keperawatan.ums.ac.idkeperawatan.ums.ac.id/.../2020/09/keperawatan-komunitas.docx · Web viewDelivering the purpose of the Rumple leed measurement and informing the procedures in

OSCA NURSING COMMUNITY RUBRIC

RUMPLE LEED MEASUREMENT RUBRIC

No. Rated Aspects ValueSCORE

Yes No

A. PRE-INTERACTION PHASE & ORIENTATION (25%)

1 Checking nurse's records and doctor's orders

2,5

Able to identify health problems, especially the signs and symptoms of Dengue Hemorrhagic Fever (DHF)

Unable to identify the patient's health problems

2 Washing hands2,5

Washing hands using clean water and soap following the proper steps

Not washing hands using clean water and soap

3 Greeting the patient (also his family, if any) 2,5

Saying "Assalamu’alaikum” or “good morning.”

Not greeting the patients or family

4 Introducing yourself and making a contract

2,5

Giving name, hometown information, and making a contract related to the actions to be taken

Not giving name, hometown information, or making a contract

5 Calling the patient according to his/her preferable name 2,5

Asking the patient’s nickname and calling his/her preferable name

Not asking the patient’s nickname or calling his/her preferable name

6 Informing the objectives and procedures for actions taken

5

Delivering the purpose of the Rumple leed measurement and informing the procedures in sequential actions (a-b-c-d-e)

Not delivering the purpose of actions taken and informing the procedures less than 3 orders (a-b-d-d-e)

7 Preparing tools near the patient

5

Preparing the complete and appropriate tools according to the actions and putting them near the patient

Not preparing the complete and appropriate tools or putting them near the patient

B WORKING PHASE (60%)8 Asking the patient to adjust to

a comfortable position10

Asking the patient whether his/her position is comfortable for nursing actions.

Not asking the patient whether his/her position is comfortable for nursing actions.

9 Measuring the patient’s blood pressure

10

Measuring the patient’s blood pressure correctly using a sphygmomanometer and a stethoscope, placing the sphygmomanometer cuff around three fingers above the brachial artery, and the cuff pump above the patient’s usual blood pressure around 20 mmHg, lowering the cuff slowly and listening carefully to the corrective sound

Not measuring the patient’s blood pressure correctly

10 The results of systole and diastole are added up then divided by 2.

10

Adding up the blood pressure results of systole and diastole then dividing it by 2

Not calculating the systole and diastole blood pressure results correctly

11 Repumping according to the results no.3 then clamping for 5-10 minutes

10

Sphygmomanometer pumping according to the calculation results then clamping for 5-10 minutes

Not clamping following the results of the calculation correctly

12 Counting the number of petechiae that appears on the patient’s hand

10Counting the number of petechiae after rumple leed action

Not counting the number of petechiae after rumple leed action

C. TERMINATION PHASE (20%)

13 Tidying up the client5

Helping the patient to return to the previous position

Not helping the patient to return to the previous position

14 Evaluating actions/ concluding the results of the assessmentINTERPRETATION:• If petechiae appear <10 (negative) • If petechiae appear > 10 (positive)

10

Evaluating the actions taken Not evaluating the actions taken

15 Saying goodbye to the client and making a contract for the next meeting

5 Saying goodbye to the patient, telling him/her if they need help from the

Not saying goodbye to the patient or making a contract for the next

nurse, they can ask the family to call by pressing the button next to the patient’s bed and submit a contract for the next meeting

meeting

16 Washing hands2,5



17 Recording activities in the nursing notes sheet

5Documenting the actions taken

Not documenting the actions taken

TOTAL 100

ORAL REHYDRATION THERAPY (ORT) RUBRIC


Yes No


1 Checking nurse’s records and doctor’s orders

2,5

Able to identify health problems especially with signs and symptoms of dehydration

Unable to identify the patient’s health problems

2 Washing hands

2,5




Saying “Assalamu’alaikum” or “good morning.”



