nursing process for child

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Mosby items and derived items 2005, 2001 by Mosby, Inc.

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


7/48Mosby items and derived items 2005, 2001 by Mosby, Inc.

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



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



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

nursing process for child

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