Modul Fix Psik

Courses
Study Program Nursing sciences Meeting First

Code / credits (1 P) Module I
Name of course Scientific report Number of page 4
Lectures Team Update 2019
MODULE I
Introduction: Case study
I. General Instructions
This general guide, contains an explanation of the steps to be taken in lectures, as
follows:
1. Basic Competence
So that students know and able to develop a nursing project: case study regarding area
interest.
2. Material
Introduction: Case study
3. Indicators of Achievement
Students can explain and how to develop case study
4. References
a. Alfaro-LeFevre, R. (2014) Applying Nursing Process: The Foundation for
Clinical Reasoning. Philadelphia: Lippincott Williams & Wilkins
b. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb's Fundamentals of
nursing: Concepts, process, and practice, (9th ed.). Upper Saddle River, N.J.: Pearson
Education, Inc.
c. Caple, C. (2011). Physical assessment: Performing- cultural considerations. Glendale,
CA: Cinahl Information Systems.
d. Centers for Disease Control and Prevention. (2013). Heart Disease Facts and Statistics.
Retrieved July 2014 from: http://www.cdc.gov/heartdisease/statistics.htm
e. D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological assessment:
Treatment planning for rehabilitation. (2nd ed.). NY: Springer Publishing.
f. Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced physical assessment
skills by cardiac nurses. British Journal of Nursing, 19(5), 282-287.
g. Jarvis, C. (2012). Physical examination and health assessment, (6th ed). St. Louis:
W.B. Saunders. Mosby Company. (2012). Mosby’s medical dictionary (9th ed.). New
York: Elsevier.
h. Scanlon, V. (2011). Essentials of anatomy and physiology (6th ed.). Philadelphia: F.A.
Davis Co.
i. Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd ed.).
Philadelphia: F.A. Davis Co.
j. Zambas, S.I. (2010). Purpose of the systematic physical assessment in everyday
practice: Critique of a “sacred cow”. Journal of Nursing Education, 49(6), 305-310
5. Learning Strategy
Learning strategy used is contextual instruction, class scenario with time 100
minutes, steps are performed, as follows:
1
a. Lecture materials have been given to students 1 (one) week before the lecture,
students are required to read and understand the material in order to more easily
reveal the latest cases that occurred.
b. The lecturer gives material explanation based on the present condition
c. After the conceptual explanation by the lecturer, the students are divided into
discussion groups to discuss deeper the concept described.
d. After finishing the discussion, the students are asked to explain the results of the
discussion and the other groups provide a rebuttal or denial.
e. Each group is given the opportunity to explain the outcome of the discussion and
defend their opinion by arguing according to the concept of the material.
f. The learning approach may change according to progress, material and agreement
with students.
6. Learning Activity
a. Understand and master this material well, so that at the time of discussion and
ridicule about your brother does not have much difficulty.
b. Begin self-motivation to read, from the easy ones, and start reading now.
c. Read scenarios in general instructions, making it easier for students to learn in the
classroom.
7. Evaluation
a. after the end of the learning activities, students are asked to do the test (post test), so
it can be known how far learning objectives in the discussion of these materials can
be achieved.
b. If the student can answer 70% of the test questions correctly mean that the student
has achieved the learning objectives in the discussion of the material delivered by the
lecturer
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II. Material
Introduction: Case Study
Case study is a research methodology, typically seen in social and life sciences. There is no one
definition of case study research. However, very simply… ‘a case study can be defined as an
intensive study about a person, a group of people or a unit, which is aimed to generalize over
several units’. A case study has also been described as an intensive, systematic investigation of a
single individual, group, community or some other unit in which the researcher examines in-
depth data relating to several variables. Researchers describe how case studies examine complex
phenomena in the natural setting to increase understanding of them. Indeed, Sandelowski
suggests using case studies in research means that the holistic nature of nursing care can be
addressed. Furthermore, when describing the steps undertaken while using a case study
approach, this method of research allows the researcher to take a complex and broad topic, or
phenomenon, and narrow it down into a manageable research question(s). By collecting
qualitative or quantitative datasets about the phenomenon, the researcher gains a more in-depth
insight into the phenomenon than would be obtained using only one type of data. This is
illustrated in the examples provided at the end of this paper.
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 or identifying a group of similar cases that can then be
incorporated into a multiple-case study. A search to determine what is known about the case(s) is
typically conducted. This may include a review of the literature, grey literature, media, reports
and more, which serves to establish a basic understanding of the cases and informs the
development of research questions. 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 phenomenon arising 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. Multiple-case studies allow
for more comprehensive exploration of research questions and theory development. Despite the
advantages of case studies, there are limitations. The sheer volume of data is difficult to organise
and data analysis and integration strategies need to be carefully thought through. There is also
sometimes a temptation to veer away from the research focus. Reporting of findings from
multiple-case research studies is also challenging at times,particularly in relation to the word
limits for some journal papers.
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Examples of case studies
Example 1: 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. 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 NPLC model (media, annual reports, research
articles, grey literature and regulatory legislation).
2. Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their
perceptions of the impact of the NPLC model on the quality of care provided to patients
with multimorbidity.
3. Chart audits conducted at the five NPLCs to determine the extent to which evidence-
based guidelines were followed for patients with diabetes and at least one other chronic
condition.
The three sources of data collected from the five NPLCs were 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 primary care providers at the NPLCs, and this positively impacts the
quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in
salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs.
This, along with insufficient resources in the communities where NPLCs are located and high
patient vulnerability at NPLCs, have a negative impact on the quality of care.
Conclusion
These examples illustrate how collecting data about a single case or multiple cases helps us to
better understand the phenomenon in question. Case study methodology 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 perspective that informs improved patient care
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Courses
Study Program Nursing sciences Meeting 2

Code / credits (1 P) Module II
MODULE II
The Nursing Process
follows:
1. Basic Competence
interest.
2. Material
Introduction in Nursing Process: The Nursing Process
4. References
Education, Inc.
York: Elsevier.
Davis Co.
5
with students.
classroom.
7. Evaluation
be achieved.
lecturer
6
II. Material
The Nursing Process
The common thread uniting different types of nurses who work in varied areas is the
nursing process—the essential core of practice for the registered nurse to deliver holistic,
patient-focused care.
1. Assessment
An RN uses a systematic, dynamic, rather than static way to collect and analyze
data about a client, the first step in delivering nursing care. Assessment includes not only
physiological data, but also psychological, sociocultural, spiritual, economic, and life-
style factors as well.
2. Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response
to actual or potential health conditions or needs.
3. Planning / Goal / Outcome
Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for this patient that might include moving from bed to chair
at least three times per day; maintaining adequate nutrition by eating smaller, more
frequent meals; resolving conflict through counseling, or managing pain through
adequate medication.
4. Implementation
Nursing care is implemented according to the care plan, so continuity of care for
the patient during hospitalization and in preparation for discharge needs to be assured.
Care is documented in the patient’s record.
5. Evaluation
Both the patient’s status and the effectiveness of the nursing care must
be continuously evaluated, and the care plan modified as needed
Component and Purpose Activities

Description
Assessment To establish a database about Establish a database:
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the client’s response to health Subjective data (not measurable) Objective
concerns or illness and the data (measurable)
Collecting, organizing, ability to manage health care
validating, and documenting Obtain a nursing health history
needs
client data Review client records
Review nursing literature
Consult support persons
Consult health professionals
Update data as needed

Organize data Validate data
Communicate/document data
Diagnosis To identify client strengths and Interpret and analyze data:
health problems that can be Compare data against standards
prevented or resolved by Cluster or group data (generate tentative
Cluster, Analyze and
collaborative and independent hypotheses)
synthesize data.
nursing interventions. Identify gaps and inconsistencies
Problem identification To develop a list of nursing

Determine client’s strengths, risks, and
Nursing diagnosis label diagnoses and collaborative problems
problems
Formulate nursing diagnoses and
collaborative problem statements
Actual Nursing Diagnosis (3-part)

PES = Problem related to the
Etiology (cause) as
evidenced/manifested by the Signs
and Symptoms (defining
characteristics).
Potential Nursing Diagnosis/Risk (2-

part)
PE = Potential problem related to the
Etiology (cause). There are no signs and
symptoms, because the problem has not
occurred yet.
Planning/Goal/Outcome To develop and individualized Set priorities and write goals/outcomes in

care plan that specifies client collaboration with client. Consult with
Determining how to prevent, goals/desired outcomes and other health professionals
reduce, or resolve the related nursing interventions.
identified client problems; Write nursing orders and nursing care plan
how to support client Outcome statement must be
strengths; and how to patient centered, specific, and Communicate care plan to relevant
implement nursing measurable healthcare providers
interventions in an organized,
individualized, and goal- Short term and long term goals
directed manner
Implementation To assist the client to meet Select nursing strategies/interventions
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desired goals/outcomes;
promote wellness and disease; Determine need for nursing assistance
Carrying out the planned restore health; and facilitate
nursing interventions Perform or delegate planned nursing
coping with altered
interventions
functioning
Communicate what nursing actions were
implemented:
Document care and client responses to care
Give verbal reports as necessary
Carry out the plan; “DO” what it takes to

meet goals.
Nurse initiated – Physician initiated –

Collaborative
Evaluation To determine whether to Collaborate with client and relate nursing
continue, modify, or actions to client outcomes
terminate the plan of care.
Measuring the degree to Determine if goals/outcomes have been
which goals/outcomes have met/achieved. If not, re-evaluate:
been achieved and identifying
factors that positively or
negatively influence goal 1. Data – did you collect enough/correct
achievement data?
2. Diagnosis – did you analyze the data
accurately?
3. Etiology – is it accurate?
4. Outcome – patient centered, measurable
and realistic?
5. Interventions – realistic and doable?
6. Revise/modify the care plan as
indicated
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Courses