2,5







5




2,5



B. WORKING PHASE (60%)8 Pouring water (tea or starch

water) into a glass of ± 200 ml10

Preparing ± 200 ml of boiled water

Not preparing ± 200 ml water

9 Taking one teaspoon of sugar10

Preparing one teaspoon of sugar

Not preparing one teaspoon of sugar

10 Taking ¼ teaspoon of salt 10 Preparing ¼ teaspoon of Not preparing ¼

salt teaspoon of salt 11 Stirring the ORT solution until it

dissolves 10Mixing water with sugar and salt accordingly then stirring until it dissolves

Not dissolving sugar and salt into the water properly

12 Encouraging children to drink as much as possible or one glass each time defecating

10

Encouraging children to drink ORT solution as much as possible or one lass each time defecating; however, if a child has drunk 7-10 glasses of the solution, he/she should be immediately taken to the nearest health service for further action.

Not providing correct information on how to give ORT solution to children





14 Evaluating actions10

Evaluating the actions taken

Not evaluating the actions taken


5

Saying goodbye to the patient, telling him/her if they need help from the nurse, they can ask the family to call by pressing the button next to the patient’s bed and submit a contract for the next meeting

Not saying goodbye to the patient or making a contract for the next meeting

16 Washing hands

2,5






Total 100

BASIC MOBILIZATION RUBRIC FOR ELDERLY AT HOME


Yes No



Able to identify health problems especially with overall mobilization of patients


2 Washing hands Washing hands using clean water and soap following the proper steps


3 Greeting the patient (also his family, if any)






5 Calling the patient according to his/her preferable name






7 Preparing tools near the patient Preparing the complete and appropriate tools according to the actions and putting them near the patient


B WORKING PHASE (60%)Biceps Muscle Exercise

8 Sit up straight with arms at your sides with the weight in your hands

Encouraging the patient to sit in a chair with his back straight, and his arms at his sides

Not asking the patient to sit up straight and use a chair without backrest

9 Bend the arm at the elbow joint and lift the weight towards the shoulder

Asking the patient to carry weights in both hands, then flexing the elbows so that the hands are parallel to the shoulders

Carrying a burden that is too heavy or not according to the patient’s ability, and not informing to make movements according to the strength of patients

10 Then lower the weight to the starting position

Extending the elbow with the patient’s hand while carrying the load gently

Not explaining is like doing a slow extension.

Upper arm and shoulder exercise

11 Sit upright in a chair with your arms hanging by your side, weight in your hands

With a sitting position that is still upright, asking the patient to hang his hands on the side of the body with a load

Not asking the patient to sit up straight and carrying a load that is not according to the patient’s ability

12 Raise both arms laterally then up, hands clasped together over the head

Asking the patient to do the abduction with both arms to shoulder level, then continuing until both hands are placed above the head

Not informing the patient to perform abduction movement according to his ability

13 Then lower arms back to their original position and repeat

Asking the patient to do the adduction movement slowly until both arms are attached to the sides of the body and repeat this movement

Not informing the patient to do adduction movements slowly

Knee extensor exercise14 Sit upright on a chair, and the

weight is placed on the anklesWith a sitting position that is still upright, asking the patient to hang or put a load on the ankles

Not asking the patient to remain in a straight sitting position

15 Lift one leg forward so that the knee is straight, then lower it to its original position

Asking the patient to lift one leg towards the front until the knee is straight

Not informing patients to make movements according to their

and then lower to the starting position, and doing it alternately on the other leg

abilities

16 Repeat this movement alternately by raising both legs

Asking the patient to lift both legs simultaneously, then slowly moving to the starting position

Not asking the patient to do this movement repeatedly

Knee flexor exercise17 Bend one knee at a time so that

the heel is as close to the back of the thigh

Flexing the knee until the heel reaches or approaches the back of the thigh and the other leg stays straight

Not informing the patients to flex their knees according to their abilities

18 The other leg stays straight and then lower the foot to the starting position.

Extending the knee until it returns to the starting position gently

Not informing the patients to do the extension slowly

19 Do alternately left and right legs Asking the patient to do this movement alternately

Not asking the patient to do this movement alternately

Hip extensor exercise20 Stand on the footrests and bend

forward about 45 degrees at the waist

Asking the patient to stand on the footrest and bending forward approximately 45 degrees at the waist

Not helping the patient to place the patient correctly

21 Lift one leg straight back up as high as possible without bending the knee

Asking the patient to lift one leg straight back up as high as he can, but the knee should not be bent

Not informing the patients to make movements according to the ability of patients and not providing information when doing this movement, the knee should not be bent.

