COURSE BOOK 2

B. INGGRIS 2
(MATERIALS USED ONLY FOR INTERNAL CAMPUS)

PRODI D3 KEPERAWATAN

Arrange By:
Nita Yuanita, S.Pd., M.Si.

Lectured by:
Nita Yuanita, S.Pd., M.Si.
Irsyad Nugraha, M.Pd.

UNIVERSITAS BHAKTI KENCANA

FAKULTAS KEPERAWATAN
PROGRAM STUDI D3 KEPERAWATAN – PSDKU GARUT
2022

Nama Mata Kuliah
B. INGGRIS 2
Otorisasi
R. Siti Jundiah, M.Kep.
Dekan Fakultas Keperawatan
Capaian Pembelajaran (CP)
Diskripsi Singkat MK
Bahan Kajian / Materi
Pembelajaran
Metode & Media Pembelajaran
Metode Penilaian dan
Pembobotan
Daftar Referensi
D3 Keperawatan – Universitas Bhakti Kencana- PSDKU Garut
UNIVERSITAS BHAKTI KENCANA
FAKULTAS KEPERAWATAN
PROGRAM STUDI DIPLOMA 3 KEPERAWATAN
RENCANA PEMBELAJARAN SEMESTER
(RPS)
Kode Mata Kuliah Bobot (sks) Semester Tgl Penyusunan
FK062004 2 SKS (1T,1P) 4 22 Februari 2022
Nama Koordinator Koordinator Bidang Ka PRODI
Pengembang RPS Keahlian (Jika Ada) D3 Keperawatan PSDKU Garut
Nita Yuanita, S.Pd., M.Si Ns.Winasari Dewi, M.Kep
CPL-PRODI (Capaian Pembelajaran Lulusan Program Studi) Yang Dibebankan Pada Mata Kuliah
S1 Bekerjasama dan memiliki kepekaan sosial serta kepedulian terhadap masyarakat dan lingkungan
(CP.S.07)
KU1 Menyusun laporan tentang hasil dan proses kerja dengan akurat dan sahih, mengkomunikasikan
secara efektif kepada pihak lain yang membutuhkannya (CP.KU.04)
CPMK (Capaian Pembelajaran Mata Kuliah)
CPMK 1 Mampu menguasai tentang tata bahasa (grammar), susunan kalimat (simple sentences) dan
perbendaharaan kata (specific vocabulary), berkomunikasi (speaking), membaca (reading), menulis
(writing) dan memahami bahan-bahan referensi bahasa Inggris sederhana yang berhubungan
dengan tema (daily healthcare activities)
CPMK 2 Mampu menerapkan bahasa Inggris dalam pemberian pelayanan dan asuhan keperawatan
Mata kuliah ini menguraikan tentang tata bahasa (grammar), susunan kalimat (simple sentence), dan perbendaharaan kata
(specific vocabulary) yang memungkinkan mahasiswa berkomunikasi (speaking) secara santun dengan orang lain (pasien)
dalam konteks lingkungan kerja perawat sehari-hari di rumah sakit, membaca (reading), menulis (writing) dan memahami
bahan-bahan referensi bahasa inggris sederhana yang berhubungan dengan tema (daily healthcare activities).
Pengalaman belajar meliputi dialog sederhana, diskusi kelompok, penggunaan laboratorium Bahasa serta penugasan
perorangan.
Bahan Kajian Bahasa Inggris sebagai pengantar bahasa Internasional; Structure; Grammar; Vocabulary; Reading;
CPMK 1 Speaking; Listening; Writing
Bahan Kajian Penerapan bahasa Inggris dalam pelayanan dan asuhan keperawatan
CPMK 2 a. Komunikasi teurapeutik pada pasien
b. Komunikasi dengan tim kesehatan
c. Dokumentasi asuhan keperawatan
d. Presentasi/ Seminar
Metode pembelajaran dilakukan secara Cooperative Learning menggunakan media pembelajaran daring melalui aplikasi
eLearning BKU yang dapat diakses mahasiswa melalui link https://elearning.bku.ac.id. Dosen pengampu dalam hal ini
mengunggah materi pembelajaran yang dapat diunduh mahasiswa pada laman materi di elearning, serta latihan/ kuis pada
laman tugas, juga ujian UTS/ UAS pada laman ujian serta diskusi/ tanya jawab melalui forum di eLearning tersebut.
Adapun grup Whatsapp disediakan sebagai alternatif live chat jika terdapat kendala dalam mengakses eLearning agar
kegiatan pembelajaran secara daring dapat terlaksana dengan optimal.
Nilai Angka Nilai Mutu Angka Mutu Sebutan Mutu
80 - 100 A 4 Sangat Cemerlang
75 – 79,99 A- 3,75 Cemerlang
70 – 74,99 AB 3,5 Sangat Baik
65 – 69,99 B 3,0 Baik
60 – 64,99 B- 2,7 Hampir Baik
55 – 59,99 C+ 2,3 Lebih dari Cukup
50 – 54,99 C 2,0 Cukup
45 – 49,99 D 1 Kurang
<44,99 E 0 Gagal
Penilaian akhir pada pembelajaran ini didasarkan pada aspek-aspek berikut:
a. Kehadiran : 10 %
b. Tugas : 10 %
c. Aktivitas : 10 %
d. Skor UTS : 30 %
e. Skor UAS : 40 %
Utama :
1. Ardiansyah. (2004). Let’s Speak English, Nurse!. Jakarta: EGC
2. Djauhari, Imam D. (…). Mastery on English Grammar. Jakarta: -
3. Grice, Tony. (2009). Everyday English for Nursing, 1st & 2nd ed.. Jakarta: EGC
4. Murphy, Raymond. (1987). English Grammar in Use: A self-study reference and practice book for intermediate students.
Cambridge: Cambridge University Press
5. Nursalam. (2010). English in Nursing-Midwifery Science and Technology. Jakarta: Salemba Medika
6. Philips, Deborah. (2001). Longman Complete Course for the Toefl Test. NY: Longman
7. Pramudya, Leo A. (2011). English for the Professional Nurses, Course Book 1 & 2. Jakarta: EPN Consultant
8. Richards, Jack C. (1984). Person to Person. England: Oxford University Press
9. Rizka, Haira, dkk. (…). English for Nursing: Practical English Conversation for Professional Nurses. Yogyakarta: Pustaka
Baru Press
Pendukung : www.englishmed.com; www.englishclub.com; www.thoughtco.com; ww.languageguide.org/english/vocabulary
www.businessenglishsite/nursing_english1-2-3
Page 2
 Serta berbagai sumber lain yang dapat menunjang pengembangan pembelajaran.
Nama Dosen Pengampu 1) Nita Yuanita, S.Pd., M.Si. (Periode UTS)
2) Irsyad Nugraha, M.Pd. (Periode UAS)
Mata kuliah prasyarat -
(Jika ada)