Code / credits (1 P) Module III
MODULE III
Overview of Nursing Health Assessment: Assessment Techniques
follows:
1. Basic Competence
So that students know and explain and can apply the concept of English I in Nursing
Science.
2. Material
4. References
Education, Inc.
York: Elsevier.
Davis Co.
10
with students.
classroom.
7. Evaluation
be achieved.
lecturer
11
II. Material

1. General Health Assessment
A comprehensive or complete health assessment usually begins with obtaining a
thorough health history and physical exam. This type of assessment is usually performed in
acute care settings upon admission, once your patient is stable, or when a new patient
presents to an outpatient clinic
2. Assessment Techniques:
a. Inspection
Inspection is the most frequently used assessment technique. When you are
using inspection, you are looking for conditions you can observe with your eyes, ears,
or nose. Examples of things you may inspect are skin color, location of lesions, bruises
or rash, symmetry, size of body parts and abnormal findings, sounds, and odors.
Inspection can be an important technique as it leads to further investigation of findings
(Jarvis, 2012)
b. Palpation
Palpation, another commonly used
physical exam technique, requires you to touch
your patient with different parts of your hand
using different strength pressures. During light
palpation, you press the skin about ½ inch to ¾
inch with the pads of your fingers.
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When using deep palpation, use your finger pads and compress the skin
approximately 1½ inches to 2 inches. Light palpation allows you to assess for texture,
tenderness, temperature, moisture, pulsations, and masses. Deep palpation is performed
to assess for masses and internal organs (Jarvis, 2012).
c. Percussion
Percussion is used to elicit tenderness or sounds that may provide clues to

underlying problems. When percussing directly over suspected areas of tenderness,
monitor the patient for signs of discomfort. Percussion requires skill and practice
These sounds may include:
Tympany sounds like a drum and is heard over air pockets.
Resonance is a hollow sound heard over areas where there is a solid structure and some
air (like the lungs).
Hyperressonance is a booming sound heard over air such as in emphysema.
Dullness is heard over solid organs or masses.
Flatness is heard over dense tissues including muscle and bone (Jarvis, 2012)
d. Auscultation
Auscultation is usually performed following inspection, especially with
abdominal assessment. The abdomen should be auscultated before percussion or
palpation to prevent production of false bowel sounds.
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3. Health History
The purpose of obtaining a health history is to provide you with a description of
your patient’s symptoms and how they developed.. The basic components of the complete
health history (other than biographical information) include
a. Chief complaint
b. Present health status
c. Past health history
d. Current lifestyle
e. Psychosocial status
f. Family history
g. Review of systems
4. Chief Complaint
In your patient’s own words, document the chief complaint. The chief complaint may
be elicited by asking one of the following questions:
a. So, tell me why you have come here today?
b. Tell me what your biggest complaint is right now?
c. What is bothering you the most right now?
d. If we could fix any of your health problems right now, what would it be?
e. What is giving you the most problems right now?
PQRST
P = Provocative or Palliative
• What makes the symptom(s) better or worse?
Q = Quality
• Describe the symptom(s).
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R = Region or Radiation
• Where in the body does the symptom occur? Is there radiation or extension of the
symptom(s) to another area of the body?
S = Severity
• On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another
visual scale may be appropriate for patients that are unable to identify with this
scale.
T = Timing
• Does it occur in association with something else (i.e. eating, exertion, movement)?
Courses

Code / credits (1 P) Module IV
MODULE IV
Overview of Nursing Health Assessment: Review of Systems and Physical Exam, Skin
Assessment, Neurological Assessment, Head, Face and Throat, Cardiovascular,
Pulmonary, Gastrointestinal, Musculoskeletal, Reproductive and Nutritional Assessment
This general guide, contains an explanation of the steps to be taken
in lectures, as follows:
1. Basic Competence
interest.
2. Material
Overview of Nursing Health Assessment: Review of Systems and Physical Exam, Skin
Assessment, Neurological Assessment
15
4. Referensi
Education, Inc.
York: Elsevier.
Davis Co.
with students.
classroom.
7. Evaluation
16
be achieved.
lecturer.
II. Material
A. Overview of Nursing Health Assessment: Review of Systems and Physical Exam, Skin
Assessment, Neurological Assessment
1. Review of Systems and Physical Exam

The physical examination can be performed in a “head-to-toe” fashion, starting with
the head and ending with the toes.
A physical examination should include:
a. Complete set of vital signs (blood pressure, heart rate, respiratory rate and temperature)
b. Immediate pain level - Can use acronym “PQRST” for quick pain assessment:
• P=provoking factors (what brought on the pain?); Q=quality (describe the pain-
i.e. stabbing, throbbing, burning); R=radiation (does the pain radiate
anywhere?); S=severity/symptoms (how bad is the pain- rate it; are there other
symptoms with the pain?); T=timing (is it constant?
What makes it better/worse?)
17
2. Skin Assessment
Skin assessment can be performed throughout the physical examination. As each
body system is examined, assessment of the skin can be incorporated into findings (Jarvis,
2012).
When assessing the skin, EXAMINE the following:
a. General pigmentation (evenness, appropriate for heritage)
b. Systemic color changes (pallor, erythema, cyanosis, jaundice)
c. Freckles and moles (symmetry, size, border, pigmentation)
d. Temperature (hypothermia, hyperthermia)
e. Moisture and texture (diaphoresis, dehydration, firm smooth texture)
f. Edema (location and degree)
g. Bruising (location, pattern, consistent with history – especially in at risk populations)
h. Lesions (color, elevation, pattern or shape, size, location, exudates)
i. Hair (normal color, texture, distribution)
j. Nails (shape, contour, color) (Jarvis, 2012)
Remember that skin breakdown is a common problem with ill and hospitalized patients.
Skin assessment is vital to identify areas of vulnerability in the prevention of pressure
ulcers
3. Neurological Assessment
When performing the complete neurological exam, examine the following
12 Cranial Nerves:
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1. Cranial Nerve I: Olfactory
2. Cranial Nerve II: Optic
3. Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, and Abducens
4. Cranial Nerve V: Trigeminal
5. Cranial Nerve VII: Facial Nerve
6. Cranial Nerve VIII: Acoustic (Vestibulocochlear)
7. Cranial Nerve IX & X: Glossopharyngeal and Vagus
8. Cranial Nerve XI: Spinal Accessory
9. Cranial Nerve XII: Hypoglossal
1. Testing the Motor System
Inspect and palpate the motor system
(Tests muscle groups and for motor neuron disease)
1. Muscles appropriate size for body (atrophy, hypertrophy)
2. Muscle strength (asymmetric, weak for patient)
3. Muscle tone (range of motion, pain, flaccidity, spasticity, rigidity)
4. Involuntary movements (tic, tremor, fasciculation)
2. Cerebellar Function and the Sensory System
Check cerebellar function
(Tests balance and coordination and skilled movements)
1. Gait (stiff posture, staggering, wide base of support, lack of arm swing, unequal steps,
dragging or slapping of foot, ataxia)
2. Romberg’s test (loss of balance increases when eyes are closed)
3. Rapid alternating movements (lack of coordination, slow, clumsy)
4. Finger to finger test (misses mark)
5. Finger to nose test (misses mark)
6. Heel to shin test (misses mark, lower extremity coordination impaired)
3. Assess the sensory system

(Tests intactness of peripheral nerves, sensory tracts, and higher cortical discrimination)
1. Superficial pain
2. Light touch
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3. Vibration
4. The Complete Neurological Exam

Assess the spinothalmic tract
(Tests for ability to sense pain, temperature, and light touch)
1. Presence of pain (hypoalgesia, hyperalgesia, analgesia)
2. Temperature (test only if pain test is normal)
3. Light touch (hypoesthesia, anesthesia, hyperesthesia)
5. Assess posterior column tract

(May identify lesions of the sensory cortex or vertebral column)
1. Vibration
2. Position
3. Tactile discrimination (stereognosis, graphesthesia)
4. Two point discrimination
6. Assessing Reflexes
Check the reflexes
(May identify upper motor neuron disease, diseases of the pyramidal tract, or
spinal cord injury)
1. Stretch or deep tendon reflexes (clonus, hyporeflexia, hyperreflexia)
2. Superficial reflexes (Abdominal, cremasteric, plantar) (Berman, Snyder, Kozier & Erb,
2012; Jarvis, 2012)
7. Glasgow Coma Scale

The Glasgow Coma Scale assesses how the brain functions as a whole and not as
individual parts (Altman, 2010).
The scale assesses three major brain functions:
 Eye opening
 Motor response
 Verbal response
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A completely normal person will score 15 on the scale overall. Scores of less than
7 reflect coma. Using the scale consistently in the healthcare setting allows healthcare
providers to share a common language and monitor for trends across time (Jarvis, 2012)
Self test
Clarify Unfamiliar Word
Skin Neurological
Bruising Fainting
Lesions Seizures
Pruritus , paralysis
Jaundice Incoordination
evenness, appropriate for heritage gait problems
pallor, , numbness or tingling sensations
Cyanosis Clonus
Erythema Hyperreflexia
symmetry, Hyporeflexia
Pigmentation Abdominal
border, Cremasteric
size, Plantar
Hypothermia Atrophy
Hyperthermia Hypertrophy
Diaphoresis Hypoalgesia
Dehydration Analgesia
firm smooth texture Hyperalgesia
Moisture and texture range of motion
Edema Pain
Nail Flaccidity
Color Spasticity
Exudates Rigidity
B. Overview of Nursing Health Assessment: Head, Face and Throat Assessment

