NURSING REPORT

By :

NI LUH PUTRI RAHAYU (18.321.2895)

A12-B

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN

WIRA MEDIKA BALI

DENPASAR

2019
A. 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 journal represents an exhilarating opportunity to make a unique and

significant contribution to nursing and the wider community by addressing
topics, theories and issues that concern the whole field of Nursing Science,
including research, practice, policy and education. The primary intent of the
journal is to present scientifically sound and influential empirical and
theoretical studies, critical reviews and open debates to the global community
of nurses. Short reports, opinions and insights into the plight of nurses the
world-over will provide a voice for those of all cultures, governments and
perspectives. 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. In addition, reviews of the literature, open
debates on professional issues and short reports from around the world are
invited to contribute to our vibrant and dynamic journals. All published work
will be the most stringent ethical standards and journalistic principles of
fairness, worth and credibility. Our journal publishes Editorials, Original
Articles, Review articles, Critical Debates, Short Reports from Around the
Globe and Letters to the Editor.

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."

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.

Questions to Ask During Nursing Report:

 Does that patient have any family?
 Who is the patient’s primary contact if something was to happen?

 Does the patient have any type of testing that they must be NPO for?

 Does the patient need assistance eating, showering, or using the bathroom?
 How does the patient take their pills? Swallows them or needs them crushed?

 How is the patient tolerating their new medications? Any major changes in
Blood Pressure, Heart Rate etc?

 What PRN medications does the patient have?

 Does the patient have pain? How are we controlling the pain? Medications, if
so with what? When is it due next?

 Can the patient go off the floor for testing without a nurse?

 Is the patient a telemetry or non-monitored patient?

 Does the patient leave the room and go outside?

 How well does the patient walk on their own?

 When was the last time the patient was out of bed?

 Is the patient hard of hearing or have difficulty seeing?

 Are there any outstanding doctor orders that need to be completed?

 Does the patient have informed consent signed? (If patient is having surgery)

 Is IV tuding dates still in date or do they need to be changed today?

 Wound Care-Next Dressing Change Due?

 Any concerns or requests you have about the patient?

B. NURSING PROCESS

The nursing process functions as a systematic guide to client-centered care

with 5 sequential steps. These are assessment, diagnosis, planning,
implementation, and evaluation.
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.

Diagnosing

The diagnosing phase involves a nurse making an educated judgment

about a potential or actual health problem with a patient. Multiple diagnoses
are sometimes made for a single patient. These assessments not only include
an actual description of the problem (e.g. sleep deprivation) but also whether
or not a patient is at risk of developing further problems. These diagnoses are
also used to determine a patient's readiness for health improvement and
whether or not they may have developed a syndrome. The diagnoses phase is
a critical step as it is used to determine the course of treatment.

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

Implementing Phase

The implementing phase is where the nurse follows through on the

decided plan of action. This plan is specific to each patient and focuses on
achievable outcomes. Actions involved in a nursing care plan include
monitoring the patient for signs of change or improvement, directly caring for
the patient or performing necessary medical tasks, educating and instructing
the patient about further health management, and referring or contacting the
patient for follow-up. Implementation can take place over the course of hours,
days, weeks, or even months.

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.

1. Useful Expression

Useful Expressions To Express Your Opinion

 In my opinion, ... In my eyes, ...
To my mind, ... As far as I am concerned, .. Speaking personally, ...
From my point of view, ... As for me / As to me, ...
My view / opinion / belief / impression / conviction is that ...

I hold the view that ...

I would say that ... It seems to me that ...
I am of the opinion that ...
My impression is that ... I am under the impression that ...
It is my impression that ...
I have the feeling that ... My own feeling on the subject is that ...
I have no doubt that ... I am sure / I am certain that ...
I think / consider / find / feel / believe / suppose / presume / assume that ...
I hold the opinion that ... (I form / adopt an opinion.)
I dare say that ...
I guess that ... I bet that ....
I gather that ...
It goes without saying that ...
 Useful Words To Express Your Agreement
I agree with you / him ... I share your view.

