Lampiran 1 Naskah Role Play

ROLE PLAY TIMBANG TERIMA PASIEN

DI RUANG BEDAH EDELWEIS RSUD Dr. SOETOMO SURABAYA
1. Hari/ Tanggal : Jumat, 8 Mei 2020
Date : Friday, May, 8th 2020
2. Waktu : 14.00 WIB
Time : 14.00 o’clock
3. Tempat : Nurse station
Place : Nurse station
4. Metode : Diskusi
Method : Disscussion
5. Pemeran
Cast
a. Kepala Ruangan : Adilla Kusuma D, S.Kep
Nurse Unit Manager (NUM) : Adilla Kusuma D, S.Kep
b. Perawat Primer Pagi : Annisa P, S.Kep
Perawat Associate Pagi : Ayu Rahma W, S.Kep
Morning Primary Nurse : Annisa P, S.Kep
Morning Associate Nurse : Ayu Rahma W, S.Kep
c. Perawat Primer Siang : Fara Anggita R, S.Kep
Perawat Associate Siang : Rifki Fauzi M, S.Kep
Noon Primary Nurse : Fara Anggita R, S.Kep
Noon Associate Nurse : Rifki Fauzi M, S.Kep
d. Narator : Nanda Elanti Putri, S.Kep
6. Pembimbing Pendidikan :
1) Dr. Rizky Fitryasari., S.Kep., Ns., M.Kep.
2) Dr. Mira Triharini, S.Kp. Ns., M.Kep.
Pembimbing Klinik :
1) Nina Asminatin, S.ST
7. Persiapan
Preparation
a. Kedua kelompok yang bertugas dipersilahkan mempersiapkan diri (shift jaga)
Both of groups are allowed to prepare themselves (morning shift and noon shift)
b. Rekam medis
Medical record
c. Buku Laporan
 Report book
d. Teks doa, 6 sasaran keselamatan pasien, dan teks 5 momen cuci tangan
Prayer text, patient safety goals, and five moment of hand washing text

Session I di Nurse Station

Session I in the Nurse Station
Di ruang Bedah E pukul 14.00 WIB, akan dilakukan operan di Nurse Station dari
perawat shift pagi kepada perawat shift siang yang dihadiri oleh kepala ruangan (KARU),
Perawat Primer (PP), dan Perawat Associate (PA).

In Edelweis room at 02.00 PM, there will be a handover at Nurse Station from morning shift to
noon shift attended by nurse manager, primary nurse, and associate nurse.

KARU (Ners Adilla) : Selamat siang semuanya (Duduk) Apakah semua yang dinas pagi dan
dinas siang sudah berkumpul semuanya ?
Good afternoon everyone (Sit down) are the morning and noon shift
already gathered yet?

Ners : Selamat siang! Sudah semua.

Good afternoon. Yes of course nurse

KARU (Ners Adilla) : Assalamualaikum Wr.Wb. Selamat siang rekan-rekan, salam sejahtera
bagi kita semua, hari ini Jumat, 8 Mei 2020 sebelum pergantian dinas
akan dilakukan operan terlebih dahulu antara perawat yang shift pagi
dengan perawat yang shift siang hari ini. Sebelum kita memulai operan,
marilah kita berdo’a terlebih dahulu menurut agama dan kepercayaan
masing-masing, semoga diberi kelancaran dan bisa bermanfaat bagi
pasien. Kepada Perawat Asossiate siang, Ners Rifki untuk membaca
do’a.
Assalamualaikum Wr.Wb. Good afternoon everyone, best wishes to
all of us, today May 8th 2020 before we switch the shift, first we will
doing handover between morning shift and noon shift. Before we start
our handover, let’s pray according to own beliefs, hopefully what we
have fluent and what we will do is beneficial to the patient. Toward
Noon Asossiate Ners, Ners Rifki please leads us to pray.

