MAKALAH

OLEH :

NAMA : REITYA SIPAHELUT

NPM : 1420117200

KELAS : SIANG (AMBON)

PRODI/SEMESTER : KEPERAWATAN/ V

SEKOLAH TINGGI ILMU KESEHATAN (STIKes)

MALUKU HUSADA

AMBON
FOREWORD

Our praise and gratitude to the presence of God Almighty, for the blessing and grace I
can complete this paper that aims to fulfill the assignment of English courses. I realize there are
many shortcomings and limitations in the making of this paper, so that criticism and suggestions
that are supportive I hope for the perfection of this paper
TABLE OF CONTENTS

FOREWORD
TABLE OF CONTENTS
I. CHAPTER I PRELIMINARI :
a. Background
b. Aim
c. The Benefits
II. CHAPTER II DISSCUSION :
a. Perspective on nursing theory
b. Evolution of nursing theory
c. Explain about patient assessment
d. Explain how giving instruction and expression during the
implementation in nursing
e. Find picture of surface anatomy regions ( anterior view of female )
III. CHAPTER III COVER :
a. Conclusion
IV. REFERENCES
CHAPTER I

PRELIMINARY

A. BACKGROUND
Nursing as an integral part of health care is a form of professional service
based on nursing knowledge. In its development, the science of nursing always follows
the development of other sciences, considering that nursing is an applied science that
always changes with the times.
The nurse's role is very comprehensive in handling clients because the nurse's
role is to meet the client's biological, sociological, psychological, and spiritual needs.
Communication is a very important factor in the nursing process. In fact,
communication is one of the barometers of success and failure of the nursing process. It
is impossible for a nurse to go through the nursing process if he is unable to foster and
establish good communication with patients.

B. AIM

To know :

1. Perspective on nursing theory

2. Evolution of nursing theory
3. Explain about patient assessment
4. Explain how giving instruction and expression during the implementation in nursing
5.Find picture of surface anatomy regions ( anterior view of female )

C. THE BENEFITS

So students can find out how:

1. perspective on nursing theory
2. evolution of nursing theory
3. patient assessment
4. giving instructions and expressions during implementation in nursing
5. surface anatomy (female front view)
CHAPTER II

DISSCUSION

A. Perspective on nursing theory

1. VIRGINIA HENDERSON

In 1929 Henderson became a teaching supervisor at the Strong Memorial

Hospital clinic in Rochester New York. He returned to Teacher’s college in 1930 as a
teacher until 1948. He joined Yale University in 1950 and did much for further
nursing research through this association.
Mulai tahun 1959 hingga 1971, henderson mengepalai Nursing Studies Indeks Project
yang di sponsori Yale. Di tahun 1980 Henderson masih aktif sebagai Research
Associate Emeritus di Yale. Prestasi Henderson dan pengaruhnya dalam profesi
keperawatan telah memberikan lebih dari tujuh gelar doctoral dan Christiane
Reimann Award pertama kali untuknya.
The main concepts of Henderson's theory cover human, nursing, health, and the
environment. According to Henderson, basic human needs consist of 14 components
which are components of care handling. The fourteen needs are as follows: Breathing
normally, Nutrition, Elimination, Body movement and balance, Sleep rest, Dressing,
Personal Hygiene, Safety and Comfort, Communicating, Spiritual needs, Recreational
needs, Work needs, Work needs, Play needs, recreation and study.
In the field of nursing has a unique function to help individuals, both healthy and
sick. As a member of the health team, nurses have an independence function in
handling care based on human needs (14 components above). In the Health Sector as
a quality of life on which a person can function for humanity. Getting health is more
important than treating a disease. To achieve healthy conditions, independence and
interdependence are required. Individuals will gain or maintain health if they have
enough strength, will, and knowledge.
While the Environment needs to consider some of the following relationships:

1. Healthy individuals are able to control their environment, but sick conditions will
inhibit this ability.

2. Nurses must be able to protect patients from mechanical injury.

3. Nurses must have knowledge about environmental safety.

4. Doctors use nurses' observations and assessments as a basis for prescribing.

5. Nurses must minimize the chance of injury through suggestions for building
construction and maintenance.

6. Nurses must know about social habits and religious practices to estimate the
danger.

The focus of nursing on Henderson's theory is clients who have an attachment

to life individually during the life cycle, from the phase of dependency to independence
according to age, circumstances, and environment. The nurse is the client's main helper in
carrying out important activities to maintain and restore the client's health or achieve a
peaceful death. This assistance is provided by nurses due to lack of knowledge of
strength, or client's willingness to carry out the 14 components of basic human needs.

