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Nursing Process for
ChildAndi Yudianto
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If you should die before me,
ask if you could bring a friend.
If you live to be a hundred,
I want to live to be a hundred minus one day,
so I never have to live,
without you.
True friendship is like sound health;
the value of it is seldom known
until it is lost.
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Peran Perawat Anak PHC
Pembinaan hubungan terapeutik
Pembela Anak/Keluarga
Promosi Penc. Primer Pendidik
Konseling
Pelaksana Koordinator
Perujuk
Pembuat perawat etis
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Disease Prevention Primary prevention protection from a
disease while still in a healthy state.
Secondary prevention early detectionand treatment of disease.
Tertiary prevention preventcomplications and to maintain healthonce the disease process has occurred.
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Pendekatan Responmanusia/ANA - NANDA
Exchanging saling take and give Communicating komunikasi terapiutik Relating ikatan/pertalian Valuing penghargaan Choosing alternatif pemilihan Moving pergerakan Perceiving penerimaan Knowing pengetahuan Feeling perasaan
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M. Gordon; 11 pola fungsikesehatan:
Pola pengelolaan sehat dan persepsi sehat
Pola metabolit nutrisi
Pola eliminasi
Pola Aktivitas dan kegiatan
Pola Istirahat dan tidur
Pola Persepsi kognitif dan daya nalar
Pola Konsep diri dan persepsi diri Pola Hubungan sosial dan peran
Pola Reproduksi dan seksual
Pola Toleransi terhadap stress koping
Pola Nilai Belief
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The Nursing Process
An organizational framework for thepractice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by the
nurse in caring for a patient
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Definition of the NursingProcess
An organized sequence of problem-solving steps used to identify and tomanage the health problems of clients
It is accepted for clinical practiceestablished by All Nation Nurses
Association
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Assessment
Data base assessmentcomprehensive information you gatheron initial contact with the person toassess all aspects of health status.
Focus assessment the data yougather to determine the status of a
specific condition.
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Sources of Data
Primary source: Client
Secondary source: Clients family,
reports, test results, information incurrent and past medical records, anddiscussions with other health careworkers
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ASSESSMENT
Observation
Interview
Types of questions
Environment (physical and
emotional) Spiritualconciderations
Examination
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Types of Data To Collect:
Objective data-observable andmeasurable facts (Signs)
Subjective data-information that only theclient feels and can describe(Symptoms)
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Sumber-sumber Data
Interview/riwayat kesehatan
Anak
Keluarga
Individual Significant
Observasi Interaksi Sosial
Pengkajian Perkembangan
Pengkajian Fisik Data Laboratorium
Konsultasi Profesi Kesehatan Lain
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Pengkajian Yang Lengkap
Data tentang anak dan kelas
Kebutuhan perawatan kesehatan
diuvaluasi Penyebabfungsi anak dan kelas
terganggu
Susun masalah-masalah yangmungkin ada.
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Interpretasi dan membuatkeputusan tentang data yangdikumpulkan
Tidak ada masalah kesehatan, tidak adaintervensi
Potensial disfungsi kesehatan , intervensiuntuk menfasilitasi promosi kesehatan
Aktual disfungsi kesehatan, intervensimeminimalkan disf (x) max kes naik
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Diagnosa Keperawatan
Pernyataan klinis tentang responindividu, keluarga, masyarakatterhadap masalah kesehatan / proseskehidupan baik aktual / potensial
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Diagnostic Statements
Name of the health-related issue orproblem as identified in the NANDA list
Etiology (its cause)
Signs and Symptoms
The name of the nursing diagnosis islinked to the etiology with the phraserelated to, and the signs and symptomsare identified with the phrase asmanifested (or evidenced) by
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3 Komponen : P. E . S.PROBLEM
P Menggambarkan respon anak terhadapberkurangnya pola kesehatan anak, keluargadan masyarakat.
Respon Gangguan proses kehidupan
Gangguan pola
Gangguan F (x)
Gangguan perkembangan
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ETIOLOGI
E Faal, situasi, maturasi yang menyebabkan masalah/pengaruh terhadap perkembangan
Menggunakan kategori diagnostik NANDA
Bervariasi penting untuk tindakan intervensi Selalu melihat Etiologi
Co/ : Non compliance in dieatary restriction
Etiologi yang mungkin :
< pengetahuan Menolak sakit
Sumber ekonomi lemah / rendah
Konflik budaya
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SIMPTOM
S : Derifat dari pengkajian pasien Merujukpada defisiensi karakteristik (membantumembedakan kategori diagnostik)
Masalah :
Kesehatan yang aktual
Katagore diagnostik berhubungandengan F (x) dan koping keluarga
Definisi karakteristik
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Cara prioritaskan masalah :
Fokus ancaman kehidupan
Fokus kepada keluhan / masalah
Fokus pada akibat dari masalah utama
Fokus kepada kebutuhan
Perawat harus bisa berkomunikasidengan anak dan keluarga
.
