NURSING REPORT

By :

NAME : NI KOMANG MULIADNYANI

STUDENT ID NUMBER : 18. 321.2889

CLASS : A12-B

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN

WIRA MEDIKA BALI

DENPASAR

2019
 NURSING REPORT

Reporting is one component of nursing documentation. Reporting gives an

assessment of the activities of observations that were seen, made or heard. With
consideration, nurses can communicate information about clients so that all
members can make the best decisions about clients and their care.

 Task Exchange Report

Task exchange reports occur two or three times a day in each type of nursing unit
in all types of health care environments. At the end of the shift the nurse reports
information about the client that is his responsibility to the nurse working on the
next shift. The aim of the launch is to provide continuity of better care among
nurses caring for clients. The full report upholds the nurse's accountability in the
belief that client care is not interrupted.

 Telephone Report

Telephone communication is often required by members of the nursing team as a

medium to convey information. Telephone reports are used when nurses inform
doctors about changes in client conditions, nurses from one unit inform nurses of
other units about client transfers, or information on radiological reports or
diagnostic examinations. Information in telephone reporting must be documented
permanently in written format if a significant event has occurred to the client.
Thus people involved with telephone reporting ensure that the information
conveyed is clear, accurate and concise.

 Client Transfer Report

The client transfer report includes communication about information about the
client from the sending unit nurse to the receiving unit nurse. That is, when
patients are transferred from unit to unit to get a different level of nursing.

Client transfer reports can be initiated by telephone or directly to the person

concerned. Information included in the client transfer report includes:

1. Client's name, age, primary doctor, and medical diagnosis.

 2. Summary of medical progress until the time of transfer.

3. Latest health status (physical and psychological).

4. The diagnosis of recent nursing or nursing problems and plans.

5. All important assessments or interventions that must be carried out

immediately after transfer (assisting the receiving nurse to set care
priorities).

6. Any specific considerations, such as isolation status or resuscitation

status.

7. Need for special equipment.

After the sending nurse completes the transfer report, the receiving nurse must
make time to ask questions about the client's status.

 Accident Report

Accidents are all events that occur not in accordance with the routine activities of
the health care unit or the routine nurse of the client. Clients, visitors, or labor can
be at risk when something unusual happens in the nursing field. Therefore,
accident reports can help identify high risk trends in nursing care or daily
activities that require improvement.

There are many different approaches to hand-off communication,

including shift report in a room, at the nurses' station, by phone, and at the
bedside. Much of the literature indicates a need for a standardized communication
method such as the Situation-Background-Assessment-Recommendation (SBAR)
technique. This technique provides a framework for effective communication
among members of the healthcare team and helps create an environment that
allows individuals to speak up and express their concerns. This, in turn, reduces
the risk of adverse events and ultimately fosters a culture of patient safety.

Improving the communication between caregivers can prevent negative

patient outcomes and strengthen a teamwork approach to care. The SBAR
technique provides common expectations such as what will be communicated,
how it's structured, and what are the required elements. It allows communication
to be focused on the problem and not the people. This is very important when staff
members are communicating hand-off information at the change of shifts.

The SBAR technique also provides a way to hand-off relevant information

in the presence of the patient, allowing active participation of the patient in his or
her care. The patient is central to all information surrounding care activities.
Patients can ask questions or add information to the discussion. Through this
process, the patient sees the staff working as a team and is assured that all
involved know and agree on the plan of care. Evidence suggests that better-
informed patients are less anxious and more likely to follow medical advice.

Now, let's take a look at how following the steps in the SBAR acronym
leads the speaker to convey information in a methodical and logical way so that
the listener can easily follow.

Following the steps

Situation. The "S" component should take about 8 to 12 seconds. The

nurse states what's happening now. If giving a shift report to the next caregiver,
the nurse states the patient's name, why the patient is on the unit, and introduces
the nurse coming on duty to the patient. For example: "Ms. J, this is Tina Jones,
the registered nurse who will be caring for you today. Tina, Ms. J is here to have
rehab after her right knee replacement." To be effective, you must be concise,
clear, and to the point when giving the report, leaving irrelevant information out
of the conversation.