2. DOROTHEA ELIZABETH OREM

The Orem Theory view in the order of nursing services is aimed at the needs
of individuals in carrying out independent nursing actions and regulating their needs.
In the concept of nursing Orem developed three forms of self care theory including:

a. Self Care (self care)

In the theory of self care, Orem argues that self care includes: first,
self care itself is an activity and initiative of the individual and is carried out by the
individual itself in fulfilling and maintaining life, health and well-being. second, self
care agency is an individual's ability to perform self-care, which can be influenced by
age, development, socio-cultural, health and others. third, there are demands or
requests for self-care which are independent actions carried out within a certain time
to care for yourself by using methods and tools in the right course of action. fourth,
the need for self care is an action aimed at providing and caring for oneself that is
universal and is related to the prises of human life and in an effort to maintain bodily
functions, self care that is universal is daily activities (ADL) by grouping into needs
basic human.
b. Self Care Deficit
It is an important part of care in general where all nursing plans are
given when care is needed that can be applied to minors, or needs that exceed
ability and there is an estimate of decreased ability in care and demands for
increasing self care, both in quality and quantity.

c. Nursing System Theory

It is a theory that clearly explains how the patient's self-care needs
are met by the nurse or the patient himself based on Orem which states about the
fulfillment of one's own needs, patient needs and the patient's ability to perform
self-care. In view of the theory of this system Orem provides identification in
nursing service systems including: Wholly Compensatory System, Partially
Compensatory System, and Supportive and Educational System.

The goal of Orem Theory nursing is to treat and help clients achieve total self-care. This
theory is a theory of lack of self-care. Nursing care becomes important when the client is
unable to meet biological, psychological, developmental and social needs.

3. IMOGENE KING

King is an Associate Professor (1961-1966) and Professor (1971-

1980) at Loyola University. Chicago Raja retired in 1990 after previously serving as
Professor, College of Nursing, University of South Florida. An active member of the
District IV, Florida Nurses Association (FNA) (past president of the Florida Nurses
Foundation and FNA Hall of Fame was inaugurated), American Nurses Association
(ANA 1996 Jessie Scott Award and Hall of Fame appointed) and Sigma Theta Tau
International ( STTI 1989 Elizabeth Russell Award Founder and Virginia Henderson
Fellow) and Fellow at the American Academy of Nursing (2005 Life inaugurated
Legend).
King understands the concept model and nursing theory by using an open systems
approach in a constant interaction relationship with the environment, so King put
forward in the interaction concept model.

In achieving interaction, King put forward the concept of his work which includes the
existence of personal systems, interpersonal systems and social systems that are
interconnected with one another. According to King, a personal system is an open
system in which there is a perception, a pattern of growth and development, body
image, space and time of the individual and the environment, then interpersonal
relationships are a relationship between nurses and patients and social relationships
which means that a nurse's interaction and patients in enforcing social systems,
according to the situation. Through this basic system, King sees humans as reactive
individuals, ie reacting to situations, people and objects.
Humans as time-oriented creatures are inseparable from the past and present that can
influence the future and as social creatures humans will live with other people who
will interact with one another.
Based on this, humans have three basic needs, namely: Health information, Disease
prevention, and the need for nurses when sick. So it can be explained that the concept of
human relations according to King consists of components, namely:

 Action, is the initial process of the relationship between two individuals in

behavior, in understanding or recognizing the conditions that exist in nursing with
a picture of the relationship between the nurse and client to carry out the contract
or expected goals.

 Reaction is a form of action that takes place in an action and is a response from
the individual. Interaction is a form of cooperation that affects each other between
nurses and clients manifested in communication.

