MAKALAH

NURSING INTRUCTION
Dosen : Desi Natalia, M.Pd

Disusun oleh :
Ceciy Anti 2019.B.20.0501
Devia 2019.B.20.0502
Noor Anisa Wulandari 2019.B.20.0506
Wiri Worda 2019.B.20.0508

YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
PRODI DIII KEPERAWATAN
TAHUN AJARAN 2020/2021
 CHAPTER 2
DISCUSSION

NURSING INTRUCTION
Nursing instructions are specific actions tahat are implemented by nurses to assist
clients in achieving the outcome criteria.
Nursing instructions indicate specific,measurable,observable and realistic actions
performed by the nurse.
Types of nursing instructions: Diagnostic,therapeutic,conseling,referral.
As for some nursing instructions that can be done in choosing nursing actions,namely
:
 Nursing actions must be safe for clients
 Nursing actions must be in line with other treatment actions
 Nursing actions must be based on principles and knowledge and experience
 Write a set of nursing actions
 Select one from a set of nursing actions
 Nursing actions must be realistic
 Nursing actions should improve the client’s health and be in line with values
and goals
 Use the patient as a resource in selecting nursing actions

1. Useful Expression
In health or nursing service activities,communication is a process to create a
relationship between health workers and clients or patients,doctors or nurses
with other health teams,and health workers with families/communities,in
digging up data or information to identify client problems,create action
plans,and implement and evaluate health service actions that have been
implemented.
2. Dialogue
Nurse : Good morning,Mrs.Yuni.
Patient : Good morning,nurse.
Nurse : How do you feel?
Patient : I don’t feel well. My eyes are sore and also itchy.
Nurse : How long have you felt like this?
Patient : Since Yesterday morning,nurse.
Nurse : Have you try to cure your eyes yourself?
Patient : No,nurse. I haven’t.
 Nurse : Ok. I’II check your eyes. Please follow my instruction,Ma’am.
Patient : I will,nurse.
Nurse : Please put off your spectacles,Mrs.Yuni.
Nurse : Keep your eyes open. Done. Now,you can put on your spectacles.
Patient : What’s wrong with my eyes,nurse?
Nurse : I can’t make sure,Ma’am.Just wait for some minutes until dr.Yusran
check them.
Patient : Thanks,Nurse.
Nurse : You are welcome, Ma’am.
3. Vocabulary
Nouns: People,year,maet,music,food,bird,nature
Verbs : Are,see,need,know,come,would,bring
Adjectives : Used,every,large,various,useful
Adverbs : Never,early,also,very,always,below
Pronoun : I,you,we,who,its,my,everyone,myself
Preposition : With,at,from,until,against,for,by
4. Grammar Focus
Present Continous Tense
+ Subject +Tobe +V-ing + Object
Ex: You are reading my article at present

- Subject + Tobe + Not + V-ing + Object

Ex : You are Not reading my article at present

? Tobe + subject + V-ing + Object

Ex: Are you reading my article at present?
5. Practice
Nursing practice is a service provided by nurses in the form of nursing care.
Nursing as an integral part of health services in Indonesia realizes that the
need for clients (individuals,families,groups and communities),therefore the
services provided by nurses are always based on the ideal of pure intentions
for safety and welfare people without distinction.
6. Exercise
Sport is a movement of the body that has an effect on the body as a whole.
Exercise,such as walking,running,dancing,swimming or yoga,stimulates the
muscles and various other parts of the body to move.
The benefits of exercise for the body include:
1) Preventing heart disease and stroke
2) Controlling diabetes
3) Reducing high blood pressure
4) Preventing back pain
 5) Preventing obesity
6) Reducing the risk of osteoporosis
7) Overcoming stress
8) Improving mood
7. Case Study
A case study using nursing care is a series of nursing processes in individuals
with disorders through assessment, diagnosis, planning, implementation
(nursing actions) and patient evaluation.

Conclusion
Nursing instructions in choosing nursing actions must be carried out carefully
in order to create patient safety.Therefore,a nurse must have knowledge and
experience when doing nusing care to clients.

