NURSING REPORT

BY

Name : Putu Suci Kristina Dewi

Nim : 18.321.2898

Class : A12-B

PROGRAM STUDI SI KEPERAWATAN

SEKOLAH TINGGI ILMU KEPERAWATAN

WIRA MEDIKA BALI

DENPASAR

2019
1. Nursing Report
1). Definition Nursing Report

Nursing Reports is an open access, peer-reviewed, online-only journal that

aims to influence the art and science of nursing by making rigorously conducted
research accessible and understood to the full spectrum of practicing nurses,
academics, educators and interested members of the public. The emphasis of
Nursing Reports will be on ensuring that the highest quality of evidence and
contribution is made available to the greatest number of nurses. Nursing Reports
aims to make original, evidence-based, peer-reviewed research available to the
global community of nurses and to interested members of the public.

Nursing report is usually given in a location where other people can not hear
due to patient privacy. If you are required to give report outside of a patient’s
room try to keep your voice down so other patients and family members can not
hear.Most nurses use the SBAR tool as a guide to help them give report, which is
highly recommended. SBAR stands for Situation, Background, Assessment, and
Recommendation.The SBAR tool is a piece of paper usually kept in the patient’s
chart that is a summary of why the patient is there, what has happened up to that
time, important health history, allergies, doctors seeing the patient etc. It is usually
written on in pencil and updated by every shift.
2). Nursing Proses

In 1958, Ida Jean Orlando started the nursing process that still guides
nursing care today. Defined as a systematic approach to care using the
fundamental principles of critical thinking, client-centered approaches to
treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations,
and nursing intuition. Holistic and scientific postulates are integrated to provide
the basis for compassionate, quality-based care. The nursing process functions as a
systematic guide to client-centered care with 5 sequential steps. These are
assessment, diagnosis, planning, implementation, and evaluation.

(1). Assessment
 Assessment is the first step and involves critical thinking skills and
data collection; subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is measurable,
tangible data such as vital signs, intake and output, and height and weight.

Data may come from the patient directly or from primary caregivers
who may or may not be direct relation family members. Friends can play a
role in data collection. Electronic health records may populate data in and
assist in assessment.

Critical thinking skills are essential to assessment, thus the need for
concept-based curriculum changes.

(2). Diagnosis

The formulation of a nursing diagnosis by employing clinical judgment

assists in the planning and implementation of patient care.

The North American Nursing Diagnosis Association (NANDA)

provides nurses with an up to date list of nursing diagnoses. A nursing
diagnosis, according to NANDA, is defined as a clinical judgment about
responses to actual or potential health problems on the part of the patient,
family or community.

A nursing diagnosis encompasses Maslow's Hierarchy of Needs and

helps to prioritize and plan care based on patient-centered outcomes. In
1943, Abraham Maslow developed a hierarchy based on basic fundamental
needs innate for all individuals. Basic physiological needs/goals must be met
before higher needs/goals can be achieved such as self-esteem and self-
actualization. Physiological and safety needs provide the basis for the
implementation of nursing care and nursing interventions. Thus, they are at
the base of Maslow's pyramid, laying the foundation for physical and
emotional health.

Maslow's Hierarchy of Needs

  Basic Physiological needs: Nutrition (water and food), elimination
(Toileting), airway (suction)-breathing (oxygen)-circulation (pulse,
cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and
exercise.

 Safety and Security: Injury prevention (side rails, call lights, hand
hygiene, isolation, suicide precautions, fall precautions, car seats,
helmets, seat belts), fostering a climate of trust and safety (therapeutic
relationship), patient education (modifiable risk factors for stroke,
heart disease).

 Love and Belonging: Foster supportive relationships, methods to avoid

social isolation (bullying), employ active listening techniques,
therapeutic communication, sexual intimacy.

 Self-Esteem: Acceptance in the community, workforce, personal

achievement, sense of control or empowerment, accepting one's
physical appearance or body habitus.

 Self-Actualization: Empowering environment, spiritual growth, ability

to recognize the point of view of others, reaching one's maximum
potential.

