SUMMARY

NURSING FUNDAMENTALS
NURSING PROCESS, PATIENT ADMISSION, TRANSFER,
AND DISCHARGE

This summary was made to fulfill an English assignment

supervisor
Nursanti Dwi Yogawati, M.Pd

arranged by:

Zakkia Zahra Devaani 108119014

PROGRAM STUDI S1 KEPERAWATAN 1A

STIKES AL-IRSYAD AL-ISLAMIYYAH CILACAP
 TAHUN 2020
A. Nursing Process
The nursing process so there are 5 steps in the nursing process:
1. Assessment and data collection
This includes collecting data such as subjective information like the patient's pain
level and with that pain feels like and also objective information such as the
patient's vital signs so what's really important for you to remember is as a nurse
you always one to assess before you take action.
2. Analysis's and data collection
So you want to cluster the collected data during this stage identify any patterns or
trends and then compare the data you collected to be expected values.
3. Planning
Where you with prioritize your interventions and identify measureable outcomes
so you wanna make sure these outcomes are time limited and specific so they are
not gonna be something vague like the patient will be feeling better in a couple
days right it's just very big.
4. Implementation
This is where you going to perform your nursing care and you're going to
document your patience responses to the interventions that your doing.
5. Evaluation
This is where you're gonna compare the actual results with the planned outcomes
and determine next steps so if you're interventions were successful and the patient
has met those outcomes then great if not then you got up work on a plan B and
determine next step.
B. Patient Admission
1. Document your patients advance directive
If you can't feel a pulse do you call a code blue or are they a DNR do not
resuscitate patients so you have to get real clear at that at the beginning you want
to document the patient's vital signs their height and weighed their allergies you
wanna do a head to toe assessment take a health history.
C. Patient transfer
When there came from 1 unit to another you want to use some kind of tool such as an S
bar so S bar stands for situation background assessment and recommendations so this is a
great tool to use as you are giving report to the receiving nurse at the other unit so you're
let them know what the patient's situation is a little bit of the background and your
current assessment and what your recommendations are for the patient and than in terms
of discharge.

D. Discharge patient
how this patient is going to discharge as soon as they walk in the door at admission

components of of discharge paperwork and just the teaching you need to do so in the
discharge paperwork you definitely went to include that the patient's diet and activity
restrictions you want detailed instructions provided to the patient for procedures that will
need to be done at home such as wound care and then you wanna provide a list of
medications to the patient when to take each medication and any kind of precautions were
guarding the medications you want to provide the patient information about signs and
symptoms of complications and went to seek medical attention and you want to provide a
follow-up appointment information so 9 times out of 10 as a patient is leaving the
hospital they will need to follow up with their primery care provider within a couple days
and then you always want to provide names and numbers of providers and or community
resources that the patient may need when they discharge.