Nursing is a process or series of events in nursing practice provided directly to clients / patients in various health care arrangements. Implemented based on the rules of Nursing as a profession based on science and the issue of nursing, is humanistic, and based on objective needs of the client to address the problems faced by the client.Nursing care provided in an effort to meet the needs of clients. According to Abraham Maslow, there are five basic human needs, namely:
Physiological needs include oxygen, fluids, nutrients
The need for security and protection
The need for love and belonging
The need for self-esteem
The need for self-actualization
Based on the above understanding, it can be concluded that Nursing is a whole series of the nursing process is given to patients who continued with nursing tips on everything from assessment to evaluation in improving or maintaining optimal health.
Nursing goal
The purpose of the provision of nursing care include:
Helping individuals to self-
Encouraging individuals or community participation in health
Help individuals develop their potential to maintain optimal health in order not to depend on others in maintaining health
Helping individuals obtain optimal health
Nursing Process Functions
Nursing process works as follows:
Provide guidelines and systematic and scientific guidance for nursing personnel in solving client problems with nursing care.
Characterize the professionalization of nursing care through a problem-solving approach and the approach of effective and efficient communication.
Frees the client to get the optimum service in accordance with kebutuhanya kemandirianya in health.
Nursing Process Stages
1. Assessment
Assessment is an effort to collect data in a complete and systematic to be studied and analyzed so that the medical and nursing problems in dealing with patients physically, mentally, socially and spiritually to ditentukan.tahap includes three activities: Data Collection, Data Analysis and Determination of health problems and nursing.
a. The data collection
Purpose:
Obtained data and information about health problems in the patient so that it can be determined what action to take to resolve the issue related to the physical, mental, social and spiritual and environmental factors that influence it. The data should be accurate and easy to analyze.
The type of data include:
Objective data, ie data obtained through a measurement, inspection, and surveillance, such as body temperature, blood pressure, and skin colors.
Subjekif data, ie data obtained from the patient's perceived grievances, or the patient's family / other witnesses eg headaches, pain and nausea.
The focus of data collection include:
Previous and current health status
Coping patterns before and now
Function status before and now
The response to medical therapy and nursing actions
The risk for potential problems
The things that a push or force the client
b. Analysis of data
Data analysis is the ability to develop the ability to think rationally in accordance with science background.
c. Formulation of the problem
After data analysis, it may be formulated some health problems. There are health problems that can be interfered with Nursing (Nursing Issues) but some are not and require more medical treatment. Furthermore Nursing Diagnosis arranged according to priority.
Priority is determined based on criteria important issue and soon.
Important include the gravity and if not addressed will lead to complications, while soon include time for example in stroke patients who are not aware of the action to be taken to prevent more severe complications or death.
Priority issues could also be established according to Maslow's hierarchy of needs, which are: life-threatening condition, health-threatening conditions, perceptions of health and nursing.
2. Nursing Diagnosis
Nursing Diagnosis is a statement that describes the human response (health status or risk of changes in the pattern) of an individual or group in which nurses are able to identify and provide accountability for certain interventions to maintain health status decrease, limit, stop and change (Carpenito, 2000).
Formulation of nursing diagnoses:
Actual: Explains the real problem now corresponds to clinical data found.
Risk: Explaining the real health problems would occur if no intervention.
Chances: Explaining the need for additional data to ascertain the possibility of nursing problems.
Wellness: clinical decision about the state of the individual, family or community in transition from a certain level of prosperity the higher the level of prosperity.
Syndrome: diagnosis group consisting dar actual nursing diagnoses and the high risk that is expected to appear / arise because of an event or situation.
3. Nursing plan
All the actions taken by nurses to help clients shift from the current health status of health kestatus chronicled in the result that is expected (Gordon, 1994).
Is written guidelines for client care. The treatment plan organized so that each nurse can quickly identify actions the care provided. Nursing care plans are being formulated to facilitate proper care konyinuitas care from one nurse to another nurse. As a result, all nurses have the opportunity to provide high-quality care and consistent.
