Individualizing nursing care practice

2009 ◽  
pp. 27-72
Keyword(s):  
Physical Examination ◽  
Communication Skills ◽  
Mental Status ◽  
Nursing Care ◽  
Care Plan ◽  
Care Practice ◽  
Nursing Process ◽  
Nursing History ◽  
Examination Procedure ◽  
Status Assessment

The nursing process 28 Implementing the nursing care plan (or pathway) 30 The nursing history 32 Interviewing tips and communication skills 34 General mental/psychological assessment 36 Mental status assessment 38 Performing a nursing physical examination: overview 40 Performing a nursing physical examination: procedure 44 Assessing spirituality ...

scholarly journals ІНФОРМАЦІЙНІ МОДЕЛІ ЗАГАЛЬНОГО ДОГЛЯДУ ЗА ХВОРИМИ З ПІДТРИМКОЮ АЛГОРИТМІВ ПРИЙНЯТТЯ РІШЕНЬ НА ОСНОВІ КЛАСИФІКАТОРА ICNP

2018 ◽  
Author(s):  
V. P. Matrtseniuk ◽  
I. Ye. Andrushchak ◽  
I. V. Tsikorska
Keyword(s):  
Decision Trees ◽  
Nursing Care ◽  
Care Plan ◽  
Care Planning ◽  
Nursing Process ◽  
Plan Implementation ◽  
Physical Assessment ◽  
Nursing Diagnosis ◽  
Information Models

The paper presents information models of the nursing process through a conceptual presentation, including assessments of the patient's overall condition (nursing interviews, physical assessment, measurement, documentation analysis), nursing diagnosis, nursing care planning, determination of expected results, nursing manipulation, care plan implementation and care results evaluation. Particular attention is drawn to the possibility of using international terminology in describing nursing practices. Analysis of solutions is carried out using the terminology of decision trees.

scholarly journals Sistem Komputerisasi Untuk Pencatatan Laporan Asuhan Keperawatan Untuk Mahasiswa Ilmu Keperawatan

2019 ◽  
Vol 4 (4) ◽  
pp. 245
Author(s):  
Novan Aries Tuharea ◽  
Darpianto Sampe Payung ◽  
I Gede Purnawinadi ◽  
Reymon Rotikan
Keyword(s):  
Information Technology ◽  
Nursing Students ◽  
Health Services ◽  
Nursing Care ◽  
Computer Application ◽  
Care Plan ◽  
Nursing Process ◽  
Application Development ◽  
Computer Based

Proses keperawatan tidak terlepas dari peran seorang perawat dalam menjalankan tugas dan tanggungjawabnya dalam memberikan layanan kesehatan terhadap pasien. Salah satu hal yang penting dalam proses keperawatan adalah membuat dokumentasi. Hal ini menjadi penting oleh karena dokumentasi asuhan keperawatan atau proses keperawatan merupakan dokumen yang mencatat tindakan yang dilakukan oleh perawat terhadap pasien. Namun dengan beban kerja yang cukup tinggi membuat banyak perawat tidak dapat menyusun dokumentasi asuhan keperawatan dengan baik. Penelitian ini bertujuan untuk membuat sebuah metode pencatatan asuhan keperawatan dengan memanfaatkan teknologi informasi dengan membuat sebuah aplikasi komputer. Adapun dalam penelitian ini menggunakan mahasiswa Fakultas Ilmu Keperawatan, Universitas Klabat sebagai objek penelitian, dengan pertimbangan kemudahan dalam melakukan observasi dan wawancara untuk mengetahui kebutuhan dalam pengembangan aplikasi. Aplikasi yang dikembangkan mengikuti standar asuhan keperawatan dari NANDAInternational. Adapun hasil penelitian menunjukkan penggunaan aplikasi dalam membuat dokumentasi dan laporan asuhan keperawatan memberikan kemudahan bagi mahasiswa, dimana dapat mempersingkat waktu penyusunan laporan. Dan walaupun penelitian ini menggunakan mahasiswa sebagai objek penelitian, namun hasil penelitian juga dapat digunakan oleh perawat yang bekerja di Rumah Sakit.Kata Kunci — laporan, asuhan keperawatan, sistem terkomputerisasiThe nursing process is inseparable from the role of a nurse in carrying out its duties and responsibilities in providing health services to patients. One of the things that are important in the nursing process is to make the documentation or the nursing care plan. This is important because this documentation is a document that records the actions taken by nurses to patients. However, the workload is high enough for a nurse to be able to make the documentation.Therefore, in this study an attempt has been made to create a reporting tools for nursing care plan by utilizing information technology with creating a computer application. As in this study, the students at the Faculty of Nursing, Universitas Klabat are becoming the research object, with consideration of ease of observation and interviews to assess the needs in application development. The developed application follows the standards of nursing care documentation of NANDA-International. The research results indicate, that the use of applications in creating nursing care plan report provides convenience for students, which can shorten the time ofpreparation of the report. And although in this study using nursing students as research the object, but the computer application can also be used by nurses who are working at the hospital.Keywords — reporting, nursing care plan, computer-based system

scholarly journals Standaard verpleegvoorskrifte vir voorgeboorte kliënte

Curationis ◽  
1984 ◽  
Vol 7 (4) ◽  
Author(s):  
S. Venter ◽  
P. Du Plooy
Keyword(s):  
Nursing Care ◽  
Care Plan ◽  
Nursing Process ◽  
Scientific Education