Some of the following points fall outside of the general scope of nursing practice but
may be observed by the nurse, or practiced in advanced nursing roles.
1. Head, Face and Throat Assessment

When examining the head, ears, eyes, nose, mouth, and throat, ask the following
questions:
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• Do you get frequent or severe headaches?
• Any past history of head injury?
• Do you frequently get dizzy?
• Do you have any neck pain, swelling, or lumps?
• Do you have a history of head or neck surgery (Jarvis, 2012)?
Look for:
• General facial symmetry
• Hair distribution
• General facial expressions
• Lymph nodes or lesions (Jarvis, 2012)
a. Assessment of the Eyes

Eyes
• Any vision changes or difficulty?
• Any eye pain?
• Do you have double vision?
• Any redness, swelling or discharge?
• Do you have a history of glaucoma?
• Do you wear glasses or contacts (Jarvis, 2012)?
Look for:
• Visual acuity
• Visual fields (confrontation test)
• Extraocular muscle function (nystagmus, abnormal corneal light reflex)
• Conjunctiva and sclera (redness, irritation)
• Pupil (shape, symmetry, light reflexes, accommodation)
• Ocular fundus (red reflex, optic disc, retinal vessels, macula) (Jarvis, 2012)
b. Assessment of the Ears

Ears
• Have you had many ear infections?
• Do you have any discharge from your ears?
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• Do you have any hearing difficulty?
• Do you have any environmental or occupational exposure to loud noises?
• Any ringing in your ears (tinnitus)?
• Any dizziness (vertigo) (Jarvis, 2012)?
Look for:
• Size, shape, skin condition, and tenderness
• External canal (redness, swelling, discharge)
• Tympanic membrane [color & characteristics (amber, redness), air/fluid levels]
• Hearing acuity (also examined as you collect the patient’s history)
C. Assessment of the Nose

Nose
• Any nasal discharge?
• Do you get frequent colds?
• Do you have sinus pain?
• Do you get nose bleeds?
• Do you have allergies?
• Have you had a change in sense of smell (Jarvis, 2012)?
Look for:
• Nasal cavity (discharge, rhinorrhea, swollen, boggy, mucosa)
• Sinuses (tenderness and transillumination) (Jarvis, 2012)
2. Assessment of the Mouth and Throat

Mouth and Throat
• Skin integrity (lesions or blisters)
• Teeth (discoloration, bleeding or swollen gums)
• Tongue (color, surface characteristics, moisture, lesions)
• Buccal mucosa (discoloration, Koplik’s spots, leukoplakia)
• Uvula (midline)
• Throat (tonsils, Cranial Nerve XII by sticking out tongue) (Jarvis, 2012)
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Look For:
• Do you have any sores or lesions in your mouth or throat?
• Do you have a sore throat and hoarseness?
• Do you have a toothache or get bleeding gums?
• Any difficulty swallowing?
• Do things taste differently than usual?
• Do you smoke, drink or chew tobacco (Jarvis, 2012)?
Head, Face, Throat

Headaches Blisters
Dizzy Discoloration
neck pain, , bleeding or swollen gums
swelling or lumps surface characteristics, ,
facial symmetry Lesions
Hair Buccal mucosa
facial expressions moisture
Lymph nodes or lesions discoloration
Vision Koplik’s spots
Redness leukoplakia
Swelling sore throat
Glaucoma hoarseness
nystagmus, Ocular fundus
abnormal corneal light reflex retinal vessels
Pupil macula
light reflexes tinnitus
Accommodation vertigo
C. Overview of Nursing Health Assessment: Cardiovascular, Pulmonary, Gastrointestinal

Assessment
1. Cardiovascular Assessment
When examining the cardiovascular system, ASK about the following:
• Any chest pain? (use PQRST pneumonic)
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• Do you ever get short of breath? (associated with what)
• How many pillows do you sleep on at night? (orthopnea)
• Do you have a cough? (describe, frequency, timing, severity, sputum production)
• Are you frequently fatigued? (morning or night)
• Do you have any swelling or skin color changes? (edema, cyanosis, pallor)
• How often do you get up at night to urinate? (nocturia)
• Do you have a past history of cardiac or cardiovascular events or disorders?
• Do you have a family history of cardiovascular disease?
• Assess cardiac risk factors? (Jarvis, 2012; Edmunds, Ward, & Barnes, 2010)
When assessing the cardiovascular system, examine the following:

• Palpate and auscultate the carotid artery (strength of pulsation, bruits, murmurs)
• Inspect and palpate the jugular veins (jugular vein distention)
• Inspect the precordium (heaves, lifts)
• Palpate the precordium (location of apical impulse, presence of thrill)
• Percuss cardiac borders
• Auscultate heart sounds
• Auscultate in a Z-pattern (listening over the aortic, pulmonic, mitral, and tricuspid
valves and over Erb’s point).
• Identify S1 and S2
• Listen to S1 and S2 separately (split S1 or S2)
• Listen for any extra heart sounds (S3, S4, clicks, rubs)
• Listen for murmurs (note timing, loudness, pitch, pattern, quality, location, radiation,
position)
• Palpate peripheral pulses: brachial, radial, femoral, popliteal, dorsalis pedis, posterior
tibial (strength and symmetry)
• Inspect extremities (color, capillary refill, edema, ulcerations) (Jarvis, 2012; Edmunds,
Ward, & Barnes, 2010)
2. Pulmonary Assessment
When examining the pulmonary system, ask the following for both abbreviated and
25
complete examinations:
• Do you have a cough? (use PQRST pneumonic)
• Do you frequently get short of breath? (position, associated night sweats, related to
any triggering event)
• Pain with breathing? (constant or periodic, describe the quality, treatment)
• Any past history of breathing trouble or lung disease? (frequency and severity of colds,
allergies, asthma family history, smoking, environmental or occupational risk factors)
Pulmonary Assessment
When examining the pulmonary system,
explore the following as indicated by your patient’s
history, symptoms or disease processes they are
exhibiting:
• Inspect the thoracic cage (symmetry of expansion,
anterior- posterior diameter, any areas of retractions)
(See appendix for retraction sites)
• Palpate the thoracic cage (tactile fremitus)
• Percuss the thoracic cage (hyperressonance, dullness,
diaphragmatic excursion)
• Auscultate the anterior and posterior chest:
Have patient breath slightly deeper than normal through their mouth
• Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You
should auscultate between every rib.
• Listen for bronchial, bronchovesicular, and vesicular breath sounds
• Identify any adventitious breath sounds, their location, and timing in relation to the
cardiac cycle (crackles, or rales and wheezes or rhonchi) (See appendix for auscultation
landmarks)
• Auscultate voice sounds including bronchophony, egophony and whispered pectoriloquy
(Jarvis, 2012)
Assessing the Abdomen/Gastrointestinal System

When examining the abdomen/gastrointestinal system, ASK about the following:
26
• Any change in appetite?
• Any difficulty swallowing? (dysphagia)
• Any abdominal pain? (use PQRST pneumonic)
• Any nausea or vomiting? (color, odor, presence of blood, food intake in past 24 hours)
• Any change in bowel habits? (constipation, diarrhea, blood in stool, or dark, tarry stools)
• Do you have any hemorrhoids? (bleeding, treatment)
• Any past history of abdominal problems? (gall bladder, liver, pancreas, digestion,
elimination)

Assessment of the abdomen includes inspection,
auscultation, percussion and palpation.
Inspection:
• For bulges, masses, hernias, ascites, spider
nevi, veins, pulsations or movements, or a
patient’s inability to lie flat.
Auscultation:
• Auscultate after inspection so you do not produce false bowel sound through percussion
or palpation;
auscultate for bowel sounds (normal, hyper- or hypo-active) and bruits. Begin by
dividing the abdomen into 4 quadrants, by drawing an imaginary line vertically and
horizontally across the abdomen, to intersect at the umbilicus. This will divide the
abdomen into:
• Right Upper Quadrant (RUQ)
• Left Upper Quadrant (LUQ)
• Right Lower Quadrant (RLQ)
• Left Lower Quadrant (LLQ) (Jarvis, 2012).
Auscultation should begin in the right lower quadrant. If bowel sounds are not heard, in
order to determine if bowel sounds are truly absent, listen for a total of five minutes
(Jarvis, 2012)
27
Percussion:
• Percuss for general tympany, liver span, splenic dullness (dullness over the spleen),
costovertebral angle tenderness, presence of fluid wave and shifting dullness with
ascites
Palpation:
• Palpate lightly then deeply noting any muscle
guarding, rigidity, masses or tenderness (tender
areas last)
• Palpate the liver margins (often it is not palpable)
• Palpate the spleen (enlargement occurs with mononucleosis and trauma)
• Palpate the kidneys (enlargement may indicate a mass)
• Assess for rebound tenderness (pain on release of pressure to the
abdomen usually indicates peritoneal irritation)
• When acute abdominal pain is present perform the iliopsoas muscle test and obturator
test (Jarvis, 2012)