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 8. PART OF THE BODY & HEALTH PROBLEMS

When working in English, one of the first things you need to know is the human body parts. You will
need to learn the names of the internal (inside the skin) and external body parts. You will also need to
learn the words for the functions of each of these body parts.
Here are the basics to get you started.

Head
Inside the head is the brain, which is responsible for thinking. The top of a person's
scalp is covered with hair. Beneath the hairline at the front of the face is the forehead.
Underneath the forehead are the eyes for seeing, the nose for smelling, and the mouth
for eating. On the outside of the mouth are the lips, and on the inside of the mouth are
the teeth for biting and the tongue for tasting. Food is swallowed down the throat. At the
sides of the face are the cheeks and at the sides of the head are the ears for hearing. At
the bottom of a person's face is the chin. The jaw is located on the inside of the cheeks
and chin. The neck is what attaches the head to the upper body.

Upper Body
At the top and front of the upper body, just below the neck is the collar bone. On the
front side of the upper body is the chest, which in women includes the breasts. Babies
suck on the nipples of their mother's breasts. Beneath the ribcage are the stomach
and the waist. The navel, more commonly referred to as the belly button, is located
here as well. On the inside of the upper body are the heart for pumping blood and the
lungs for breathing. The rear side of the upper body is called the back, inside which
the spine connects the upper body to the lower body.

Upper Limbs (arms)

The arms are attached to the shoulders. Beneath this area is called the armpit or
underarm. The upper arms have the muscles known as triceps and biceps. The joint
halfway down the arm is called the elbow. Between the elbow and the next joint, the wrist,
is the forearm. Below the wrist is the hand with four fingers and one thumb. Beside the
thumb is the index finger. Beside the index finger is the middle finger, followed by the ring
finger and the little finger. At the ends of the fingers are fingernails.

Lower Body
Below the waist, on left and right, are the hips. Between the hips are the reproductive
organs, the penis (male) or the vagina (female). At the back of the lower body are the
buttocks for sitting on. They are also commonly referred to as the rear end or the bum
(especially with children). The internal organs in the lower body include the intestines
for digesting food, the bladder for holding liquid waste, as well as the liver and the
kidneys. This area also contains the woman's uterus, which holds a baby when a
woman is pregnant.

