NURSING PROCESS

Indriana
Rakhmawati
Nursing Process?
 NURSING PROCESS
• A systematic, rational method of planning
and providing individualized nursing care
• Framework = method = formula

• Systematic approach
• Dynamic
• Interpersonal
• Patient-centered
• Goal-oriented
 Quote . . .
• Nurses are responsible for a unique
dimension of healthcare – “ the
diagnosis and treatment of human
responses to actual or potential health
problems”
 HISTORICAL PERSPECTIVE OF
THE NURSING PROCESS
Nursing process in the beginning previous to
developed :
• Nurse perform nursing care based on medical
order written by physician/doctor
• Focused on specific condition/disease, not
focused on basic needs.
• Nursing practice  mengacu pada pengalaman,
bukan pada metode ilmiah
 Historical ……
• Hall (1955)  originated the term of nursing
process.
• Wiedenbach (1963)  describe 3 steps in
nursing : observation, ministration of help,
and validation.
• Knowles (1967)  “five Ds” yang
diperlukan dalam praktik keperawatan :
discover, delve, decide, do, and
descriminate.
 Historical …..

• Discover & delve  mengumpulkan data ttg klien

• Decide  mengidentifikasi rencana tindakan
• Do  melakukan tindakan yang telah direncanakan
• Discriminate  mengkaji reaksi pasien terhadap
tindakan perawatan
 Historical …..
• ANA (1973)
standards of nursing practice  5 steps :
1. assessing
2. diagnosing
3. planning
4. intervention
5. evaluation
 Historical …
• Sr. Calista Roy (1976)
six steps nursing process :
1. Assessment : of client behaviors and
influencing factors
2. Problem identification
3. Goal setting
4. Intervention
5. Selection of approaches (implementation)
6. Evaluation
 Trends
• Initially plans of care were long and
handwritten

• Today’s care plans are

• Standardized
• Computerized
• Focus on similarities between illnesses, etc
 Nursing Process
as Problem Solving
• Combination of
• Trial-and-error
• Scientific process
• Intuition
 Purpose
• Provide
patient care
that is

• Scientific
• Holistic
• Creative
 Characteristics of the
Nursing Process
• Cyclic and dynamic nature
• Client centeredness
• Focus on problem-solving and decision-
making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking

Copyright 2008 by Pearson Education, Inc.

Skill in Nursing Process

Copyright 2008 by Pearson Education, Inc.

 Critical Thinking
• Ability to
• identify a problem • Form
• analyze it conclusions
• develop a response • Make
• follow through decisions
• Draw
• Based on
inferences
• experience
• reflect
• Knowledge
• Intuition
 Critical Thinking
Characteristics
• Independent thinker
• Fair-minded
• Intellectually humble
• Intellectually courageous
• Good faith & integrity
• Curious & persevering
• Disciplined
• Creative
• Confident
 ASSESING

Steps
(Parts) PLANNING

PLANNING

IMPLEMEN
TING

EVALUATING
 Assessing
• Goal :
Establish a database about the client’s
response to health concerns or illness
• Collecting data
• Organizing data
• Validating
“double-checking” or verifying data to
confirm that it is accurate and factual.
• Documenting data
Copyright 2008 by Pearson Education, Inc.
 ASSESSING
• Data : bio-psiko-sosio-spiritual.
• Method : interview, physical assessment
Ketrampilan :
• observing,
• communicating
 Diagnosing
• Analyzing and synthesizing data
• Goals
• Identify client strengths
• Identify health problems that can be
prevented or resolved
• Develop a list of nursing and collaborative
problems

Copyright 2008 by Pearson Education, Inc.

 DIAGNOSING
• proses analisa dan sintesa data
“diagnostic statement” atau diagnosa
keperawatan.

• Diagnosa keperawatan : pernyataan

tentang status kesehatn klien yang
aktual atau potensial/risiko.
 Planning
• Determining how to prevent, reduce, or resolve
identified priority client problems
• Determining how to support client strengths
• Determining how to implement nursing interventions in
an organized, individualized, and goal-directed manner
• Goals
• Develop an individualized care plan that specifies client
goals/desired outcomes
• Related nursing interventions

Copyright 2008 by Pearson Education, Inc.

 PLANNING
• perumusan tujuan, kriteria hasil, dan
• mengembangkan intervensi keperawatan
untuk menyelesaikan atau meminimalisir
masalah klien.
• sesuai diagnosa keperawatan.
 Implementing
• Carrying out planned nursing interventions
Independent, Interdependent, Dependent
• Goals
• Assist the client to meet desired
goals/outcomes
• Promote wellness
• Prevent illness and disease
• Restore health
• Facilitate coping with altered functioning
Copyright 2008 by Pearson Education, Inc.
 IMPLEMENTING
Activities of the Implementing Phase
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing nursing interventions
• Supervising delegated care
 Evaluating
• Measuring the degree to which
goals/outcomes have been achieved
• Identifying factors that positively or
negatively influence goal achievement
• Formative and Sumative
• Goal
• Determine whether to continue, modify, or
terminate the plan of care
Copyright 2008 by Pearson Education, Inc.
 EVALUATING
• Adalah mengkaji kembali respon klien
terhadap intervensi yang telah
dilakukan dan kemudian
membandingkan respon tersebut
terhadap standar yang telah ditetapkan
sebelumnya.
• Standar tersebut mengacu pada :
kriteria hasil.
 Components of the
Evaluation Process
• Collecting data related to the desired
outcomes (NOC indicators)
• Comparing the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem
status
• Continuing, modifying, or terminating
the nursing care plan
 KOMPONEN, DAN AKTIVITAS
PROSES KEPERAWATAN
KOMPONEN AKTIVITAS
ASSESSING • Mengkaji riwayat kesehatan
• Melakukan pemeriksaan fisik
• Mereview catatan medik : catatan
laboratorium, dll
• Mewawancarai orang terdekat
klien
• Menggunakan literatur
• Memvalidasi data pengkajian
KOMPONEN AKTIVITAS

DIAGNOSING • Organisasi data

• Bandingkan data dengan standar

• Mengelompokkan data
• Membedakan masalah kesehatan klien,
risiko, dan kekuatan
• Memformulasikan diagnosa keperawatan
KOMPONEN AKTIVITAS

PLANNING • Menetapkan prioritas dalam merawat klien

• Menulis tujuan dan kriteria hasil
• Memilih strategi perawatan
• Konsultasi dengan tim kesehatan lain
• Menulis nursing order
• Menulis rencana tindakan keperawatan
 KOMPONEN AKTIVITAS
IMPLEMENTING • Mengkaji ulang klien

• meng-update data dasar

• Mereview dan merevisi rencana
perawatan
• Melakukan atau mendelegasikan rencana
tindakan keperawatan yang telah disusun
KOMPONEN AKTIVITAS
EVALUATING • Mengumpulkan data tentang respon klien

• Membandingkan antara respon klien dengan

kriteria evaluasi
• Menganalisa alasan dari hasil yang dicapai
• Memodifikasi rencana perawatan