ENGLISH FOR NURSING

Patient Handover, Skill Of Nursing, Collaboration, Health Education,

And Discharge Planning

By

First group

1. Hani oktavia rahayu (1411311006)

2. Rani afdila pratiwi (1411311016)
3. Adila yuliani (1411311026)
4. Sandra merza aranti (1411312005)
5. Tuti anggraini (1411312011)
6. Rifka Aulia Rahmi (1411312014)
7. Jerry kurnia sandy (1411311027)

NURSING FACULTY

ANDALAS UNIVERSITY

PADANG

2016
Scenario 1: Surgery following trauma

Micheal is 38 years-old male who is on a surgical ward 48 hours after surgery

for a fractured right femur and debridement of facial abrasions following a
motorcycle accident. Chief concern : severe, sharp pain, on movement around
incision in right leg NRS 9/10, at rest 2/10, constant burning pain in his right wrist
NRS 7/10 on movement, facial and right torso contusions/ abrasions painful when
moves NRS 4/ 10, some postoperative facial pain but says it is not as bothersome
NRS 3/10. History of present illness, motorcycle accident 48 hours ago, driving
under the influence of alcohol. PACU pain control inadequate NRS 10/10 , PCA –
morphine initiated to achieve level of NRS 4-6/ 10.

Physical exam: BP 130/82, P 88 Regule, R 28, T 38,2. Height 188 cm, weight
118 kg, small lump over clavicle fracture, small incision scar at L-5 incision over
surgical site healing well with slight redness. medication: oxycodone SR 100 mg
PO q8h; Acetaminophen 500 mg PO q6h ATC; Gabapentin 200 mg PO q8h;
oxycodone IR 40 mg PO q4h PRN (3 doses in the past 24 h ); ibuprofen 400 mg PO
q6h ATC; lorazepam (ativan) 1 mg q8h PRN sl (anxiety) or oxazepam (serax ) 30
mg PO hs PRN (Sleep).

Role Play

a. The Process Of Hand Over Verbal

Nurse surgery room : Good Afternoon nurse ! I am nurse reni at the surgery room.

Nurse surgical ward : Afternoon nurse reni, Iam nurse sandra part of care of surgical
ward. Can I help you ?

Nurse surgery room : Yes Nurse, Iwould like to inform that a patient, his name’s micheal
in the surgery room has been finished surgery process, and he will be
move to unit care of surgical ward. Now, The patient condition is
surgery on righ femur due fracture and debridement of facial abrasions.
The nursing problems of the patient are acute pain related factor
physical injury agent and have obest.

Nurse surgical ward : yes, and then how is condition of patient now ?
Nurse surgery room : The Patient undergo pain when moving around incision on the
right leg with rating scale 9, at rest 2. Then burning pain in his right
wrist 7 when moving, and pain in facial when moves is 4. The
History of present ilness are motorcycle accident 48 hours ago
because he was driving influanced of alcohol. There are small incision
at L- 5.

The medication that morphine to reduce pain and it reduce the

pain scale of 10 – 4 .Given been are medication: oxycodone SR 100
mg PO q8h; Acetaminophen 500 mg PO q6h ATC; Gabapentin 200
mg PO q8h; oxycodone IR 40 mg PO q4h PRN (3 doses in the past 24
h ); ibuprofen 400 mg PO q6h ATC; lorazepam (ativan) 1 mg q8h PRN
sl (anxiety) or oxazepam (serax ) 30 mg PO hs PRN (Sleep).

Nurse surgical ward : ok , How about the physical examination ?

Nurse surgery room : The BP 130 /82 mmhg , P 88 x Reguler , R 28, T 38,2 . his Weight
is 118 kg, and tall is 188 cm.

Nurse surgical ward : So, have you recommendation for me ?

Nurse surgery room : I have suggest for you, such as

 Monitoring acute pain of patient

 Monitoring in part right leg, right wrist, facial post surgical
and part of other body
 Setting diet of patient
 Preventing risk of infection post –op
 After third day, change dressing post-op
 Monitoring effect of medication

Nurse surgical ward : ok nurse, thanks for information , what time the patient will be
move to unit care of surgical room ?

Nurse surgery room : 20 minutes latter nurse !

Nurse surgical ward : ok nurse. Patient comming on a bed no 30

Nurse surgary room : ok I will be back 20 minutes letter move the patient.

To be used at shift change and during in – house patient transfers between departemen
 Form SBAR Communication in Hospital X

Patient name : Date / Time of Admission :

Room Number :
Reporter nurse : (name, position ) Receive report : (name, position )
 b. Skill Of Nursing

Nurse : Good morning Mr

Patient : Good morning nurse

Nurse : I’m nurse sandra can I know your name?

Patient : Of course nurse. My name is Mr jerry

Nurse : Oke Mr jerry, I am your nurse from intervention 07.00 am – 02.00 pm

Patient : Oke nurse

Nurse : Oke Mr . How are you today?

Patient : I feel pain on my surgical wound and i still have difficulty while moving

Nurse : hmm, I see the pain occor on your wound is normal because your surgical just
finished 3 days ago

Patient : Hmm I see nurse

Nurse : That’s good Mr. Now i would like to change The bandager to avoid the infection and
you can be way more comfortable can we start if now Mr Jerry ?

Patients : Of course nurse

Nurse : Oke this action is will be hold around15 minutes

Phase of work
Nurse : first we wash our hand, after that use a steril handscoond. Second open the old
bandage Third,we clean the wound with Nacl dipped the gauze and driena with dry
gauze. Forth closed the wound with sterile gauze and tied with tape all the former
bandage discharged to the place of medical waste.