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 Lower Limbs (legs)
The top of the leg is called the thigh, and the joint in the middle of the leg is the knee.
The front of the lower leg is the shin and the back of the lower leg is the calf. The ankle
connects the foot to the leg. Each foot has five toes. The smallest toe is often called the
little toe while the large one is called the big toe. At the ends of the toes are toenails.

EXERCISE 1
Choose the correct word to complete the sentences!
1. Your tonsils can get swollen when you have a sore _______ (thigh/ toe/ throat)
2. The _______ is a joint that connects the upper arm and the forearm. (elbow/ ankle/ wrist)
3. My Dad's little _______ was lost in the accident. (thumb/ toe/ shoulder)
4. The patient lost so much weight his _______ were sunken in. (calves/ ears/ cheeks)
5. We'll put a cool cloth on your _______ to get your fever down. (forehead/ tongue/ knees)
6. Another word for "belly button" is _______ (nipple/ navel/ uterus)
7. The newborn is getting his _______ changed in the nursery. (buttocks/ nappy/ shin)
8. She may never walk again because her _______ was so badly injured. (uterus/ spine/ finger)
9. The _______ on his knee was scraped off when he hit the road. (joint/ gum/ skin)
10. Your grandfather will be able to walk better after his _______ surgery. (chin/ wrist/ hip)

ASKING AND TELLING ABOUT HEALTH PROBLEMS

Ami : What’s the matter? Cathy : What’s wrong with you?
Betty : I have a headache. Deasy : I got a sore throat
Ami : Owh...that’s too bad. Cathy : Oh...I’m sorry to hear that

Eric : How do you feel today?

Felix : I feel terrible, I have pain on my chest.
Eric : Really! Hopefully you fell better

EXERCISE
Look at this health problem. Find good advice for each health problem
Problems Advice
A headache ___ 1. Take some aspirin
A toothace ___ 2. Go to bed and rest
A sore throat ___ 3. Drinks a lot of water
A cough ___ 4. Take some Vit.C
A backache ___ 5. Put some lotion on it
A fever ___ 6. Give taped water compress
A burn ___ 7. Close the mouth when coughing/ sneezing
___ 8. Don’t lift anything heavy
___ 9. Brush the teeth regularly
___ 10. See the Dentist
___ 11. Don’t exercise

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 9. CHECKING VITAL SIGN

It is now common practice for nurses to communicate with patients as much as possible when they are doing
routine nursing task. If nurses talk, the patients become involved in their treatment. As a nurse take the patient’s
vital signs, it will be better a nurse says what she/ he is going to do, explains why she/ he is doing it and give the
patient feedback.

USEFUL EXPRESSION
1. Explaining the procedures
It’s time for me to… measure your blood pressure
I just want to… count your pulse
I would like to… check your respiration
I am going to… measure your temperature
put this cuff (around your upper arm)
insert this (thermometer) into your armpit

2. Instruction and expression during the implementation

Would you… lie down on the couch
Would you mind…(verb –ing) lie flat on the bed
Please,… roll your sleeve up
Now, I want you to… give me your right/ left hand
slip off your top things (buka baju)
unbutton your shirt (buka kancing baju)
roll yourself into side lying position
take a deep breath
breathe in… breathe out…
to put this (thermometer) into our mouth

3. Nurse Response 4. Patient’s Response

 OK, Fine. That’s it  Yes, please
 Fine/ good  Okay nurse
 All is done/ Finished  No problem

VOCABULARY
Pulse rate
Tension or compressibility
Beats per minute
Expiration-breathing out
Inspiration-breathing in
: jumlah denyutan Patient’ chart : lembar (penilaian) pasien
: ketegangan Normal pulse rhythm : irama denyutan normal
: denyutan per menit Rhythm or regularity : irama denyutan/ cepat-lambat
: hembuskan nafas
: tarik nafas

EXERCISE 1. Translate into communicative English!