 Transaction is a condition in which between nurse and client an agreement occurs

in the nursing action plan that will be carried out.

King understands the concept model and nursing theory by using an open
systems approach in a constant interaction relationship with the environment, so King put
forward in the interaction concept model. To utilize communication to help clients
achieve positive adaptation back to the environment. This theoretical framework The
nursing process is defined as a dynamic interpersonal process between nurses, clients and
the health care system. From the main concepts (interactions, perceptions,
communication, transactions, roles, stress, growth and development) derived from the
goal achievement theory.

4. BETTY NEWMAN

The concept model proposed by Betty Neuman is a Health Care System

concept model which is a concept model that examines proposed nursing activities to
discuss stress reduction by increasing flexible or normal self-defense lines as well as
resistance to service targets

In general, the focus of Nueman's concept of nursing models is on responses to

stressors and factors that influence the adaptation process in patients. For that, the
actions taken by nursing are carried out in accordance with Neuman's prevention or
reduction due to stress reactions. These efforts can also be referred to as primary,
secondary, and tertiary.
 Primary prevention can help deal with stressors, prevent the body's reaction
because there are stressors and support coping in patients with constructive.

 Secondary prevention includes various treatments that can reduce stress and
cause stress

 Tertiary prevention can be carried out in routine and regular care against
resistance to further complications of the disease. Recovery efforts are
concerned with health and health care. Complete routine and regular treatment
to overcome further damage or complications from the disease.

The goal of Newman's nursing is to help individuals, families and groups to obtain and
maintain their maximum level of health through certain interventions.
The Neuman model includes intrapersonal, interpersonal and extrapersonal stress. This
theoretical framework is a decrease or adaptation status to stress. Nursing actions include
primary, secondary, or tertiary preventive measures that focus on variables that influence
the client's response to stressors

5. SISTER CALISTA ROY

Roy describes the method of adaptation in nursing. Individuals are

biospicosocial beings as a whole as a whole. Someone said to be healthy if able to
function to meet biological, psychological and social needs. Everyone always uses
coping, both positive and negative, to be able to adapt. A person's ability to adapt is
influenced by three components, namely: Condition factors, situations that are the
main causes of change, beliefs and experience in adapting.

Each individual has a different response to physiological needs, the need for positive
self-concept, the ability to live independently / independence, and the need for ability
through optimal roles and functions to maintain self-integrity.

The position of individuals in the healthy range of pain continues to change, closely
related to the effectiveness of coping that is done to maintain the ability to adapt.

Roy believes there are 2 coping methods, namely: Regulator is a systematic process
of input through nerve, chemical and endocrine pathways. Cagnator which processes
input through cognitive ways such as perception, information process, learning,
decision and emotion. Individuals are biopsychosocial beings as a whole that has a
coping mechanism to be able to adapt to environmental changes.

Individuals always interact constantly or always adapt to changes in the environment.

The environment is all that is around us and influences human development. Healthy
is a state of process in maintaining personal integrity. The role of the nurse is to help
patients adapt to existing changes.
According to Roy, nursing actions are aimed at increasing individual adaptation to
health and disease. The four adaptation models are physiology models: fluid and
electrolytes, circulation and oxygenation, nutrition and elimination, protection,
neurology and endocrine. Self-concept models: self-image, self-ideal, self-morale.
Role function model: the need for integrity. Interdependent model (independence): a
person's relationship with another and a source system that provides help, affection
and attention.

Roy's nursing goals are to identify the type of client's needs, assess the adaptability to
the needs and help the client adapt. Individuals are biopsychosocial adaptive systems in
an environment. Individuals and the environment provide three classes of stimuli-focal
points, residual and contextual. Through two adaptive mechanisms, regulators and
cognators, individuals showing adaptive or ineffective responses require nursing
intervention. This adaptation model is based on physiological, psychological,
sociological, and dependency and independence adaptation models.

6. MARTHA ELIZABETH ROGERS

Roger's Nursing goal is to maintain and improve health, prevent pain, and
treat and rehabilitate diseased and incapable clients with a humanistic approach to
nursing. The theoretical framework of this "whole person" encompasses a life-long
process. Clients constantly change and harmonize with their environment laying the
basics that describe the process of human life. The process of human life is
characterized by wholeness, openness, unidirectionality, patterns and organization,
science, and thought.