Cardiovascular, Pulmonary, Gastrointestinal Assessment
orthopnea strength of pulsation, , hyperressonance, ,
fatigued Bruits dullness
edema, Murmurs diaphragmatic excursion
cyanosis jugular vein distention tactile fremitus
pallor the aortic crackles
Sputum Pulmonic rales
nocturia Mitral wheezes or rhonchi
dysphagia Tricuspid constipation
hernias brachial diarrhea
ascites Radial blood in stool
spider nevi Femoral tarry stools
veins Popliteal masses
pulsations or movements dorsalis pedis tenderness
palpat ions posterior tibial cough
pneumonia Weakness chest
28
D. Overview of Nursing Health Assessment: Musculoskeletal, Reproductive Assessment
and Nutritional Assessment
1. Musculoskeletal System
When assessing the musculoskeletal system, examine the following:
• Inspect the size and shape of any problem joints (color, swelling, masses, deformities)
• Palpate each joint for temperature and range of motion (heat, tenderness, swelling,
masses, limitation in range of motion, crepitation)
• Test muscle strength and strength against resistance of the major muscle groups of the
body
• Assess the temporomandibular joint (swelling, crepitus, pain)
• Assess the cervical spine (alignment of head and neck, symmetry of muscles,
tenderness, spasms, range of motion)
• Inspect and assess upper extremity strength and range of motion for the shoulders,
elbows, wrists, and hands
• Inspect and assess lower extremity strength and range of motion for the hips, knees,
ankles and feet (Jarvis, 2012)
2. Reproductive System
a. Male Reproductive System
When examining the reproductive
systems, ask about the following:
• Do you urinate more than usual? (frequency, urgency, nocturia)
• Any pain or burning upon urination?
• Any difficulty starting or maintaining the stream of urine?
• Any difficulty controlling your urine?
• Any blood in your urine?
• Any problems with your penis? (pain, lesions, discharge)
• Any problems with your scrotum?
(lumps, tenderness, swelling)
• Are you in a sexually active relationship and if so any
29
difficulties in this relationship related to the physical act of intercourse?
• Do you use contraceptives? (what type, questions or concerns)
• Any sexual contact with a partner whom may have had a sexually transmitted disease?
• Do you perform self-testicular examinations monthly? (Jarvis, 2012)
When assessing the male reproductive system, examine the following:

• Inspect and palpate the penis (inflammation, lesions, freely moveable foreskin in
uncircumcised male, location of urinary meatus, pubic lice or nits, narrowed urethral
opening)
• Inspect and palpate the scrotum (scrotal edema, lesions or inflammation, absent,
atrophied or fixed testes, tenderness of testicle or spermatic cord)
• Inspect and palpate for hernia
• Inspect and palpate inguinal lymph nodes
• Discuss and encourage self-testicular exams monthly (Jarvis, 2012)
b. Female Reproductive System

When examining the reproductive systems, ask about the following:
• Do you urinate more than usual? (frequency, urgency, nocturia); Any pain or burning
upon urination?
• Any difficulty starting or maintaining the stream of urine?
• Any blood in your urine? Any difficulty controlling your urine?
• Any unusual vaginal discharge?
• Are you sexually active? Any difficulties related to the physical act of intercourse?
• Do you use contraceptives? (what type, questions or concerns).
• Any sexual contact with a partner whom may have had a sexually transmitted disease?
• Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating,
PMS, age of first period, age of menopause).
• Have you ever been pregnant? (if so how many times, how many live births, any
miscarriages or abortions, any complications).
• Have your periods slowed down or stopped? (associated symptoms of
menopause, estrogen replacement therapy, psychological well-being).
30
• Any breast tenderness, lumps, discharge or concerns? Do you perform self-breast
examinations monthly?
• Do you have regular PAP smears? (Jarvis, 2012).
The complete female reproductive system examination is usually only performed by

specially trained nurses or a physician. Please consider the following when examining the
female reproductive system:
In the lithotomy position examine the external genitalia:
• Skin color
• Hair distribution
• Labia and clitoris (swelling, lesions)
• Urethral opening (stricture, inflammation)
• Vaginal opening (foul-smelling discharge, inflammation, lesions)
• Palpate the vagina (tenderness, swelling, discharge, Bartholin’s glands)
c. Assessing the Female Breasts & Axilla

Examine the breasts and axilla:
• Inspect the breasts for size, symmetry, and nipple dimpling
• Palpate the breasts and axilla in a circular pattern, covering all areas (note
inconsistencies and tenderness)
• If you palpate a mass, note its size, shape, consistency, mobility, degree of tenderness, and
location (Jarvis, 2012)
3. Nutritional Assessment
Assessing nutritional status of your patients is important for several reasons. A thorough
nutritional assessment will identify individuals at risk for malnutrition and provide baseline
information for nutritional assessments in the future. A nutritional screening is indicated for
all patients. A complete nutritional assessment is indicated for only those individuals at risk
for malnutrition. A screening assessment includes
When performing your physical exam, OBSERVE for the following signs and
symptoms of nutritional deficiency:
31
• Eyes dry
• Pale or red conjunctivae
• Blepharitis
• Cheilosis
• Cracks at the side of mouth
• Tongue pale
• Bleeding gums
 Dry, flaky skin
• Petechiae
• Bruising
• Dry, bumpy skin
• Cracked skin
• Eczema
• Xanthomas
• Dull, dry, thin hair
• Hair color changes
• Brittle nails
• Joint pain
• Muscle wasting
 Pain in calves
• Splinter hemorrhages of nails
• Peripheral neuropathy
• Hyporeflexia
• Confusion or irritability
32
Courses

Code / credits (1 P) Module V
MODULE V
Nursing Process: Nursing Diagnosis, Nursing Care Plan, Implementation, and Evaluation
follows:
1. Basic Competence
interest.
2. Material
Introduction in Nursing Process: Nursing Diagnosis
4. References
33
Education, Inc.
York: Elsevier.
Davis Co.
with students.
classroom.
7. Evaluation
a. after the end of the learning activities, students are asked to do the test (post test), so it
can be known how far learning objectives in the discussion of these materials can be
achieved.
b. If the student can answer 70% of the test questions correctly mean that the student has
achieved the learning objectives in the discussion of the material delivered by the
lecturer
34
II. Material
A. Nursing Diagnosis
“Nursing diagnosis is a clinical judgment about individual, family, or community
responses to actual or potential health problems/life processes. Nursing diagnosis provides the
basis for selection of nursing interventions to achieve outcomes for which the nurse is
accountable.” .
Elements of a nursing diagnosis statement
Nursing diagnosis = problems + its etiology or cause (if known)
The Problem. The first element of the nursing diagnosis is the identified problem that
the patient is experiencing or may experience.
There are fine types of problems.

1. Actual: a problem that is experienced or perceived by the client, one that is occurring in
the “here and now.” This type of problem is validated by the presence of defining
characteristics or signs and symptoms.
Examples: Alteration in nutrition, less than body requirement.
Ineffective airway clearance related to incisional pain.
2. Risk/High Risk: a problem which may develop in the future due to the presence of
certain risk factors; and altered state which may occur unless specific nursing
actions are ordered and implemented. This type of problem is validated by risk
35
factors.
Examples: Risk for fluid volume deficit related to prolonged vomiting.
Risk for impairment of skin integrity related immobility.
3. Possible: a problem which may exist, but additional data is needed to confirm its presence;
“possible”
alerts the nurse the need for further data collection.
Example: Possible self-care deficit related to IV in right hand.
NURSING DIAGNOSIS: NANDA