1. Pak, sekarang saya mau mengukur tekanan darah anda.
2. Silahkan berbaring di tempat tidur itu.
3. Sekarang saya mau masukkan thermometer ini ke ketiak ibu, tolong angkat tangan ibu.
4. Silahkan buka bajunya, saya ingin mengecek pernafasan anda..tarik nafas dalam-dalam, lepaskan nafas…
tarik nafas…lepaskan…
5. Tolong ulurkan lengan kiri Anda, saya akan menghitung denyut nadi.
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CONVERSATION PRACTICE
Situation: A nurse comes to Mr. Jack’s room to take his vital signs
Nurse : Good morning Mr. Jack After the nurse pump the bulb to inflate the cuff then
Mr. J : Good morning too, nurse she puts stethoscope over brachialis artery and
Nurse : How are you doing now, Sir? listens the sound of artery from beginning to ending,
Mr. J : I am feeling terrible after she gets the result of B/P, she release the cuff
Nurse : Terrible! What’s going on with you? then puts it back onto trolley
Mr. J : I have pain on my head Nurse : Well Mr. Jack, I am going to check your
Nurse : I see, do you have any else complaint, Sir? temperature now?
Mr. J : And a little stiff on my leg Mr. J : Okay
Nurse : Okay Mr. Jack, let me check your blood Nurse : Could you raise your arm because I’ll put this
pressure and your temperature first? thermometer on your armpit?
Mr. J : Yes, please Mr. J : Like this nurse?
Nurse : Would you mind lying down on the bed Nurse : Yes, thanks (then the nurse puts it at his
please? armpit) and now place your left hand on your
Mr. J : No problem shoulder for a moment?
Nurse : Can I have your arm, Mr. Jack? Mr. J : With my pleasure.
Mr. J : Here it is. Nurse : Very good
Nurse : Good… will you roll your sleeve up, please? After 5 minutes, she takes thermometer back from Mr.
Mr. J : Yes Jack’s armpit.
Nurse : Good, now, I want to put this cuff around your Nurse : Well Mr. Jack, your blood pressure is high
upper arm then I’ll search your pulse on your enough; it’s about 160/90 mmHg and
inner of lower arm temperature 37.5 0C, pulse 88 bpm, Rr:
Mr. J : Okay 20x/m, I will report to Dr. Frank about your
Nurse : Now, I am going to pump this bulb to inflate complaints. I’ll be back in a few minute.
the cuff, maybe you will have tingling on your Mr. J : Thank you very much nurse
finger for a while but it’s okay. Nurse : You’re welcome
Mr. J : I see

Now Read This:

The normal temperature of a healthy adult ranges from 370C to 37,20C
A temperature of 360C is below normal
A temperature of 380C is above normal
The normal pulse rate of an adult at rest ranges from 72 to 80 beats per minute
72 beats per minute is the maximum normal pulse rate
80 beats per minute is the maximum normal pulse rate

EXERCISE 2. Now complete these sentences:

a) the most suitable temperature for a patient’s room … 200C to 23,30C
b) A … of 370C is normal
c) A pulse rate of 100 beats per minute for an adult at rest is …
d) … blood pressure in a young adult is about 120/80 mm/Hg
e) A pulse rate of 65 beats per minute is …

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 10. GIVING INSTRUCTION ON PHYSICAL MOTION
USING POLITE REQUEST

Patients in hospital are usually anxious and fearful. It is important that hospital and staff put them and
their ease by being polite and pleasant. The following drills teach you polite form in English. Be careful
about the way your voice rises and falls when you say these sentences.
Basic Instruction
 Please…/ …Please!  Would you mind…(V-ing)
 Will you…  I want you to…
 Would you…  I would like you to…
 Could you…  I just want to see you…
USEFUL EXPRESSION
Change each command request into polite request using basic instruction!
Command Request Come in, Please! (Silahkan masuk)
1. Sit down (duduk)
2. Stand up (berdiri)
3. Turn around (berputar)
4. Say “Ah” (katakan “Ah”)
5. Flex your neck (tekukan leher)
6. Bend down (membungkuk)
7. Lay down (berbaring)
8. Look up (lihat ke atas)
9. Raise your arm (angkat tangan)
10. Move your head (gerakan kepala)
Command Request Will you come in, Please!
1. Lift your leg (angkat kaki)
2. Arch your back (bungkukan punggung)
3. Lower your foot (turunkan kaki)
4. Open your mouth (buka mulut)
5. Put out your tongue (keluarkan lidah)
6. Bend your knees (tekuk lutut)
7. Touch your toes (sentuh jari kaki)
8. Wriggle your finger (gerakan jari)
9. Take your shirt off (buka baju)
10. Roll your sleeve up (gulung lengan baju)
Command Request Would you come in, please!
1. Hold your head up (tengadahkan kepala)
2. Take deep breath (tarik napas panjang)
3. Touch your ankle (sentuh pergelangan kaki)
4. Fist your finger (kepalkan jari)
5. Put on your shirt (kenakan baju)
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 6. Lower down your trouser (turunkan celana anda)
7. Take your trouser off (lepaskan celana)
8. Keep your mouth open (tetap buka mulut)
9. Keep your eyes hut (tutup mata)
10. Extend your hand (rentangkan tangan)
Command Request Would you mind coming in, please! (V-ing)
1. Take the breath in (tarik nafas dalam)
2. Take your breath out (hembuskan nafas)
3. Shake your head (gerakan kepala)
4. On the knee down (berlutut)
5. Put your body upside down (tengkurap)
6. Slight over/ scoot over (bergeser)
7. Fold your knees (lipat lutut)
8. Hold your breath (tahan nafas)
9. Fold your elbow (lipat siku)
10. Lay onto your tummy (tengkurap)