7. FAYE GLENN ABDELLAH

The nursing theory developed by Faye Abdellah includes the provision of nursing
care for all humans to meet the physical, emotional, intellectual, social and spiritual
needs of both the client and family. When using this approach, nurses need
knowledge and skills in interpersonal relations, psychology, human growth and
development, communication and sociology, as well as knowledge of basic sciences
and certain nursing skills.

The nurse is the giver of the road in solving problems and also as a decision maker
and formulates a picture of the client's needs individually, which may occur in the
areas of comfort, cleanliness, security, physiological balance, psychological and
social factors, and sociological and community factors.
In that area, Abdellah identified client needs specifically, often known as 21 Abdellah
nursing problems, namely:

 Maintaining good physical hygiene and comfort,

 Maintaining optimal activity, physical exercise, rest and sleep,
 Prevent accidents, injuries or other trauma and prevent the spread of infection,
 Maintain good body mechanics and prevent and improve deformity,
 Facilitate oxygen input throughout the body,
 Maintaining nutrition for all body cells,
 Maintaining elimination,
 Maintaining fluid and electrolyte balance,
 Recognize the body's physiological responses to disease conditions-
pathological, physiological, and compensatory,
 Maintaining regulatory mechanisms and functions,
 Maintaining sensory functions,
 Identifying and accepting positive and negative expressions, feelings and
reactions,
 Identifying and accepting the reciprocal relationship between emotions and
organic diseases.
 Maintaining verbal and nonverbal communication,
 Facilitating the development of productive interpersonal relationships,
 Facilitating progressive personal spiritual goals,
 Generate and / or maintain a therapeutic environment,
 Facilitating self-awareness as individuals who have different physical,
emotional and developmental needs,
 Accept the optimal goals that can be achieved with respect to physical and
emotional limitations,
 Using resources in the community as a source of help in overcoming problems
that arise as a result of disease,
 Understanding the role of social problems as factors that influence the
emergence of a disease.

Abdellah Faye's theory focuses on the goal of nursing to give to individuals, families, and
society. To be a good and understanding nurse, also has a high intelligence ability,
competent and has good skills in providing nursing services. Practical Framework: This
theory covers 21 nursing problems

8. HILDEGARD ELIZABETH PEPLAU

Hildegard E. Peplau, PhD, RN, FAAN, known as "the soul of nursing

mothers," died at the age of 89 on March 17, 1999. The only nurse to serve ANA as
executive director and then as president, he served two terms on the International
Council of Nurses (ICN). In 1997, she received the highest honor of nursing, the
Christiane Reimann Prize, at the ICN Congress which lasted four years. In 1996, the
American Academy of Nursing Peplau was honored as "The Legend of Life", and in
1998, ANA was inducted into the Hall of Fame.
Interpersonal relationships are the main factors in the Peplau nursing model which
consists of 4 main concepts, namely:

 Humans where the individual is seen as an organism that struggles in its own
way to reduce the tension caused by needs.
 Society / environment is a culture and adaptation which is also a factor that
needs to be considered in dealing with life.
 Health is defined as the continuous development of personality and human
processes towards a creative, constructive and productive life.
 Nursing is seen as a meaningful interpersonal process. The interpersonal
process is a good materina force and educational tool for nurses and clients.

In relation to patients, nurses have 6 roles, namely as partners (phatner), resource persons
(resource persons), Educators (teachers), Leadership (leadership), surrogate caregivers,
and counselors (consellors).
The interpersonal process referred to describes the method of energy transformation or
client anxiety by nurses consisting of 4 phases, namely:

o The Orientation Phase, is more focused on helping patients realize the availability
of help and trust in the nurse's ability to play an effective role in giving askep to
the client.
o Identification Phase, Occurs when the nurse facilitates the expression of the
patient's behavior and gives nurses without rejection the nurse's experience allows
the experience of suffering pain as an opportunity to re-orient feelings and
strengthen the positive parts and personality of the patient.
o Exploration Phase, where the patient can feel the value of the relationship
according to his views / perceptions of the situation. This phase is the core.
o Phase Resolution, this resolution enables strengthening the ability to meet their
own needs and channel energy towards realizing potential. The four phases are a
series of developmental processes in which nurses guide patients from a sense of
high dependency into interdependent interactions in the social environment.