AIR HYGIENE
RESPIRATION Self-care deficit (specify): feeding, bathing/
Airway clearance, ineffective hygiene, dressing/grooming, toileting
Aspiration, risk for
Breathing pattern, ineffective
Gas exchange, impaired
Spontaneous ventilation: inability to
sustain Ventilatory weaning response,
dysfunctional Ventilation, impaired
spontaneous
WATER COMFORT
CIRCULATION Pain, (acute) Pain, chronic Injury, risk for
Adaptive capacity intra-cranial, Perioperative positioning injury, risk for
decreased Physical mobility, impaired
Cardiac output, decreased Social isolation
Dysreflexia
Tissue perfusion, ineffective
(specify):
cerebral, cardio-pulmonary, renal,
gastrointestinal peripheral)
SOLITUDE–SOCIAL ISOLATION
FLUID EGO INTEGRITY
Fluid volume deficit Adjustment, impaired Anxiety, death
Fluid volume deficit, risk for Anxiety (specify level) Body image disturbed
Fluid volume excess Conflict, decisional (specify)
Fluid volume imbalance, risk for Coping, ineffective
Fluid volume, readiness for Conflict, parental role
enhanced Oral mucous Coping, ineffective community
membranes, impaired Coping, community, readiness for enhanced
Swallowing, impaired Coping, compromised family
36
Coping, disabled family
Coping, family, readiness for enhanced
Coping, defensive
Coping, readiness for enhanced
Denial, ineffective Energy field, disturbed Fear
Grieving, anticipatory Grieving, dysfunctional
Hopelessness
Personal identity disturbed Post trauma response
Powerlessness Powerlessness, risk for Rape-trauma
syndrome
Rape-trauma syndrome: compound reaction Rape-
trauma syndrome: silent reaction Relocation stress
syndrome
Relocation stress syndrome, risk for Self-concept,
readiness for enhanced Self-esteem, chronic low
Self-esteem, situational low
Self-esteem, situational low, risk for
Sorrow, chronic
Spiritual distress
Spiritual distress, risk for
FOOD FOOD/FLUID SOCIAL INTERACTION
Breastfeeding, effective Breastfeeding, Caregiver role strain Caregiver role strain, risk for
ineffective Breastfeeding, interrupted Communication impaired, verbal Communication,
Dentition, impaired readiness for enhanced Community coping,
Infant feeding pattern, ineffective enhanced, potential for Community coping,
Nausea ineffective
Nutrition, imbalanced: less than body Environmental interpretation syndrome, Impaired
requirements Failure to thrive, adult
Nutrition, imbalanced: more than body Family coping, ineffective: compromised Family
requirements
Nutrition, readiness for enhanced coping, ineffective: disabling Family coping,
Nutrition, imbalanced: risk for more potential for growth
than body requirements Family process, dysfunctional: alcoholism
Family processes, interrupted
Family processes, readiness for enhanced
Loneliness, risk for
Parent/infant/child attachment impaired, risk for
Parental role conflict Parenting, Impaired Parenting,
impaired, risk for
Parenting, readiness for enhanced
Role performance, Ineffective
Role strain, caregiver
Role stain, caregiver, risk for Social interaction,
impaired Social isolation
ELIMINATION ELIMINATION NEUROSENSORY
Constipation Constipation, risk for Confusion, acute
Constipation, perceived Diarrhea
Confusion, chronic
Incontinence, bowel Incontinence, Infant behavior, disorganized
37
functional (urinary) Incontinence, Infant behavior, disorganized, risk for
reflex (urinary) Incontinence, stress Infant behavior, organized, readiness for enhanced
(urinary) Incontinence, total (urinary) Memory, impaired
Peripheral neurovascular dysfunction, risk for
Incontinence, urge (urinary)
Sensory-perceptual disturbed (specify):
Incontinence, urge (urinary) risk for
visual, auditory, kinethetic, gustatory, tactile,
Urinary elimination, impaired Urinary
elimination, readiness for olfactory
enhanced
Urinary retention
NEUROSENSORY NORMALY
Adaptive capacity, decreased – EGO
intracranial NTEGRITY
Confusion, acute Fear
Confusion, Grieving,
chronic
Dysreflexia, anticipatory
autonomic Grieving,
Dysreflexia, risk for autonomic dysfunctional
Infant behavior, disorganized Hopelessness
Infant behavior, disorganized, risk for Personal identity disturbed
Infant behavior, organized, Post-trauma syndrome
potential for Post-trauma syndrome, risk for
enhancement Spiritual well-being, Readiness for enhanced
Memory, impaired
Peripheral neurovascular dysfunction,
risk for
Sensory-perceptual alterations
(specify): visual, auditory, kinethetic,
gustatory, tactile, olfactory
Thought process, disturbed
TEACHING/LEARNING
SEXUALITY (COMPONENT OF
EGO INTEGRITY AND SOCIAL Development, risk for delayed Growth and
INTERACTION) Sexual
dysfunction development, delayed Growth, Risk for
Sexuality patterns, ineffective disproportionate Health-seeking behaviors (specify)
Knowledge deficient (specify)
Knowledge [specify], readiness for enhanced
Management of therapeutic regime, effective
Management of therapeutic regime, Ineffective
Management of therapeutic regime, readiness for
enhanced
Management of therapeutic regimen: Community,
ineffective
Management of therapeutic regimen, family
Ineffective
Non-compliance [compliance, altered] (specify)
HAZARDS
SAFETY
Body temperature, imbalanced, risk
38
for
Environmental interpretation
syndrome, impaired
Falls, risk for
Health maintenance,
ineffective Home
Maintenance, impaired
Hyperthermia
Hypothermia/infection,
risk for Infection: Risk
for or actual Injury, risk
for
Latex allergy, response
Latex allergy response,
risk for Mobility
impaired, physical
Mobility impaired, bed
Mobility impaired, wheelchair
Perioperative positioning injury,
risk for Poisoning, risk for
Protection, ineffective
Self-mutilation
Self-mutilation, risk for
Skin integrity, impaired
Skin integrity, impaired, risk for
Suffocation, risk for
Suicide, risk for
Surgical recovery,
delayed
Thermoregulation
ineffective Tissue
integrity, impaired
Trauma, risk for
Violence, other directed, risk for
Violence, self directed, risk for
Wandering
B. Nursing Care Planning
After the data has been colleted and organized and nursing diagnoses have been
formulated, it is time for the planning phase of the nursing process.
There are four essential steps in the planning process:
1. Prioritizing the identified nursing diagnoses.
39
2. Developing goals/outcome statements.
3. Planning nursing actions.
4. Documentation-the Nursing Care Plan.
1. Prioritizing
Knowledge of scientific and nursing practice principles is necessary to prioritize
correctly. Diagnoses can be classified as priority or important. Priority nursing diagnoses are
the most urgent or immediate needs of the patient, and may be considered life-threatening.
These priorities can be either physical or psychological in nature.
Examples: Ineffective breathing pattern related to effects of anesthesia. (Physical)

Ineffective
coping related to unknown medical diagnosis. (Psychological).
2. Developing Goal/Outcome Statements

The second step in the planning phase is to establish goal/expected outcome
statements for nursing diagnoses and collaborative problems. Goal/expected outcome
statements are a necessary part of the nursing care planning process because they
1) delineate for the client and the nurse what is to be accomplished and when it is to be
accomplished, and
2) provide the criteria for evaluation of the effectiveness of the plan of care.
3. Planning Nursing Action

The nursing interventions identify what the nurse is to do to reduce, resolve, or
prevent each of the problems expressed in the nursing diagnoses.
The first step in planning nursing interventions is to examine the second element of
the nursing diagnosis statement. This phrase identifies the etiological factors: cause,
contributing factors, or risk factors.
Examples: Potential impairment of skin integrity related to prolonged bedrest.
Example: Impaired skin integrity related to prolonged bedrest as evidenced by red sacral
pressure point.
40
41
NURSING CARE PLAN GUIDE
ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES
DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient.
ASSESSMENT P
Universal Self Care Requisites Nursing Expected Outcomes L
Nursing Interventions R
Diagnosis a
DEFINTION: DEFINITION: DEFINITION: DEFINITION: DEFINTION:
(USCR) the category of self-care requites that are basic Problem: statement of Desired or expected Direction for nursing action Scientific
and common to all humans and are constantly present; the patient's risk for or outcomes or resolution of designed to assist the client and/or principles, theories
these needs must be met to achieve optimal health and actual health problem nursing diagnosis. significant other to meet the or concepts
well- being. There are eight universal self-care that the nurse is licensed expected outcomes. Nursing actions underlying nursing
requisites: and accountable to treat. "Patient will" are specific, realistic, and interventions:
individualized for a particular patient.
(1) AIR Etiology: factors Document all reference
(2) FOOD "related to" or Components of nursing actions: sources with author,
(3) WATER "associated with" o 1. Precision action verb title edition and page.
(4) ELIMINATION the patient's r 2. Content area
problem. a. What-the actual measure
(5) ACTIVITY AND REST
to performed
(6) SOLITUDE AND
Signs and Symptoms: b. Where - specific area
SOCIAL INTERACTION manifestations of c. How- the means by which
(7) PREVENTION OF problem identified. measures will be adopted
HAZARDS d. When - time element, how
(8) NORMALCY
long or how often the
nursing action is to occur
Self-Care Agency (SCA) - assets or abilities of an
3. Categories of Interventions
individual to perform self-care.
A - assessment
C - care & comfort measures
Self-Care Deficit (SCD) - deficit relationship that exists
T - teaching
when the demand for self-care exceeds the person's
ability to perform self-care.
Independent, dependent,
Nursing System: the series of organized concrete action collaborative, and supportive -
educative nursing actions are to be
performed by nurses in collaboration with the patient.
There are three types of nursing systems: considered when writing the plan
(1) wholly compensatory (2) partly
compensatory (3) supportive-educative
41
C. Nursing process: implementation in nursing
Before the plan can be implemented, certain preparations are necessary.

1. Review the plan and validate with the client and other health team
members that the plan is appropriate for the client’s current health status.
Then make modifications as needed with the RN.
2. Assess knowledge and skills which are needed to implement the plan.
If knowledge or skills are lacking, you may choose to refer the plan to
someone else or request assistance from other staff members.
3. Prepare the client. Explain the nursing actions, their purposes, expected
sensations, and the client’s role.
4. Prepare the environment in terms of space, lighting, equipment, and
resources.
Action
The physical and psychological safety of the client are of utmost
importance throughout the delivery of care. Ensure physical safety through
such things as use of aseptic technique, obtaining assistance when needed, or
placing the client in a safe environment. Psychological safety measures include
careful explanations and offering emotional support throughout the delivery of
care.
Nursing interventions may include any of the following:
1. Directly performing an activity for a client.
2. Assisting the client as he/she performs an activity.
3. Observing or supervising the client as he/she independently performs an
activity.
4. Teaching the client and/or family.
5. Counseling the client (or family).
6. Monitoring or assessing the client for potential complications of illness.
Guidelines
1. Prior to performing any nursing action, always reassess the status
42
of the client and determine whether the interventions are still
appropriate.
2. Before performing any nursing action, identify the rationale,
expected results, possible side- effects, and possible adverse
effects of the activity.
3. When performing nursing activities, include the client and family as
much as possible.
4. Provide a safe and therapeutic environment for delivery of nursing care.
5. When implementing nursing interventions, refer to the institutional
protocols and procedures to ascertain the appropriateness of the
interventions.
D. Nursing Process: Evaluation in Nursing

