CHAPTER I

REFERRENCE

What is a nursing handover?

A nursing handover occurs when one nurse hands over the responsibility of care for a patient
to another nurse, for example, at the end of a nursing shift. On average, nursing handovers
occur three times a day for each patient.

What styles of nursing handover exist?

In daily practice handovers are done in various ways, some handovers are done through
nurses talking to each other (verbal handovers). Others are done through nurses reading the
patient’s medical notes or through a combination of reading and talking to each other. In
some cases they are done at the patient’s bedside, so that the patient can contribute, if desired.

Why does the style of nursing handovers need to be investigated?

When a nurse hands over responsibility of care to another nurse there is an opportunity for
error if all the important medical information is not shared thoroughly and efficiently. Failing
to mention ‐ or grasp ‐ information may result in delays in treatment or diagnosis for the
patient, inappropriate treatment, or failure to provide appropriate care. Consequently, an
accurate handover of clinical information is essential to ensure continuity of care and
patients’ safety.
Resource:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009979.pub2/full
An effective handover in nursing brings numerous benefits, such as:

 Keeping patients’ care progressing smoothly.

 Making patients feel calmer and more confident in your healthcare service.
 Reducing the need for service users to repeat themselves.
 Helping to maintain records of a patient’s progress.
 Helping staff to deliver more consistent care.
 Allowing staff to communicate issues and concerns, so the next person can address
them swiftly.
 Saving staff time and energy, which helps to prevent stress and minimise mistakes.
 Helping staff feel more prepared and confident to do their job.
  Promoting a culture of teamwork and support in your care setting
Resource: https://www.highspeedtraining.co.uk/hub/effective-handover-in-nursing/
CHAPTER II

INTRODUCTION AND CONVERSATION

Cast:

Berlianda as primary nurse at evening shift and Mrs. Hani (patient at room C202 bed 1)

Nico as primary nurse at morning shift

Ina as associate nurse at evening shift and Mrs. Alice (patient at room C202 bed 3)

Susan as nursing unit manager

Wahyu as Associate nurse at morning shift

Rizka as associate nurse at morning shift

One day at Widya Mandala Hospital there will be a handover in the morning by
a nurse who works the night shift. It was still 6:45 a.m., there were some nurses in the
surgical room on the 3rd floor who had come, including Ns. Wahyu and Ns. Susan as
NUM. Night shift nurses and morning shift nurses do a small talking for a while to wait
for handover time and wait for the arrival of Ns. Nico and Ns. Dinda

W: good morning everybody... how are you today? I hope you all are well

S: morning Ns. Kevin.. I’m fine

I: morning Ns. Kevin.. I’m fine too (re-write documentation in the medical record)

W: Mmm.. nurse Susan.. I see you look very happy today. What happen?

S: Of course.. because today my boyfriend and his family from Brazil will come this
afternoon

B: (coming from the medicine room while carrying a patient's medication map) really? Ns.
Susan? Surely today there will be a meal together ..
W: That's what I think. Invite us Ns. Susan
I: (putting the patient's medical record on the trolly) Oh My God ... that's a private event Ns.
Susan with her future in-laws. How can you ask to be invited? But if you bring the food
tomorrow, you may also be Ns. Susan hehehe
S: I will send further invitations via J&T Express, okay?

I: up to you, the important thing is eating

W: It's the same ... then I'll go to the toilet first. By the way, it seems like Ns. Nico and Ns.
Dinda isn't here yet?

B: That's what I want to ask. It's already 6:50.

I: I'll contact both of them first ...

B: Good idea...  Ns. Wahyu you said you want to go to the toilet?

W: hehehehe ... don't start the handover without me.

B: Waiting per minute is valued at Rp. 10,000, okay?

W: Okay .. deal (Ns. Wahyu passed to the toilet) 2 minutes later

S: how's Ns. Nico and Dinda?

I: Ns. Nico is already in the lobby of the hospital, if Ns. Dinda coming in 5 minutes

S: Okay, thank you Ns. Ina At 06.55 Ns. Nico is coming. At 07.00 Ns. Dinda come

B: This is what we have been waiting for, finally coming. 10 minutes late do not get
afternoon snacks.

N: what are the new rules?

I: do not believe in Ns. Berlin.

D: sorry everyone I'm late again, I just came from Bandung at 02.00.

S: did you get some sleep?

D: I sleep only 3 hours.

S: You're free tomorrow, right?

D: That’s right Ns. Susan

And then Ns. Wahyu comes

S: Alright, let's start the hand over this morning on Thursday, March 5, 2020 and everyone
has gathered. We begin this morning by praying. Pray start .... amen ... today we will take
into account that we routinely carry out at each shift change, but before that I will register
the nurse first. For the night shift, Berlin nurses and Nurse Ina?