(3). Planning

The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines. These patient-specific
goals and the attainment of such assist in ensuring a positive outcome.
Nursing care plans are essential in this phase of goal setting. Care plans
provide a course of direction for personalized care tailored to an individual's
unique needs. Overall condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care across the healthcare
continuum.

Goals should be:

 1. Specific

2. Measurable or Meaningful

3. Attainable or Action-Oriented

4. Realistic or Results-Oriented

5. Timely or Time-Oriented

(4). Implementation

Implementation is the step which involves action or doing and the

actual carrying out of nursing interventions outlined in the plan of care. This
phase requires nursing interventions such as applying a cardiac monitor or
oxygen, direct or indirect care, medication administration, standard
treatment protocols and EDP standards.

(5). Evaluation

This final step of the nursing process is vital to a positive patient

outcome. Whenever a healthcare provider intervenes or implements care,
they must reassess or evaluate to ensure the desired outcome has been met.
Reassessment may frequently be needed depending upon overall patient
condition. The plan of care may be adapted based on new assessment data.

3). Useful expression

 Hello/ Good Morning/ Good Afternoon/ Good Evening.
 I am nurse, my name is …….
 I will take care for you today.
 What can I do with you? What do you need? May I check your identity?
 Is it “Miss or Mrs.?”
 What is your name? How old are you? What brings you to the hospital?
 Do you have a health insurance?
 If you need (help/anything) you can call me or other nurses.
 The nurse will help you.

4). Vocabulary
 Anatomy - (noun)  Approved - (adjective)
 Anesthesia - (noun)
 Assist - (verb)
 Anesthetist -(noun)
 Assistance - (noun)
 Assistant - (noun)
 Bathing - (adjective)
 Blood - (noun)
 Board - (noun)
 Bsn- (acronym)
 Cancer - (noun)
 Care - (noun / verb)
 Career - (noun)
 Care for - (verb)
 Center - (noun)
 Certified - (adjective)
 Clinical - (adjective)
 Clinic - (noun)
 Communication - (noun)
 Condition - (noun)
 Consulting - (noun)
 Continuing - (adjective)
 Council - (noun)
 Credentialing - (noun)
 Critical - (adjective)
 Demand - (noun / verb)
 Determine - (verb)
 Diabetes - (noun)
 Diagnoses - (noun)
 Diagnostic - (adjective)
 Difficulty - (noun)
 Diploma - (noun)
 Disability - (noun)
 Disease - (noun)
 Disorder - (noun)
 District - (noun)
 Dressing - (adjective)
 Duty - (noun)
 Educational - (noun)
 Elderly - (adverb)
 Eligibility - (noun)
 Emergency - (noun)
 Emotional - (adjective)
 Entry - (noun)
 Environment - (noun)
 Exam - (noun)
 Examination - (noun)
 Facilities - (noun)
 Facility - (noun)
 Faculty - (noun)
 Follow - (verb)
 Formally - (adverb)
 Geriatrics - (noun)
 Gerontology - (noun)
 Health - (noun)
 Hold - (verb)
 Hospital - (noun)
 Illness - (noun)
 Increase - (noun / verb)
 Infectious - (adjective)
 Injection - (noun)
 Injury - (noun)
  Internal - (adjective)  Laboratory - (noun)
 Junior - (noun)

5). Grammar Focus (Arithmatic)

Languages form the terrain of computing. Programming languages, protocol
specifications, query languages, file formats, pattern languages, memory layouts,
formal languages, config files, mark-up languages, formatting languages and
meta-languages shape the way we compute. In computer science, the most
common type of grammar is the context-free grammar. Context-free grammars
have sufficient richness to describe the recursive syntactic structure of many
(though certainly not all) languages.