PA Siang (Ners Rifki) : Marilah kita berdoa. Berdoa dimulai. Berdoa selesai.
Let’s pray. Pray begin. enough. Aamiin
KARU (Ners Adilla) : Baik, Terimakasih Ners Rifki. Selanjutnya perlu dibacakan kembali 6
indikator sasaran keselamatan pasien dan juga 5 momen cuci tangan yang
benar, kepada PA pagi Ners Ayu dipersilahkan.
Well, Thank you Ners Rifki, Next Ners Ayu please read the 6 indicators of
international patient's safety goals and 5 right moments of hand hygiene.

PA Pagi (Ners Ayu) : Sasaran Keselamatan Pasien, (1) Ketepatan identifikasi pasien, (2)
Meningkatkan komunikasi efektif, (3) Peningkatan kewaspadaan obat-
obatan risiko tinggi, (4) Kepastian benar lokasi, benar prosedur, benar
pasien operasi, (5) Mengurangi risiko infeksi nosokomial, (6)
mengurangi risiko pasien jatuh.
International Patient Safety Goals, (1) Identify patients correctly, (2)
Improve effective communication, (3) Improve the safety of high-alert
medications, (4) Ensure correct site, correct procedure, correct patient
surgery, (5) Reduce the risk of health care associated infections, (6)
Reduce the risk of patient harm resulting from falls.

PA Pagi (Ners Ayu) : 5 moment cuci tangan, (1) Sebelum menyentuh pasien, (2) Sebelum
melakukan tindakan aseptik, (3) Setelah menyentuh pasien, (4) Setelah
terpapar cairan tubuh pasien, (5) Setelah bersentuhan dengan benda-benda
di sekitar pasien.
Five moment of hand hygiene. (1) Before contact to patient (2) Before an
aseptic task (3) After contact with patient (4) After body fluid exposure risk
(5) After contact with patient surroundings

KARU (Ners Adilla) : Terima kasih Ners Ayu. Untuk PP pada shift pagi tadi ada Ners Annisa
dan di dampingi oleh PA Ners Ayu, Sedangkan untuk PP shift siang ada
Ners Fara, dibantu dengan PA Ners Rifki. Sebelum melanjutkan timbang
terima, mungkin dari perawat dinas pagi ada yang ingin disampaikan
terkait kendala atau masalah saat tadi dinas pagi ?
Thankyou Ners Ayu. This morning, Nurse Annisa as PN accompanied by
Nurse Ayu as AN. While for PN in this afternoon is Nurse Fara and
Nurse Rifki as AN. Before we continue this handover, are there any
problem want to inform from morning shift ?

PP Pagi dan PA Pagi : Tidak ada nurse

Nothing nurse

KARU (Ners Adilla) : Silahkan kepada PP dinas pagi Ners Annisa untuk menyampaikan
keadaan dan perkembangan pasien selama bertugas kepada PP yang akan
berdinas saat ini (siang).
 Please PN morning shift Ners Annisa give the report of patient condition
and patient progress to the noon shift.

PP (Ners Annisa) : Selamat siang semuanya, terima kasih atas waktunya.