Evaluation of the nursing process can be defined as the planned,
systematic comparison of the client’s health status with the goals/expected
outcomes. It is an ongoing activity, done on a day-to-day basis, which involves
the client, the RN, and other health team members.
The major purposes of evaluation are to:
• Evaluate the status of the client
• Determine the client’s progress toward achievement of the stated
goals/expected outcomes.
• Judge the effectiveness of the nursing orders, strategies, and care plan.
Example
Nursing diagnosis: Fluid volume deficit related to fluid loss associated with
vomiting.
Expected outcome: The client will resume and maintain normal fluid balance
by discharge as evidenced by:
1. normal skin turgor
2. moist mucous membranes
3. stable weight
4. BP and pulse within normal limits and stable with position change
43
5. urine specific gravity between 1.010 and 1.025.
6. absence of lethargy, confusion, excessive thirst
When you determine that the goal was partially met or not met at all, you
must fully document this and then consider possible explanations for the
client’s lack of progress toward the goal. Some reasons for unsuccessful goal
achievement might be:
• The nursing diagnosis from which the goal was derived was inaccurate or
inappropriate.
• The goal was unrealistic for the client’s capabilities.
• The nursing actins were not appropriate for achieving the desired
outcome.
 The client’s condition Evaluation: On discharge, patient has normal skin
turgor, mucous membranes are pink and moist. The patient’s weight has
stabilized at 150# which is 5# less than normal weight. Vital signs are
within normal limits. Urine specific gravity is 1.020-1.025. Patient is
alert and oriented, with appropriate thirst.
44
Courses

Code / credits (1 P) Module VI
MODULE VI
Perfoerming assessment form: Adult Nursing
This general guide, contains an explanation of the steps to be taken in

lectures, as follows:
1. Basic Competence
So that students know and able to develop a nursing project: case study
regarding area interest.
2. Material
Perfoerming assessment form: Adult Nursing
4. References
a. Alfaro-LeFevre, R. (2014) Applying Nursing Process: The
Foundation for Clinical Reasoning. Philadelphia: Lippincott
Williams & Wilkins
b. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb's
Fundamentals of nursing: Concepts, process, and practice, (9th ed.).
Upper Saddle River, N.J.: Pearson Education, Inc.
c. Caple, C. (2011). Physical assessment: Performing- cultural
considerations. Glendale, CA: Cinahl Information Systems.
d. Centers for Disease Control and Prevention. (2013). Heart Disease
Facts and Statistics. Retrieved July 2014 from:
http://www.cdc.gov/heartdisease/statistics.htm
e. D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological
assessment: Treatment planning for rehabilitation. (2nd ed.). NY:
Springer Publishing.
f. Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced
physical assessment skills by cardiac nurses. British Journal of Nursing,
19(5), 282-287.
g. Jarvis, C. (2012). Physical examination and health assessment, (6th ed).
St. Louis: W.B. Saunders. Mosby Company. (2012). Mosby’s medical
dictionary (9th ed.). New York: Elsevier.
h. Scanlon, V. (2011). Essentials of anatomy and physiology (6th ed.).
i. Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd
ed.). Philadelphia: F.A. Davis Co.
j. Zambas, S.I. (2010). Purpose of the systematic physical assessment in
everyday practice: Critique of a “sacred cow”. Journal of Nursing
Education, 49(6), 305-310
45
Learning strategy used is contextual instruction, class scenario with
time 100 minutes, steps are performed, as follows:
a. Lecture materials have been given to students 1 (one) week before the
lecture, students are required to read and understand the material in
order to more easily reveal the latest cases that occurred.
c. After the conceptual explanation by the lecturer, the students are
divided into discussion groups to discuss deeper the concept described.
d. After finishing the discussion, the students are asked to explain the
results of the discussion and the other groups provide a rebuttal or
denial.
e. Each group is given the opportunity to explain the outcome of the
discussion and defend their opinion by arguing according to the
concept of the material.
f. The learning approach may change according to progress, material and
agreement with students.
a. Understand and master this material well, so that at the time of
discussion and ridicule about your brother does not have much
difficulty.
b. Begin self-motivation to read, from the easy ones, and start reading
now.
c. Read scenarios in general instructions, making it easier for students to
learn in the classroom.
7. Evaluation
a. after the end of the learning activities, students are asked to do the test
(post test), so it can be known how far learning objectives in the
discussion of these materials can be achieved.
b. If the student can answer 70% of the test questions correctly mean that
the student has achieved the learning objectives in the discussion of the
material delivered by the lecturer
46
II. Materi
ASSESSMENT FORM ADULT OF NURSING
Client Identity
Name : …………….. No RM : ……………
Age : …………… Date of entry : ……………
Gender : …………… Date of Assessment : ……………
Adress : ……………… Inforamtion Source : ……………
Mobile phone : ……………… Closest family : ……………
Marital Status : ……………… Alamat & No telp : ……………
Religion : ……………… medical diagnosis : ....................
Tribe : ………………
Edcation : ……………
Occupation : ……………
Lama bekerja : ……………
Health History
Current Health
main complaint : …………………………………………………................………..
: ………………………………………………………….................
Predisposing : …………………………………………………………................
factors …………………………………………………................………..
…………………………………………………………..................
Precipitation : …………………………………………………................………..
factors …………………………………………………………..................
47
Current Health History (PQRST)
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
: …………………………………………………................……...........…..
Objective …………………………………………………................……...........…..
Dat
a
Nursing problems:………………………………………………………
Previous Health History

Disease that has been experienced:
Accident :…....………………………………
Operations (type and time) :………………………
Disease (chronic and acute) :……………………………………
Last entered the hospital :……………………………………
Allergies (drugs, food, plaster, etc.)…………………………….
Habit
Type Frequency total Duration
Smoke : ……… …………… …………………..
Coffee : ……… …………… …………………..
Alcohol : ………… ……………… …………………..
Medicines used
Type Duration Dose
………………… ……………………….. ………………………..
………………….. ………………….. …………………..
48
Family History :
Genogram
Case Handling Notes (Begins when the patient is treated in the care room until the
case is managed)
Nursing Assessment (12 Domains NANDA)

Health Improvement
49
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…...
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat
a
50
Nursing problem:
Nutrition
51
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…...
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
52
Nursing Problem:
Elimination
53
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
54
Nursing Problems:
Activity / Rest
55
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................
Objective : ……...........…..
Dat …………………………………………………................……...........…..
a …………………………………………………................……...........…..
56
Nursing Problems:
Perception / Cognitive
57
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
58
Nursing Problems:
Self Perception
59
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
60
Nursing Problems:
Role of Relationship
61
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
62
Nursing Problems:
Sexuality
63
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
64
Nursing Problems:
Tolerance / Koping Stress
65
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
66
Nursing Problems:
Principles of life
67
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
68
Nursing Problems:
Safety / Protection
69
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
70
Nursing Problems:
Convenience
71
Subjective : …………………………………………………................……...........…..
data …………………………………………………................……...........…..
…………………………………………………................……...........…..
Objective : …………………………………………………................……...........…..
Dat …………………………………………………................……...........…..
a
72
Nursing Problems:
Assessment Review of System and physical

Respiration system
Subjective data :
Objective Data
73
Inspection : …………………………………………………................……....
Palpat : …………………………………………………................……....
ion : …………………………………………………................……....
Percus : …………………………………………………................……....
sion
Auscu
ltation
74
Nursing Problems:
Cardiovascular system
Subjective data :
Objective Data
75
Inspection : …………………………………………………................……..
Palpat : …………………………………………………................……..
ion : …………………………………………………................……..
Percus : …………………………………………………................……..
sion
Auscu
ltation
76
Nursing Problems:
Nerve System
Subjective data :
Objective Data
77
XII Cranial nerves : …………………………………………………........
Physiological : …………………………………………………........
reflexes : ........
Pathological ………………………………………………
Reflexes …
78
Nursing Problems:
Urination System
Subjective data :
Objective Data
79
Inspection : …………………………………………………................…
Palpation : …………………………………………………................…
Percussi : …………………………………………………................…
on : …………………………………………………................…
Ausculta
tion
80
Nursing Problems:
Digestive system
Subjective data :
Objective Data
81
Inspection : …………………………………………………..............
Palpation : …………………………………………………...............
Percussi : …………………………………………………................
on : …………………………………………………................
Ausculta
tion
82
Nursing Problems:
Musculoskeletal System
Subjective data :
Objective data
83
Inspection : …………………………………………………................…
Palpation : …………………………………………………................
84
Nursing Problems:
Integumen System
Subjective data :
Objective data
85
Inspection : …………………………………………………........
Palpation : ………………………………………………….......
86
Nursing Problems:
Endocrine System
Subjective data :
Objective data
87
Inspection : …………………………………………………........
Palpation : …………………………………………………........
Nursing problems:
Sensing System
Vision
Subjective data :
Objective data
Inspection : …………………………………………………........
Palpation : ........
………………………………………………..
Nursing problems:
Hearing
Subective data :
Obective data
Inspection : …………………………………………………...............
Palpation : …………………………………………………..........
Nursing problems:
snub
Subjective data :
Objective data
Inspection : …………………………………………………....
Palpation : …………………………………………………......
Nursing problem:
88
Psychosocial Assessment
Client's perception of the disease
Nursing problems:
Reaction during interaction

Cooperation………… Uncooperative………….
Explain :
Nursing Problems:
Supporting Examination (Laboratory, Radiology, ECG, etc.)

