BAHASA

INGGRIS 2
Lectured by:
Mrs Nita Yuanita, S.Pd., M.Si.
Mr. Irsyad Nurgraha, M.Pd.

1
NURSING PROCESS &
SHARING
OBSERVATION
INDIKATOR:

1. Memahami proses/ tahapan

pelaksanaan tugas keperawatan i.e.
Assessing, Diagnosing, Planning,
Implementing and Evaluating.
2. Menggunakan ungkapan yang
berkaitan dengan observasi terhadap
kondisi pasien
 1ST MEETING
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

IMPLEMENTING

EVALUATING
 1ST MEETING

1. ASSESSING
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.
 1ST MEETING

2. DIAGNOSING
Diagnosing/ 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
 1ST MEETING

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
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4. IMPLEMENTING
Implementing/ 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: 3C
Competently, Caringly (peduli), and Creatively.
 1ST MEETING

5. EVALUATING
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)
 1ST MEETING

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) Papery : (adj.) kelihatan tipis dan kering
perih
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
 1ST MEETING
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
eyesreddish moving your (hand)
nail yellowish, etc. changing your clothes, etc.
… to have a problem with + (part of the body)
 1ST MEETING
EXERCISE 1
Translate these 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
…………………………………………………………………………
5. Jari tangan anda kelihatannya bengkak
…………………………………………………………………………
6. Anda terlihat tidak nyaman ketika mengganti baju anda, bruise on
your skin looks painful
…………………………………………………………………………
 1ST MEETING
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)
……………………………………………………………………………
5. (seem- with- uncomfortable- you- sling- that)
……………………………………………………………………………
 1ST MEETING
EXERCISE 3
Giving more sample about sharing observation
Use the suitable statement to express sharing observation based on the
picture
Example:

You seem to have a problem with tooth

Now, make possible statement about sharing observation based on the

pictures below!

Picture No.1 Picture No.2 Picture No.3

End Session
Thank you