KONSEP PROSES

KEPERAWATAN

By Rahmawati Maulidia
STIKES MAHARANI
 Definition:
Nursing A systematic, rational method of planning and
Process providing individualized nursing care.
Purpose of Nursing Process:
1. Identify a client health status and actual or
potential health care problems and needs.
2. Establish plans to meet the identifying needs.
3. Deliver specific nursing intervention to meet
needs.
 characteristic of nursing process:
Cont’s  It is cyclic and dynamic.
 It is client centered.
 It is planned.
 It is goal directed.
 It is universally applicable.
 Pengka-
jian

The Nursing
Process 1. Assessment
2. Nursing Diagnose
3. Planning Evaluasi
Diag- Inter-
vensi
4. Implementation nosis
5. Evaluation

Implemen-
tasi
Assessment  Assessment is the first step and involves critical
thinking skills and data collection; subjective
and objective
 Assessment : is the process of collecting,
validating, and clustering data
Nursing
Diagnosis  Nursing diagnosis : is identifying and
prioritizing actual or potential health problems
or responses.
 A nursing diagnosis, according to NANDA can
be actual, potential, possible, or collaborative
problems as well as wellness issues
Types of nursing diagnosis:
1- An actual diagnosis:
is a client problem that is present at the
time of nursing assessment, and is based
on the presence of associated signs and
symptoms.
2- A risk nursing diagnosis:
is a clinical judgment that a problem does
not exit, but the presence of risk
factors indicate that a problem is likely to
develop unless nurses intervention.
Maslow's
Hierarchy of
Needs
Cont’s  Basic Physiological needs: Nutrition (water and food),
elimination (Toileting), airway (suction)-breathing (oxygen)-
circulation (pulse, cardiac monitor, blood pressure) (ABC's),
sleep, sex, shelter, and exercise.
 Safety and Security: Injury prevention (side rails, call lights,
hand hygiene, isolation, suicide precautions, fall
precautions, car seats, helmets, seat belts), fostering a
climate of trust and safety (therapeutic relationship),
patient education (modifiable risk factors for stroke, heart
disease).
 Love and Belonging: Foster supportive relationships,
methods to avoid social isolation (bullying), employ active
listening techniques, therapeutic communication, sexual
intimacy.
 Self-Esteem: Acceptance in the community, workforce,
personal achievement, sense of control or empowerment,
accepting one's physical appearance or body habitus.
 Self-Actualization: Empowering environment, spiritual
growth, ability to recognize the point of view of others,
reaching one's maximum potential.
DIAGNOSA MENURUT
NANDA 2018-2020
JENIS
DIAGNOSIS
(SDKI)
Tanda/Gejala
Aktual Mayor dan Minor
Negatif
Diagnosis Risiko Faktor Risiko
Keperawatan

Positif Promosi Tanda/Gejala

Kesehatan Mayor dan Minor

Diadaptasi dari:
Standar Praktik Keperawatan Indonesia (PPNI, 2005); International Classification of
Nursing Practice – Diagnosis Classification (ICNP, 2015)
SDKI
  The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
Planning EDP guidelines
  Output Goal should be….
1.Specific
Cont’s
2.Measurable or Meaningful
3.Attainable or Action-Oriented
4.Realistic or Results-Oriented
5.Timely or Time-Oriented
Implementation

 Implementation : This is the “doing”phase of

the nursing process, in which you actually
implement the nursing interventions in the
plan.
Process of implementing:
1- Reassessing the client.
2- Determining the nurse need for assistance.
3- Implementing the nursing orders( strategies).
4- Delegating and Supervising.
5- Communicating the nursing actions.
Evaluation
 Evaluation : involves determining the
effectiveness of your plan. If the goals and
outcomes have not been met, you’ll need to
rethink the plan and work through the process
again to develop a more effective plan of care
for your patient
Process of evaluating client responses:
1- Identify the desired out comes.
2- Collecting data related to desired out comes.
3- Compare the data with desired out comes
4- Relate nursing actions to client goals/desired outcomes.
5- Draw conclusions about problem status.
6- Continue to modify or terminate the clients care plan