22 Then lower the foot to the starting position

Asking the patient to lower the foot until returning to the starting position slowly

Not informing the patients to make slow movements

Plantar flexor exercise23 Stand straight, hold on to the back Asking the patient to Not asking the patient to

of the chair stand up straight and holding on to the back of the chair

hold onto the back of the chair and increase the risk of the patient falling

24 Lift your body as high as possible, on your toes

Asking the patient to lift the body as high as possible with the toes following the patient’s ability

Not informing the patients to do these movements according to the ability of patients

25 Then lower the body slowly back to the starting position

Asking the patient to lose weight slowly

Not informing the patient to lose weight slowly

C. TERMINATION PHASE (20%)Tidying up the client Helping the patient to

return to the previous position


Evaluating actions Evaluating the actions taken


Saying goodbye to the client and making a contract for the next meeting



Washing hands Washing hands using clean water and soap following the proper steps


Recording activities in the nursing notes sheet

Documenting the actions taken


Total 100

TOPICAL MEDICATION RUBRIC FOR PATIENTS WITH SKIN PROBLEM (ITCHES)

No. Rated Aspects Value SCOREYes No

A. PRE-INTERACTION AND ORIENTATION PHASE (25%)


2,5

Able to identify health problems, especially the signs and symptoms of infection and itching on the surface of the patient’s skin


2 Washing hands

2,5






4 Introducing yourself and making a contract 2,5







5




2,5



B WORKING PHASE (60%)8 Adjusting the position of the

patient 5

Adjusting the patient’s position according to which part of the skin to have topical medication

Not adjusting the patient’s position properly

9 Freeing the area affected by scabies

5

Taking off the patient’s clothing or anything that covers the area of the skin affected by scabies for cleaning

Not taking off the patient’s clothing or anything that covers the skin area affected by scabies

10 Opening the cover like the instrument

5

Opening the lid like an instrument, then pouring NaCl liquid into the compost that is inside the instrument

Not opening the lid like an instrument or preparing NaCl liquid poured into the container

11 Placing a pad on the side of the body affected by scabies

5

Putting a pad beside the patient’s body affected by scabies before cleaning

Not putting a pad with the correct position based on which part of the skin affected by scabies

12 Wearing gloves

5

The principle of topical medication is clean, so the nurse should use clean gloves.

Not wearing gloves properly

13 Cleaning scabies with NaCl using gauze and tweezers

10

Entering the gauze into a com filled with NaCl, then squeezing using two tweezers, after that, cleaning the skin area affected by scabies

Cleaning the skin area affected by scabies in the wrong way such as gauze moistened with NaCl is not squeezed properly, and rubbing too hard when cleaning the affected area of scabies

14 Drying scabies using gauze10

Drying the area of skin cleaned with NaCl liquid by using dry gauze

Not drying the area of skin affected by scabies

15 Applying with ointment using a cotton swab

10

Applying the ointment sufficiently and evenly to the area affected by scabies using a cotton swab.

Applying ointments unevenly or too much

16 Taking off gloves5

Taking off the glove and putting it in a kidney dish

Taking off the gloves used and not putting it into a kidney dish


15 Tidying up the client2,5



16 Evaluating actions 5 Evaluating the actions taken



5 Saying goodbye to the patient, telling him/her if they need help from the nurse, they can ask the


family to call by pressing the button next to the patient’s bed and submit a contract for the next meeting

18 Washing hands

2,5



19 Recording activities in the nursing notes sheet 5 Documenting the actions

takenNot documenting the actions taken

Total 100

SIMPLE STEAM INHALATION RUBRIC

No Rated Aspects Value SCOREYes No


1 Checking nurse’s records and doctor’s orders 2,5

Able to identify the patient’s health problems, especially the respiratory system


2 Washing hands

2,5




Saying “Assalamu’alaikum” or “good morning ...”


