NURSING PROCESS

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 PENGERTIAN

Suatu proses pemecahan masalah yg digunakan

perawat dalam berinteraksi dengan pasien,
keluarga / orang yang penting bagi klien di dalam
memberikan askep (McFarland & McFarlane, 1997)
Tahapan 01 Pengkajian

Proses
02 Pendiagnosian

03 Perencanaan

04 Pengimplementasian

05 Pengevaluasian
 EVALUATION ASSESSMENT

IMPLEMENTATION DIAGNOSIS

PLANNING
 Pengkajian
Tahap I
Perawat secara sistematis mengumpulkan,
verifikasi, analisa, dan mengkomunikasikan data
tentang klien

pengumpulan menganalisa data

dan verifikasi sebagai basis untuk
data dari sumber tahapan berikutnya
Pengkajian: nurses play as a health detective
• Data collection (who, what, where, when, why and how)
Contoh:
Who: primary & secondary source
What: data subyektif dan obyektif
• Data analysis:
- validasi dan interpretasi data
- mengelompokkan data
- menetapkan data yang normal dan tidak
normal
ENM/FIKUI/2011 6
 Sumber data
• Klien
• Keluarga
• Anggota tim kesehatan
• Rekam medik
• Record lainnya
• Literature review
• Pengalaman perawat

ENM/FIKUI/2011 7
Jenis Data
Data Subjektif

Persepsi pasien tentang masalah kesehatan

mereka. Data ini biasanya meliputi perasaan
cemas, ketidaknyamanan fisik atu stres
mental
Data Objektif

hasil observasi atau pengukuran yang dibuat

oleh pengumpul data
 Nursing Diagnosis

Perawat memngintegrasikan apa yg telah diketahui

dari pengalaman sebelumnya dan pengetahuan ilmiah
serta praktiknya, menerapkan sikap berpikir kritis dan
standard intelektual dan merujuk pada standar praktik
dalam membuat diagnosa keperawatan yang
“reasonable, accurate and relevant”
 Nursing Doagnosis
It is a statement that
describes the client’s
actual or potential
response to a health
problems that the
nurse is licensed and
competent to treat
The second step of
nursing process
A clinical judgment
about individual, family
or community
responses to actual
and potential health
problems or life
processes
Planing
for Nursing
The nursing assessment and the formulations of nursing
diagnoses are essential to the planning step

Planning is a category of nursing behaviors in which the client-

centered goals and expected outcomes are established and
nursing interventions are selected to achieve the goals and
outcomes of care
During planning, priorities are set, in order to help the nurse
anticipate and sequence nursing interventions when client has
multiple problems
 Implementing Nursing Care

• The step where the nurse provides care to patient

• Nurse initiates and completes actions or interventions
necessary for achieving goals and expected outcomes of
nursing care
• Nursing intervention is any treatment based upon the
clinical judgment and knowledge that a nurse performs
to enhance the client outcomes
• Include both direct and indirect care
Direct Care Measure
* Assisting with daily living
activities Indirect Care
* Physical care techniques

• Communicating nursing
* Conseling interventions
* Teaching
* Controlling for adverse • Delegating, supervising
reaction and evaluating the work
of other staff members
* Preventive nursing actions
* The nurse evaluates whether the
client’s behaviors or responses Evaluation
reflect a reversal or improvement in a It is important to
nursing diagnosis or in maintenance evaluate each client
according to the
of a healthy state level of wellness or
* It measures the client’s response to recovery

nursing actions and the client’s

progress toward achieving goals
* Data are collected on an ongoing
basis to measure changes in
functioning, in daily living, and in
availability or use of external
resources
 Perbandingan Proses perawatan dan Proses Medis
Proses Perawatan
Pengkajian komprehensif yang mencakup
dimensi fisiologis, psikologis,
sosiokultural, perkembangan dan
spritual klien
Tujuan membantu klien dan keluarganya
beradaptasi terhadap penyakit
mereka dan untuk menghilangkan
masalah perawatan kesehatan
Diagnosa tingkat kesehatan / respons
terhadap penyakit atau proses
patologis, status emosional,
fenomena sosiokultural / tahap
perkembangan
Medis
sistem fisiologis dan
personal serta sistem
sosial.
untuk merancang rencana
pengobatan untuk
menyembuhkan penyakit /
proses patologis
mengidentifikasi status
penyakit spesifik. Fokus :
diagnosis dan pengobatan
terhadap penyakit.
Karakteristik Proses perawatan:

1. Tujuan
2. Sistematis
3. Dinamik
4. Interaktif
5. Fleksibel
6. Teoritis
THANK YOU