EXERCISE
Choose the correct answer for these items in the list
1. Can you …your mouth … please! a. On the knee down
2. Now, will you … your knee, please! b. Raise arm
3. I’m going to check your mouth, would you mind … your tongue … c. Open – widely
4. I would like to listen your lungs, please take … and … d. Fold – knee
5. I want to take your BP, would you mind … your sleeve …, please! e. Upside – down
6. A nurse asks Mr. Black to … the body …because she wants to inject pain f. Bend
killer on his buttock. g. Breath in – out
7. I will … to ask you to forgive my fault. h. Put – out
8. If you don’t understand what I have said, please… and I will re-explain. i. Put on
9. Well Miss, please tell me if you feel pain when I … your … to your j. Rolling – up
abdomen.
10. Everything is okay, now … your dress.

11. MEDICAL INSTRUMENTS

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USEFUL EXPRESSION
Asking and explaining the function of a medical instrument
Asking:
 What is this (instrument) for?
 Would you take a/ an+ (medical instrument) for…
 Can you explain the function of+ (medical instrument)?
Explaining:
 This is used to…/ This (instrument) is use to…
 I’ll introduce you a medical instrument. Its name is … It’s used (for/ to…) or (it is functioned…)
 A/ an … is an instrument that I used for… verb-ing
Example in conversation:
A: What is this wheel chair for? C: What is the thermometer for?
B: This wheel chair is use to bring a disable D: This is used to measure body temperature.
patient to walk.
Susan: What is this called in English Sarah? Amy : Bob, can you tell me what this is?
Sarah: Oh... this is called a kidney dish Bob : I think this is a stethoscope
Susan: What is the kidney dish for? Amy : Stethoscope? What is this for?
Sarah: It’s used to place soiled dressing Bob : This used for listening sound of
lungs, abdomen or heart
VOCABULARIES
Medical Instrument used for Measuring Vital Sign

EXERCISE
Now, find other vocabularies on Medical Instruments then write with its meanings
12. ADMISSION TO HOSPITAL
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Admission is the act or process of accepting someone into a hospital, clinic, or other treatment facility
as an inpatient. While Admission form/card/ note is part of a medical record that documents the
patient's status (including history and physical examination findings), reasons why the patient is being
admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
A nurse needs to ask several questions to fill in the admission form. There are three basic question
types:
 Yes/No: the answer is "yes or no"
 Question-word: the answer is "information"
 Choice: the answer is "in the question"

ADMISSION FORM
Hospital Reg. No. Unit Adm. Date Adm. Time

Complete Name First Name Family Name ID. No.

Age (DOB/POB) Sex Religion Marital Status Occupation

[__] M [__] F [M/ S/ W/ Wr]
Transport Mode [__] WC [__] Walking [__] Stretchers [__] Other
Oriented to Environment [__] Yes [__] No
Permanent Address

ZIP Code Phone No.

Name& Address of Next Kin

ZIP Code. Phone No.

Relationship :
Allergies [__] Food [__] Meds/ Other
Admitting Vital Sign Temp Pulse Respiration B/ P Weight/ Height

HEALTH HISTORY
Current Medication Last Dose Cardiac Medication Last Dose
1. .......................................... ................................ ......................................................... ............................
2. .......................................... ........................ ......................................... ............................
3. ........................................... ………………… ………………………………… ............................

PAST MEDICAL & SURGICAL HISTORY Complete By Date

USEFUL EXPRESSION

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Here are several useful expression/questionnaires that might be asked to the patient or patient’s family
to fill in Admission Form
 Complete Name/ Surname  Age (Date of Birth/ Place of Birth)
- What is your complete name? - Where/ when were you born?
- What’s your surname? - Your date of birth, please?
- How do you spell it?  Occupation
 First Name/ Family Name - What’s your occupation?
- What is your first name? - What’s your father occupation?
- What is your family name?  Address & Telephone No.
 ID No. - Where’s your address?
- May I know your ID number? - Where do you live?
- May I have your ID number? - Your phone number, please?
- May I borrow your ID card?  Next of Kin
 Marital Status - Who’s your nearest relative?
- Are you married? - Who’s your next of kin?
- Are you single? - Is there any contact person in emergency
 Religion case/ situation?
- What’s your religion?
Note: In some states, it’s not appropriate to ask this question. It’s necessary to follow the custom