4 Introducing yourself and making a contract 2,5







5



7 Preparing tools near the patient 2,5 Preparing the complete and appropriate tools

Not preparing the complete and appropriate

according to the actions and putting them near the patient

tools or putting them near the patient

B WORKING PHASE (60%)8 Adjusting the patient’s sitting

position (fowler or sitting upright)

5

Adjusting the patient’s position with the fowler’s position; This position aims to allow the patient to make maximum chest expansion.

Not adjusting the patient’s position correctly

9 Placing the rubber sheet in front of the patient 5

Placing the rubber sheet in front of the patient

Not placing the rubber sheet in front of the patient

10 Putting a basin filled with steamy water 5

Pouring warm or hot water (by using the water vapor) into the basin

Pouring water that is no longer steaming

11 Giving menthol/eucalyptus oil to the basin 10

Pouring menthol or eucalyptus oil into a basin of warm or hot water

Not pouring menthol or eucalyptus oil

12 Spreading vaseline around the nose using tissue

10

Spreading vaseline around the patient’s nose and mouth to avoid the risk of burns due to steam from warm or hot water

Not spreading vaseline around the patient’s nose and mouth

13 Putting a towel on the patient’s head to cover their face in a cone shape

10

Using a towel or cardboard modified (cone-shaped) to cover the surface area of the basin

Using a towel or cardboard modified but not covering the entire surface of the basin to avoid moisture the patient inhales becomes small

14 Asking the patient to breathe vapor and release it through the mouth for 10-15 minutes

10

Asking the patient to breathe the vapors then releasing them through the mouth for 10-15 minutes; If it hasn’t been done for 10-15 minutes, but the steam in the basin is gone, then the nurse can add more hot water and menthol or eucalyptus oil

Not teaching teach the patient how to breathe correctly and how long to use simple inhalation

15 Cleaning the nose and mouth 5 Cleaning the nose and Not cleaning the

using tissue mouth area of the patient by using tissue

patient’s nose and mouth after a simple steam inhalation


16 Tidying up the client2,5



17 Evaluating actions 5 Evaluating the actions taken



5



19 Washing hands

2,5



20 Recording activities in the nursing notes sheet 5 Documenting the actions

takenNot documenting the actions taken

Total 100

TRADITIONAL INGREDIENTS RUBRIC FOR URI (Upper Respiratory Tract Infection)

No Rated Aspects ValueSCORE

Yes No

A.PRE-INTERACTION AND ORIENTATION PHASE (25%)


2,5

Able to identify the patient’s health problems, especially the respiratory system


2 Washing hands 2,5 Washing hands using Not washing hands using

clean water and soap following the proper steps

clean water and soap


Saying “Assalamu’alaikum” or “good morning ...”



2,5







5




2,5



B WORKING PHASE (60%)8 Splitting the lime into 2 parts

10

Cutting the lime horizontally or slice each side of the lime into 4 parts

Cutting the lime the wrong way

9 Squeezing the lime over a sieve and an empty glass 10

Squeezing the cut lime on a sieve and putting it into an empty glass

Not using a sieve when squeezing lime

10 Mixing the lime juice with one tablespoon of soy sauce

10

Adding one tablespoon of soy sauce into a glass of lime juice and stirring them until mixed

Adding too much soy sauce and not stirring the lime juice with it well

11 Giving the traditional herbs of the lime juice with soy sauce to the patient

10Asking the patient to drink the lime juice with soy sauce

Not asking the patient to drink the lime juice with soy sauce

12 Then giving a glass of warm 10 Asking the patient to Not asking the patient to

water to the patient drink warm water drink warm water after drinking traditional herbs for URI

13 Cleaning the tools used7,5

Cleaning up the tools used

Not cleaning up the tools used





15 Evaluating actions5

Evaluating the actions taken



5



17 Washing hands

2,5






Total 100

SKIN DISEASE TREATMENT USING POTASSIUM PERMANGANATE (Kalium permanganate) RUBRIC


A.PRE-INTERACTION

PHASE & ORIENTATION (25%)

