A.

Nursing Process
1. Client Condition
S : The client said couldnt swallow the food and felt nausea when
see a food
The client said her bodys weak
O:

the client vomit looks a yellowish

the client appear weak

2. Nursing Diagnosis
Trouble the needs of nutrition less than body requirements related to
intake of oral decreased, nausea and vomit
3. Nursing Action (Tindakan Keperawatan)
collaboration in the Naso Gastrointestinal Tube pair
4. Goal (Tujuan)
The client will be paired Naso Gastrointestinal Tube

B. Theraupetic Greeting
Orientation Phase (mengecek kebenaran data pasien)
N : Good morning mam, Im Adam your nurse do you remember me?
P : Yes Nurse
N : Ok mam, before that I will check your medical record.
Your name is Rina Windari
You were born on March 17, 1994
Your register number is 12200072
Right mam ?
P : Yes nurse, its right
N : Ok mam, today Im working in this room from two oclock until nine
p.m. Today I will to
take care of you. So, if you need my help you can call me in the nurse
offfice. Do you
understand mam ?
P : Yes I do nurse
Validation / Evaluation
N : Are you feeling better ?
P : Yes nurse I feel better than yesterday
N : I hope you will be better soon
P : Yes nurse, I hope think so

Contracts ( menjelaskan apa saja yang akan dilakukan pasien saat itu dan
membuat janji tindakan)
N : Ok mam, from your medical record today at three p.m you will be
paired Naso Gastrointestinal Tube. Do you understand?
P : Yes, Im understand nurse
N : Ok mam, so in the first I will prepare an instruments and then I will
come back again at three p.m. to pair you Nasogastrointestinal Tube.
P : Ok nurse

Work Phase
Remember contracts ( dengan membawa alat )
N : Ok mam, because now at 3 p.m. and I have brought an instruments.
Do you remember our promised ?
P : Oh ys nurse Im remember
N : So I will pair you Nasogastrointestinal Tube now. Are you ready mam ?
P : Is the hurt and dangerous nurse ?
N : yes mam just little hurt but it isnt dangerous, and this action will help
you to fulfilly your nutrition.

Work Phase (meyakinkan pasien dan jelaskan tujuan tindakan dilakukan)

N : This action do because you cant swallow the food better and the
purpose of do the action to help you your nutrition, so you can be better
soon. Dont be afraid. Do you understand? And are you ready now mam?
P : Of course nurse Im understand and Im ready now
N : Ok mam, please help me to set your potition. Up your head. I will put
Nasogastrointestinal Tube now. When I put the tube and if you feel the
tube entry to your throat please help to swallow. Okay keep calm and
relax, hold for a while mam.
P : Ok nurse
N : Ok finish mam
Termination Phase
Objective Evaluation

N : Are you feeling something like hurt after I paired you

Nasogastrointestinal Tube
P : I just feel little not pleasant.
N : oh it will be better soon
Subjective Evaluation
N : Can you tell me why I do this action ?
P : Yes nurse to make me easy when I am eating.
Follow Up-plan
N : Verry good mam. Do you have any question mam ?
P : Oh I dont think so nurse
N : Ok if you no question. I have finished , if you need my help again you
can call me , just
call me in the nurse office.
Contracts Up-coming
N : Tomorrow I will come back again to your room to check your condition
at eight oclock, do you agree mam ?
P : Yes nurse I agree
N : Ok mam I will permitted you now. Be better mam
P : Of course thank you very much nurse.