B: That’s right Ns. Susan

S: For morning shift, nurse Nico was the team leader this morning, with members of Wahyu's
nurses and Nurse Dinda.

I: Right Ns. Susan

S: I invite the night shift nurse to explain the condition of each patient.

B: Thank you Ns. Susan. I am Ns. Berlianda C3 surgical medical space. The number of
patients currently is 9 people with a level of dependency care starting from a total care of 4
people, partial care of 3 people, minimum care of 2 people. The patient identity for patients
with the first level of total care dependence is Mr. Dio, 49 yo, room C101 with a medical
diagnosis post laparotomy. The patient complained of still feeling weak and dizzy as well as
nausea. The implementation that has been carried out is the administration of Ondancentron
8 mg and Tramadol 100 mg via IV. Intervention that has not been done is to manage pain.
Today is the time to change the urine catheter. Vital sign = BP: 120/80 mmHg, body
temperature: 37, RR: 20x / minute, HR: 89x / minute. Doctor Yeri today will visit, for
uncertain hours.

The patient with the second level of total care dependence is Tn. Smith Anderson, 38 yo,
room C 201 with medical diagnosis post second day humeral fracture. The patient still
complained of pain in the left arm and from the nurse had given injection of Tramadol 100
mg and Metronidazole 5 mg / ml every 8 hours. Vital sign = BP: 115/70 mmHg, body
temperature: 36, RR: 20x / minute, HR: 75x / minute. Advice dr. Yeri the patient must be
tilted right every 2 hours.
 Next is the patient with the level of partial care dependence. The first patient is Mrs. Hani,
room C 202 bed 1 with a medical daignosis third day ileostomy, dr. Jeff. Patient complaints
are sometimes pain, pain scale 2, nausea rarely, vomiting once at 22:00. the patient has a

seafood allergy, the patient already wants to eat 10 tablespoons. Actions that have been
taken are giving permanent medication therapy and pain management. Later at 10:00, time
to post-surgery wound care Mrs. Hani changed her clothes at the same time.

N: how is the wound situation Mrs. Hani

B: the wound is still wet, no blood seepage, no redness around the incision area. Don't forget
later Ns. Dinda can treat his wound.

D: Okay

N: I had a chance to see the steroid cream runs out. Just a reminder to contact dr. Yeri to be
prescribed in pharmacy.

B: I asked the pharmacy yesterday, they said the stock was empty. Yes, after this I will
contact Dr. Yeri Thank you, Ns. Nico N: You're welcome. If there is no prescription steroid
cream, you can use sucralfate powder to prevent irritation.

B: Ahhh ... that's right. W: Ns. Nico only gives advice Ns. Berlin, prescription drugs
following the advice of Dr. Yeri

B: Okay. I only remember the name of the topical medication earlier and remembered earlier.

Next ... The first self care patient is Mrs. Eli, 35 yo, room C 202 bed 2 with medical
diagnosis post mastectomy on the fifth day and at 21.30 dr. Hanna is visiting and
tomorrow the patient plans to go home.

I: good morning everyone. I am Ns. Ina from C3 surgical medical room. I will submit data
about Mrs. Alice was Total Patient Care, 25 yo, post mastectomy, dr. Hanna, room C202
bed 3, complaints of pain in right upper arm wound with a scale of 6. Nursing problems of
acute pain, risk of infection and impaired skin integrity. Vital sign: BP: 110/80, HR: 89x /
minute, RR: 22x / minute, body temperature: 37. Interventions that have been made are
monitor vital signs, pain management, assess postoperative wounds. Giving injection of
 Tramadol 1 ampoule, Cefotaxim via IV 500 mg. Therapy: Tramadol 3x1 ampoule,
Cefotaxim 2x500 mg, infusion of 20 tpm NaCl.

