NURSING REPORT

By :

NI KOMANG SURYANTINI

183212890

A12-B

PROGRAM STUDI ILMU S1 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 insight 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 journal. All published work will adhere to the most stringent ethical
standards and journalistic principles of fairness, worth and credibility.

There are many different approaches to hand-off communication, including

shift report in a room, at the nurses' station, by phone, and at the bedside. Much of
the literature indicates a need for a standardized communication method such as the
Situation-Background-Assessment-Recommendation (SBAR) technique. This
technique provides a framework for effective communication among members of
the healthcare team and helps create an environment that allows individuals to speak
up and express their concerns. This, in turn, reduces the risk of adverse events and
ultimately fosters a culture of patient safety.
 Improving the communication between caregivers can prevent negative
patient outcomes and strengthen a teamwork approach to care. The SBAR technique
provides common expectations such as what will be communicated, how it's
structured, and what are the required elements. It allows communication to be
focused on the problem and not the people. This is very important when staff
members are communicating hand-off information at the change of shifts.

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

1. Situation.
2. Background
3. Assessment.
4. Recommendation.

B. Nursing Proces
The nursing process is a scientific method used by nurses to ensure the
quality of patient care.Thisapproach can be broken down into five separate
steps.
1. Assessment Phase
The first step of the nursing process is assessment. During this phase, the
nurse gathers information about a patient's psychological, physiological,
 sociological, and spiritual status. This data can be collected in a variety of
ways. Generally, nurses will conduct a patient interview. Physical
examinations, referencing a patient's health history, obtaining a patient's
family history, and general observation can also be used to gather assessment
data. Patient interaction is generally the heaviest during this evaluative phase.
2. Diagnosing Phase
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.
3. Planning Phase
Once a patient and nurse agree on the diagnoses, a plan of action can be
developed. If multiple diagnoses need to be addressed, the head nurse will
prioritize each assessment and devote attention to severe symptoms and high
risk factors. Each problem is assigned a clear, measurable goal for the
expected beneficial outcome. For this phase, nurses generally refer to the
evidence-based Nursing Outcome Classification, which is a set of
standardized terms and measurements for tracking patient wellness. The
Nursing Interventions Classification may also be used as a resource for
planning.
4. 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.

5. Evaluation Phase
Once all nursing intervention actions have taken place, the nurse completes
an evaluation to determine of the goals for patient wellness have been met.
The possible patient outcomes are generally described under three terms:
patient's condition improved, patient's condition stabilized, and patient's
condition deteriorated, died, or discharged. In the event the condition of the
patient has shown no improvement, or if the wellness goals were not met,
the nursing process begins again from the first step.

1. Useful Expression
1) In my opinion, ...
2) To my mind, ...
3) From my point of view, ...
4) My view / opinion / belief / impression / conviction is that ...

5) I hold the view that ...

