CHAPTER I

INTRODUCTION

1.1 Background Of Study

Nursing one form of professional service is an integral part that can not be separated
from the overall health care effort. Besides nursing services is one of the determinants of the
quality and image of the hospital, therefore the quality of nursing services needs to be
maintained and left as optimal as possible.
Characteristics of good nursing quality include:
1. Meet the established professional standards
2. Resources for nursing care services are used fairly, efficiently and effectively
3. Safe for patients and nursing staff as service providers
4. Satisfying patients and nursing staff as well
5. Social, economic, cultural, religious, ethical and community values are considered and
respected
Besides the requirements for improving the quality of nursing care include:
1. A caring and supportive leader
2. There is an awareness that quality must be improved (quality standards)
3. Health workers are prepared through efforts to increase their knowledge and skills by
holding a training program
4. Facilities and implementation and supporting environment
5. Nursing care standards are available and applied
Based on the mindset as mentioned above, the Directorate General of Medical Services,
the Ministry of Health of the Republic of Indonesia, together with the organization of the
nursing profession, has developed nursing care standards and has officially adopted nursing care
standards to be applied in all hospitals, through the "Decree of the Director General of Medical
Services, NO. YM.00.03.2.6.7637 of 1993 concerning the entry into force of nursing care
standards in hospitals ". This means that all nursing staff at the hospital in providing nursing
care must be guided by the intended nursing care.

1.2 Formulation of the problem

1.2.1 What is Asking about health problem?
1.2.2 What is Reporting on the nursing diagnose ?
1.2.3 What is Reporting the symtoms of health problem?
1.3 Purpose
1.3.1 General Purpose
The purpose of this study generally are students able to understand the nursing
report. That students are able to perform nursing care nursing care to clients .

1.3.2 Specific Objectives

1. Explaining about Asking about health problem
2. Explaining about Reporting on the nursing diagnose
3. Explaining about Reporting the symtoms of health problem

1.4 Benefits
This paper is expected to increase the repertoire of the development of science and
provide information about nursing report

1.4.1 For Educational Institutions

The creation of the students who know and understand about nursing report
1.4.2 For the Nursing Profession
 The creation of professional health workers.
 The creation of a sense of comfort in every patient treated.
 The creation of high intellectual human resources.
1.4.3 For Student
 Can understand the concept of definition about nursing report .
 More knowing the skills and knowledge to analyze information that is not in
the know.
 Can understand about definition of nursing report
 CHAPTER 2
LITERATURE

2.1 Discussion
2.1.1 Asking about health problem
1. Definition of assessment
Assessment is the initial stage of the nursing process and is a systematic
process in collecting data from various data sources to evaluate and identify the
health status of patients according to Lyer et al. Assessment is a systematic
approach to collecting data and analyzing it. Assessment is the basic thinking of the
nursing process that aims to collect information or data about patients, in order to
identify, recognize problems, health and nursing needs of patients, both physical,
mental, social and environmental according to Effendy (Dermawan, 2012).
2. The purpose of the assessment
The objectives of the study according to (Dermawan, 2012) are as follows:
a. To obtain information about the state of the patient's health.
b. To determine the patient's nursing and health problems.
c. To assess the state of health of the patient.
d. To make the right decision in determining the next steps.
3. Data type
Data types according are as follows:
a. Subjective data
Subjective data are verbal descriptions of patients about their health
problems. Subjective data were obtained from nursing history including patient
perceptions, feelings and ideas about his health status. Other data sources can
be obtained from families, consultants and other health workers.

b. Objective data
Objective data is the result of observation or measurement of the
patient's health status.
4. Matters that must be considered in the assessment
 The things that must be considered in the assessment according to
Dermawan (2012) are as follows:
a. Data collected must cover all aspects of bio-psycho-social and spiritual.
b. Use various sources that are relevant to the patient's problem and use data
collection methods that are appropriate to the patient's needs.
c. Be carried out systematically and continuously.
d. Recorded in a nursing record systematically and continuously.
e. Grouped according to bio-psycho-social and spiritual needs.
f. Analyzed with the support of relevant knowledge.

