The document discusses the roles and responsibilities of a nurse in developing, implementing, and evaluating nursing care plans. It explains that nurses contribute to care planning by prioritizing patient needs, using established nursing diagnoses. Care plans must be specific, measurable, achievable, reasonable, and time-bound. Nursing care plans can be nurse-initiated, physician-initiated, or collaborative. The implementation process involves reporting, performing care, setting priorities, documentation, and reassessing. Nurses provide care through effective communication, collaborate with the health team, and instruct patients. Evaluation determines if goals were met and patients' needs have changed. Nurses seek guidance to modify approaches and revise care plans as needed.
The document discusses the roles and responsibilities of a nurse in developing, implementing, and evaluating nursing care plans. It explains that nurses contribute to care planning by prioritizing patient needs, using established nursing diagnoses. Care plans must be specific, measurable, achievable, reasonable, and time-bound. Nursing care plans can be nurse-initiated, physician-initiated, or collaborative. The implementation process involves reporting, performing care, setting priorities, documentation, and reassessing. Nurses provide care through effective communication, collaborate with the health team, and instruct patients. Evaluation determines if goals were met and patients' needs have changed. Nurses seek guidance to modify approaches and revise care plans as needed.
The document discusses the roles and responsibilities of a nurse in developing, implementing, and evaluating nursing care plans. It explains that nurses contribute to care planning by prioritizing patient needs, using established nursing diagnoses. Care plans must be specific, measurable, achievable, reasonable, and time-bound. Nursing care plans can be nurse-initiated, physician-initiated, or collaborative. The implementation process involves reporting, performing care, setting priorities, documentation, and reassessing. Nurses provide care through effective communication, collaborate with the health team, and instruct patients. Evaluation determines if goals were met and patients' needs have changed. Nurses seek guidance to modify approaches and revise care plans as needed.
plans, prioritizes Pt. care needs & assists in revising such care plans. Uses established Nsg. Diagnoses in this planning process for Pts. With common, well-defined health problems S = Spesifik ( tujuan harus spesifik dan tidak menimbulkan arti ganda ) M = Measurable ( tujuan keperawatan harus dapat diukur, khususnya tentang, Perilaku klien; dapat di lihat, didengar, diraba, dirasakan dan dibau ) A = Achievable ( tujuan harus di capai ) R = Reasonable ( Tujuan harus dapat dipertanggungjawabkan secara ilmiah ) T = Time ( Tujuan keperawatan tercapai dalam jangka waktu yang ditentukan ) Types: Nurse Initiated, Physician initiated, Collaborative Elements: ◦ Requires decision making ◦ Scientific rationale based ◦ Psychomotor ◦ Clinical functioning Address: Who, What, When, Where, How The actual process of putting the PLAN into action, a team effort including: ◦ 1. Reporting ◦ 2. Performing the care ◦ 3. Setting Priorities ◦ 4. Documentation ◦ 5. Assessing & reassessing ◦ 6. Adhere to polices Provides care using effective communication, collaborating with other health team members and instructing Pts. Regarding health maintenance. Uses accepted standards of practice & records & reports implementation activities To judge or appraise Determine if expected outcomnes were met A constant on-going process for determining if patient goal(s) are being met or if patient needs are changing 3 Goal Possibilities: Met, Partially Met, Not Met Seeks guidance & continues collaboration with others in modifying Nsg. Approaches and revising Nsg. Care plans Evaluates client’s progress toward goals & the effects of interventions, revising care plans as needed