THE STAGES OF THE PROCESS OF NURSING
1. Assessment
Objective data, i.e. data obtained through a measurement, inspection, and observations, such as body temperature, blood pressure, as well as skin color.
Subjekif data, i.e. data obtained from patients ' perceived grievances, or from the patient's family/other witnesses such as; head dizziness, pain and nausea.
As for the focus in data collection include the following:
Health status before and now.
The study is the effort of collecting data in a complete and systematic to be examined and analyzed so that the nursing and health issues in dealing with patients both physical, mental, social or spiritual can be determined. this stage includes three activities , namely, Data collection, Data analysis and the determination of the issue of health care as well as nursing.
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| The Nursing Step And Proses Skills |
a. Data collection
Purpose:
Obtained data and information on existing health problems in patients so that it can be determined that action must be taken to resolve the issue concerning aspects of physical, mental, social and spiritual as well as the environmental factors affected him. Such data should be accurate and easily analyzed.
Types of data include:Objective data, i.e. data obtained through a measurement, inspection, and observations, such as body temperature, blood pressure, as well as skin color.
Subjekif data, i.e. data obtained from patients ' perceived grievances, or from the patient's family/other witnesses such as; head dizziness, pain and nausea.
As for the focus in data collection include the following:
Health status before and now.
The pattern of the previous and present koping
a.Function status before and now
Response to medical therapy and nursing actions
The risk for potential problems
Things become a boost or strength of clients
b. data analysis
Data analysis is the ability in developing the ability to think rationally in accordance with background knowledge.
c. formulation of the problem
After the data analysis done, can be formulated some health problems. The health problems there are can be intervened with Nursing Care (Nursing Problem) but some are not and require more medical actions. Next are arranged in accordance with thepriority Nursing Diagnosis.
The priority issues are determined based on important criteria and immediately.
Important include kegawatan and if not resolved would cause complications, while Immediately include time for example in stroke patients are not aware then the action should be done to prevent more severe complications or death.
Priority issues can also be determined based on the hierarchy of needs according toMaslow, namely: life threatening Circumstances, circumstances that threaten health,perceptions of health and nursing.
2. Nursing Diagnosis
The nursing diagnosis is a statement that describes the response of a human (health status or risk a change of pattern) from individuals or groups where nurses in accountability can identify and provide for certain interventions for keep lowering the health status, limit, prevent and modify (Carpenito,2000).
3. the nursing Plan
All actions performed by the nurse to help clients shift from the current kestatus health status of health care in the describe results in expect (Gordon,1994).
Is the written guidelines for the care of the client. Treatment plan organized so that each nurse can quickly identify actions the care given. A nursing care plan in deduceexactly facilitate konyinuitas orphanage care from one nurse to another nurse. As a result, all nurses have the opportunity to provide the care that is of high quality andconsistent.
Nursing care plan written organize exchange of information by nurses in Department of Exchange reports. A written treatment plan also includes long-term client needs (potter,,1997)
4. Implementation of nursing
Is an initiative of the plan of action to achieve the goals that are specific. The implementation phase began began after the action plan was drawn up and is aimed at nursing orders to help clients achieve the goals expected. Therefore, a specific action plan is implemented to modify the factors that affect the health problems of the client.
As for the stages in the nursing action is as follows:
Phase 1: preparation
The early stages of this nursing action demanding to evaluate a nurse diindentifikasiin the planning stages.
Stage 2: intervention
The focus of care is the Act of implementation phase activities and the implementation of action planning to meet physical and emotional needs. The approach includesthe action of nursing actions: independent, dependent, and interdependen.
Stage 3: documentation
Implementation of nursing actions must be followed by a complete and accurate record-keeping to a Genesis in nursing process.
5. Evaluation
Planning the evaluation contains criteria of success and the success of the process of nursing actions. The success of the process can be seen by the way comparing between the process of with guidelines/plan the process. While the success of the action can be seen by comparing the patient's independence between levels in everyday life and the level of advancement of the health of the patient with the goal that has been on previous deduce.
Evaluation objectives are as follows:
The process of nursing care, based on the criteria/plan drawn up.
The results of the nursing Act, based on the criteria of success has been in evaluation plans deduce.
The Results Of The Evaluation
There are 3 possible outcomes evaluation, namely:
The goal is achieved, when the patients have showed improvements/advancementsin accordance with criteria that have been set.
The goal was reached in part, when the goal was not reached to the maximum, thus the need in the search for the causes and how to overcome it.
The goal is not reached, if the patient does not show the changes/progress at all even new problems arise. in this case the nurse need to examine in greater depth if there is data, analysis, diagnosis, actions, and other factors not appropriate that the cause is not the achievement of business objectives.
After a nurse do the whole process of nursing studies up to evaluation to the patient, all actions must be documented correctly in the documentation of nursing.
Formulation of nursing diagnosis:
Formulation of nursing diagnosis:
Actual: explain the real problems currently corresponds to data clinic found.
Risks: Explaining the real health problems will occur if the intervention is not done.
Possibilities: explains that the need for additional data to ensure nursing issues likely.
Wellness: Clinical Decision about an individual, a family or a community in transitionfrom a certain level of peace ketingkat peace.
Syndrom: diagnose, which consists of the actual nursing diagnosis group dar and high risk expected to appear/arising from an event or situation.
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