Good afternoon everyone, thank you for your time.
Sebelum kami menyampaikan keadaan pasien, saya akan menyampaikan
terkait aspek umum : M1-M5 terlebih dahulu.
Before we give report of patient condition and progress, I will report about
general aspects related M1-M5
M1 (Man) : Jumlah perawat shift pagi ada .. orang, mahasiswa ... orang,
Pramu bakti ada ... orang, gizi ...orang, farmasi ....Orang. Tidak ada yang
izin masuk semua. Semua sudah menjalankan tugas masing-masing dengan
baik. Jumlah pasien … dengan ketergantungan parsial …, minimal …,
total care …. Jumlah BOR … %.
M1 (Man) : There are ... morning shift Nurses, ...Nursing student,...
Transporter, ... Pharmacist, and... Nutritionist. Everyone was present and
have carried out their duties well. There are...Patient with ...partial
care, ...... minimal care patient, and ...... total care patient. Total BOR …%
M2 (Material) : Jumlah bed ... , Kelas satu.. terisi.., kelas dua.. terisi..,
kelas tiga terisi..., O2 sentral sejumlah .., tabung O2 di ruangan … ,
tensimeter…stetoskop…, saturasi oksigen… nebulizer.. suction.., infus
pump.., kursi roda…, APAR.., set rawat luka… semua dalam keadaan baik.
There are … bed, Firs class filled… empty…, Second class filled…
empty…, Third Class filled…empty…, there are…central O2,....O2 tube in
room, …tensi-meter, …stetoscope,…Oxygen saturation, ….Nebulizer, …
Suction, …infusion pump,…wheel chair, …Fire Extinguisher, … set of
wound care and all instrument are in good condition.
M3 (Method) : MAKP yang digunakan moduler, dengan pembagian PP
shift pagi ada saya dibantu dengan PA ada Ners Ayu, sedangkan PP shift
siang ada Ners Fara dibantu dengan PA Ners Rifki
The MAKP used is modular, with me as PN accompanied by Nurse Ayu as
AN in morning shift, and PN is Nurse Fara accompanied by Nurse Farhan
as AN in noon shift.
M4 (Money) : Pasien BPJS kelas 1 ada..., BPJS kelas 2 ada.., BPJS kelas 3
ada.., Pasien Umum...
There are... patient first class, ...patient second class, ...patient third class
and...patient on general payment.
M5 (Mutu ) : Jumlah pasien risiko jatuh tinggi ada... orang, pasien
dekubitus..., pasien infeksi luka operasi..., pasien terpasang drain..., pasien
plebitis.. Pasien terpasang infus.., pasien terpasang dower kateter.., Pasien
operasi..., Pasien tunggu acara operasi.. Pasien post operasi...
 There are... patient with high risk fall, ... patient decubitus, ...patient
surgical site infection, ...patient with drain,...patient phlebitis,...patient with
IV line,... Patient dower catheter, ... patient surgery, ... patient waiting for
the surgery,...patient post surgery.

Selanjutnya untuk laporan pasien bed no 1-5

And next report of patient condition and progress bed 1 until 5
Bed SBAR
01 Situation :
Name : Mr. M
Age : 20 years old
Medical Record : 12849832
12 th day of treatment,
Medical Diagnosis : Spondilitis TB vertebral thoracal 12 Frankle B,
Doctore in charge : dr. Mateen,
Nursing Diagnosis : Acute Pain

Background :
 Patient feel back pain now
 Pain in the spine since 2 months ago
 Therapy is taking OAT drugs = ethambutol 250 mg tablets 15
mg / kgBB orally once a day, and rifampicin 300 mg capsules at a
dose of 8-12 mg/kgBB once a day

Assessment :
 Vital signs : Pulse =  80x/menit, Temperature = 36,8OC, blood
presure = 130/70 mmHg, RR =20 x/menit
 Pain Monitoring
P = Pain arises when the patient tilts or moves
Q= dull pain
R= backbone
S= 2
 T = pain felt disappear
 Lab Result this morning
a) HB = 11,2 (normal 13,0-16,0)
b) WBC = 13,520 (normal 3,37-10)
c) Albumin = 38 (normal 37-52)
d) Na/K = 140/3,4 (normal 135-145/3,5-5,0)
e) BUN = 6 (normal 10-20)
 f) HbSAg= NR (non reactif)
g) HIV = NR (non reactif)

Recommendation :
 Pain Monitoring
 Position the patient as comfortable as possible = supine
 Observe vital sign
 Provide a comfortable environment for patients by closing the
curtains so he can rest
 Encourage the patient to wear a TLSO spinal brace to reduse pain
and support his back
 Debridement surgery plan + posterior stabilization

02 Situation :
Name : Mr. A
Medical Record : 2767843
Medical Diagnosis : Osteosarcoma distal cruris sinistra
1 th day of treatment,
Doctore in charge : dr. Mulan
Nursing Diagnosis : Acute Pain

Background :
New patient from poli today.