References
Haryanto. (2008). Konsep Dasar Keperawatan dengan Pemetaan Konsep.
Jakarta : Salemba Medika
Hutahaean,S. (2010). Konsep dan Dokumentasi Proses Keperawatan.Jakarta :
TIM
Tarwoto & Wartonah. (2010) Kebutuhan Dasar Manusia dan Proses
Keperawatan.
Jakarta : Salemba Medika
Hidayah, N. (2014). Manajemen Model Asuhan Keperawatan Profesional
(MAKP) Tim dalam Peningkatan Kepuasan Pasien di Rumah Sakit.
Kesehatan, 7(2), 410-426.
Nursalam. (2008). Proses dan Dokumentasi Keperawatan. Ed. 2. Jakarta:
Salemba Medika.
Nursalam. (2011). Proses dan Dokumentasi Keperawatan: Konsep dan
Praktik. Ed. 2.
Jakarta: Salemba Medika.
Make a conversation about cases in the nursing
1. Conversation of nurses, doctor, and clients about Chickenpox
nurse: Good morning mom, how can I help you?
patient: Good morning, this is my son for several days with a cold accompanied by
fever, he has taken medicine but it does not go away instead he appears red spots
filled with water and feels itchy when you touch it, it hurts.
Ms. I: (looks weak, tired and lethargic?
nurse: "Good morning doc, in the ER there are patients based on the examination and
the patient's complaints show symptoms of a diagnosis of varicella virus
(chickenpox), please check the doctor first.
Doctor: okay, alright
(The doctor examines the patient)
Doctor: Good morning, mother, sister.
Patient: morning doc, how is my child, doc?
Doctor: You see, your child has chicken pox. With Ms. I's current condition, Ms. I
needs hospitalization until her condition improves.
patient: OK doc, I will follow orders from the doctor.
Doctor: nurse please prepare a room for this patient.
Nurse: OK doc, (let mother come with me).
patient: Ok nurse.
nurse: Please take a break and I will go back to check on Ms. I's skin after some time.
don't forget to wear clothes so you can absorb sweat.
Patient : Ok.
nurse: If anything is needed, you can call the nurse in the nurse's room.
Patien : Ok, Thank you.
2. Conversation of nurses, doctor, and clients about TBC
Day 1
Doctor: Good morning sir, with whom and what are you complaining about?
Patient: I am Candra, doc. recently I was coughing with phlegm and it hasn't been
healed for more than 2 weeks, even though I've been taking cough medicine, and
usually shortness of breath until the chest feels pain, and recently I often get night
sweats.
Doctor: Did Mr Candra have a decreased appetite?
patient: Yes doc, I also have less appetite
Doctor: According to the symptoms you are complaining about right now are
symptoms of tuberculosis, so you will come back tomorrow for a laboratory
examination to confirm your illness, and don't forget to bring your sputum which is
placed in a clean ointment pot and can be purchased at a pharmacy.
Day 2
doctor: good morning sir, what are you complaining about?
patient: yesterday I was told to come back to bring my sputum
Doctor: Oh, Mr. Candra yes .. How is there phlegm?
patient: I have put this in the ointment pot
Doctor: Okay sir, sorry beforehand you can wait in the waiting room to find out the
lab results
patient: Yes sir, thank you.

A few moments later

Doctor: Mr. Candra, the lab results have come out, you are positive for TB disease
Patient: What disease is doc?
Doctor: TB is an infectious disease caused by TB germs or mycobacterium
tuberculosis, these germs attack the lungs but some also attack other limbs such as
bones, intestinal skin, lining of the brain and others, and TB is not a hereditary
disease, not caused by curses or witchcraft.
Patient: Can this disease be cured?
Doctor: The possibility of recovery, the important thing is you regularly take
medication and maintain your lifestyle.
Patient: Yes sir, thank you.

3. Conversation of nurses, doctor, and clients about Allergy

Doctor: Hi, Maria. How are you feeling today?
Patient: I’m feeling a little bit better.
Doctor: What about the headache?
Patient: I feel dizzy sometimes. But I’ve never thrown up anymore.
Doctor: What about your sight? Can you see clearly?
Patient: It got a little bit blurry yesterday, but everything’s fine now
Doctor: That’s good to hear. Your test results came in this morning.
Patient: So, is it going to be a good news or bad?
Doctor: It’s a bit of both, I guess.
Patient: Oh no.
Doctor: You ready?
Patient: Um, okay.
Doctor: You’ve got fragrance allergies. You’ll have to avoid any products that have
perfume or fragrance in it. Besides being sensitive to scents, seems like you’re having
sinus infection. I would recommend the use of antibiotics and nasal decongestant
spray for now. But if the drug therapies fail, you may need a surgery next month.
Patient: Thank God it’s not that bad.