I think so.

I really think so.

(The author / the narrator / the protagonist / etc.) is right
He is quite right / absolutely right He may be right.
I have no objection. I approve of it.

I have come to the same conclusion I hold the same opinion.

We are of one mind / of the same mind on that question.
I am at one with him on that point. It is true.
That is right.

That's just it ! Fair enough ! Quite so !

Just so ! Yes of course !

Useful Words To Express Your Disagreement

I don't agree. I disagree. I
don't think so.

You are / he is wrong. I think otherwise.

I don't think that's quite right.

I don't agree with you/him. I don't agree with what you say.

I am afraid that is not quite true.

 I take a different view. I don't share his/her/your view.
This argument does not hold water.
Not at all ! Nonsense !
Rubbish !

He's off his head !

2. Vocabulary
A vocabulary is a set of familiar words within a person's language. A
vocabulary, usually developed with age, serves as a useful and fundamental
tool for communication and acquiring knowledge. Acquiring an extensive
vocabulary is one of the largest challenges in learning a second language.

A. Health Habits

Aerobics : Exercise that increases one’s dependence on oxygen

Calorie : The amount of energy needed to increase the heat of 1g of

water by 1 degree Celsius

Diet :To restrict the foods that you eat for a period of time, usually
to lose weight

Excess : Having too much of something

Function : What something can be used for

Growth : Irreversible increase in the mass and height of an organism

Gymnasium : A place with various equipment for physical training

Gym : Short for gymnasium

Habit : Something that a person does out of custom

Harmful : Something that can cause damage

Health : A state of well-being, without disease

Hygiene : Practices that contribute to disease prevention, particularly

with sanitation and cleanliness

Nutrition : The process of eating the right balance of foods to provide

your body with enough energy

Posture : The position of the body

Respiration : The act of breathing

B. Vocabulary for Checkups

Addiction : Becoming unable to quit something, i.e. a drug addiction

Allergy : A hypersensitive reaction to something

Ache : A dull but persistent pain

Blood pressure: The pressure that blood exerts of the walls of blood vessels;
can be measured quickly to assess health

Calcium : The element Ca, which strengthens bones and is used in nerve
signaling

Clinical trial : Research that is done to test how well a health product works,
such as a drug or other medical treatment
Diagnose : To determine what an illness or disease is Disability: when
one is not able to perform normally

Hormone : A substance released by a gland that influences the body’s

emotions, growth, digestion, and other processes

Immunization : The act of protecting a person from disease

Insurance : A guarantee by a company or government to pay for certain

medical expenses if you have pay a premium beforehand

Vital signs : Clinical measurements that indicate the state of a patient’s

body functions

Weight : The mass of a person

C. Vocabulary for Diseases

Anemia : A deficiency of red blood cells
Anorexia : A prolonged starving of the self
Antidote : A medicine that reverses the effects of a poison
Anxiety : An unpleasant worrying about the future
Bacteria :Single-celled organisms that can be either beneficial

HIV : The human immunodeficiency virus that causes AIDS; spread

through bodily fluids

Hyperglycemia: Having excess sugar in the blood

Hypertension : High blood pressure

 Infertility : The inability to or difficulty with becoming pregnant and
having children

Inflammatio : Aswelling of a body part due to an infection, usually by a

virus or bacteria

Influenza : A highly contagious viral disease that resembles a cough;

causes fever, aches, and general discomfort.

3. Grammar Focus (arithmetic)

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.

So, what shapes languages?

Grammars do.

Grammars are the language of languages.

Behind every language, there is a grammar that determines its structure.

This article explains grammars and common notations for grammars, such as Backus-
Naur Form (BNF), Extended Backus-Naur Form (EBNF) and regular extensions to
BNF.

After reading this article, you will be able to identify and interpret all commonly used
notation for grammars.

Defining a language
A grammar defines a language.

In computer science, the most common type of grammar is the context-free grammar,
and these grammars will be the primary focus of this article.

Context-free grammars have sufficient richness to describe the recursive syntactic

structure of many (though certainly not all) languages.