1 Validating client-family problems and their

3 Able to identify health problems, especially skin

Only able to identify without providing solutions to the

needs disease problems (scabies) and provide solutions for resolution

problems

2

Preparing tools: (2 basins, clean water, potassium permanganate, Povidone-iodine/antiseptic, gauze, gloves, rags/towels)

4

Preparing tools such as 2 basins, clean water, potassium permanganate, Povidone-iodine/antiseptic, gauze, gloves, rags/towels

Not preparing the tools or only preparing 4 of the 8 tools needed

3 Greeting the patient 2Saying “Assalamu'alaikum” or "good morning ..."


4Introducing oneself

2 Giving name, hometown information

Not giving name, hometown information

5

Explaining the purpose of the activity

3 Informing the purpose of the activity to the patients' family, providing, and teaching how to do potassium permanganate baths

Not informing the purpose of the activity

6Explaining the procedures

4 Explaining the sequence of giving potassium permanganate baths (a-b-c-d-e)

Explaining less than 3 sequences (a-b-d-d-e)

7 Asking if the patient is ready

2 Asking if the client-family is ready to start the procedure

Not asking if the client-family is ready to start the procedure

B WORKING PHASE (60%)

8Washing hands

5 Washing hands using clean water and soap following the proper steps


9

Saying ‘Bismillah’

5 Saying "Bismillahirrohmanirrohim ..." which is heard by client-family

Not saying "Bismillahirrohmanirrohim ..." before the procedure starts

9Providing a comfortable position for the patient

5 Placing the patient comfortably according to the position required

Not letting the patient feeling comfortable according to the required position

10 Wearing gloves 5 Wearing latex gloves Not wearing latex gloves

11Preparing the potassium permanganate solution in a basin (a)

10 Preparing a basin with a ± 5% potassium permanganate solution of 2-3 liters

Not preparing a basin with a ± 5% potassium permanganate solution of 2-3 liters

12Arranging a comfortable chair for the patient to sit-in

5 Placing the client comfortably when the patient's hands are soaked in the basin

Not placing the client comfortably when the patient's hands are soaked in the basin

13 Putting a rubber sheet under the basin

5 Putting plastic or rubber sheet under the basin to avoid spilling water

Not putting plastic or rubber sheet under the basin to avoid spilling water

14

Dipping the hands into a basin containing potassium permanganate solution (b)

10 The patient soaks his/her infected hands in a basin containing a potassium permanganate solution.

Not asking the patient to soak his/her infected hands in a basin containing a potassium permanganate solution

15Rubbing the wound area with gauze thoroughly (c)

5 Rubbing gently on scabies using gauze

Not rubbing gently on scabies using gauze

16Moving the patient's hand to a basin of clean water and rinsing it (d)

5 Cleaning the infected part of scabies by using clean water

Not cleaning the infected part of scabies by using clean water

17Drying the patient's hands with a dry towel (e)

5 The patient's hands are dried using a clean and dry cloth or towel.

The patient's hands are not dried using a clean and dry cloth or towel.

18Applying Povidone-iodine to the scabies wound cleaned

5 Tested for applying Povidone-iodine to the scabies wound cleaned

Failed for applying Povidone-iodine to the scabies wound cleaned

19 Conducting therapeutic communication

5 Encouraging the nurses and patients to work together; The nurse tries to identify and assess the problem and evaluate the actions

Not encouraging the nurses and patients to work together; The nurse does not try to identify and assess the problem and evaluate the actions

20 Cleaning the tools after the treatment

5 Cleaning and returning all tools used

Not cleaning and returning all tools used


21Doing an evaluation

10 Assessing the positive and negative impacts that arise from the given procedure

Not assessing the positive and negative impacts that arise from the given procedure

22

Informing a follow-up plan

5 Explaining plans for further activities, especially those related to after potassium permanganate treatment

Not explaining plans for further activities, especially those related to after potassium permanganate treatment

23Saying goodbye

5 Excusing oneself from the patient's room

Not saying goodbye or excusing oneself from the patient's room

TOTAL 100

PROCEDURES OF HYPERTENSION RUBRIC


A.PRE-INTERACTION

PHASE & ORIENTATION (25%)

1 Say greetings and ‘Bismillah.’ 2

Saying "Assalamu'alaikum" or "good morning."