(1). Components of a context-free grammar

A set of rules is the core component of a grammar.
Each rule has two parts: (1) a name and (2) an expansion of the name.
For instance, if we were creating a grammar to handle english text, we might add a
rule like:
noun-phrase may expand into articlenoun.
from which we could ultimately deduce that "the dog" is a noun-phrase. Or, if we
were describing a programming language, we could add a rule like:
expression may expand into expression+expression

If we're working with grammars as mathematical objects, then instead of writing

"may expand into," we'd simply write →:
noun-phrase→articlenoun
expression→expression+expression

As an example, consider the classic unambiguous expression grammar:

expr→term+expr
expr→term
term→term∗factor
term→factor
 factor→(expr)
factor→const
const→integer

So, how do we know that 3 * 7 is a valid expression?

Because:
expr may expand into term;
which may expand into term*factor;
which may expand into factor*factor;
which may expand into const*factor;
which may expand into const*const;
which may expand into 3*const;
which may expand into 3*7.

(2). Backus-Naur Form (BNF) notation

When describing languages, Backus-Naur form (BNF) is a formal notation for
encoding grammars intended for human consumption. Many programming
languages, protocols or formats have a BNF description in their specification.
Every rule in Backus-Naur form has the following structure:
name::=expansion
The symbol ::= means "may expand into" and "may be replaced with."
In some texts, a name is also called a non-terminal symbol. Every name in
Backus-Naur form is surrounded by angle brackets, < >, whether it appears on the
left- or right-hand side of the rule.
An expansion is an expression containing terminal symbols and non-terminal
symbols, joined together by sequencing and choice. A terminal symbol is a literal
like ("+" or "function") or a class of literals (like integer). Simply juxtaposing
expressions indicates sequencing. A vertical bar | indicates choice.
For example, in BNF, the classic expression grammar is:
<expr> ::= <term> "+" <expr>
| <term>
 <term> ::= <factor> "*" <term>
| <factor>

<factor> ::= "(" <expr> ")"

| <const>

<const> ::= integer

Naturally, we can define a grammar for rules in BNF:
rule→name::=expansion
name→<identifier>
expansion→expansionexpansion
expansion→expansion|expansion
expansion→name
expansion→terminal

We might define identifiers as using the regular expression [-A-Za-z_0-9]+.

A terminal could be a quoted literal (like "+", "switch" or "<<=") or the name of a
class of literals (like integer). The name of a class of literals is usually defined by
other means, such as a regular expression or even prose.

(3). Extended BNF (EBNF) notation

Extended Backus-Naur form (EBNF) is a collection of extensions to Backus-Naur
form. Not all of these are strictly a superset, as some change the rule-definition
relation ::= to =, while others remove the angled brackets from non-terminals.
More important than the minor syntactic differences between the forms of EBNF
are the additional operations it allows in expansions.
 Option
In EBNF, square brackets around an expansion, [ expansion ], indicates that this
expansion is optional.
For example, the rule:
<term> ::= [ "-" ] <factor>
allows factors to be negated.
  Repetition
In EBNF, curly braces indicate that the expression may be repeated zero or more
times.
For example, the rule:
<args> ::= <arg> { "," <arg> }
defines a conventional comma-separated argument list.
 Grouping
To indicate precedence, EBNF grammars may use parentheses, (), to explictly
define the order of expansion.
For example, the rule:
<expr> ::= <term> ("+" | "-") <expr>
defines an expression form that allows both addition and subtraction.
 Concatenation
In some forms of EBNF, the , operator explicitly denotes concatenation, rather
than relying on juxtaposition.
(4). Augmented BNF (ABNF) notation
Protocol specifications often use Augmented Backus-Naur Form (ABNF).
For example, RFC 5322 (email), uses ABNF.
RFC 5234 defines ABNF.
ABNF is similar to EBNF in principle, except that its notations for choice, option
and repetition differs. ABNF also provides the ability to specify specific byte
values exactly -- detail which matters in protocols.
In ABNF:
• choice is /; and
• option uses square brackets: [ ]; and
• repetition is prefix*; and
• repetition n or more times is prefixn*; and
• repetitionn to m times is prefixn*m.
EBNF's { expansion } becomes *(expansion) in ABNF. Here's a definition of a
date and time format taken from RFC 5322.
date-time = [ day-of-week "," ] date time [CFWS]
day-of-week = ([FWS] day-name) / obs-day-of-week
 day-name = "Mon" / "Tue" / "Wed" / "Thu" /
"Fri" / "Sat" / "Sun"
date = day month year
day = ([FWS] 1*2DIGIT FWS) / obs-day
month = "Jan" / "Feb" / "Mar" / "Apr" /
"May" / "Jun" / "Jul" / "Aug" /
"Sep" / "Oct" / "Nov" / "Dec"
year = (FWS 4*DIGIT FWS) / obs-year
time = time-of-day zone
time-of-day = hour ":" minute [ ":" second ]
hour = 2DIGIT / obs-hour
minute = 2DIGIT / obs-minute
second = 2DIGIT / obs-second
zone = (FWS ( "+" / "-" ) 4DIGIT) / obs-zone