EXERCISE
Now, fill the admission form based on the conversation below!
Mr. Smith : Excuse me, is this emergency room?
Nurse : Yes, this is emergency room.
S: Well I’m Smith Johnson, I got information that my daughter just got an accident and she was sent to
this hospital.
N : Let me check the list first, Sir and what is your daughter name?
S: Her name is Jane Johnson.
N : That’s right Mr. Smith, would you come in and have a seat, please!
S: Thanks a lot, Nurse!
N : Well, Mr. Smith, we have to fill in an admission form first.
S: All right, Nurse!
N : Good, now your daughter complete name is Jane Johnson, can you spell her first name?
S: J-A-N-E and Her last name is J-O-H-N-S-O-N
N : What is her religion?
S: Islam, she is a Moslem.
N : Is she married?
S: No, she is not.
N : And what is she?
S: She is a student.
N : Then when and where was she born?
S: She was born in Sidney on June 13th 2003.

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N : Now, where does she live?
S: She lives with us at Cadbury Street No.01. West Rock, Canada.
N : Do you have phone number, Sir?
S: Yes, sure, my phone number is 0765-84995231
N : It says here ‘Name and Address of Next Kin’ who is her nearest relation in this town that we can
contact in emergency situation?
S : Me and my wife, you can contact me or her if there is something about my daughter
N : Do you live at the same address, Sir?
S: Yes, you right.
N : Okay, is she allergic about something, such as food or drug, Sir?
S: Yes, my daughter has an allergic to penicillin and shrimp.
N : Has she ever suffered from any disease before?
S: Yes she has, she ever has suffered a pharingitis for 4 days.
N : Did you bring her medicine from previous doctor, Mr. Smith?
S: Yes.
N : May I see those medicines, Sir?
S: Here they are (Amoxil 3x500mgs, FG Throches 2x1 tab, Panadol 3x500mgs)
N : Thanks and when did she take these medicines?
S: This morning, Nurse?
N : What about cardiac medicines, did she have it, Sir?
S: No, she hasn’t it.
N : And now, last question, do you know her body weight and height, Sir?
S: If I’m not mistaken, her weight is 45 kg & height 165 cm
N : All right Mr. Smith, I’ll record that. Well I think is enough for the data, if you would like to wait here
for a moment, I will call Dr. Scoot who treat your daughter, to explain you about her condition.
S: Thanks a lot Nurse.
N : No Problem.

13. NURSING DOCUMENTATION

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 The Need for Good Records: Anything that makes reference to a patient, such as a care
plan or diary, can be used as evidence in a law court. Care plans and diaries are used, for
example, when investigating complaints of medical negligence or professional misconduct

Medical form and documentation are not standardized; they vary between hospital and even
between departments in the same hospital. Sometimes “Nursing Instructions” are called “Nursing
Interventions”; sometimes “Eating and Drinking” is called “Food and Fluid Intake”, sometimes “Daily
Living” is called “Work and Play” and sometimes “Aims and Objectives” are called “Discharge Goals”,
“Intended Goals”, and so, on.
Things like Patient Care Plans are usually hand-written, not typed, and usually written quickly
by people in a hurry in short note form- not full sentences. Notes are not complete and “good” English;
they are full abbreviations, arrows crossing the paper here and there, slashes, asterisks, stars, dots,
underlining, etc. sometimes it is difficult to understand another person’s notes – hard enough in your
own language – extra difficult in a language not your own. Sometimes medical abbreviations differ
according to the field of healthcare. For example, POP is “Plaster of Paris in Orthopedics” and
“Posterior Occipital Position” in Midwifery

TIPS ON WRITING NURSING REPORT/ NURSING DOCUMENTATION:

 Ensure the statements are factual and recorded in consecutive order, as
they happen. Only record what you, as the nurse, see, hear, or do.
 Do not use jargon, meaningless phrases, or personal opinions (e.g., “the
patient's vision appears blurred” or “the patient's vision appears to be
improving”). If you want to make a comment about changes in the patient's
vision, check the visual acuity and record it.
 Do not use an abbreviation unless you are sure that it is commonly
understood and in general use. For example, BP and VA are in general use
and would be safe to use on records when commenting on blood pressure
and visual acuity, respectively.
 Do not speculate, make offensive statements, or use humor about the
patient. Patients have the right to see their records!
 If you make an error, cross it out with one clear line through it, and sign. Do
not use sticky labels or correction fluid.
 Write legibly and in clear, short sentences.
 Remember, some information you have been given by the patient may be
confidential. Think carefully and decide whether it is necessary to record it
in writing where anyone may be able to read it; all members of the eye care
team, and also the patient and relatives, have a right to access nursing
records.