6) I would say that ...
7) I am of the opinion that ...
8) My impression is that ...
9) It is my impression that ...
10) I have the feeling that ...
11) I have no doubt that ...
12) I think / consider / find / feel / believe / suppose / presume / assume that ...
13) I hold the opinion that ...
14) I dare say that ..
15) I guess that ... .
16) I gather that ...
17) It goes without saying that ...
2. Vocabulery
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. Definition and usage
Vocabulary is commonly defined as "all the words known and used by a
particular person".Knowing a word, however, is not as simple as merely being
able to recognize or use it. There are several aspects of word knowledge that are
used to measure word knowledge.
b. Productive and receptive knowledge
The first major distinction that must be made when evaluating word
knowledge is whether the knowledge is productive (also called achieve) or
receptive (also called receive); even within those opposing categories, there is
often no clear distinction. Words that are generally understood when heard or
read or seen constitute a person's receptive vocabulary. These words may range
from well-known to barely known (see degree of knowledge below). A person's
receptive vocabulary is the larger of the two. For example, although a young
child may not yet be able to speak, write, or sign, he or she may be able to
follow simple commands and appear to understand a good portion of the
language to which they are exposed. In this case, the child's receptive
vocabulary is likely tens, if not hundreds of words, but his or her active
vocabulary is zero. When that child learns to speak or sign, however, the child's
active vocabulary begins to increase. It is also possible for the productive
vocabulary to be larger than the receptive vocabulary, for example in a second-
language learner who has learned words through study rather than exposure, and
can produce them, but has difficulty recognizing them in conversation.
Types of vocabulary
Listed in order of most ample to most limited:
1. Reading vocabulary
A literate person's vocabulary is all the words they can recognize when
reading. This is generally the largest type of vocabulary simply because a reader
tends to be exposed to more words by reading than by listening.
2. Listening vocabulary
A person's listening vocabulary is all the words they can recognize when
listening to speech. People may still understand words they were not exposed to
before using cues such as tone, gestures, the topic of discussion and the social
context of the conversation.
3. Speaking vocabulary
A person's speaking vocabulary is all the words they use in speech. It is
likely to be a subset of the listening vocabulary. Due to the spontaneous nature of
speech, words are often misused. This misuse, though slight and unintentional,
may be compensated by facial expressions and tone of voice.
4. Writing vocabulary
Words are used in various forms of writing from formal essays to social
media feeds. Many written words do not commonly appear in speech. Writers
generally use a limited set of words when communicating.For example, if there
are a number of synonyms, a writer may have a preference as to which of them to
use, and they are unlikely to use technical vocabulary relating to a subject in
which they have no knowledge or interest.
5. Focal vocabulary
Focal vocabulary is a specialized set of terms and distinctions that is
particularly important to a certain group: those with a particular focus of
experience or activity. A lexicon, or vocabulary, is a language's dictionary: its set
of names for things, events, and ideas. Some linguists believe that lexicon
influences people's perception of things, the Sapir–Whorf hypothesis. For
example, the Nuer of Sudan have an elaborate vocabulary to describe cattle. The
Nuer have dozens of names for cattle because of the cattle's particular histories,
economies, and environments This kind of comparison has elicited some
linguistic controversy, as with the number of "Eskimo words for snow". English
 speakers with relevant specialised knowledge can also display elaborate and
precise vocabularies for snow and cattle when the need arises.
6. Vocabulary growth
Main article: Vocabulary development
During its infancy, a child instinctively builds a vocabulary. Infants imitate words
that they hear and then associate those words with objects and actions. This is the
listening vocabulary. The speaking vocabulary follows, as a child's thoughts
become more reliant on his/her ability to self-express without relying on gestures or
babbling. Once the reading and writing vocabularies start to develop, through
questions and education, the child starts to discover the anomalies and irregularities
of language.
In first grade, a child who can read learns about twice as many words as one
who cannot. Generally, this gap does not narrow later. This results in a wide range
of vocabulary by age five or six, when an English-speaking child will have learned
about 1500 words.
Vocabulary grows throughout our entire life. Between the ages of 20 and 60,
people learn some 6,000 more lemmas, or one every other day.An average 20-year-
old knows 42,000 words coming from 11,100 word families; an average 60-year-old
knows 48,200 lemmas coming from 13,400 word families.People expand their
vocabularies by e.g. reading, playing word games, and participating in vocabulary-
related programs. Exposure to traditional print media teaches correct spelling and
vocabulary, while exposure to text messaging leads to more relaxed word
acceptability constraints

Importance
 An extensive vocabulary aids expression and communication.
 Vocabulary size has been directly linked to reading comprehension.
 Linguistic vocabulary is synonymous with thinking vocabulary.
 A person may be judged by others based on his or her vocabulary.
3. Grammar Pocus ( artihmatic)
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.
a. 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.
b. 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:
c. 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.
d. 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.
1. 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.
2. 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.
3. 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.
4. Concatenation
In some forms of EBNF, the , operator explicitly denotes concatenation,
rather than relying on juxtaposition.
e. 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

f. 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.

1. 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.

2. 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.