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PERENCANAANPerbedaan standar dengan
Asesment - Informasi khusus hanya masalah
Dx Perawatan - Semua masalah denganetiologi yang umum
Planning - Tujuan luas dan menggambarkantujuan pasien
Implementasi - Intervensi keperawatan luas
dan bisa diterapkan u/ sebagian besar Pasiendengan masalah
Evaluasi - Kemajuan pasien diharapkan bisadiidentifikasi.
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PERENCANAAN
Mengembangkan rencana dan tujuan.
Hasil * Meningkatkan status
kesehatan * Kondisi klinik
* Tingkah laku
Standar care plan
Individualised care plan
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Pada anak > dipakai individualisedcare planIndividualised
Informasi spesifik identitikan masalahanak dan keluarga
Khusus untuk anak dan keluarga rencanaasuhan langsung kepenyakit
Tujuan khusus dan menggambarkantujuan pasien
Kemajuan pasien secara aktual bisadiidentifikasi
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DOMAIN OF PROFESIONALNURSING OF PEDIATRIC
Dependent Perawat dalammelakukan tindakan sesuai medical orderyang didapat
Interdependent Implementasimelibatkan 2 disiplin ilmu
Independent Wewenang utuh
perawat untuk melakukan tindakankeperawatan
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The Nursing Process
Nursing Diagnosis
Judgment or conclusion about the risk foror
actualneed/problem of the patient NANDA format
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DIAGNOSIS
Sort, cluster, analyze information
Identify potential problems and strengths
Write statement of problem or strength
Risk of infection related to compromisednutrition
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Nursing Diagnosis (cont.)
Potential for effective breastfeedingrelated to knowledge level and supportsystem
Prioritize the problems
Not a medical diagnosis
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NANDA North American NursingDiagnosis Association
Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromisednutritional state
Potential complication of seizure disorderrelated to medication compliance
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Planning
Establish the goals, interventionsand outcomes
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General Guidelines for SettingPriorities
1. Take care of immediatelife-threatening issues.
2. Safety issues.3. Patient-identified issues.
4. Nurse-identified priorities based on the
overall picture, the patient as a wholeperson, and availability of time andresources.
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Nurse Identified Priorities
Composite of all patients strengths andhealth concerns.
Moral and ethical issues. Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
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Identifying Client-centeredOutcomes
State what the patient will door experience at the completionof care.
Give direction to the patientsoverall care.
Patient behaviors not nurse behaviors!!
The patient will
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Steps for deriving outcomesfrom Nursing Diagnosis
Look at the first clause of the nursing dxand restate in a statement thatdescribes improvement, control or
absence of the problem.
Risk for infect ionr/t surgicalprocedure.
The client will demonstrate no signs orsymptoms of infection.
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Components of Outcomes
Subject: who is the person expected toachieve the outcome?
Verb: what actions must the person take to
achieve the outcome?
Condition: under what circumstances is theperson to perform the actions?
Performance criteria: how well is the personto perform the actions?
Target time: by when is the person expectedto be able to perform the actions?
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Nursing Interventions
Road maps directing the best ways to providenursing care.
Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
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Interventions
Direct intervent ion s: actionsperformed through interactionwith clients.
Ind irect intervent ion s: actionsperformed away from the client,
on behalf of a client or group ofclients.
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Predict, Prevent, and Manage
Focus on early intervention
Based on research
Predict and anticipate problems
Look for risk factors
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Collaborative Problems-NursesResponsibility
Correlating medical diagnoses or medicaltreatment measures with the risk forunique complications
Documenting the complications for whichclients are at risk
Making pertinent assessments to detect
complications
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Continued
Reporting trends that suggestdevelopment of complications
Managing the emerging problem withnurse- and physician-prescribedmeasures
Evaluating the outcomes
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Documenting the Plan of Care
To ensure continuity of care, the plan must bewritten and shared with all health carepersonnel caring for the client.
Consists of:
1. Prioritized nursing diagnosticstatements.
2. Outcomes.
3. Interventions.
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Documentation
Clear and concise
Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
Overview of symptoms
Diet
Each body system
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Documentation
Use patients own words in subjectivedataenclose in ___ (quotationmarks)
Avoid generalizations be specific
Dont make summative statements describe - e.g.patient is being ornery
should be patient resists instruction orpatient states Dont talk to me, I dontcare about that
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Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting
outcome achievement3. Deciding whether to continue, modify,
or terminate the plan
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If all my friends were
to jump off a bridge,
I wouldn't jump with them,
I'd be at the bottom to
catch them.
Hold a true friend with both your hands