Nursing care plan written by a nurse organize the exchange of information in the report exchange service. Written treatment plan also includes a long-term client needs (Potter, 1997)
4. Implementation of nursing
An initiative of the plan of action to achieve a specific goal. Phase begins after implementation begins and the action plan prepared aimed at nursing orders to help clients achieve their desired objectives. Therefore, specific action plans implemented to modify the factors that affect the client's health issues.
The stages in the nursing actions are as follows:
Phase 1: preparation
The initial phase of this nursing action requires nurses to evaluate the identified at the planning stage.
Phase 2: intervention
Focus the implementation phase of care measures are activities and the implementation of action plans to meet the physical and emotional needs. Nursing actions approaches include action: independent, dependent, and interdependent.
Stage 3: documentation
The implementation of nursing actions to be followed by a complete and accurate records to an event in the nursing process.
5. Evaluation
Planning evaluation criteria includes measures of success and the success of the nursing process. The success of the process can be seen by comparing the process with guidelines / plan process. While the success of the action can be seen by comparing the patient's level of independence in their daily lives and health of patients with the progress of the goals formulated in advance.
Objective evaluation is as follows:
The process of nursing care, based on the criteria / plans have been prepared.
The results of nursing actions, based on the success criteria that have been formulated in the evaluation plan.
Evaluation Results
There are 3 possible results of the evaluation are:
Objectives are achieved, the patient has shown improvement / progress according to established criteria.
The purpose is achieved in part, if the goal was not reached its full potential, so it needs to find the cause and how to cope.
The purpose is not achieved, the patient did not show any change / progress at all in fact this problem arises baru.dalam nurses need to examine in greater depth whether there is data, analysis, diagnosis, action, and other factors that do not fit the cause is not achievement of objectives.
Having a nurse to do the whole process of nursing assessment to evaluate the patient, all actions must be documented properly in the nursing documentation.
Nursing documentation
Documentation is everything that is written or printed that can be relied upon as a record of evidence for an authorized individual (Potter 2005).
Potter (2005) also describes the purpose of the document is: 1. Communication
As a way for the health care team to communicate (explain) care clients including individual care, client education and the use of referral for repatriation plan.
2. Bill
financial documentation to explain the extent to which care agencies to indemnification (reimbursement) for services provided to clients.
3. Education
With this record the students learn about the patterns that must be met preformance various health problems and be able to anticipate the type of care needed clients.
4. Assessment
Records provide the data used to identify and support nurses nursing diagnosis and plan appropriate interventions.
5. Research
Nurses can use client records for a research study to gather information about certain factors
6. Audit and monitoring
Regular review of the information in the client's record provides a basis for the evaluation of the quality and timeliness of care provided in an institution.
7. Legal documentation
Accurate documentation is one of the best defenses against claims related to nursing care.
DOCUMENTATION NECESSARY TO IMPROVE EFFICIENCY AND MAINTENANCE CLIENTS IN INDIVIDUAL.
There are six critical importance in nursing documentation, namely:
1. Factual basis
Information about the client and the treatment should be based on the fact that what the nurse can see, hear and feel.
2. Accuracy
Client records must be accurate so that proper documentation be retained clients.
3. Completeness
The information included in the notes should be complete, contains brief information about perawtan clients.
4. Recency
Enter data in a timely manner is important in the treatment with the client
5. Organization
Nurses communicate information in a format or a logical sequence. Examples of records are regularly describe pain clients, assessment and intervention nurses and doctors.
6. Secrecy
The information given by one person to another with trust and confidence that the information will not be leaked.
Through nursing documentation will be seen the extent to which the roles and functions of nurses in providing nursing care to clients. This will be useful for improving quality of care and consideration in the career increment / promotion. Besides nursing documentation can also describe the performance of a Nurse
STORED DATA ANALYSIS WITH DIKAITKATAKAN nursing, nursing, nursing DEFINITION, Nursing Diagnosis, Evaluation, METHOD nursing, nursing DEFINITION, THE PRACTICE NURSING, NURSING ACTION
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