The theory of peplau aims to develop nurse interactions with clients with four phases of
the nurse-patient relationship, namely: Orientation, Identification, and Exploitation.
Resolution The framework is Nursing is an important, therapeutic and interpersonal
process. Nursing participates in structuring the health care system to facilitate the natural
conditions of the human tendency to develop interpersonal relationships.
9. FLORENCE NIGHTINGALE

Nightingale made a theory known as modern nursing theory. Nightingale

believes that healthy environmental conditions are important for proper care handling.
The environmental aspect that Nightingale prioritizes in caring for clients is adequate
ventilation for clients. He believes that the continuous availability of fresh air is the
main principle in maintenance.

Therefore, every nurse must keep the air that the client has to breathe clean, as clean
as the outside air without having to make it cold. Another component that is no less
important in client care is sunlight. Nightingale believes that sunlight can be of great
benefit to the client's health. Therefore, nurses also need to take clients out for
sunlight as long as there are no contraindications.

The focus of client care according to Nightingale is on cleanliness. He argues, the

client's health condition is strongly influenced by the level of cleanliness, both client
hygiene, nurses and the environment. Nightingale defines health as a prosperous
condition and is able to utilize every power possessed to the maximum extent, while
disease is a process of improvement carried out by the body to free itself from the
disturbances experienced so that individuals can return to health. To achieve health
conditions, nurses must use their reasoning, accompanied by perseverance and
observation.

He calls this health care and distinguishes it from proper nursing, which means caring
for a sick client so he can survive or at least get better until the time of his death.
Nigtingale's theory, is the first step in the formalization and further development of
nursing science. He has laid a foundation for the development of nursing theory
afterwards. Based on or not, Nightingale has provided general guidelines for nurses in
caring for clients. Nightingale's ideas have encouraged productive thinking for nurses
and the nursing profession.

Nightingale's goal is to facilitate the "healing process of the body" by manipulating

the client's environment. The framework of this theory is that the client environment
is manipulated to get calm, cleanliness, light, comfort and socialization and
expectations accordingly.

10. MYRA ESTRIN LEVINE

The core, or central concept, of Levine's theory is conservation. When a

person is in a state of conservation, it means that the individual's adaptive response
adjusts change productively, and with the least expenditure of effort, while
maintaining optimal functioning and identity. Conservation is achieved through
successful activation of adaptive pathways and behaviors that are appropriate for the
various responses needed by human functions.
Myra Levine describes the Four Principles of Conservation. These principles focus on
preserving the integrity of the individual.

He advocated that nursing is a human interaction and the principles of conservation

proposed four nursing related to individual unity and integrity. The framework
includes:

    Energy conservation: Refers to input balancing energy and output to avoid

excessive fatigue. This includes adequate rest, nutrition and exercise. Example:
Availability of adequate rest; Maintenance of adequate nutrition.

 Conservation of structural integrity: Refers to maintain or restore body

structure, prevent physical damage and promote healing. Example: Assisting a
patient in ROM exercises; Maintenance of patient's personal hygiene.

 Conservation of personal integrity: Recognize individuals as people who

struggle for recognition, respect, self-awareness and self-determination.
Example: Recognize and protect the patient's room needs.

 Conservation of social integrity: an individual is recognized as someone who

lives together in a family, community, religious group, ethnic group, political
system and nation. Example: Individual assistance to preserve its place in the
family, community and community.

Therefore, nursing interventions based on Levine's theory have current and short-term
focus and do not support health promotion and disease prevention principles,
although this is an important component of current nursing practice.

11. IDA JEAN ORLANDO

Orlando's theory describes the function of nursing as a professional effort to

meet patient needs for help. Orlando's theory is focused on how to make progress on
the actions of a patient. After nurses do the needs of the client, they have an impact
on the level of health needs of the client and will act automatically or planned to meet
the needs, which in turn to reduce the pressure or stress experienced by the client.