Background. During the "B" component, the nurse gives the next
caregiver brief background information specific to the patient's relevant history.
This section sets the context for what's being discussed, which may include the
patient's diagnosis, history of procedures done, and family situation. For example:
"Ms. J had a right knee replacement on June 3rd by Dr. Smith. She has a history of
hypertension, diabetes, and arthritis. She lives with her husband who's retired and
able to care for her at home when discharged."
 Assessment. During the "A" component, the nurse reports the current
condition of the patient. For example: "Blood glucose levels have been stable,
vital signs within normal limits, and the incision line is clean and dry with no
drainage noted. The dressing was changed today. Ms. J is able to ambulate to the
restroom with a contact guard of one and the use of a walker. Her pain has been
reported as a 7 on a 0-to-10 scale and she was given two hydrocodone pills at 9
a.m. The hydrocodone appears to be helping her, especially when given before
therapy."

Recommendation. During the "R" component, the nurse states what he or

she thinks would be the desired response to the patient's care of the day. She may
suggest that discharge planning be initiated by discussing needs with the patient,
contacting the physician with discharge plans, and conveying to the rest of the
care team what needs to be done before discharge. You don't need to read the
entire patient profile or orders. For example: "Ms. J is scheduled for discharge this
Friday and will need to speak to the discharge planner today."

Remember, not everything about the patient needs to be conveyed, just

what's pertinent to the situation at that time. Also remember that effective
communication takes two: Ask if there are any questions and remind team
members and the patient that you'll be available should further clarification be
needed.

1. Useful Expression
It is important for students to increase their understanding for their
physical and patient emotional signs ( expression of anger,
melancholy,etc),because this can provide important clues to their welfare or
eating mind. Nurses must also be careful to reflect their own appropriate body
language communication or non verbal communication.
10 expression to us in speaking and writing :
1) Well, you see..
2) Now, let me see
3) Just a moment / just a second
4) Hang on a moment / second / mo / see
5) How shall I put it ?
6) What’s the word for it
 7) Now, let met think
8) Let me get this right
9) It’s on the ti of my tongue

2. Vocabulary
1) Definition of Vocabulary
Vocabulary is the basic that must be learnt first by learners. It will help the
leaner in learning English language well. As harmand and stork stated that
vocabulary is a stock of words which are at the disposal of speaker or writer.
As in brainy media.com that vocabulary is a list or collection of words
arranged in alphabetical order and explained : a dictionary or lexicon either of
whole languange, a single work or author, a branch of science or wordbook.
Besides, Hindmarsh R (1980) stated that vocabulary is a core compenent of
language proficiency and provides much of basis for how well learners speask,
listen, read and write. Vocabulary refers to the words we must understand to
communicate effectively. Educators often consider four types of vocabulary
there are :
(1) Reading vocabulary
A person’s reading vocabulary is all the words he or she can recognize
when reading. This is the largest type of vocabulary simply because it
includes the other there.
(2) Listening vocabulary
A person’s listening vocabulary is all the words he or she can
recognize when listening to speech. This vocabulary is aided in size by
context and tone of voice.
(3) Writing vocabulary
A person’s writing vocabulary is all the words he or she can employ in
writing. Contrary to the previous two vocabulary types, the writing
vocabulary is stimulated by its user.
(4) Speaking vocabulary
A person’s speaking vocabulary is all the words he or she can use in
speech. Due tp the spontaneouse nature of the speaking vocabulary,
words are often misuse-though slight and unintentional, may be
compensated by facial expressions, tone of voice, or hand gestures