I'll discuss grammars beyond context-free at the end.

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+exprexpr→termterm→term∗factorterm→factorfactor→(expr)factor→c
onstconst→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.

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.

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.

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

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.

The grammar for the entire Python language uses a slightly different (but still regular)
notation.

Grammars in mathematics

Even when grammars are not an object of mathematical study themselves, in texts
that deal with discrete mathematical structures, grammars appear to define new
notations and new structures.

For more on this, see my article on translating math into code.

Beyond context-free grammars

Regular expressions sit just beneath context-free grammars in descriptive power: you
could rewrite any regular expression into a grammar that represents the srings
matched by the expression. But, the reverse is not true: not every grammar can be
converted into an equivalent regular expression.

To go beyond the expressive power of context-free grammars, one needs to allow a

degree of context-sensitivity in the grammar.
Context-sensitivity means that terminal symbols may also appear in the left-hand
sides of rules.

Consider the following contrived grammar:

<top> ::= <a> ")"

<a> ::= "(" <exp>

"(" <exp> ")" ::= 7

<top> may expand into <a> ")";

which may expand into "(" <exp> ")";
which may expand into 7.

While this change appears small, it makes grammars equivalent to Turing machines
in terms of the languages they can describe.

By restricting the rules so that the the left-hand side has strictly fewer symbols than
all expansions on the right, context-sensitive grammars are equivalent to (decidable)
linear-bounded automata.

Even though some languages are context-sensitive, context-sensitive grammars are

rarely used for describing computer languages.

For instance, C is slightly context-sensitive because of the way it handles identifiers

and type, but this context-sensitivity is resolved by a special convention, rather than
by introducing context-sensitivity into the grammar.

Parsing

This article covered the process of interpreting grammars and common notations.

A closely related topic is parsing.

Parsing takes a grammar and a string and answers two questions:

1. Is that string in the language of the grammar?

2. What is the structure of that string relative to the grammar?

4. Case Study
A case study report is an article that describes a particular patient's
diagnosis and treatment plan. Most of the cases chosen for published medical
case studies are of unusual diagnoses, or include complications in treatment.
A case study report is written in a specific format and can be submitted to
peer-reviewed journals.

A well-written case study report in nursing requires good planning and

consideration. In the planning stage, you should determine a focus and format
of your case study and write some objectives or outcomes that show what can
be learned from this report.

A nursing case study report usually contains several sections that can be
organized into three categories:

 The patient status

 The nursing assessment of the patient

 Current care plan and possible recommendations

1. The patient status

The patient status section should provide information about

demographic data (age, race), medical history, and current diagnosis and
 treatment. You can describe the patient’s family and social history and explain
the reasons why he/she sought medical attention and what the subsequent
diagnosis was. Then, you should discuss the disease process and define
causes, describe symptoms and observations, and explain how the current
treatment can affect the nursing care.

2. The nursing assessment

When discussing the patient’s nursing assessment, you should describe

nursing diagnoses. You should describe vital signs and test results and provide
information on nursing observations. You should be specific and explain why
you identified a particular diagnosis. These nursing diagnoses will help you
determine the nursing care plan.

3. The current care plan and your recommendations for improvement

In this section, you should describe details of the nursing care plan,
including the measurable goals and interventions. You should explain how the
nursing care plan can improve the patient’s quality of life. You should also
evaluate the current care plan and provide your recommendations on how it
can be improved. You recommendations should be based on the patient’s
diagnosis, its current status, and prognosis. You should support your
recommendations with relevant authoritative sources and cite them using the
proper style according to the style guidelines. Here you should take into
account your instructor’s requirements. When you finish writing your nursing
case study report, you should proofread it, check punctuation, and fix
grammar and spelling errors. You should add references list if there are any.
 REFERENCES

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2003:4(10): 681-689.
Glaser D, Hebert A, Pariser A, Solish N. Primary focal hyperhidrosis: scope of the
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https://www.registerednursern.com/nursing-report-questions-to-ask-during-nurse-
shift-to-shift-report-about-your-patient/