Jean Orlando Theory contains the concept of a framework for professional

nurses that contains 3 elements: client behavior, nursing reactions and actions,
changing the nurse's situation after the nurse estimates the client's needs, the nurse
knows the causes that affect the health status, then acts spontaneously or collaborates
to provide services health.

The Orlando Theory of Orlando describes the nursing model as the

development of five related concept factors, namely: The function of professional
nursing, the behavior exhibited by patients during the nursing process, the direct
response or internal response given by the nurse, the discipline of the nursing process,
and the improfisation in do the nursing process.

The Orlando theory radically changes the focus of nursing from the client's
medical diagnosis and automatic activities to client behavior according to the client's
urgent needs and is determined if the needs can be met with nursing actions. The
framework of this theory is Three elements, namely client behavior, nurse reaction and
nurse action, will shape the nursing situation. After nurses do the needs of the client, they
have an impact on the level of health needs of the client and will act automatically or
planned to meet the needs, which in turn to reduce the pressure or stress experienced by
the client

B. Evolution of nursing theory

Year Name Emphasis

1952 Hildegerad E. Peplau the interpersonal process is an impulse to
mature personality

1960 Faye G. Abdellah the patient's problem determines the care

needed

1961 Ida Jean Orlando interpersonal processes eliminate distress

1964 Ernestine Weidenbach the process of providing assistance to meet
needs by using the art of individual care

1966 Lydia E. Hall nursing care as a direction for people to be able

to love themselves

1967 Joice Travelbee understanding of the meaning of pain

determines how people respond

1970 Martha E Rogers human - environment is an energy field that

produces negentropy conditions

1971 Dorothea E Orem self care maintaining overall / wholeness

Imogine M King transactions provide a framework for achieving

goals

Year Name emphasis

1974 Sister Calista Roy stimulus relationship with the adaptive system

1976 Josephine G Paterson nursing is an experience in caring for people /

northuring
1978 Madeline M Leininger caring is universal and culturally varied

1979 Jean Watson caring as an ideal moral: mind, mind, soul,

Margaret A Newman related to one another
disease as proof of lifestyle that has not yet
happened

1980 Dorothi E Johnson the subsystem is in dynamic stability

1981 Rosemarie Rizzo Parse concrete human and healthy environment

C. Explain about patient assessment

When finding a sufferer there are several things that must be done to determine the
next course of action, both to resolve the situation and to overcome the victims.The steps
of assessment in sufferers:
a. Situation Assessment
b. Early Assessment
c. Physical examination
d. Patient History
e. Periodic or Advanced Checks
f. Handover and reporting
1. State assessment
A state assessment is carried out to ascertain the situation encountered in a relief
effort. As helpers, we must ascertain what we are actually achieving, whether there
are further dangers or things that could endanger a helper. Always remember that one
or more are victims, do not add to the helper who is a victim. Safety helper is number
one.

a. Location security
Actors of first aid when reaching the scene, must be responsive and
immediately assess the situation by asking questions as below.
1. How was the condition at that time
2. What possibilities will happen
3. How to overcome it
After the situation is overcome then we approach and help the victim.
Sometimes these two go together.

b. Actions when arriving at the location

If you have confirmed that the situation is safe then the next action is:
1. Ensuring the safety of rescuers, sufferers, and people around the scene.
2. Helpers should introduce themselves, if possible:
 Name Helper
 Name of Organization
 Request permission to help from sufferers / people
3. Determine the general state of the event (mechanism of injury) and begin an
early assessment of the patient.
4. Recognize and overcome life-threatening disorders / injuries.
5. Stabilize the patient and continue monitoring.
6. Ask for help.

c. Resources
Additional information about the case we are facing can be obtained from:
1. The event itself.
2. Sufferers (when conscious).
3. Family or witness.
4. Mechanism of occurrence.
5. Real deformation or obvious injury.
6. Typical symptoms or signs of an injury or disease.