2 Validating family problems and their needs 5

Able to identify health problems, especially skin disease problems (scabies) and provide solutions for resolution

Only able to identify without providing solutions to the problems

3 Setting an appropriate place 5

Arranging and placing the client-family seats, tools, and media used for counseling

Not arranging and placing the client-family seats, tools, and media used for counseling

4 Explaining the purpose of today's activity 3

Explaining the purpose of the nurse visiting to provide health education

Not explaining the purpose of the nurse visiting to provide health education

5Creating a contract agreement (time-topic)

5Making a contract to reach an agreement of the time needed for health education activities

Not making a contract to reach an agreement of the time needed for health education activities

B WORKING PHASE (60%)Tested Explaining

a. Definition of Hypertension

10 Explaining what hypertension or high blood pressure is. It is a disease characterized by an increase in blood pressure.

Not explaining what hypertension or high blood pressure is. It is a disease characterized by an increase in blood pressure.

b. Causes and Symptoms

10 Explaining that there are two causes of hypertension, namely primary and secondary. Primary hypertension is due to genetic or hereditary factors, while secondary hypertension includes kidney failure,

Not explaining that there are two causes of hypertension, namely primary and secondary. Primary hypertension is due to genetic or hereditary factors, while secondary hypertension includes

nervous breakdown, hormones disorder, drugs, and others.

kidney failure, nervous breakdown, hormones disorder, drugs, and others.

c. Complications of Hypertension

10 Explaining complications that occur after hypertension are heart failure, kidney failure, and stroke, and DM.

Not explaining complications that occur after hypertension are heart failure, kidney failure, and stroke, and DM.

d. Treatment for Hypertension

10 Explaining how to treat HT include exercising regularly, maintaining weight, managing stress, not smoking, and drinking alcohol, periodically checking blood pressure.

Not explaining how to treat HT include exercising regularly, maintaining weight, managing stress, not smoking, and drinking alcohol, periodically checking blood pressure.

e. Explaining the Hypertension Diet

10 Delivering DASH (Dietary Approaches to Stop Hypertension) by reducing the intake of sodium (salt), fat, and cholesterol and increasing the intake of protein, fiber, and vitamins and minerals from the food consumed daily

Not delivering DASH (Dietary Approaches to Stop Hypertension) by reducing the intake of sodium (salt), fat, and cholesterol and increasing the intake of protein, fiber, and vitamins and minerals from the food consumed daily

f. Sounding loud, clear and easy to understand

10 In providing information, using easy terms for the client-family as well as with a clear voice.

In providing information, not using easy terms for the client-family as well as with a clear voice


1. Providing opportunities to ask questions and evaluate the results of counseling

10 Providing time for the client-family and the opportunity to ask

Not providing time for the client-family and the opportunity to ask

2. Tidying up tools and places

5 Tested to tidy up the tools and the place

Tested not to tidy up the tools and the place

3. Saying goodbye 5 Saying goodbye and thank you Not saying goodbye and thank you

TOTAL 100

EVALUATION OF DAILY ACTIVITIES USING KATZ INDEX

Rated Aspects Value SCOREYes No

A.PRE-INTERACTION PHASE & ORIENTATION (25%)

1Validating client-family problems and their needs 5

Able to identify health problems in the family and their needs

Unable to identify health problems in the family and their needs

2Preparing tools and a place as needed 5

Preparing and carrying the tools used to conduct family assessments

Not preparing and carrying the tools needed

3Greeting (Assalamualaikum) and saying ‘Bismillahirrahmannirrahim’

3Saying "Assalamu'alaikum" or "good morning."