3. 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

What is it?
Case study is a research methodology, typically seen in
social and life sciences. There is no one definition of case
study research.
1. However, very simply... ‘a case study canbe defined as an intensive study about
a person, a group ofpeople or a unit, which is aimed to generalize over
severalunits’.A case study has also been described as an inten-sive, systematic
 investigation of a single individual, group,community or some other unit in
which the researcherexamines in-depth data relating to several variables.
2. Researchers describe how case studies examinecomplex phenomena in the
natural setting to increaseunderstanding of them.
3. Indeed
4. Sandelowski
5. Suggestsusing case studies in research means that the holisticnature of nursing
care can be addressed. Furthermore,when describing the steps undertaken while
using acase study approach, this method of research allows theresearcher to take
a complex and broad topic, or phenom-enon, and narrow it down into a
manageable researchquestion(s). By collecting qualitative or quantitative data-
sets about the phenomenon, the researcher gains a morein-depth insight into the
phenomenon than would beobtained using only one type of data. This is
illustrated inthe examples provided at the end of this paper. Often there are
several similar cases to consider such as educational or social service
programmes that are delivered from a number of locations. Although similar,
they are complex and have unique features. In these circumstances, the
evaluation of several, similar cases will provide a better answer to a research
ques- tion than if only one case is examined, hence the multi- ple-case study.
Stake asserts that the cases are groupedand viewed as one entity, called the
quintain.
6. ‘We studywhat is similar and different about the cases to under-
stand the quintain better’. Method The steps when using case study
methodology are the same as for other types of research.The first step is
defining the single case oridentifying a group of similar cases that can then be
incorporated into a multiple-casestudy. A search to determine what is known
about the case(s) is typically conducted. This may include a reviewof the
literature, grey literature, media, reports and more,which serves to establish a
basic understanding of the cases and informs the development of research ques-
tions. Data in case studies are often, but not exclusively, qualitative in nature. In
multiple-case studies, analysis within cases and across cases is conducted.
Themes arise from the analyses and assertions about the cases as a whole, or the
quintain, emerge.
Benefits and limitations of case studies If a researcher wants to study a
specific phenomenonarising from a particular entity, then a single-case study is
warranted and will allow for a in-depth understanding of the single phenomenon
and, as discussed above, would involve collecting several different types of data.
This is illustrated in example 1 below. Using a multiple-case research study
allows for a more in-depth understanding of the cases as a unit, through
comparison of similarities and differences of the individual cases embedded
within the quintain. Evidence arising from multiple-case studies is often
stronger and more reliable than from single-case research. Multi-ple-case studies
allow for more comprehensive explo- ration of research questions and theory
development.Despite the advantages of case studies, there are limitations. The
sheer volume of data is difficult to orga- nise and data analysis and integration
strategies need to be carefully thought through. There is also sometimesa
temptation to veer away from the research focus.Reporting of findings from
multiple-case research studies is also challenging at times,
1. particularly in rela-tion to the word limits for some journal papers.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:
1. Observational data to gain a picture about actualpain management
practices.
2. Questionnaire data about nurses’ knowledge aboutpaediatric pain
management practices and how wellthey felt they managed pain in
children.
3. Questionnaire dataabout how critical nursesperceived pain management
tasks to be. These datasets were analysed separately and
thencompared7–9and demonstrated that nurses’ level oftheoretical did
not impact on the quality of their painmanagement practices.7Nor did
individual nurse’s percep-tions of how critical a task was effect the
likelihood ofthem carrying out this task in practice.8There was also
adifference in self-reported and observed practices9; actual (observed)
practices did not confirm to best practice guide- lines, 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. 10 Five NPLCs served as individual cases that,
together, represented the quatrain. Three types of data were collected
including:
1. Review of documentation related to the NPLCmodel (media, annual
reports, research articles, greyliterature and regulatory legislation).
2. Interviews with nurse practitioners(NPs) practicing at the five
NPLCs to determine their perceptions ofthe impact of the NPLC
model on the quality of careprovided to patients with multimorbidity.
3. Chart audits conducted at the five NPLCs to determinetheextent to
which evidence-based guidelines werefollowed for patients with
diabetes and at least oneother chronic condition.The three sources of
data collected from the five NPLCswere 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
primarycare providers at the NPLCs, and this positively impactsthe
quality of care for patients with multimorbidity.Healthcare policy,
such as lack of an increase in salaryfor NPs for 10 years, has resulted
in issues in recruitmentand retention of NPs at NPLCs. This, along
with insuf-ficient resources in the communities where NPLCs
arelocated and high patient vulnerability at NPLCs, have anegative
impact on the quality of care.10Conclusion.
These examples illustrate how collecting data about asingle case or
multiple cases helps us to better under- stand the phenomenon in
question. Case study meth- odology serves to provide a framework
for evaluation and analysis of complex issues. It shines a light on the
holistic nature of nursing practice and offers a perspec- tive that
informs improved patient care. Competing interests
None declared. Provenance and peer review Commissioned;
internally peer reviewed.
 DAFTAR PUSTAKA
https://www.pagepressjournals.org/index.php/nursing/
https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/09000/Looking_to_imp
rove_your_bedside_report__Try_SBAR.14
http://www.cmft.nhs.uk/directorates/mentor/documents/Assessingplanningimplementingan
devaluatingcare_001.pdf
http://s1-keperawatan.umm.ac.id/files/file/EPN%20Book%202.pdf
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