PROSES KEPERAWATAN
Nursing Process is a
“Profesional nurse’s
approach to identify,
diagnose and treat human
responses to health and
Proses
Keperawatan
Metode yang sistematis
Central pelayanan keperawatan
Karakteristik
Proses Keperawatan
Merupakan aspek legal keperawatan
Berdasarkan ilmu dan pola fikir kritis
Dilakukan secara terorganisir dan sistemik
Berfokus pada pasien
LIMA TAHAP
PROSES KEPERAWATAN
Berdasarkan National Council Of State Board Of
Nursing, 1982
1.
Tahap I
: Pengkajian
2.
Tahap II
: Diagnosa Keperawatan
3.
Tahap III
: Perencanaan
4.
Tahap IV
: Implementasi
CRITICAL THINKING and
ASSESSMENT PROCESS
Knowledge (Underlying disease process, normal grouwth
and development, normal psychology, normal assessment
findings, health promotion, assessment skills, comunication
skills)
Experience (Previous client care experience, validation of
assessment findings, observation of assessment
techniques)
Standards (ANA Scope and Standards of Nursing
Practice)
Attitudes (Perseverance, Fairness, integrity, confidence,
Pengumpulan Data
•
Sumber
: Pasien, keluarga, orang terdekat,
masyarakat, rekam medik.
•
Tipe data
: Subjektif dan objektif
•
Metode :
o
Observasi
o
Wawancara
DIMENSI PENGUMPULAN DATA
UNTUK RIWAYAT KESEHATAN
Emosi:
Status emosional,Konsep diri,
Citra Tubuh, sexuality,
mekanisme koping
Fisik dan Pertumbuhan: Persepsi
status kesehatan, maalah kesehatan,
terapi, pekerjaan, masalah anggota
keluarga
Sosial:
Status finansial, budaya,
lingkungan.hubungan sosial,
struktur dalam keluarga
Intelektual: Penampilan intelektua, tingkat
pendidikan, pola kmunikasi, memori jangka
panjang.
Spiritual: Ibadah, kegiatan
keagamaan, pengalaman religius,
kepercayaan dan nilai
Riwayat
Assessment of client’s health status
• Client, family, health care resources
• Nurse clarifies inconsistent or unclear information
• Critical thinking guide
Assessment of client’s health status
• Client, family, health care resources
• Nurse clarifies inconsistent or unclear information
• Critical thinking guide
Validate data with other sources
Validate data with other sources
Is additional data needed? Is additional data needed?
Interpret and analyze meaning of data Interpret and analyze meaning of data
Data Clustering:
Group sign and symptom Classify and organize
Data Clustering:
Group sign and symptom Classify and organize
Look for defining characteristics Look for defining
TAHAP II :
DIAGNOSA KEPERAWATAN
“ Penilaian klinik tentang respon
individu, keluarga atau komunitas
terhadap masalah kesehatan yang
aktual atau potensial”. (NANDA,
KOMPONEN
1.
Diagnosa Keperawatan
2.
Etiologi
RELATIONSHIP BETWEEN a
DIAGNOSTIC LABEL and ETIOLOGY
Problem Kelebihan volume cairan Balance cairan tidak seimbang Perubahan volume cairan: Berlebih Penurunan fungsi ginjal Peningkatan ur, cr, edema, sesak, CCT menurun Produksi urin menurun, Etiology Related to Related to
Nurse’s use critical thingking skills to identify best
etiology
DIAGNOSA KEPERAWATAN
•
AKTUAL
“Merupakan deviasi dari status kesehatan
yg normal (diagnosa, etiologi dan batasan
karakteristik)”
•
RESIKO
TAHAP III
PERENCANAAN
•
KOMPONEN
1.
Membuat prioritas
2.
Membuat kriteria hasil
3.
Menulis rencana keperawatan
GOALS OF CARE
Nursing
DX
Nursing
DX
Goal expected
outcome
Goal expected
outcome
Nursing Intervention
Choices,
capabilities
and
resources
of the
client
Choices,
capabilities
and
resources
of the
client
Research
findings
Research
findings
Knowledge
and
experience
of the nurse
Knowledge
and
•
Berdasarkan Hierarki Maslow (1968) :
TUJUAN & KRITERIA HASIL
•
Tujuan
: Sasaran atau hasil yang diharapkan
PERENCANAAN
•
TIPE RENCANA KEPERAWATAN :
1.
Diagnostik
2.
Terapeutik
3.
Penyuluhan
CONTOH
•
INTERVENSI DIAGNOSTIK
Kaji ROM ekstremitas atas pasien tanggal
6-4-2012
•
INTERVENSI TERAPEUTIK
CONTOH
•
INTERVENSI PENYULUHAN
Ajarkan pasien menggunakan walker tanggal
8-4-2012
•
INTERVENSI RUJUKAN
TAHAP IV
IMPLEMENTASI
•
Domains of Nursing Practice (Benner P, Calif 1984)
1.
The helping role
2.
The teaching coaching function
3.
The diagnostic and patient monitoring function
4.
Effective management of rapidly changing situations
5.
Administering and monitoring therapeutic interventions
and regimens
6.
Monitoring and ensuring quality of health care practices
Nursing Practice Includes
•
Cognitive Skills
•
Interpersonal Skills
DIRECT CARE
Activity of Daily living
Instrumental activities of Daily Living
Physical care techniques
Lifesaving measures
Counseling
Teaching
INDIRECT CARE
Communicating nursing
interventions
Delegating, supervising,
TAHAP V
EVALUASI
•
Komponen :
1.
Pencapaian kriteria hasil
2.
Keefektivan tahap-tahap proses
keperawatan
CONTOH
•
S
: Sekarang saya sudah dapat mengeluarkan
dahak saya
•
O
: Hasil auskultasi paru bersih
•
A
: Gangguan bersihan jalan nafas sudah teratasi