4Explaining the purpose of today's activity

5 Explaining to families the purpose of conducting daily activities assessments using the KATZ index

Not explaining the purpose of the activities to the family

5

Explaining the purpose of the assessment

4 Delivering the purpose of the assessment of daily activities using the KATZ index

Not delivering the purpose of assessing daily activities using the KATZ index to clients and families

6 Obtaining family approval to start

4 Asking for approval from the family before the assessment

Not asking for approval of actions (assessment of daily activities)

B WORKING PHASE (60%)

1

Assessing Bathing Needs:I: Not needing any help (in and out of the bathtub, when bathing with these facilities)A: Receiving assistance when washing only on specific body parts (back or legs)D: Needing help with more than one body section / no bathing at all

9 Asking questions related to the patient's ability to meet the daily needs of bathing, by assessing the level of independence of the patient whether they belong to Independent, Assisted or Dependent category

Not doing a specific assessment or providing an assessment with the category that is less appropriate for the independence of patients in terms of Bathing

2 Assessing Dressing Needs:I: Able to take and wear complete clothing without needing helpA: Dressing completely without help except when buttoning shirt or tying

9 Asking questions related to the ability of patients to meet their daily needs in terms of Dressing, by assessing the level of independence of the patient whether they belong to Independent, Assisted or

Not assessing accurately with the category for the independence of patients in terms of Dressing

shoesD: Needing help taking and wearing clothes or else the patient will not be fully clothed

Dependent category

3

Assess the fulfillment of toileting needs:I: Being able to go to the toilet, cleaning, and choosing clothes without assistance (perhaps using an object as support such as a stick, legs, and wheelchair) may also be able to use the shelter while in bed or also the empty chamber in the morning.A: Needing help to go to the toilet, cleaning, choosing, or fixing the clothes, after elimination either with a night storage device or the pottyD: Unable to go to the bathroom or use the potty in the process of elimination

9 Asking questions related to the ability of patients to meet their daily needs in terms of toileting, by assessing the level of independence of the patient whether they belong to Independent, Assisted or Dependent category

Not assessing accurately with the category for the independence of patients in terms of Toileting

4 Assessing the fulfillment of moving needs:I: Moving up and down from the bed and chair without any help (may use support objects such as walking sticks or walkers)A: Getting on and off from the bed or chair with the helpD: No getting out of bed at all (needing a full help when coming down)

9 Asking many questions related to the patient's ability to meet daily needs in terms of Moving, by assessing the level of independence of the patients belong to Independent, Assisted or Dependent category

Not assessing accurately with the category for the independence of patients in terms of Moving

5 Assessing continence:I: Controlling urination and defecation independentlyA: Sometimes, urination happens "accidentally." Supervision is through a catheter or even

9 Asking questions related to the ability of patients to meet their daily needs in terms of continence, by assessing the level of independence of the patient whether they belong to Independent, Assisted or

Not assessing accurately with the category for the independence of patients in terms of Continence

incontinence.D: Monitoring is an aid in controlling the patient's urination and defecation, can use a catheter, or even have full incontinence.

Dependent category

6 Assessing eating needs:M: Eating without helpD: Eating without needing help except when cutting meat or buttering breadT: Needing help when eating, or feeding through tubes or intravenous fluids either as a menu or completely

9 Asking questions related to the ability of patients to meet their daily needs in terms of Eating, by assessing the level of independence of the patient whether they belong to Independent, Assisted or Dependent category

Not assessing accurately with the category for the independence of patients in terms of Eating


1 Tidying up client4 Tidying up the patient and the

tools used when assessing daily activities

Not tidying up patients and tools used

2Evaluating actions / concluding the results of the assessment

4 Evaluating and providing conclusions on the assessment done

Not evaluating or providing conclusions on the assessment done

3Saying goodbye to the client and making a contract for the next meeting

3 Saying goodbye to the patient and making a contract for the next meeting

Not saying goodbye to the patient after taking action

D APPEARANCE DURING ACTION (5%)

1 Having a clear voice and easy to understand

4 The nurse speaks in a clear and understandable voice to the patient.

Speaking in a low and incomprehensible voice

2 Using media to explain

3 Nurses use the media when giving explanations to patients, so they will quickly understand the actions (assessment).

Nurses do not use media when giving explanations.

