Study is an attempt to compile a complete and systematic data to be reviewed and analyzed to health and nursing problems of the patient’s face either physical, mental, social or spiritual can ditentukan.tahap includes three activities, namely data collection, data analysis and determination of health problems and nursing.
a. Data collection
Obtained data and information about health problems in patients who have to be able to determine what action to take to solve the problem concerning the aspects of physical, mental, social and spiritual and environmental factors that affect it. Such data must be accurate and easily analyzed.
Other types of data:
Objective data, that the data collected through a survey, inspection, and surveillance, for instance body temperature, blood pressure, and skin color.
Subjekif data, ie data obtained from the patient’s perceived grievances, or the patient’s family / other witnesses, namely, head dizzy, pain and nausea.
Now the focus of data collection include:
Previous and current health status
Koping pattern before and now
Function of previous and current status
Response to medical therapy and nursing actions
Risk for potential problems
The things that have been an inducement or force the client
b. Data analysis
Analysis of the data is the ability to expand our ability to think rationally according to background knowledge.
c. Formulation of the problem
Once the data analysis is done, it can be concluded some health problems. The health problems that could have intervened with Nursing (Nursing problem) but some are not and are more in need of medical action. Nursing diagnosis is further sorted according to priority.
Priority is determined based on criteria important problem and soon.
Includes significant turmoil and when not addressed will cause complications, including Instant whereas such time on stroke patients who do not consciously then action should be taken immediately to prevent more serious complications or death.
Priority problems can also be determined based on need according to Maslow’s hierarchy, namely: life-threatening condition, a condition that threatens the health, perceptions of health and nursing.
2. Nursing Diagnosis
Nursing diagnosis is a statement explaining the human response (health status or risk change pattern) from individuals or groups where caregivers are able to identify and provide accountability for certain interventions to maintain health status reduce, limit, prevent and transform (Carpenito, 2000).
Formulation of nursing diagnosis:
Actual: Explaining the real problem at this time according to clinic data found.
Risk: Explaining the apparent health problems will occur if no intervention is done.
Possibilities: Explaining that there should be additional data to ensure the possibility of nursing problems.
Wellness: Results of the clinic on the condition of individuals, families or communities in the transition from the level of certain prosperous prosperous ketingkat higher.
Syndrome: the diagnosis group consisting dar actual nursing diagnosis and the predicted high risk appear / arise because of a particular event or situation.
3. Nursing plan
All acts done by the nurse to help clients shift from the current health status of the health kestatus describe the expected results in (Gordon, 1994).
Is written guidelines for client care. Organized treatment plan so that each nurse can quickly identify treatment given action. Nursing care plan which accurately summarize konyinuitas facilitating care from a nurse care to other caregivers. As a result, all nurses have the opportunity to provide high-quality care and consistency.
Nursing care plan written by a nurse arranging exchange information in exchange reporting service. Written treatment plan includes a long-term client needs (Potter, 1997)
4. Implementation of nursing
Is an initiative of the plan of action to achieve a specific purpose. The level of implementation of the action plans initiated starting after compiled and directed at nursing orders to help clients achieve the desired purpose. Therefore a specific action plan implemented to modify the factors that affect the client’s health problems.
As for the levels of the nursing action is as follows:
Stage 1: preparation
Early stages of nursing action is demanded to evaluate the diindentifikasi nurse at the planning stage.
Level 2: the intervention
Focus the implementation of nursing actions are activities and implementation of the action plan to meet the emotional and physical needs. Nursing action includes action approach: independent, dependent, and interdependen.
Level 3: documentation
Implementation of nursing actions should be followed by a complete and accurate recording of an event in the nursing process.
Load planning criteria evaluation process results and outcomes of nursing actions. Results can be seen in the way the process of comparing the process with guidelines / plan process. While the results can be seen by comparing the actions of the patient’s level of independence in daily life and the patient’s level of health with the aim of progress that has been previously summarized.
Target evaluation is as follows:
Nursing care process, based on the criteria / articles that have been compiled.
Results nursing actions, based on the success criteria that have been formulated in the evaluation plan.
There are 3 possible results of the evaluation, namely:
The aim is reached, when the patient has shown improvement / progress in accordance with predetermined criteria.
Achieved some purpose, when the goal is not reached it’s full potential, so that should be looking for causes and ways to overcome them.
The aim is not achieved, when the patient showed no change / improvement at all but this problem arises baru.dalam caregivers need to examine in more detail whether there is data, analysis, diagnosis, action, and other factors that do not fit, which is why no achievement of goals.
Having a nurse to do the whole process of nursing research to evaluate the patient’s reach, all actions must be documented correctly in nursing documentation.
Documentation is everything that is written or printed as a record of reliable evidence of the authorized person (Potter 2005).
Potter (2005) also explained the purpose of the documentation, namely: 1. Communication
As a way for teams to communicate health (explain) treatment, including treatment of individual clients, client education and the use of returning a reference to an article.
Financial documentation to explain how to obtain compensation board treatment (reimburse) for the services provided to clients.
With this record learners should learn about patterns found preformance various health problems and be able to anticipate client needed treatment type.
Notes provide data used to identify and support nurse nursing diagnose and plan appropriate interventions.
Nurses can use client records for research studies to gather information about certain factors
6. Audit and monitoring
Regular surveys of client records provide information on the basis for the evaluation of the quality and timeliness of care provided in an institution.
7. Legal documentation
That accurate documentation is one of the best self defense against claims related to nursing care.
IMPORTANT DOCUMENTATION AND TREATMENT TO IMPROVE EFFICIENCY IN INDIVIDUAL CLIENT.
There are six key essential in nursing documentation, namely:
1. Factual basis
Information about the client, and low maintenance should be based on the fact that is what the nurse can see, hear and feel.
2. The accuracy
Notes client must be accurate until proper documentation is maintained client.
The information included in the notes should be complete, containing brief information about perawtan client.
Enter data in a timely manner important in the treatment with the client
Nurses communicate the information in a logical format or sequence. Sample entries clients regularly describe pain, study and intervention caregivers and physicians.
Information provided by a person to another person with the belief and confidence that they are not going