2.1.2 Reporting on the nursing diagnose

1. Definition of nursing diagnoses
Nursing diagnosis is a conclusion that results from data analysis (Carpenito,
2009).
Diagnosis Nursing is a clinical assessment of the response of an individual
family, or community, to a health problem or actual life process or potential.
Nursing diagnoses provide the basis for selecting nursing interventions to achieve
outcomes that are the responsibility of nurses according to the North American
Nursing Diagnosis Association (NANDA) (2010, in Allen, 2011).
2. Criteria for nursing diagnoses
Criteria include the following (Nursalam, 2015):
a. Health status compared to standards to determine gaps.
b. Nursing diagnoses are related to the cause of the gap and the fulfillment of the
patient's needs.
c. Nursing diagnoses are made according to authority.
d. The diagnostic component consists of PE / PES
e. Review and revision of diagnoses based on the latest data.
3. The purpose of nursing diagnoses
The purpose of nursing diagnoses is to identify according to Dermawan
(2012) as follows:
a. Problems where the client's response to health or disease status.
b. Factors that support or cause a problem.
c. The ability of clients to prevent or solve problems.
d. Communicating the client's problem to the health team.
e. Demonstrating responsibility in identifying client problems.
f. Identifying the main problems for the development of nursing orders.
4. Components of nursing diagnoses
Components of nursing diagnoses according to Dermawan (2012) as
follows:
a. Problem
 The problem is a picture of the patient's condition where nursing
actions can be given. Problems or problems are gaps or deviations from normal
circumstances that should not occur.
Objective: to explain the patient's health status clearly and as concisely
as possible. Nursing diagnoses are prepared using agreed standards, so that:
1) Nurses can communicate with terms that are generally understood.
2) Facilitating and accessing nursing diagnoses.
3) As a method for identifying differences in nursing problems with medical
problems.
4) Enhancing nurse collaboration in defining diagnoses from nursing
assessment and intervention data.
b. Etiology
Etiology or causal factors are clinical and personal factors that can
change health status or influence the development of the problem. Is a
guideline for formulating interventions. The elements in etiological
identification include PSMM elements:
1) Pathophysiology of disease: all disease processes, acute or chronic that can
cause or support a problem.
2) Situational: personal and environmental (lack of knowledge, social
isolation).
3) Medication (related to treatment programs

2.1.3 Reporting the symtoms of health problem

1. Health Perception Patterns
The client's ignorance of information about his illness. In general,
hyperthyroidism is a result of hyperactivity of the thyroid gland in producing
thyroid hormones. This disease is included in autoimmune which produces
antibodies that can increase the production of thyroid hormone freely. Lack of
client knowledge about the causes and factors that influence the occurrence of
hyperthyroidism.
Example: The patient said that he was very worried about his illness,
because previously the patient had never experienced the disease as felt at this time
which is shortness of breath and chest pain and swelling in the legs, the patient
looked restless, the patient said he rarely controlled and checked his health at the
health clinic, and this was a the first time the patient was hospitalized at the
hospital.
2. Metabolic Nutrition Patterns
Sudden weight loss, increased appetite, heavy eating, thin, frequent eating,
thirst, nausea and vomiting.
Example: The patient said that the appetite was good, the food provided by
the hospital could be finished, the patient ate by being fed by nurses, and the patient
did not eat side foods / food from outside the Hospital. Patients drink up to 5
glasses / day
3. Elimination Pattern
Large amounts of urine, pale and yellow thin urine, changes in feces
(diarrhea), frequent bowel movements and sometimes diarrhea, excessive sweating,
cold sweats.
Example: The patient said that the bowel and bladder was smooth, the
patient had a DC, yellow urine color and a distinctive urine odor