D: isn't today Mrs. Alice also have to change the dressing post-surgery wound? It's already
the second day of Mrs. Alice post surgery.
B: Yes, right. Ns. Dinda please take care of the wound later.
D: Okay
W: Next patient ...
I: Okay, Mrs. Emma, 47 yo, with medical diagnosis CA Recti, dr. Jeff Weak general
condition, composmentis, anemic. Complaints of pain in the anal area, scale 7. BP: 100 /
60x / minute, HR: 80, RR: 22x / minute. Interventions already carried out: monitor vital
signs and pain management. Interventions that have not been administered mefenamic acid
500 mg orally. Therapy: Mefenamic acid 3x500 mg, vitamin B complex 3x1 tablets. Other
preparations: Abdomen ultrasound and albumin check. Consult to Internists. Colon
preparation in loop.
I: Mr. Smith, 67 yo, room C302 bed 2, with post-surgical medical diagnosis Debriment et
DM + cellulitis on the left upper arm, dr. Wendy. Complaints of pain with a scale of 7.
General condition is good, composmentis. BP: 130/70, HR: 80x / minute, RR: 24x / minute,
body temperature: 37. Hb: 10, KGD: 145. M2 diet, concentrated urine. Advice dr. Wendy
checks for hemoglobin, controls intake and output, checks vital sign every 3 hours, checks
KGD every 2 hours.
N: How much was the final month? Ina?
I: Last Hb is 10, check Hb again later don't forget
N: Okay ..
I: Mr. Collin, 35 yo, with medical diagnosis of hepatitis. Isolation room C 401. Patients are
weak, lack of appetite. Bilirubin 2.1 mg / dl, normal values 0.1-1.2 mg / dl. Do not have a
history of allergies. Vital sign: BP: 110/90, HR: 60 x / minute, RR: 24 x / minute, body
temperature: 36.7. M2 diet. IVFD RL 20 tpm. Advice dr. Leo check bilirubin and check
SGOT SGPT.
D: how much is the Mr. Collin’s hemoglobin?
I: The results of the complete blood lab have not yet come out, later you can take it.
D: Okay, Ns. Ina

I: Finish. Is something unclear?

W: Nothing, everything is clear. Let's go to the patient, and bring along a handbook of
friends.

S: Okay, please nurse Nico, Wahyu and Dinda directly to the patient's room.

D: Okay, Ns. Susan ... let's go ...

The four of them went to Mrs. Hani room’s in C202

S: Good morning .. I am Ns. Susan. I am the Nursing unit manager of C3 room. Today I and
my nurses are in the morning shift. This is Ns. Nico, this is Ns. Wahyu, and this is Ns.
Dinda

Mrs. Hani: Good morning.

D: I am Ns. Dinda, I'm a morning shift nurse. Are you with Mrs. Hani

Mrs. Hani: Yes, that's me

D: How is your condition today?

Mrs. Hani: I'm already a little better, it's not too painful.

D: Still nauseous?

Mrs. Hani: It's not like that ...

D: so Dr. Jeff has provided us with information that today is your time to replace the
ileostomy bag while treating the surgical wound area. Are you willing?

Mrs. Hani: Yes, Ns. Dinda I am willing.

D: Okay. Hmm Mrs. ... you told Ns. Berlin that you are changing clothes today.

Mrs. Hani: Right Ns, I have begun to be uncomfortable with my clothes

D: Okay mam. ... later I will help you clean yourself and change your clothes.
Mrs. Hani: Yes Ns. thanks.

D: Okay mom. Excuse me.

Then the four of them goes to Mrs. Alice room’s

S: Good morning .. I am Ns. Susan. I am the head of room C3. Today I and my nurses are in
the morning shift. This is Ns. Nico, this is Ns. Wahyu, and this is Ns. Dinda

Mrs. Alice: good morning .. how are you today?

W: good morning .. I'm fine. Mrs., I'm Ns. Wahyu, I'm a morning shift nurse. How is mother?
Mrs. Alice: I'm good Ns ...
W: still in pain with the post surgery?
Mrs. Alice: Yes, but the pain disappears when I change positions.
W: Now it hurts?
Mrs. Alice: No.
W: Did you eat this morning?
Mrs. Alice: I've had wheat bread this morning.
W: Wahh ... your snack is very healthy.
Mrs. Alice: Yes, my husband bought it. I also like wheat.
N: wheat to prevent Mrs. cholesterol ... very good. To speed up the healing of your surgical
wounds, you are advised to consume foods containing protein such as eggs, fish, tempeh.
W: Very true.
Mrs. Alice: Alright, thanks for your advice Ns ..
N: You’re welcome Mrs..

S: Then, excuse me Mrs.

They came out of the patient's room and returned to the nurse station to continue their
activities. Ns. Susan signed the results of the night hand over shift.

S: Friends ... let's go back to the nurse station. For hand over this morning it's over. Well ...
for those in the morning service, enjoy your work. And the night shift, before you go home,
you have to submit the results of the night shift hand over so that I can sign it. (do a
signatures). Night shifts you can go home and rest. See you later.
W: Ns. Susan, I just remembered that today is my actual night shift, but I'm too diligent.

S: Ns. Wahyu, do you want my hours to be added in 1 hour?

W: hehehehe ... don't want Ns. Susan ... I'm just kidding so that there is enthusiasm for work.

S: I'm already too excited. now you should prepare the injection.

W: okay (to the medicine storage room)