Make nursing daily progress report in medical ward

A.PENGAKAJIAN
I.Identification of patients
Name                                       : ny "N"
Age                                         : thirty seven years
Family                                     : five people
Last education                         : elementary school
Occupation                              : housewife
Address                                   : jln.T.A.Gani
Hospital admission date          : 16 December 2014
Diagnostic medic                    : effusion fleura

II. Family history

1. The main complaint : tightness
Trigger factor                          : due to accumulation of fluid in the cavity fleura
Nature of complaint                : settle
Location anddistribution        : chest
Scale complaint                       : severe (6-10)
Start and duration of pain       : from entering the hospital
Things that ease / burden        : break / tightness
2. Past health history
Patients say the illness / complaint that is often experienced shortness
Patients say never hospitalized earlier
The patient said he had never had surgery
Patients say no allergies

III. Vital signs:
a. Blood pressure        : 100 / 70mmHg
b. Pulse                        : 70x / i
c. Body temperature   : 37 C
d. Respiratory             : 32x / i
IV. History needs comfort
 Patients say never suffered trauma resulting in pain
 Location of pain: chest area
 The nature of pain: sedentary
Patients say never impaired body temperature changes
 Patients say the disease is often experienced shortness
 Patients say never experienced flatulence
Physical examination
1. Inspection
a. Vocal: wince
b. Facial expressions: grimacing
2. Palpation
a. Pain scale: severe (6-10)
b. Quality of pain: sharp
3. Percussion
a. Beep: timpani
4. Auscultation
a. Bowel sounds: wheezing

DATA FOCUS
Name: ny "N"                                               
needs: security and comfort
Age: 37 years old                               
room: surgical treatment
Gender: female                                  

date: 8 January 2015

Subjective data Objective data

The patient said congested while Patient appears pale
sleeping on their backs
Patients seems weak 
 The patient said chest pain
Grimacing facial expressions
Patients say often cough
Observation of vital signs:
Blood pressure: 100/70 mmHg
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i
 DATA ANALYSIS

Name: ny "N"                                   needs: security and comfort

Age: 37 years old                               room: surgical treatment
Gender: female                                  date: 8 January 2015
DATA ETIOLOGY PROBLEM
Subjective Data permeability changes fleura Impaired sense of comfort
1. The patient said congested while
sleeping on their backs Decreased plasma osmotic
pressure
2. Patients report pain in the chest area

3. Patients say often cough Increased systemic capillary

hydrostatic pressure
Objective data
1. The patient appears pale Reduced dranaise limfatif

2. Patients seems weak Pulmonary edema fluid

movement and passing
3. grimacing facial expression through the pleural lining
viselaris
4. Observation of vital signs
Blood pressure: 100/70 mmHg
Increased peritoneal fluid
Temperature: 37 c
Nadi: 70x / i
Respiratory: 32x / i

V. DIAGNOOSA NURSING
 Impaired sense of comfort associated with shortness
Objective: after the act of nursing 2x24 hours expected of patients showed comfort
with criteria results:
a. Shortness bekurang
b. Pain is reduced
c. Cheerful facial expressions

VI. INTERVENTION NURSING

1. Assess breathing pattern
Rational: to determine the pattern of breathing
2. Observation of vital signs
 Rational: to recognize and facilitate action
3. Give a comfortable position
Rational: to reduce pain with semi-Fowler's position
4. Create a quiet neighborhood
Rational: to improve comfort
5. Collaboration with other nurses and other medical team in delivering drugs
Rational: to reduce the complaints

VII. IMPLEMENTATION OF NURSING
1.      Assess breathing pattern
Results: Respiratory 32x / i
2. Observe vital signs
Results: vital signs
 Blood pressure: 100/70 mmHg
 Temperature: 37 c
 Breathing: 70x / i
3. Provide a comfortable position possible (semi-Fowler)
Results: The patient can perform semi-Fowler's position
4. Creating an environment that is quiet
Results: The patients can calm
5. Treatment with nurses and other medical team in delivering drugs
Results: The administration of analgesic drugs

VIII. EVALUATION OF NURSING

 Subjective:
 patients say claustrophobic when sleeping on their backs
 Clients say pain in the chest
 Clients say often cough
 Objective:
 patient appears pale
 patients seems weak
 grimacing facial expressions
 observation of vital signs
Blood pressure: 100 / 70mmHg
temperature: 37 C
Pulse: 70x / i
Respiratory: 32x / i
 Asesmennt: Issues not resolved interference comfort
 Planning: continue intervention
1. examine the pattern of breathing
2. The observation of vital signs
3. give a comfortable position
4. create a calm environment
5. collaboration with nurses and medical teams provide drug