4. Pattern of Activity - Exercise

increased sensitivity, weak muscles, impaired coordination, severe fatigue,
palpitations, chest pain, fast and hoarse speech, disorders of mental status and
behavior, such as: confusion, disorientation, anxiety, excitement, delirium,
psychosis, stupor, coma, smooth tremor in hands, aimlessly, some parts are jerky,
hyperactive deep tendon reflexes (RTD). increased respiratory rate, tachypnea,
dyspnea, pulmonary edema (in thyrotoxicosis crisis), trembling fingers, rapid heart
palpitations, rapid pulse, often up to more than 100 times per minute Fatigue,
muscle weakness, especially upper arm and thigh , Heat intolerance Increased
bowel movements Trembling Anxiety; agitation.
5. Rest and Sleep Patterns
Insomnia so it is difficult to concentrate.
Example: The patient said that he had started sleeping soundly at night if the
tightness and chest pain did not appear, the patient had been sleeping since 20.00-
05.00, and the patient was napping 1-2 hours
6. Perceptual Cognitive Patterns
There are worries due to dizziness, tingling, vision problems, double vision,
impaired coordination, difficulty concentrating.
 Example: The patient can communicate well, the view of the patient is good
and clear, the patient can answer the nurse's questions, the patient says he has never
paid attention to the illness he has experienced since his parents were sick and the
patient still did not understand about the disease he was suffering from. Patients and
families ask a lot about their illness
7. Patterns of Self-Reliance
Impaired self-image due to changes in anatomical structure, large eyes
(wide-eyed = exophthalmus), other complaints in the eye (such as pain, light
sensitivity, vision disorders and conjunctivitis), enlarged thyroid gland (goitre
nodosa), thin, thin velvety skin, fine and thin hair, hair loss.
Example:
1. Identity: The patient is able to recognize himself as a family head with 3
teenagers, and has 8 subordinates in his work
2. Self-image: The patient feels that he is sick and needs help.
3. Ideal self: The patient says he wants to get well soon and can gather with his
family at home.
4. Self-esteem: Patients do not feel inferior to the current situation and seem to
always be cooperative with the nurses who care for them.
5. Self role: During this time the patient has the role of head of the household for
his family.
8. Role-Relations Pattern
Nervus, tension, anxiety, anxiety, irritability. If the bias is adjusted, it will
not be a problem in relation to family members.
Example: Not reviewed
9. Patterns of Sexuality - Reproduction
Decreased libido, hypomenorrhea, amenorrhea and impotence, menstruation
becomes irregular and slight, pregnancy often ends in miscarriage, protruding
eyeballs, can be accompanied by double vision (double vision).
Example: The patient's family says the patient is able to interact and get to
know the environment well, the patient is friendly with the family and the
surrounding environment.
10. Koping Pattern - Stress tolerance
Experience severe stress both emotionally and physically. Unstable emotions
(moderate euphoria to delirium), depression.
 Example: The patient's family said the patient if there are problems always
discussing with his wife, the patient looks anxious and afraid of the illness in his
suffering
11. Trust Value Patterns
Depending on the habits, teachings and rules of the religion adopted by the
individual. Nervus, tension, anxiety, anxiety
Example: The patient says that he always prays 5 times and seems to always
pray for his recovery

CHAPTER 3
CLOSING

3.1 Conclusion
Assessment is the initial stage of the nursing process and is a systematic process in
collecting data from various data sources to evaluate and identify the health status of patients
according.
Diagnosis Nursing is a clinical assessment of the response of an individual family, or
community, to a health problem or actual life process or potential. Nursing diagnoses provide
the basis for selecting nursing interventions to achieve outcomes that are the responsibility of
nurses according to the North American Nursing Diagnosis Association

3.2 Suggestions
3.1.1 For Nurses
Expected nurses trained in accordance with the nursing actions. Where it can
improve optimal health services and understanding of Nursing Standards (IFRSs),
developed the noble soul of nurses (friendly, attentive, communicative, teamwork,
responsibility). For nurse managers should implement a reward and punishmen.

3.1.2 Nursing Education Institutions

 Expected capable menciftakan graduates who are competent, one of them in the
health care field and is able to act in accordance with what is expected by the patient /
client without forgetting / ignoring the code of ethics.
3.1.3 For Hospital
Is expected to provide training and seminars for health workers in order to
improve health services as one of the nursing actions performed correctly, accurately and
quickly. The hospital is expected to further improve the facilities and infrastructure,
incentives and the implementation of laws and regulations related hospital.

BIBILIOGRAFI

Dermawan.2012. Nursing Process Application of Concepts & frameworks work

(1st ed). Yogyakarta Goyen Publishing.

North American Nursing Diagnosis Association (NANDA) (2010, in Allen, 2011).

Nursalam. (2015). Nursing Management Jakarta: Salemba Medika.Purwanto

Carpenito. (2009). Nursing Diagnosis Pocket Book. EGC. Jakarta