Date of Examination:
Therapy
Type of
No Medicine Dose medi Rute Indication Contraindicatedi
cine
89
DATA ANALYSIS
DATA/PROBLEM ETIOLOGY NURSING PROBLEM
90
LIST OF NURSING PROBLEM
......................................................................................................................
......................................................................................................................
.......................................................................................................................
PRIORITY OF NURSING PROBLEM

......................................................................................................................
......................................................................................................................
...................................................................................................................... .
NURSING DIAGNOSE
......................................................................................................................
......................................................................................................................
...................................................................................................................... .
91
NURSING CARE PLAN
Name :
Age :
Gender :
N Nursing care plan
Nursing diagnose
Purpose aand criteria Intervention Rational
NOC :............................................................... NIC :............................................. 1.
. .... 2.
1. 3.
N Criteria Eraly Target 2. 4.
3. 5.
1 4.
2
5.
3
4
5
Indicator :
92
IMPLEMENTATION & EVALUATION IN NURSING
Name :
Age :
93
Day, date,
No Day, date,
DIAGNOSE IMPLEMENTATION and EVALUATION SIGN
time
Time
S:
O:
A:
P:
94
Courses

Code / credits (1 P) Module VII
MODULE VII
Nursing practice (Role Play)
Vital Sign: Blood pressure, Temperature, Respiration, Pulse

follows:
1. Basic Competence
interest.
2. Material
Nursing practice (Role Play) Vital Sign: Blood pressure, Temperature, Respiration, Pulse
4. References
Education, Inc.
York: Elsevier.
Davis Co.
59
with students.
a. Understand and master this material well, so that at the time of discussion and ridicule
about your brother does not have much difficulty.
classroom.
7. Evaluation
a. after the end of the learning activities, students are asked to do the test (post test), so it
can be known how far learning objectives in the discussion of these materials can be
achieved.
b. If the student can answer 70% of the test questions correctly mean that the student has
achieved the learning objectives in the discussion of the material delivered by the
lecturer
60
Material II
Vital sign: Blood Pressure
Examination of vital signs is a way to detect changes in the body's system. Vital signs
includes body temperature, pulse rate, respiratory frequency, and blood pressure. Vital signs have
value important in bodily functions. The following is a procedure for examining vital signs
performed on patients:
Objective: To determine the value of blood pressure

Tools and materials:
1. A sphygmomanometer consisting of:
a. Mercury manometer + closing valve and opening
b. Air cuffs
c. Rubber hose
d. Air pump from rubber + opening and closing screws
2. Stethoscope
3. Notebook
4. Pen
Work procedures :
1. Explain the procedure to the client.

2. Wash hands.
3. Adjust the position of the client.
4. Place the hand you want to measure in the supine position.
5. The sleeve is opened.
6. Install the cuffs on the upper right / left leg about 3 cm above the cubital fossa (not too tight
or don't be too loose.
7. Determine the pulse rate of the right/left radial
8. The balloon pump cuff until the radial artery pulse is not palpable
9. The pump continues until the manometer as high as 20 mmHg higher than the radial point is
not palpable.
10. Place the stethoscope diaphragm over the brachial pulse and glue the cuff balloon flat
slowly and continuously by turning the screw on the air pump opposite the needle
hour.
11. Record the mmHg of the manometer when the pulse is first heard and when it is last heard.
12. Record the results.
13. Wash hands after the procedure is done
61
Vital sign: Terperature
Purpose of action:
Measurement of body temperature is done to determine the range of body temperature.
Tools and materials :

1. Thermometer
2. Three bottles containing soap solution, disinfectant solution, and clean water
3. Crooked
4. Paper / tissue
5. Vaseline
6. Temperature record book
7. Gloves
Work procedures :
Oral temperature check
2. Wash hands.
3. Use gloves.
4. Adjust the position of the patient.
5. Determine the location under the tongue.
6. Lower the thermometer temperature below 34 ° -35 ° C.
7. Lower the temperature of the thermometer under the tongue parallel to the gum.
8. Advise mouth closed for 3-5 minutes.
9. Lift the thermometer and read the results.
11. Clean the thermometer with tissue paper.
12. Wash with soapy water, disinfectant, rinse with clean water, and dry.
13. Wash hands after the procedure is done.
Rectal temperature examination

2. Wash hands.
3. Use gloves.
4. Adjust the position of the patient on the side.
62
5. Clothes are lowered below the glutea.
6. Determine the thermometer and set it to zero and apply Vaseline
7. Place the palm of the patient on the glutea side of the patient and insert the thermometer into
the rectal not
until it changes its place and measures the temperature.
8. After 3-5 minutes lift the thermometer.
10. Clean the thermometer with tissue paper.
Examination of axillary temperature

2. Wash hands.
3. Use gloves.
4. Adjust the position of the patient.
5. Determine the location of the axilla and clean the axillary area using a tissue.
6. Lower the thermometer below 34 ° -35 ° C.
7. Place the thermometer in the axillary area and the patient's arm flexed above the chest.
8. After 3-10 minutes the thermometer is lifted and read the results.
10. Clean the thermometer with tissue paper
Vital sign: Pulse
Aim :
1. Knowing the pulse (rhythm, frequency, and strength).
2. Assessing the ability of cardiovascular function.
63
1. Watch
2. Notebook
3. Pen
Work procedures :
2. Wash hands.
4. Place both hands stretched out on the side of the body.
5. Determine the location of the artery (the pulse to be calculated).
6. Check the pulse using the tip of your index finger, middle finger and ring finger. Determine
the frequency per minute and regular rhythm, and the strength of the pulse.
Vital sign: Pespiration
performed on patients
Aim :
1. Knowing the frequency, rhythm, and depth of breathing.
2. Assessing the ability of respiratory function.
64
1. Watch
2. Notebook
3. Pen
Work procedures :
2. Wash hands.
4. Count the frequency and rhythm of breathing.
6. Wash hands after the procedure is done
65
Courses

Code / credits (1 P) Module VIII
MODULE VIII
Nursing practice (Role Play) II
Vital Sign: Blood pressure, Temperature, Respiration, Pulse

follows:
1. Basic Competence
interest.
2. Material
Nursing practice (Role Play) II, Vital Sign: Blood pressure, Temperature, Respiration,
Pulse
4. References
Education, Inc.
York: Elsevier.
Davis Co.
66
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
THE MATERIAL THE SAME AS MODUL VII
67
Courses

Code / credits (1 P) Module IX
MODULE IX
Nursing Practice (Role play III): Physical Assessment

follows:
1. Basic Competence
interest.
2. Material
Nursing Practice (Role play I): Physical Assessment
4. References
Education, Inc.
York: Elsevier.
Davis Co.
68
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Nursing Practice (Role play): Physical Assessment of (Choose one of the topic bellow) :
 Cardiovascular System
 Respiratory System
 Digestive System
 Integument System
(student group)
69
Courses

Code / credits (1 P) Module X
MODULE X
Nursing Practice (Role play IV): Physical Assessment

follows:
1. Basic Competence
interest.
2. Material
Nursing Practice (Role play 2): Physical Assessment
4. References
k. Alfaro-LeFevre, R. (2014) Applying Nursing Process: The Foundation for
l. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb's Fundamentals of
Education, Inc.
m. Caple, C. (2011). Physical assessment: Performing- cultural considerations. Glendale,
n. Centers for Disease Control and Prevention. (2013). Heart Disease Facts and Statistics.
o. D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological assessment:
p. Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced physical assessment
q. Jarvis, C. (2012). Physical examination and health assessment, (6th ed). St. Louis:
York: Elsevier.
r. Scanlon, V. (2011). Essentials of anatomy and physiology (6th ed.). Philadelphia: F.A.
Davis Co.
s. Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd ed.).
t. Zambas, S.I. (2010). Purpose of the systematic physical assessment in everyday
70
g. Lecture materials have been given to students 1 (one) week before the lecture,
h. The lecturer gives material explanation based on the present condition
i. After the conceptual explanation by the lecturer, the students are divided into
j. After finishing the discussion, the students are asked to explain the results of the
k. Each group is given the opportunity to explain the outcome of the discussion and
l. The learning approach may change according to progress, material and agreement
with students.
d. Understand and master this material well, so that at the time of discussion and ridicule
e. Begin self-motivation to read, from the easy ones, and start reading now.
f. Read scenarios in general instructions, making it easier for students to learn in the
classroom.
7. Evaluation
c. after the end of the learning activities, students are asked to do the test (post test), so
be achieved.
d. If the student can answer 70% of the test questions correctly mean that the student
lecturer
II. Material
Nursing Practice (Role play II): Physical Assessment of (Choose one of the topic bellow) :
 Cardiovascular System
 Respiratory System
 Digestive System
 Integument System
(student group)
71
Courses