2. Early Assessment
The helper must be able to immediately be able to recognize and overcome the life
threatening conditions of the victim. Early assessment steps:
a. General impression
As the patient approaches, the helper must determine whether the patient's
situation is classified as a trauma case or a medical case.
Trauma Case: Having signs that are clearly visible or palpable.Medical Case:
Without visible or palpable signs

b. Check Response
A simple way to get an overview of disorders related to the sufferer's brain
There are 4 levels of patient response:
 A = Beware ( Patients are aware of and recognize the existence and
environment )
 S = Sound ( Patients only answer / react when called or hear a sound )
 N = Pain ( Patients only react to pain stimuli given by a helper, for
example pinched, pressure on the sternum )Note: for now, the
emphasis on the breastbone is no longer allowed to maintain chances
are if there is an injury in the area (chest), so if done emphasis will add
to the injury.
 T = No response
The patient does not react to any stimulation given by the helper. Not
opening eyes, not reacting to sound or not reacting to excitatory pain.

c. Ensuring the airway is open properly (Airway).

The airway is the gateway for oxygen to enter the human body. Whatever the
effort is made, but if the airway is closed everything will fail.
1. Patients with response
A simple way to judge is to pay attention to participants when
speaking. The presence of airway disorders will usually result in speech
disorders.

2. Patients who do not respond

In patients who are unresponsive, helpers must take the initiative to
open the airway. The recommended way to open the airway is to lift the
chin, press the forehead. Also make sure the victim's mouth is clean, that
there are no leftovers or other objects that might clog the airways.

d. Assess breathing (Breathing) 

Check the presence or absence of breath by looking, listening and feeling,
rated for 3-5 seconds. Good breathing has signs:
1. Chest up and down in full
2. Easy and smooth breathing
3. Normal breathing quality (<8 x / minute adults, <10 x / minute
children, 20 x / minute babies)
Poor breathing
1. Chest does not go up or down in full
2. There are breathing difficulties
3. Cyanosis (blue / gray on the skin, lips, or nails)
4. The quality of breathing is not normal

e. Assess circulation and stop heavy bleeding

Make sure the heart rate is good enough Make sure that there is no bleeding
that can be life threatening that is not visible. Thick clothing can collect blood
in sufficient quantities.

f. Contact for help

Ask for help from others or other trained personnel. The message must be
brief, clear and complete.

3. Physical Examination
Physical examination must be carried out in detail and systematically from head to
toe.
1. Three methods of physical examination:
a. Vision (Inspection)
b. Tactile (Palpation)
c. Hearing (Auscultation)
Don't waste too much time doing detailed checks. Do it quickly but make sure
nothing is missed. Physical examination ensures that nothing is missed.Some
things to look for when examining victims:
 P: Deformities - how to: compare the side of pain with the healthy
 L: Open Ijuries - how: usually blood is visible
 N: Pain (Tenderness) - how: area of injury that is soft when pressed
 B: Swelling - how: the injured area is swollen

2. Some signs of injury may be clearly visible, many are invisible and save serious
potential injuries. Listen to sufferers. By listening you can show concern and
make it possible to get information.

3. Physical examination (Head to Toe)

Observe and touch (using both hands and with pressure), compare (simetry),
smell unusual odors and listen (breath sounds or creaking of limbs), in the
following order:
1) Chief
 Scalp and skull
 Ears and Nose
 Pupils
 Mouth
2) Neck
3) Chest
 Check for changes in shape, open wounds, or changes in
violence
 Feel the change in the shape of the rib cage to the spine
 Make a touch on the bone
4) Abdomen
 Check rigidity (hardness)
 Check for potential injuries and infections
 There may be an invisible injury, do touch
 Check for swelling
5) Back
 Check for changes in the shape of the rib cage
 Check for changes in shape along the spine
6) Pelvis
7) Upper motion tool
8) Lower motion tool