2) Vocabulary growth
 Intially, in the infancy phase, vocabulary growth requires no effort. Infanys
hear words and mimic them, eventually associating them with objects and
actions. This is the listening vocabulary. The speaking vocabulary follows, as
a child’s thoughts become more reliant on its ability to express itself without
gestures and mere sounds. Once the reading and writing vocabularies are
attained – through questions and education – the anomalies and irregularities
of language can be discovered. In first grade, an advataged student knows
abaout twice as many words as a disadvantaged student. Generally, this gap
does not tighten. This translates into a wide range of vocabulary size by age
five or six, at which time an english- speaking child will know abaout 2.500 –
5.000 words. An average student learns some 3.000 words per year, or
approximately eight words per day. After leaving school. Vocabulary growth
reaches a plateau. People may then expand words per day. After leaving
school. Vocabulary growth reaches a plateau. People may then expand their
vocabularies by engaging in activities such as reading, playing word games,
and participating in vocabulary programs. The importance of vocabulary are :
1) An extensive vocabulary aids expressions and communication
2) Vocabulary size has been directly linked to reading comprehension
3) Linguistic vocabulary is synonymouse with thinking vocabulary
4) A person may be judged by others based on his or her vocabulary

3. Grammar focus (arithmatic)

In this subsection, some prepossitions are analyzed. Students again may
know them: thus the exercises will provide further practice. The grammar
point in is this unit is the Modal Verbs. This has probably been studied before.
Therefore, the authours of the book recommend to begin its study by
completing or filling in the blanks instead of explaining them although some
grammar hints are given as a reminder.
The communicative function of asking and giving information is a quite
general one and from communicative and language viewpoints the appropriate
and correct use of the patterns involved is relevant. Nevertheless, the function
has not been boxed in the section, with grammar-like exercises, yet it is
worked on througout the sections of writing and oral practice in different
ways, throughout different channels. So, the teacher must.
4. Case study
Case studies are one method of research in social science. In research that uses
this method, longitudinal examinations related to situations or events are carried
out called complex ways of observing, collecting data, analyzing information, and
reporting results. As a result, an in-depth understanding of what happened can be
obtained and can be the basis for further research. Case studies can be used to
generate and test hypotheses.

EXAMPLE :
FS employees aged 57 years, weight 85 kg with height 170 cm, came home
sick to get influenza treatment with nasal congestion, while check blood pressure
which is always done routinely. Since 5 years a then he detected hypertension
with blood pressure 140/80, and it was only done weight loss and limit salt-
containing foods. He complained over the past 1 year, gained 8 kg in weight, and
often got dizzy morning. He has a history of asthma when he was growing up.
Sometimes do swimming sports

 Family history, the father of hypertension died at the age of 58 years

because of a heart attack, the insulin-dependent diabetes patient's mother
died because of a stroke at 63 years. He felt confident that the results of
the pressure examination. His blood 170/110 is currently caused by tension
the last 2 months since he started stop working.
 Blood laboratory test results as follows: serum electrolytes - K 3,9 (3,9),
Na 142 (139), BUN 32 mg / dl (8-25), serum creatinine 0.9 mg / dl (0.6 -
1.5), glucose fasting 105 mg / dl (70-110), serum uric acid 10 mg / dl (3-
7), hb 15 (13-17), WBC 9000 (60000 - 10000), and an increase from
normal, fasting total cholesterol\and triglycerides.
 Fundoscopic examination results show narrowing of the arteries, without
bleeding, ECG and chest x-ray results show the presence of left ventricular
hypertrophy, whereas urine analysis shows proteinuria + 1. He was given
hydrochlorothiazide 25 mg / day for 2 weeks, as well pseudo ephedrine
2x1 tablet 30 mg / day.
 REFERENCES

Moleong lexy. 2002. Metodelogi Penelitian Kualitatif. Bandung : PT. Remaja

Rosda Karya

https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/09000/Lookin
g_to_improve_your_bedside_report__Try_SBAR.14

http://dosen.univpancasila.ac.id/dosenfile/2004211045140608483923July2014.pdf

https://id.wikipedia.org/wiki/Studi_kasus