1. Patient preparation
1.1. Greetings therapeutic delivered to the client
/ family friendly upon meeting
1.2. Action plan described to the client / family understand
1.3. Prograrn plan validated again
1.4. The need for tools and materials are identified
1.5. Readiness client be re-examined
1.2. Action plan described to the client / family understand
1.3. Prograrn plan validated again
1.4. The need for tools and materials are identified
1.5. Readiness client be re-examined
2.
Preparation tool
2.1 Stationary
2.2 Wristwatch
2.3 Format assessment (data collection)
2.4 Instrumeu physical examination:
2.1 Stationary
2.2 Wristwatch
2.3 Format assessment (data collection)
2.4 Instrumeu physical examination:
- Tension meter
- Stethoscope,
- Thermometers
- Ribbon meter
- Snelen chart - Flashlight
- Speculum nose
- Ear speculum
- Tounge spatel
- Percussion hammer
- The tuning fork
- Material cranial nerve function tests such as: balsam, vanilla, coffee, Vila d1l.
- Weighing Weight Loss
3.
Working procedures
3.1 If the client wants to tingbal kcluarga members in the room during the collection of medical history, if not
escorted the family to the waiting room
3:2 Wash hands
3.3 Prepare equipment for collecting nursing history and assessment
3.4 Weigh the client and record high
3.5 Assist clients to obtain nyamau position in bed or in a chair beside the bed
3.6 Collect history of nursing include:
3.1 If the client wants to tingbal kcluarga members in the room during the collection of medical history, if not
escorted the family to the waiting room
3:2 Wash hands
3.3 Prepare equipment for collecting nursing history and assessment
3.4 Weigh the client and record high
3.5 Assist clients to obtain nyamau position in bed or in a chair beside the bed
3.6 Collect history of nursing include:
- Biography
- The current health status
- Status of past health
- Family health status
- Risk factors for disease
- History of allergy
- History of drug use
- bridge
- Activity and daily habits
3.7 Assess the client's
vital signs
3.8 Perform a physical assessment by using the method of inspection, palpation, percussion and auscultation.
3.9 Instruruksikan clients about the proper techniques for preparing specimens of urine, feces, sputum and
blood
3.10 Explain to the client that the officers would take blood specimens and X-ray examination, and ECG if
necessary USG
3.11 Give client a chance to ask questions about the procedure or therapy
3.12 Doing phase termination to the patient (patient leaves the treatment room)
3.13 Perform data validation
3.14 Identify patterns or division (data analysis)
3.8 Perform a physical assessment by using the method of inspection, palpation, percussion and auscultation.
3.9 Instruruksikan clients about the proper techniques for preparing specimens of urine, feces, sputum and
blood
3.10 Explain to the client that the officers would take blood specimens and X-ray examination, and ECG if
necessary USG
3.11 Give client a chance to ask questions about the procedure or therapy
3.12 Doing phase termination to the patient (patient leaves the treatment room)
3.13 Perform data validation
3.14 Identify patterns or division (data analysis)
4.
Documentation
- Documented patient response
- The timing of the nursing assessment
- Documentation note with clear / easy to read
- Documentation signed and the full name and clearly