NOW READ THE SAMPLE OF NURSING DOCUMENTATION RECORD AS FOLLOWS!

Morning Nursing Note Afternon & Read morning report.

D3 Keperawatan – Universitas Bhakti Kencana- PSDKU Garut Page 11

Routine Evening Routine
7.00 a.m. Take over from night shift to morning shift nurses and 4.15 p.m. Patient tea and extra Ponstan 500 mgs given
do patient’s round 4.30 p.m. Patient try to ambulate
7.30 a.m. Prepare patient for breakfast 5.15 p.m. Apply urine catheter, urine (+), blood (-)
8.00 a.m. Collect used dishes and return to ward kitchen for Pain lower abdomen (-)
washing 6.30 p.m Patient’s family visit the patient.
9.15 a.m. Toilet round 7.00 p.m. Prepare patient for dinner. Patients eats a lot.
9.30 a.m. Take vital sign BP.120/90;P.88bpm;Rr.20x/m;T.37.80C 7.15 p.m. Collect plate and cup and return to ward
10.00 a.m. Dr Frank does round with nurse in charge kitchen for washing
Order> Change dressing twice a day 8.00 p.m. Treatment to be given as prescribed
> Give high calorie & high protein diet 8.15 p.m. Control all condition of the patients
> Collect urine for 24 hours 8.30 p.m. Complete intake and output charts
> Amoxicillin 3 x 500 mg 8.45 p.m. Patients settled for night
> Ponstan 4 x 500 mg 9.00 p.m. Make afternoon report. Take over the ward
> Bring the patient to X-rays Dept. from afternoon to night nurses and does
10.30 a.m. Bring him to X-rays room patient’s round
11.00 a.m. Patient returned from X-rays Dept, X-rays film (+)
Milk drinks and meals given to the patient Night
Read afternoon report
11.15 a.m. Collect plate and cup and return to ward kitchen for Routine
washing 9.00 p.m. Take over from afternoon shift nurses to night
11.30 a.m. Change dressing. The wound looks wet, bad odor. shift nurses and does patient’s round.
It’s covered by sterile and clean gauze. General condition of patient is stable, patient
11.45 a.m. Mr. Jack complains pain on the leg and lower is wathing TV with family.
abdomen. 9.30 p.m. Serve drinks
Doing examination on her abdomen, distended on 10.00 p.m. Light out
lower abdomen and no void for 2 days. 10.30 p.m. Prepare all medications for morning therapy
12.00 a.m. Report to DR. Frank about Ms. Jane complained Prepare for early morning routine
Order> Giving extra Pethidine 50 mgs 11.00 p.m. All bedpans and urinals are washed and
> Applying urine catheter boiled
> Observation for blood in urine
NURSING DAILY PROGRESS 12.00REPORT
m.n. Control all condition of patients. Patient are
> call him back within 30 minutes
12.15 a.m. DATE
Inject Pethidine 50 mgs REPORT INCLUDING TREATMENT sleeping well. SIGN
1.00 a.m. Mr. Jack complains pain in her leg.
1.00 p.m. Sept 7 patients for lunch. Patient eats little, no
Prepare Extra Ponstan 500 mgs is given
02.00appetite.
p.m. Admitted at 2 p.m. Suspected fracture leg2.00 in a.m.
a road traffic
Control condition of Mr.Carol
Jack. He is sleeping
2.00 p.m. Treatment given as order/ as prescribed. well.also
accident at 9 a.m. today, lacerations of face and hands
2.30 p.m. Make patient comfortable for afternoon rest. 4.30 a.m. Light on
present.
Make afternoon Fullyover
duty. Take conciousness
of ward from morning 5.30 a.m. Partial morning bed bath
02.30shift
p.m. Cleanshift
to afternoon thenurses
wound andwith
doesH 2 O2round.
ward and covered by sterile gauze.
Change dressing. Wound Marylooks dry.
03.00 p.m. I.V.I. Lactate Ringer in progress Bed making and make comfortable position
Afternon & Evening
Given A.T.S.Read&morning
Pethidine
report.50 mgs I.M.I. 6.30 a.m. Patient try to ambulate
Routine 7.00 a.m. Prepare patient for breakfast. Patients eats a
2.00 p.m.04.00Take
p.m.over Checked
of ward fromvital sign. T.to38.5 C;P.100
shift bpm;Rr.20x/m; BP.120/90.
0
morning shift afternoon lot.
nurses andPatient pale
does ward andGeneral
round. feel sweaty
conditionand
of frightened, reassurance
7.15 a.m.
given.
Collect plate and cup and return to ward
05.00 p.m. Took to X-rays for left leg, film(+) fracture at tibia andkitchen
patient is stable, patient is sleeping soundly. fibulafor washing Shanty
3.00 p.m.05.30Take vital sign BP.120/80;P.88
p.m. Called Dr. Frank. bpm;Rr.24x/m;T.37.5 0
C 7.30 a.m. Treatment to be given as prescribed
4.00 p.m. Evening complete bed bath 7.45 a.m. Complete intake and output charts
Order:
Dressing renewed. Wound is still wet. 8.00 a.m. Make night report. Take over the ward from
- pain
Patient still has Prepare for operation,
on the leg night to morning shift nurses and do patient’s
Bed making and - make
takepatient
bloodcomfortable
sample, position. round
- sign for a consent form.
06.00 p.m. Took blood sample for X-match & blood group, CBC, BSR. Roza
Ask the parent to send donors to theater at 9 a.m.
08.00 p.m. Ms. Jane parents visited and ask a sign consent form (+). They
will send donors
D3 Keperawatan – Universitas to theater.PSDKU
Bhakti Kencana- Last vital
Garutsign T.36.50C;P.80 bpm;Rr Page 12
16x/m;BP 120/70

