Siti Nur Qomariah, S.Kep.,Ns.,M.

Kep
Prodi Ilmu Keperawatan
Fakultas Ilmu Kesehatan Universitas Gresik
 The nursing process is the framework for the
practice of professional nursing
 It is method of problem identification and
problem solving that describe what the nurse
actually does.
1. Assessment : The nurse collects client health
data.
2. Diagnosis : The nurse analyzes data in
determining diagnoses.
3. Planning : The nurse developes a plan of care
that prescribes intervention to attain expected
outcomes
Outcome Identification : The nurse identifies
expected outcomes individualized to the client
4. Implementation : The nurse implements the
interventions identified in the plan of care
5. Evaluations : The nurse evaluates the client’s
progress towards attainment of outcomes
 Problem
Resolutions Reassessment

Evaluations Assessment

Nursing
Implementations Diagnosis

Planning with
Outcomes
setting
Actual Potential
health health
problem problem
 The initial database is obtained by means of a nursing history
and nursing examination.
 Assessment data are documented:
1. Accurately – Questionable data are validated.
2. Completely – Use of a systematic guide ensures that recorded
data describe (1) the client’s functional ability to meet each
basic human need and (2) responses to health and illness.
3. Concisely – Irrelevant data and meaningless generalizations
are avoided.
4. Factually – Client behaviors are recorded rather than the
nurse’s interpretation of these behaviors.
 The initial database communicates a”real sense” of the client
whish makes possible individualized care.
 Focused assessment data are recorded for each client problem.
 Data collection and documentation are ongoing and
responsive to changes in the client’s condition.
 Assessing Nursing / Illness History: Patients’
Identity; Chief Complaint; HPI: History of
Present Illness; PNH (past Nursing History);
Family History
 Observation Vital Signs: T-P-R-BP
(temperature – Pulse – Respirations – Blood
Pressure) and General Appearance
 PE (Physical Examination): B1 – B 6 through
Approach of IPPA (Inspection; Percussion;
Palpation; Auscultation)
 Result of Diagnostic Test: Blood; Urine; Stool;
X-ray; CTSCAN; etc
 A sign of disease is something that a nurse can
see or feel for herself. She can observe it. Ex :
Bruising; rash; swelling; weight loss
 A symptom of disease is something that only
the patient knows about. The patient tells the
nurses about it. Ex : Nausea, insomnia, all
kinds of pain
 Consists of: terdiri dari
 Contains: mengandung
 is fitted into: dipasang
 is used for: digunakan untuk
 is divided into; dibagi menjadi beberapa
 is attached: di tempelkan
 is supported: disangga
 is covered: ditutup
 is composed of: komposisi
 are connected: dihubungkan
 leads from: sambungan
 to be located / situated: terletak di
 at the top of: dibagian paling atas
 at the bottom: di bagian paling bawah
 at the sides of: disamping
 between: antara
 above: diatas
 below: dibawah
 When a nurse describes to a doctor the pain a patient is
suffering from, she can describe what kind of pain it is
and exactly where it is. Pains are described as severe if
they are bad, and slight if they are not very bad. A
throbbing pain beats like a pulse, a constant pain is
always present, while an intermittent pain comes and
goes.
 The exact location of the pain must be described. The
diagram shows the different areas of the abdomen. The
epigastrium is the area at the top of the diagram, just
below the costal margin. At the bottom of the diagram
is the supra-pubic area. Above this are the left lower
quadrant and right lower quadrant. The right upper
quadrant and left upper quadrant are between the
lower quadrants and the epigastrium.
 Abdomen
 gambar abdomen.doc
 + plus
 = equals
 x times
 0,506 naught point five oh six
 0C degrees Centigrade
 B.P. blood pressure
 1/12 one over twelve or one twelfth
Now look at these common complaints: some are
signs and some are symptoms. Make two lists like
the examples below.
 Irregular pulse, dull pain, stomachache, dizziness,
haematemesis, hunger, pallor, diarrhea, jaundice,
thirst, dyspnea, constipation, headache, cyanosis,
anorexia, laceration, abrasion, inflammation,
shallow pulse, weight gain, shallow respiration,
backache
Example:
Sign: Rapid Pulse
Symptoms: Sharp Pain