Assessment :
Pain scale: 3, patien complain pain in his left knee

Recommendation :
1 Pain scale monitoring
2 Planning to install the IV line
3 Planning to get 1 flash infusion NS 500 ml/24 jam
03 Situation :
Name : An. F
Medical Record : 12867982,
13 th day of treatment,
Medical Diagnosis : Hisprung post sigmoidectomy,
Doctore in charge : dr. Rara
Nursing Diagnosis : Hypertermia

Background :
  Children fasting now
 Getting therapy :
a. Metronidazole 40 mg/ 8 hours Intravena enter at 09.00
b. Ceforoxim 100 mg/ 8 jam hours intravena enter at 09.00
c. Paracetamol 60 mg / 6 jam Intravena enter at 12.00
 TPN 400 ml/ 24 jam, expired hour : 14.00 wib
 Infusion RL 500 ml/ 24 jam enter at 11.00

Assessment :
The last temperature monitoring at 13.30 result 38 oC

Recommendation :
 Wait for the lab result : Complete blood, albumin and serum
electrolytes if abnormal reports to the doctor
 Monitor pews every 4 hours
 Monitor body temperature every 1 hours
 Allow the family to keep compressing if the child is still fever.
04 Situation :
Name : Ny. D
Medical Record : 375
4th day of treatment, First day post operation
Medical diagnosis : Small bowel obstruction ec. Hernia Obstruction post
operation laparotomy
Doctor in Charge : dr. Vicky
Nursing Diagnosis : Acute Pain

Background :
-Patient has installed dower catheter and epidural,
-Patient post operation laparotomy
-Getting medication :
-Metoclopramide 10 mg/8 hours intravenous enter at 09.00,
-Ceftriaxone 1 gr/12 hours intravenous enter at 09.00,
-Metamizole 1 gr/8 hours intravenous enter at 09.00

Assessment :
Pain scale 2, pain felt in the abdomen, pain felt disappear,

Recommendation :
Now loading aminofluid 500 ml/24 hours, if its round out changes with
tutofusin 1500 ml/24 hours.
 Monitoring EWS,
Pain scale Monitoring
05 Situation :
Name : Mr. E
Medical Record : 12494374
2th day of treatment,
Medical diagnosis : Close Fracture Intertrochanter Femur Dextra
Doctor in Charge : dr. Pras
Nursing Diagnosis : Acute Pain

Background :
Client falls in the bathroom after performing ablution with the right hip
position. He feels pain in the right thigh. Now he says his right leg feels
pain and cannot moved

Getting medication :
- Inj metamizol 1 gr IV 3x/24jam
- KSR 2 tablet peroral 3x/24jam
- Candersatain peroral 2x/24jam
- Infus NaCl 0,9% 500cc/24jam

Assessment :
P: femur trauma (fall in the bathroom)
Q: Like being hit by a heavy project
R: upper right thigh
S: 5
T: continuous pain

Recommendation
1. Pain scale monitoring
2. Giving santagesic drugs 1gr IV, KSR 2 tablets/oral
3. Position the patient as comfortable as possible = supine/bedrest
4. Observe vital sign
5. Provide a comfortable environment for patients by closing the
curtains so he can rest
6. Facilitating clients to make minimal movement

PP (Ners Annisa) : Sekian laporan kondisi dan perkembangan bed 1-bed 5 dari saya, mungkin
ada tambahan dari PA?
 That’s all report of patient condition and progress bed 1 until 5, Is there
anything from PA ?