Family Name First Name Ward Bed

Johnson Jane Jasmine 2
EXERCISE:
Answer the questions based on ‘Nursing Daily Report” to check your comprehension!
1. Who is the complete name of the patient?
2. What happen to the patient when she is admitted to hospital?
3. What’s nurse do at 4.00 p.m. and why she’s doing it?
4. What is Dr. Frank’s order to nurse the nurse?
5. At what time should the patient’s parent send donors to theater?

14. PRESENTING JOURNAL

Journal articles have long been an essential part of the nursing profession. Online or in print, these
articles are a vital way for nurses to share experiences and expertise with others in the profession.
Nurses should familiarize themselves with the process of creating a journal-worthy article before writing.

Writing a nursing journal article isn’t as simple as putting ideas on a piece of paper and sending it off to
a publication. There are several steps nursing professionals can take to improve their chances of
getting published.

1. Draw on Your Expertise

When writing an article for a nursing journal, “write what you know” is critical. Journals allow nursing
professionals to share their expert knowledge on a subject, which could lead others to develop new
strategies, possibly resulting in the more efficient or effective delivery of health care. It’s important to
make sure that the article avoids plagiarism and adds a unique perspective to what exists in other
journals. To this end, professionals can read up on various nursing journals to become familiar with
current health care theories and philosophies.

2. Do Your Research
Extensive research is the backbone of any professional journal article. The article must contain a
detailed description of the methodology, such as the test setup and equipment used; carefully
curated analysis; accurately represented results; and a logical, well-constructed discussion that
presents the article’s hypothesis in a neutral tone.

3. Become Familiar with Nursing Journals

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 Before writers submit an article to a nursing journal, it’s important that they become familiar with the
types of articles that particular journal tends to publish. Some journals focus on a specific health
care topic.

4. Choose an Article Type

Authors can explore several kinds of journal articles. Again, an article can focus on original research
conducted to prove a hypothesis or test the parameters of a given process or procedure. It can also
be a review of an existing piece of care-related literature. Each of these article types requires
thorough research and evidence to support any proposed theories.

5. Make a Difference in Health Care

Publishing articles in nursing journals can give nurses a modest extra income and another way to
demonstrate their competency to potential employers. Publication can also help nurses’ impact care.
Articles that share carefully researched data and uncover new insights can prompt readers to
rethink their approaches to health care, possibly leading to higher-quality care and improved patient
outcomes.

Taken from https://online.regiscollege.edu/blog/tips-for-writing-nursing-journal-articles/

Here are the 10 Best Publications for Nurses
1) American Nurse Today.
2) Nursing Made Incredibly Easy.
3) The American Nurse.
4) NursingTimes.net.
5) The Open Nursing Journal.
6) International Journal of Nursing.
7) Applied Nursing Research.
8) Clinical Simulation in Nursing.
9) Nursing Education Perspectives.
10) Journal of Advanced Nursing.
(Source https://rnnetwork.com/blog/10-best-publications-for-nurses/)

Now, find a journal that attract your interest from the best publication journal of nurses above, read and
comprehend your chosen journal, write the abstract of the journal then presenting it to class!

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