(5). Regular extensions to BNF

It's common to find regular-expression-like operations inside grammars. For
instance, the Python lexical specification uses them. In these grammars:
• postfix * means "repeated 0 or more times"
• postfix + means "repeated 1 or more times"
• postfix ? means "0 or 1 times"
The definition of floating point literals in Python is a good example of
combining several notations:
floatnumber ::= pointfloat | exponentfloat
pointfloat ::= [intpart] fraction | intpart "."
exponentfloat ::= (intpart | pointfloat) exponent
intpart ::= digit+
fraction ::= "." digit+
exponent ::= ("e" | "E") ["+" | "-"] digit+
It does not use angle brackets around names (like many EBNF notations and
ABNF), yet does use ::= (like BNF). It mixes regular operations like + for non-
empty repetition with EBNF conventions like [ ] for option.
6). Case Study
Case study is a research methodology, typically seen in social and life
sciences. There is no one definition of case study research. However, very simply
a case study can be defined as an intensive study about a person, a group of people
or a unit, which is aimed to generalize over several units’. A case study has also
been described as an intensive, systematic investigation of a single individual,
group, community or some other unit in which the researcher examines in-depth
data relating to several variables.

Examples of case studies

Example 1: nurses’ paediatric pain management practices
One of the authors of this paper (AT) has used a case study approach to explore
nurses’ paediatric pain management practices. This involved collecting several
datasets:

 Observational data to gain a picture about actual pain management

practices.

 Questionnaire data about nurses’ knowledge about paediatric pain

management practices and how well they felt they managed pain in
children.

 Questionnaire data about how critical nurses perceived pain management

tasks to be.

These data sets were analysed separately and then compared and
demonstrated that nurses’ level of theoretical did not impact on the quality of their
pain management practices. Nor did individual nurse’s perceptions of how critical
a task was effect the likelihood of them carrying out this task in practice. There
was also a difference in self-reported and observed practices; actual (observed)
practices did not confirm to best practice guidelines, whereas self-reported
practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led

Clinics (NPLCs)
 The other author of this paper (RH) has conducted a multiple-case study to
determine the quality of care for patients with complex clinical presentations in
NPLCs in Ontario, Canada. Five NPLCs served as individual cases that, together,
represented the quatrain. Three types of data were collected including:

 Review of documentation related to the NPLC model (media, annual

reports, research articles, grey literature and regulatory legislation).

 Interviews with nurse practitioners (NPs) practising at the five NPLCs to

determine their perceptions of the impact of the NPLC model on the
quality of care provided to patients with multimorbidity.

 Chart audits conducted at the five NPLCs to determine the extent to which
evidence-based guidelines were followed for patients with diabetes and at
least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and
themes arose related to the quality of care for complex patients at NPLCs. The
multiple-case study confirmed that nurse practitioners are the primary care
providers at the NPLCs, and this positively impacts the quality of care for patients
with multimorbidity. Healthcare policy, such as lack of an increase in salary for
NPs for 10 years, has resulted in issues in recruitment and retention of NPs at
NPLCs. This, along with insufficient resources in the communities where NPLCs
are located and high patient vulnerability at NPLCs, have a negative impact on the
quality of care.
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