THE NURSING PROCESS

1. THE NURSING PROCESS The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. “The nursing process provides the basis for critical thinking in nursing” (Alfaro-LeFavre, 1998, p. 64).

3. THE STEPS IN THE NURSING PROCESS Outcome identification

4. Assessment Techniques • The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation.

5. THE STEPS IN THE NURSING PROCESS Outcome identification

6. Types of Nursing Diagnoses Analysis of the collected data leads the nurse to make a diagnosis in one of the following categories: • Actual problems • Potential problems (including those where risk factors exist and there are possible problems) • Wellness conditions • Collaborative problems

7. THE STEPS IN THE NURSING PROCESS Outcome identification

8. OUTCOME/GOAL IDENTIFICATION AND PLANNING AS A STANDARD COMPONENT OF CARE: ANA STANDARDS Outcome Identification • The nurse identifies expected outcomes individualized to the client. Guidelines • Outcomes should be: • Based on diagnoses • Documented in measurable terms • Developed with the client and health care providers • Realistic and achievable Planning • The nurse develops a plan of care that prescribes interventions to attain expected outcomes. Guidelines • Planning should: • Be individualized to the client’s needs and status • Be developed with the client, significant others, and health care providers • Be documented • Promote continuity of care SMART

9. THE STEPS IN THE NURSING PROCESS Outcome identification

10. Categories of Nursing Interventions • Observation • Treatment • Prevention • Health Promotion

11. THE STEPS IN THE NURSING PROCESS Outcome identification

12. EVALUATION AS A STANDARD COMPONENT OF CARE:ANA STANDARDS EvaluationThe nurse evaluates the client’s progress toward attainmentof outcomes.GuidelinesEvaluation must:• Be performed as a systemic process• Occur on an ongoing basis• Lead to revision of the plan of care when needed• Involve the client, significant others, and othermembers of the health care team• Be documented

13. Form NCP (Nursing Care Plans) Pt. Name:Age:Room/Bed:Medical Diagnosis:Physician’s Name: *must be with reference(s)

14. Form NCP (Nursing Care Plans) Pt. Name:Age:Room/Bed:Medical Diagnosis:Physician’s Name:

15. Case Padatanggal 6 juli 2012, Ny. Rita datangkeRSAM bagiandaruratpada jam 07.00 dengankeluhan rasa nyeri di abdomen bagiankananbawah yang dialaminyasejakseminggu yang lalu. Setelahdiperiksadokter, ternyatapasienmengalami appendicitis. Kemudianpasiendibawakeruanganperawatan di kamar 203-1, olehperawat ER untukrawatinap. Kemudianpada jam 08.00 Ns.Merrymengecek VS pasiendengan T= 38,5oC, P=110x/m, R=24x/m BP=130/90mmHg. Pasienbelum BAB sejakduahari yang lalu, wajahpasientampakkemerahandanmeringiskesakitan, badanpasienterabahangatdanberkeringat, ptmasihmengeluhnyeripada abdomen kananbawahskalanyeri 8 dari (0-10), pasienmengatakannyeriterasasepertiditusuk-tusukbendatajam, nyerimenjalardari abdomen sampaiekstrimitasbawah, nyeridirasakanpadasaat kaki ditekukdanpadasaatberdiri. Pada jam 08.30 pasien di pasanginfusNS 15 tetes per menit di tangankanandan jam 09.00 pt di kompres air hangatolehperawatdanpasienjugadianjurkanminum air hangat 250cc/jam. Pada jam 09.30 pt di beriobatSanmol 25 gram (PRN), Sumagesic 500 mg (PRN) sesuai order dokter. Kemudianpada jam 09.45 pasien di pasangkateter no.18 denganbalon 15cc. Pada jam 11.20 pengambilan VS olehNs.MerryT=37,5 oC, P=95x/m, R=21x/m Bp=130/90mmHg. Pasiensudah BAK belum BAB, pasienmakan ½ porsi.