Code / credits (1 P) Module XI
MODULE XI
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
72
with students.
classroom.
7. Evaluation
be achieved.
lecturer
73
II. Material
Case study
Case I
A man 34-year-old was admitted to the Muhamadiyah hospital Palembang in emergency room
with complaints of shortness of breath and left chest pain. From the assessment of patients
appearing to be Dispnue, cough, easily feel tired when doing activities so that only the patient
lying on the bed, the patient also seemed nervous and anxious about his condition. the patient
was diagnosed with heart failure. From the results of physical examination, it appears that the
lower extremity edema, hepatomegaly, anorexia, and nocturia. BP: 180/90 mmhg, RR: 28x / m,
T: 36 C, P: 88x / m. The patient had X-ray examination with the result of enlargement of the
heart and pulmonary congestive, blood gas analysis: pa O2 from-HR more than 100X / minute,
results of ECG ST segment elevation and pathological Q. and increased cardiac enzymes, namely
CK, AST, LDL / HDL. The patient is now just lying down in the treatment room to minimize
fatigue when doing activities and just waiting for the next intervention.
Case II
A man 26-year-old was treated in the internal medicine room of the AK. Gani Hospital
Palembang with complaints of coughing up phlegm over the last 1 month. Patients were
diagnosed with pulmonary tuberculosis (TB). The patient has been treated for more than 5 days,
during the assessment he got BP: 110/70 mmhg, T: 37.8 C, RR: 22x / m, P: 70x / m. Patients’
said, he have no appetite and often sweat at night. The results of supporting data obtained
Leukocytes: 16,000, Hb: 10, Mantoux test (+), Sputum culture positive for Mycobacterium
tuberculosis, and on X-Ray examination a hollow and fibrous area was seen. The patient appears
thin, malaise, and almost all activities are assisted by the family because the patient can only lie
on the bed. The patient said he did not know about his conditions, and only hoped to get well
soon and be able to return and gather with family at home.
Case III
A man 19-year-old came to Muhammadiyah Hospital Palembang with complained of abdominal

pain in the right lower quadrant with a pain scale of 7 from 3 days before entering to the hospital.
Pain will increase when he walk. Patients’ has constipation for 3 days. At present the diet of
patients is irregular and rarely consumes foods containing fiber. From the results of assessment,
the patient has anorexia and Rovsing's sign. The patient complains that his body feels hot. The
general condition of the patient really looks sick, fever. Medical diagnostics of the patient is
appendicitis. Examination results obtained BP: 130/80 mmHg, RR: 20 x / min, P: 90 x / min, T:
38.5 C, and Leukocytes: 13,000.
74
Case IV
A woman 40-year-old was treated for 2 days at the hospital because she had Burns in the right
extremity with a percentage is18% with caused by parental vinegar. The patient said, "my arm
hurts a lot especially if it's moved. When examined the client's extreme extremities appear
inflammatory with signs of inflammation of the rubor, color, dolor, Tumor. The client's husband
said that activities such as dressing were helped by the client's family. The client's face seemed to
grimace in pain, and breath faster than usual. The client's husband said that, every night patients’
often woke up and could not sleep well. The client's eyes also look red and around black eyes.
Sign vital results BP: 100/80 mmHg, Pulse: 70 X / minute, temperature 37 ° C, RR 24 x / m
Case V
A man 28-year-old came to the emergency room at the Muhammadiyah hospital Palembang after
a motorbike accident 3 days ago. From the results of the assessment, the client seemed to be
holding back a left ache. The left thigh looks swollen, bruised and wrapped in cloth with bamboo
stems during stay at home. After an x-ray examination, an open complex fracture image was
obtained. Great pain felt like being depressed appeared when move, the client seemed to grimace
to hold back pain from the left femur. Open wounds appear on the gaping left thigh. Cold and
pale acral are palpation results. GCS: 14 with BP: 100/70 mmhg, T: 370 C, RR: 22x / minute,
and P: 88x / minute with fast and shallow quality. On investigation, Hb: 12, leukocytes: 13,000
and rhythmic sinus rhythm ECG results. So far the client has not been able to mobilize and has
been assisted totally by the family in carrying out the Activities Daily Living.
Instructions
Students are divided into 5 groups

Choose one of the cases above and make it into a case report consisting of CHAPTER I, II,
III, IV, V
75
Courses

Code / credits (1 P) Module XII
MODULE XII
Case study
II. General Instructions

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
76
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Case study: Consult process (Group I, II, II, IV, and V)
Develop:
Chapter I : Background
Chapter II : Concept Theory
Chapter III: Developing Nursing process: Assessment, Nursing Diagnose, Intervention,
Implementation, and Evaluation
Chapter IV: Discussion
Chapter V : Conclusion and Recommendation
77
Courses

Code / credits (1 P) Module XIII
MODULE XIII
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
78
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
79
Courses

Code / credits (1 P) Module XIV
MODULE XIV
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
80
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
81
Courses

Code / credits (1 P) Module XV
MODULE XV
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
82
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
83
Courses

Code / credits (1 P) Module XVI
MODULE XVI
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
84
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
85
Courses

Code / credits (1 P) Module XVII
MODULE XVII
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
86
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
87
Courses

Code / credits (1 P) Module XVIII
MODULE XVIII
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
88
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
89
Courses

Code / credits (1 P) Module XIX
MODULE XIX
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
k. Alfaro-LeFevre, R. (2014) Applying Nursing Process: The Foundation for
l. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb's Fundamentals of
Education, Inc.
m. Caple, C. (2011). Physical assessment: Performing- cultural considerations. Glendale,
n. Centers for Disease Control and Prevention. (2013). Heart Disease Facts and Statistics.
o. D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological assessment:
p. Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced physical assessment
q. Jarvis, C. (2012). Physical examination and health assessment, (6th ed). St. Louis:
York: Elsevier.
r. Scanlon, V. (2011). Essentials of anatomy and physiology (6th ed.). Philadelphia: F.A.
Davis Co.
s. Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd ed.).
t. Zambas, S.I. (2010). Purpose of the systematic physical assessment in everyday
90
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Develop:
91
Courses

Code / credits (1 P) Module XX
MODULE XX
Case study

follows:
1. Basic Competence
interest.
2. Material
Case study
4. References
Education, Inc.
York: Elsevier.
Davis Co.
92
with students.
classroom.
7. Evaluation
be achieved.
lecturer
II. Material
Preparation for case presentation
group discussion
93
References
Alfaro-LeFevre, R. (2014) Applying Nursing Process: The Foundation for Clinical

Reasoning. Philadelphia: Lippincott Williams & Wilkins
Berman, A., Snyder, S., Kozier, B., & Erb, G. (2012). Kozier & Erb's Fundamentals of
nursing: Concepts, process, and practice, (9th ed.). Upper Saddle River, N.J.: Pearson Education,
Inc.
Caple, C. (2011). Physical assessment: Performing- cultural considerations. Glendale,
Centers for Disease Control and Prevention. (2013). Heart Disease Facts and Statistics.
D’Amato, R., & Hartlage, L. (2008). Essentials of neuropsychological assessment:
Edmunds, L., Ward, S., & Barnes, R. (2010). The use of advanced physical assessment
Jarvis, C. (2012). Physical examination and health assessment, (6th ed). St. Louis: W.B.
Saunders. Mosby Company. (2012). Mosby’s medical dictionary (9th ed.). New York: Elsevier.
Scanlon, V. (2011). Essentials of anatomy and physiology (6th ed.). Philadelphia: F.A.
Davis Co.
Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary, (22nd ed.). Philadelphia:
F.A. Davis Co.
Zambas, S.I. (2010). Purpose of the systematic physical assessment in everyday practice:
Critique of a “sacred cow”. Journal of Nursing Education, 49(6), 305-310
94

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Courses

Study Program Nursing sciences Meeting First

Introduction: Case Study

Benefits and limitations of case studies

Study Program Nursing sciences Meeting 2

The Nursing Process

Component and Purpose Activities

Update data as needed

Problem identification To develop a list of nursing

Actual Nursing Diagnosis (3-part)

Potential Nursing Diagnosis/Risk (2-

Planning/Goal/Outcome To develop and individualized Set priorities and write goals/outcomes in

Document care and client responses to care

Give verbal reports as necessary

Carry out the plan; “DO” what it takes to

Nurse initiated – Physician initiated –

Study Program Nursing sciences Meeting 3

Overview of Nursing Health Assessment: Assessment Techniques

Percussion is used to elicit tenderness or sounds that may provide clues to

Study Program Nursing sciences Meeting 4

1. Review of Systems and Physical Exam

3. Assess the sensory system

4. The Complete Neurological Exam

5. Assess posterior column tract

7. Glasgow Coma Scale

B. Overview of Nursing Health Assessment: Head, Face and Throat Assessment

1. Head, Face and Throat Assessment

a. Assessment of the Eyes

b. Assessment of the Ears

C. Assessment of the Nose

2. Assessment of the Mouth and Throat

Clarify Unfamiliar Word

Head, Face, Throat

C. Overview of Nursing Health Assessment: Cardiovascular, Pulmonary, Gastrointestinal

When assessing the cardiovascular system, examine the following:

Assessing the Abdomen/Gastrointestinal System

Assessing the Abdomen/Gastrointestinal System

Clarify Unfamiliar Word

When assessing the male reproductive system, examine the following:

b. Female Reproductive System

The complete female reproductive system examination is usually only performed by

c. Assessing the Female Breasts & Axilla

Study Program Nursing sciences Meeting 5

There are fine types of problems.

NURSING DIAGNOSIS: NANDA

B. Nursing Care Planning

Examples: Ineffective breathing pattern related to effects of anesthesia. (Physical)

2. Developing Goal/Outcome Statements

3. Planning Nursing Action

Before the plan can be implemented, certain preparations are necessary.

D. Nursing Process: Evaluation in Nursing

Study Program Nursing sciences Meeting 6

This general guide, contains an explanation of the steps to be taken in

ASSESSMENT FORM ADULT OF NURSING

Previous Health History

Nursing Assessment (12 Domains NANDA)

Tolerance / Koping Stress

Assessment Review of System and physical

Reaction during interaction

Supporting Examination (Laboratory, Radiology, ECG, etc.)

DATA/PROBLEM ETIOLOGY NURSING PROBLEM

PRIORITY OF NURSING PROBLEM

Study Program Nursing sciences Meeting 7

This general guide, contains an explanation of the steps to be taken in lectures, as