing Care, a nurse has to follow a
standardized Nursing Process that consists of steps:

ASSESSING

DIAGNOSING

PLANNING
IMPLEMENTATIO
N
EVALUATION
1. ASSESSING
Assessment is the first step in the nursing process and involves
systematic and deliberate (disengaja) collection of information
to determine the person’s current and past functional and health
status.

In addition, during the nursing assessment the nurse evaluates


the person’s present and past coping patterns.
Information for the nursing assessment is obtained through
interview with the person or appropriate family or staff
member; physical examination (vital signs/ TPR-BP, high,
weight, etc.); observation; review of records; and collaboration
with other health professionals.
2. DIAGNOSTIC REASONING:
Diagnostic reasoning is the second step in the nursing process
and involves the analysis of information obtained during the
assessment step and the evaluation of the person's health status
based on that information.

Formula to write Nursing Diagnosis: P (related to)+E+S


P = Problem of Human responses (bio-psycho-socio-
spiritual)
E = Etiology (P: Pathophysiology, S: Situation,
M: Medication, M: Maturation)
S = Signs & Symptoms (Result of interview, Observation,
Physical Examination and Diagnostic Test)
3. PLANNING:
Planning is the third step in the nursing process and involves
setting priorities, developing desired outcomes to problems/
needs, and designing nursing interventions.

Principles of Planning (NOC: Nursing Outcomes Classification)


should be SMART: Specific, Measurable, Achievable,
Reasonable and Time Type of Nursing Intervention (DET)
D = Diagnostic (observation) – observe, assess, explore,
report, etc.
E = Education – educate, explain, tell, teach, assist,
demonstrate, etc.
T = Treatment – Independent, Interdependent and
Dependent- position, change, insert, administer, irrigate,
etc.
4. IMPLEMENTATION:
Implementation is the fourth step in the nursing process and
involves preparation, intervention, and documentation.

The client record contains daily documentation of the nursing


measures used to
(1) assist the client to meet basic human needs,
(2) resolve health problems, and
(3) implement select aspect of the medical plan of care.
The plan of care is implemented:
 Competently,
 Caringly (peduli), and
 Creatively.
5. EVALUATION:
Evaluation is the fifth step in the nursing process. In this step
the nurse determines the person’s progress toward meeting
health goals, the value of the nursing plan of care in achieving
those goals, and the overall quality of care received by the
person. Ongoing evaluations of the client’s responses to the plan
of care are used to make decisions about terminating,
continuing, or modifying nursing care.

The conclusions of evaluation are: 1. Goal met; 2. Goal not met;


3. Goal partially met; 4. New problem.
The commonest written in evaluation uses SOAP form
(Subjective, Objective, Assessment, Planning)
SHARING OBSERVATION
Sharing observation, help patient identify and express their
health problems. Communication techniques on sharing
observation could promote patients awareness of nonverbal
behavior and feelings, underlying their behavior and helping
them to clarify the meaning of their behavior.

VOCABULARY
Pale : (adj..v.n) pucat Tired : (adj.) lelah Bouncy : (adj.) bersemangat
Tense : (adj..v.n) tegang Rigid : (adj.) kaku Daydream : (v.n) melamun
Painful : (adj.) menyakitkan Stiff : (adj..v) kaku Afraid of : (adj.) ketakutan/ takut…
Sigh : (v.n) mendesah Bruise : (v.n) memar Confuse : (v) membingungkan
Swollen : (adj.) bengkak Tender : (adj..v.n) perih Papery : (adj.) kelihatan tipis dan kering
Sallow : (adj..n) muka yang pucat kekuningan Suffocate: (v) nafas sesak seperti tercekik
Moan/ Groan : (v.n) mengerang, merintih (suffocating)
Gasp : (v.n) terengah-engah terutama karena sakit
USEFUL EXPRESSIONS
 You look… + when (v-ing)
 You seem … + with your (part of the body)
 Your (part of the body) looks… + uncomfortable
 You seem to have + (a problem with + a part of the body)
+ (a health problem: such as stomachache, headache,
fever, a chest pain, etc)
Let’s Practice. Practice the substitution drills below!
1. You look ……… 3. You look uncomfortable with your ………
tense leg
stiff position
happy stomach
sad, etc. chest, etc.
2. Your ……… looks ……… 4. You seem uncomfortable when ………
skin sallow walking
eyes reddish moving your (hand)
nail yellowish, etc. changing your clothes, etc.
… to have a problem with + (part of the body)
EXERCISE 1.
Translate this sentences into communicative English!
1. Maaf pak, sepertinya perut anda sakit

………………………………………………………………………………
……
2. Anda sepertinya kelelahan

…………………………………………………………………………………
…
3. Sepertinya bapak merasa tidak nyaman ketika berjalan

…………………………………………………………………………………
…
4. Maaf pak, kelihatannya bapak mengalami gangguan pada dada bapak

…………………………………………………………………………………
…
EXERCISE 2.
Arrange these jumbles words into a good sentence!
1. (look- scars- reddish- your)

………………………………………………………………………………
……
2 (seem- respiration- to have- you- with- problem- your)

…………………………………………………………………………………
…
3. (your- look- uncomfortable- turning- head- when- you)

…………………………………………………………………………………
…
4. (skin- dry- your- looks)

…………………………………………………………………………………
…
EXERCISE 3.

Giving more sample about sharing observation

Instruction:
 Observe your friend’s physical appearance
 Focused your observation on health condition
 Share your observation
END SECTION
Click icon to add picture

THANK
YOU

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