3 Giving the patient answers clearly and correctly

3Giving answers that are easy to understand if the patient asks questions

Providing answers with medical language or sentences that are not understood by patients and families

TOTAL 100

EMOTIONAL ASSESSMENT



1 Validating client-family problems and their needs 5

Able to identify health problems in the family and their needs

Unable to identify problems that exist in the family

2 Preparing tools and a place as needed 5 Preparing the tools used to

conduct Emotional assessment

Not preparing and carrying the tools needed

3Greeting (Assalamualaikum) and saying ‘Bismillahirrahmannirrahim’

3Saying "Assalamu'alaikum" or "good morning."


4 Explaining the purpose of today's activity 5

Explaining to families the purpose of conducting an Emotional status assessment

Not explaining the purpose of the activities to the family

5 Explaining the purpose of the assessment 4

Delivering the purpose of conducting an Emotional status assessment

Not delivering the purpose of doing Emotional assessment to patients and families

6 Obtaining family approval to start 5

Asking for approval from the family before the assessment

Not asking for approval of actions (assessment of daily activities)

B WORKING PHASE (50%)First Phase

1 Does the patient have difficulty sleeping? (Yes/No) 6

Asking the patients whether they have difficulty sleeping in the past few months

Not asking the patients whether they have difficulty sleeping in the past few months

2 Does the patient often feel nervous? (Yes/No) 6

Menanyakan kepada pasien apakah sering merasa gelisah dalam satu bulan terahlir

Not asking the patients whether they feel nervous in the past few months

3 Does the patient often feel sad or cry alone? (Yes/No) 6

Asking the patients whether they often feel moody or cry alone in the last few months

Not asking the patients whether they feel sad or often cry alone in the past few months

4 Does the patient often feel anxious? (Yes/No) 6

Asking the patients whether they often feel anxious in the last few months

Not asking the patients whether they feel anxious in the past few months

Proceed to step 2 if there is at least one "Yes" answer in stage 1

1Complaining for more than 3 months or more than once a month (Yes/No)

6

Asking the patient whether they complain for more than three months or more than once a month

Not asking the patient whether they complain for more than three months or more than once a month

2 Having many problems (Yes/No) 6 Asking the patient if they have

many problems in mind

Not asking the patient if they have many problems in mind

3 Having family issues (Yes/No) 6 Asking the patient if they are having family issues

Not asking the patient if they are having family issues

4Taking sleeping pills with or without doctor’s prescriptions (Yes/No)

6Asking the patient if they are taking sleeping pills with or without doctor’s prescriptions

Not asking the patient if they are taking sleeping pills with or without doctor’s prescriptions

5 Often alienating themselves (Yes/No) 5

Asking the patients whether they often alienate themselves or do not interact with other family members or the community

Not asking the patients whether they often alienate themselves or do not interact with other family members or the community


1

Evaluating actionsIf there is at least one "Yes" answer at stage 2, then emotional problems will be (+)

5 If the results of the assessment or questions in stage 1 get at least 1 answer "YES," then the question continues to stage 2; and if there is 1 answer "YES" in stage 2, then the patient has a mental-emotional disorder.

Not doing an evaluation correctly on the emotional status of patients

2 Tidying up client4 Tidying up the patient and the

tools used when assessing daily activities

Not tidying up patients and tools used

3Saying goodbye to the client and making a contract for the next meeting

3 Saying goodbye to the patient and making a contract for the next meeting

Not saying goodbye to the patient after taking action

APPEARANCE DURING ACTION (5%)

1 Having a clear voice and easy to understand 4

The nurse speaks in a clear and understandable voice to the patient.

Speaking in a low and incomprehensible voice

2 Giving the patient answers clearly and correctly

3 Giving answers that are easy to understand if the patient asks questions

Providing answers with medical language or sentences that are not understood by patients

and familiesTOTAL 100

Documents

keperawatan.ums.ac.idkeperawatan.ums.ac.id/.../2020/09/keperawatan-komunitas.docx · Web viewDelivering the purpose of the Rumple leed measurement and informing the procedures in