PA (Ayu) : Oke terima kasih, saya ingin menambahkan untuk pasien An. F bed No 3.
Pasien dilakukan lavemen 2 x sehari, diit Clear water 8x 20 cc dan NGT
sistem buka tutup dengan waktu dibuka 2,5 jam dan ditutup 30 menit.
(Okay, thank you, I want to inform about the patient. F bed No. 3. The
patient should be done the lavement twice a day, with Clear water 8x 20 cc
and an open-close system NGT with an opening time of 30 minutes and 2,5
hours to close)

KARU (Ners Adilla) : Terima kasih rekan-rekan dinas pagi. Mungkin dari teman-teman shift
siang ada yang ingin ditanyakan atau diklarifikasi terkait timbang terima
yang disampaikan.
(Thank you for nurse in the morning shift. Any question or clarification
from the noon shift about this hand over?)
PP shift siang (Ners Fara) : Terima kasih atas kesempatan yang diberikan, saya ingin
menanyakan terkait pasien an.F bed 3 , apakah infus RL tetap
dilanjutkan ? Karena kemarin terakhir di stop.
Thank you for the time, I will ask about Patien No. 3 Name F. for RL
insfusion is still continue ? Because yesterday has stopped.
PP (Ners Anisa) : Iya untuk pasien an. F bed no 3 infus RL nya tetap jalan Nurse, Sesuai
Advis dr. Rara tadi pagi bahwa pasien dapat tambahan cairan RL 500 ml/
24 jam karena pasien saat ini sedang dipuasakan dan tampak dehidrasi.
(Oke this is advice from dr. Rara in this morning that the patient get
additional infusion RL 500 ml/24 hour, because the patient was fasted
and looks like she is dehydrated)
KARU (Ners Adilla) : Apakah ada yang ingin diklarifikasi lagi ?
( are there anything to be clarify again ?)
Ners : Tidak nurse.
( No yet nurse)
KARU (Ners Adilla) : Baik kalau tidak ada yang ingin ditanyakan lagi, Terima kasih kami
sampaikan untuk perawat dinas pagi yang telah menyampaikan kondisi
dari semua pasien saat ini. Selanjutnya PP shift siang dan PP/PA pagi
 mari kita validasi ke pasien. nanti apabila ada hal rahasia yang ingin
dibicarakan kita bisa mendiskusikannya kembali di nurse station.
(Okay, if there are no question, thank you for nurse in morning shift which
has reported patient’s condition and progress, Let's validate to the patient
one by one, and if there are a privacy matter, we can talk about it later in
nurse station.)

Session II Di Ruang Perawatan/Bed Pasien

Perawat pagi dan siang memvalidasi kembali ke pasien, Kepala Ruangan menyampaikan
salam dan PP memperkenalkan perawat yang berjaga di sore hari (Setiap pasien).

Perawat yang melaksanakan timbang terima selanjutnya mengkaji secara penuh terhadap
masalah keperawatan, kebutuhan, dan tindakan yang telah atau belum dilaksanakan. Posisi
timbang terima saat di bed pasien : Karu berada di depan di ikuti dengan PP shift pagi, PA
shift pagi, PP shift siang dan PA shif siang.
Morning primary nurse, morning associate nurse, noon primary nurse, noon associate nurse
validate to patients, The Ners Manager give a greeting and primary nurse introduced a nurse
who will work in noon shift to every patient and family. The nurse who did handover then
assess clearly nursing problems, needs, and the actions that have been or haven’t been
implemented. Position when in patient’s bed, Ners Manager is in front followed by PP
morning shift, PA morning shift, PP noon shift, and PA noon shift.
KARU (Ners Adilla) : Selamat sore bapak/ibu dan adik-adik, siang ini akan dilakukan
operan ya pak bu dari perawat shift pagi ke perawat shift siang.
(Good afternoon everyone, in this afternoon we will doing handover
beetwen nurse whom in morning shift and noon shift).
PP siang (Ners Fara) : Selamat siang bapak/ibu /adik, siang ini akan dilakukan operan ya pak
bu saya Ners Fara dan Ners Rifki yang akan bertugas pada siang ini.
(Good afternoon everyone, this afternoon we will doing handover I’am
nurse Fara and this is nurse Rifki we will be on duty in this afternoon).