4. Vital sign examination

a. Pulse frequency: including the quality of the pulse, strong or weak, regular
or not.
b. Frequency of breathing: also whether the breathing process occurs easily,
or is there an effort to breathe, is there any signs of shortness of breath.
c. Blood pressure
d. Temperature: checked the relative temperature on the patient's forehead.
Also check the condition of the skin: dry, sweaty, reddish, discoloration
and others.
4.Patient History
In addition to conducting checks, interviews are conducted to obtain additional
data if possible. a. An interview is very important if you find a victim with an illness.
Considering the interviews conducted can develop very broadly, to help use the
acronym:
KOMPAK
 K = Main Complaints (symptoms and signs) something that is very complained
by patients
 O = Drugs taken. Treatment is being undertaken by patients or drugs that have
just been taken or drugs that should be taken but apparently not taken.
 M = Last food / drink. This event may be the basis of loss of response in sufferers.
Besides this data is also important to know if it turns out the patient must undergo
surgery then in the hospital.
 P = illness. A history of illness that has been suffered or has been suffered that
may be related to the condition experienced by patients at this time, for example
complaints of shortness of breath with a history of heart problems three years ago.
 A = Allergy experienced. It is necessary to find out whether the cause of the
disorder in this patient may be a form of allergy, usually the patient or his family
already know it
 K = event. Events experienced by the victim, before the accident or before the
onset of symptoms and signs of the disease suffered at this time. This interview
can be conducted while examining the victim, no need to wait until the
examination is completed.

5.Continuous Examination
After completing the examination and action, then do a periodic inspection,
according to the severity of the case we face. In cases considered severe, periodic
examinations are carried out every 5 minutes, whereas in mild cases it can be done
every 15 minutes. Some things that can be done on a periodic inspection are:
1. State of response
2. Re-assess the airway and correct it if necessary
3. Re-assess breathing, its frequency and quality
4. Re-check the pulse of the patient and if necessary do it in detail if time is
available.
5. Re-assess the state of the skin: temperature, humidity and conditions Check
back from head to toe, there may be parts missing or require a more thorough
examination.
6. Check back carefully there may be parts that have not been checked or
deliberately skipped due to conducting a directional examination.
7. Re-assess the management of patients, whether it is good or there needs to be
other actions. Re-examine all bandages, sterile whether it is still strong
enough, whether the bleeding can be overcome, there are parts that have not
been maintained.
8. Maintain communication with sufferers to maintain a sense of security and
comfort.

D. Explain how giving instruction and expression during the implementation in

nursing
how to give instructions in implementing nursing namely can be mapped as follows:

1. Seen from physical, which includes weather, climate, air temperature, room shape,
wall color, seating arrangement, and other available equipment.
2. Time, which covers the day, and time, morning, afternoon, evening.
3. Psychology, which covers stereotypes, prejudices, and emotions.
4. Social, which includes values, attitudes, and beliefs that include religion, culture, and
status.
5. Biologically, which covers gender and age of development.

while the expressions during implementation are:

a. Hospitality Relations with nurses in conducting communication to patients is the first

step to give the intended impression in terms of providing care to be done.

b.Autonomy and responsibility referred to from autonomy and responsibility are the
courage that must be possessed by a nurse in making choices or making decisions as
well as taking responsibility for them.

c. Assertive assertion
Assertive communication can provide a space for someone to express their feelings
and thoughts without having to judge, accuse, or hurt others. in the world of nursing,
assertiveness also serves to increase one's sense of self-confidence while at the same
time showing respect for others
E. Find picture of surface anatomy regions ( anterior view of female )
CHAPTER III

COVER

CONCLUSION

Nursing as an integral part of health care is a form of professional service

based on nursing knowledge. In its development, the science of nursing always follows
the development of other sciences, considering that nursing is an applied science that
always changes with the times.
The nurse's role is very comprehensive in handling clients because the nurse's
role is to meet the client's biological, sociological, psychological, and spiritual needs.
Communication is a very important factor in the nursing process. In fact,
communication is one of the barometers of success and failure of the nursing process. It
is impossible for a nurse to go through the nursing process if he is unable to foster and
establish good communication with patients.
REFERENCES

https://www.dictio.id/t/bagaimanakah-konsep-tentang-ilmu-keperawatan/5312/2
https://www.academia.edu/10668903/BAB_II_KOMUNIKASI_PROSES_KEPERAWATA
N

http://faridnasrullah.blogspot.com/2012/10/penilaian-pemeriksaan-pasien.html
https://www.scribd.com/doc/310234729/Macam-teori-keperawatan