Termination phase
Nurse : Oke Mr , after this change how do you feel right now Mr jerry ?

Patients: I fell way much better

Nurse : Oke Mr . I think the intervention is done. Do you have question Mr ?

Patient : Thankyou nurse. Yes please

 c. Collaboration

Situation : nurses and physiotherapists are collaborating in room A to provide treatment to

clients Michael exercise therapy. In the room.

Nurse : Good afternoon

Physiotherapist : good afternoon nurse. Is there anything I can help you?

Nurse : I want to know your opinion about the therapy for the patient. We
will do a collaboration in providing care to patients. How is Mom?

Physiotherapist : Okay nurse. How about the condition of the patient nurse?

Nurse : His name is michael, he is 38 years old. He had an accident and got a
fracture on the right femur.

Physiotherapist : how’s the diagnosis nurse?

Nurse : The first diagnosis is acute pain associated with movement of the
bone fragments.

Physiotherapist : Have you ever gave the intervention to patients nurse ?

Nurse : oke. I've also been collaborated with doctors in the administration of
drugs such as lowering the patient's pain scale.

Physiotherapist : Okay nurse. So it’s means the patient has less pain scale now ?

Nurse : yes . the second diagnosis is the physical immobilization associated

with neuromuscular damage circuitry. Now, I would like to ask what is
your opinion about the therapy for the patient ?

Physiotherapist : Okay. I think based on the data that has been mentioned earlier we
should do therapy active and passive motion exercises.

Nurse : why you choose this therapies?

Physiotherapist : for patient’s fracture he should maintain a functional position of the

body. The Treatment of active and passive motion exercises aimed at
improving blood circulation musculoskeletal, maintain range of
motion, maintaining muscle tone, prevent contractures and prevent the
reabsorption of calcium due to immobilization.

Nurse : oh i see , I agree with you. Then how if we directly provide active and
passive motion exercises to patients tomorrow?

Physiotherapy : Okay. what time we will do it nurse ?

Nurse : tomorrow we will do it at 10:00 am in mawar’s room

Physiotherapy : Okay. We also need to evaluate the daily progress of the patient's
progress

The next day at 10.00 am in mawar’s room nurses collaborate with physiotherapists to
provide measures of active and passive motion exercises to the patients.

d. Health Education,

During in the patient room, a nurse give health eduction

Nurse : good afternoon Mr

Patient : good afternoon nurse

Nurse : well, my name is Ns. Rani. How do you feel now Mr ?

Patient : I still feel the same way miss nurse

Nurse : do you feel pain on your surgery location?

Patient : yes nurse, I often grimacing during sleep and he can’t sleep well nurse

Nurse : well Mr, I will give an information to you related to your surgery situation. As we
know you just finished your operation follow trauma. This follow trauma is a situation
happened due to your fractur on your femur and to reduced those pain. I will teach
you how to reduce your pain. So you can apply this method when you feel the pain.
This method called deep breathing method.

Patient : oke nurse

Nurse : well, this method it to reduce the pain and it can also make you feel relax, so you
will be able to feel way much better and sleep well. So, when you feel pain on your
surgical location,you have to do is relax and put your hand on you stomach. After
that, take a deep breath from your nose and hold it for about 3-5 second, after that
released the air slowly through your mouth. Now, I will try to demonstrated it. ( the
nurse try to do this method) can you do that?

Patient : ok nurse I can

Nurse : oh good,You can practice it really well. So doesn’t forget to practice it when you
feel pain over your fractur.

Patient : well nurse

Nurse : oke Mr. I think that’s all about the information, I am trying to explain. Any question
so far?

Patient : no nurse

Nurse: oke, now I’ll go back to the nurse station and I’ll be back later to give your medication
Patient : ok nurse

Nurse: exuse me

Patient : yes nurse

e. Discharge Planning

Nurse : Good afternoon sir, the doctor said today you are allowed to go home, but you must
fillout a patient’s discharge

Patient : Yes, nurse

Nurse : Please tell your registration number

Patient : 0110 Nurse

Nurse :Okey, what is your name?

Patient :I’m Michael

Nurse :Where do you live?

Patient : I live at pasar barustreet number 2.

Nurse : Did you come to the hospital onmarch 20th 2016

Patient : yes, nurse

Nurse : In your home, you have to eat healthy foods in order to speed up the healing
process

Patient : yes, nurse

Nurs : For your medicine you have, oxycodone, acetaminophen, qabapetin, ibuprofen,
lorazepam and oxazepam. Oxycodone is use to relieve the pain of moderate to
severe, acetaminophen is used to relieve headaches and fever, qabapetinworks to
anti-seizure, ibuprofen is anti- inflamasi, lorazepam and oxazepam is used to
treat

Patient : yes, nurse

Nurse : Do you understand sir? Any questions?

Patient : No, Nurse

Nurse : At home, you should not do heavy work, but you must a rest.

Patient : yes, nurse

Nurse : for advanced control, you have to control one time per week at this hospital
Patient : yes, Nurse

Nurse : This is the lab result, photos rotgen and your ECG . okey sir we have finished
making the charging sheet repatriation sir. Get well soon

Patient :oke, nurse . thank you for your information

. Control of pain patients 2. Monitoring section surgery on right foot, right hand, and facial
and other 3. Control the patient's diet 4. Prevent the risk of post-surgical infection 5.
Monitoring side effects of treatment Nurse room: ok nurse, thank you for information, at how
many patients will be moved spatial surgical treatment? Nurses ok: 20 minutes nurse. Nurse
room: ok nurse Nurses ok: ok i will come back again 20 minute.