Semua perawat yang dinas pagi dan siang menuju ke tempat tidur pasien untuk
melakukan validasi
All nurses in the morning and evening shift go to the patient's bed to do the validation.

PP Pagi (Ners Annisa) : Selamat sore Bu, Ners Fara dan Ners Rifki yang akan menggantikan
saya merawat anak ibu siang ini sampai malam nanti.
 (Good evening Mrs.Y, this is Nurse Fara and Nurse Rifki who will
replace me taking care of your child this afternoon until tonight).
Ny Y : Oalah, iya iya.
Oh okay
PP Pagi (Ners Annisa) : Ners Fara, ini An. M dengan…(menjelaskan kondisi pasien)
(Nurse Fara, this is An.M with….. (explaining the patient’s condition)
PP Siang (Ners Fara): Perkenalkan, saya Ners Fara dan ini Ners Rifki. Kami yang akan merawat
anak ibu dari siang hingga malam nanti menggantikan Ners Annisa dan
Ners Ayu. Bagaimana keadaan anak ibu hari ini?
(Let me introduce myself, I’m nurse Fara and my friend Nurse Rifki. We
will take care of yor child this afternoon until tonight, substitute Nurse
Annisa and Nurse Ayu. How is your child today ?)
Ny Y : Iya terima kasih sebelumnya Bu. Nyeri sudah berkurang setelah minum
obat. Tadi malam tidurnya juga nyenyak. Ia juga menghabiskan menu
makanan pagi dan siang.
(Yes, thankyou before. His Pain has decreased after taking medication.
Last night he slept well. He also finished his breakfast and lunch well.)
PP Siang (Ners Fara) : Nanti kalau Ibu butuh bantuan untuk anak Ibu, silahkan panggil kami ya
Bu.
(If you need help for your child, please call us, Mrs.Y.)
Ny Y : Iyaa. Terimakasih banyak.
(Ok. Thankyou so much.)

Kemudian PP siang melanjutkan mengecek alat-alat invasif di pasien seperti IV line,

kateter, serta mengecek juga cairan infus dan kondisi seluruh pasien.
Then, PN in the noon shift continued checking invasive devices in patients such as IV lines,
catheters. She also checked intravenous fluids and condition of all patients.

Session III di Nurse Station

(After turning away from patients)
KARU (Ners Adilla) : Baiklah mari kembali ke Nurse Station
(Well, let’s go back to Nurse Station)
Semua :Baik Nurse.
(Yes, Nurse)
KARU (Ners Adilla) : Apakah masih ada yang perlu diklarifikasi pada perawat dinas pagi?
(Are there any question or something to be clarified from morning
shift?)
Semua :Tidak ada bu
( Nothing )

KARU (Ners Adilla) : Apabila tidak ada silahkan PP siang untuk menandatangani format
timbang terima dan PP pagi menyerahkan status pasien. (PP dan PA pagi
menyerahkan status pasien ke PP dan PA siang kemudian PP shift
siang mengecek kelengkapan status yang diserahkan). Saya ucapkan
terimakasih pada dinas pagi dan selamat bertugas pada perawat shift siang.
Teman-teman yang dinas pagi semoga selamat sampai rumah, dan yang
dinas siang tetap semangat dan selalu berhati-hati selama tindakan.. Saya
akhiri,
Wassalamualaikum, Wr.Wb.
(Well, if there is nothing to be clafiried, please the noon shift PN sign this
handover-form, and for morning shift PN please give the patient status to
the noon shift nurse in charge. (PN and PA morning shift give patient
status to PN and AN noon shift, then PN and AN noon shift checks for
complete patient status).
Thank you for the morning shift Nurse and go home safely. For the noon
shift nurse in charge, do your best and always be careful while doing your
duty. I’ll end this handover, Wassalamualaikum wr.wb.)
Semua : Waalaikumsalam, wr Wb