Inspired after attending the course in scientific education for the nursing process, given by Mrs I.M. Miles at the J.G. Strijdom Hospital in February 1984, this standard nursing care plan for antenatal clients was born. It is based on the nursing module.

scholarly journals PROCESSO DE ENFERMAGEM APLICADO À IDOSOS COM ALZHEIMER QUE PARTICIPAM DO PROJETO ESTRATÉGIAS DE REABILITAÇÃO

2011 ◽  
Vol 16 (esp) ◽  
Author(s):  
Carine Magalhães Zanchi de Mattos ◽  
Solange Beatriz Billig Garces ◽  
Fátima Terezinha Lopes da Costa ◽  
Carolina Boettge da Rosa ◽  
Angela Vieira Brunelli ◽  
...  
Keyword(s):  
Health Status ◽  
Physical Examination ◽  
Nursing Care ◽  
Memory Impairment ◽  
The Elderly ◽  
Nursing Process ◽  
Care Assistance ◽  
Nursing Diagnoses ◽  
Stimulation Of

Introdução: O aumento da população idosa em todo o mundo exige a capacitação de profissionais para o atendimento nesta área. Metodologia: Este é um estudo qualiquantitativo do tipo exploratório-descritivo realizado através da entrevista e exame físico feito nos idosos. Objetivos: O objetivo geral deste trabalho foi aplicar  o processo de enfermagem nos idosos com alzheimer participantes do projeto da UNICRUZ. Os objetivos específicos foram:  Realizar a avaliação do estado de saúde atual destes idosos; Levantar os principais diagnósticos de enfermagem encontrados; Proporcionar aos sujeitos cuidados de enfermagem integral através da realiazação das prescrições de enfermagem. Resultados: Após a coleta de dados foram levantadas as informações em comum obtidas na entrevista e exame físico que apontam idade média dos sujeitos de 76 anos, 4 idosos têm o diagnóstico de alzheimer há 5 anos; 3 deles são hipertensos; 5 deles têm distúrbios do sono; 3 têm irmãos com alzheimer e todos têm falha de memória e limitação de amplitude de movivento. Dos diagnósticos de enfermagem, pode-se destacar -  tensão do papel do cuidador e risco para o trauma. Dentre as  principais prescrições de enfermagem estão - estimular cognição e memória, atividade física e participação social. Conclusão: Foi possível aplicar o processo de enfermagem nos idosos e com isso obter um maior conhecimento do estado de saúde deles,  descrever os diagnósticos de enfermagem e levantar pontos de intervenção através da prescrição de enfermagem para promover cuidados como o estímulo à participação em grupos e encaminhamento ao odontólogo que poderão auxiliar no tratamento dos indivíduos e previnir complicações, oferecendo-os assistência e orientações de enfermagem e transdiciplinar. palavras chave Processo de enfermagem. Cuidado de enfermagem. Assistência à idosos. Doença de Alzheimer.abstract Introduction: The aging population in the world requires the training of professionals providing care in this area. Methodology: This qualitative-quantitative study is of the exploratory-descriptive type conducted by interview and physical examination in the elderly. Objectives: The aim of this work was to apply the nursing process in the elderly with Alzheimer's UNICRUZ project participants. The specific objectives were to perform the evaluation of current health status of elderly; Raise the main nursing diagnoses found; subject providing comprehensive nursing care through nursing realization prescriptions. Results: After data collection, it was raised together the information obtained in the interview and physical examination suggest that the average age of subjects 76 years, has four seniors diagnosed with Alzheimer's five years, three of them are hypertensive, five of them have disorders sleep, have three siblings with Alzheimer's and all have memory impairment and limitation of range of movivento. Of nursing diagnoses, can be highlighted - the role of caregiver stress and risk for trauma. The main requirements are nursing - stimulate cognition and memory, physical activity and social participation. Conclusion: It was possible to apply the nursing process in the elderly and therefore gain a greater understanding of their health status, describing nursing diagnoses and raise points of intervention through the prescription of nursing care and to promote the stimulation of participation in groups and referral to a dentist that can help treat and prevent complications of individuals, offering them assistance and guidance to nursing and transdisciplinary. Key wordsNursing Process. Nursing care. Assistance to the elderly. Alzheimer's disease.

scholarly journals Esclerose múltipla: implementação do processo de enfermagem

2019 ◽  
Vol 78 (16) ◽  
Author(s):  
Mariana Melo da Cruz Domingos ◽  
Thatiane Monick de Souza Costa ◽  
Bárbara Coeli Oliveira da Silva ◽  
Francisca Marta de Lima Costa Souza ◽  
Cintia Capistrano Teixeira Rocha ◽  
...  
Keyword(s):  
Nursing Care ◽  
Intervention Study ◽  
Care Plan ◽  
Scientific Language ◽  
Nursing Process ◽  
Plan Evaluation ◽  
Impaired Memory ◽  
Priority Needs ◽  
Nursing Diagnoses ◽  
Expert Validation

Objetivo: Elaborar, validar, implementar e avaliar um plano de cuidados de enfermagem a uma paciente comEsclerose Múltipla. Metodologia: Trata-se de um estudo de intervenção metodológica realizado em uma paciente deum Hospital Escola na capital do Nordeste do Brasil, no período de junho de 2014. Seguiram-se as seguintes etapas:elaboração dos Diagnósticos de Enfermagem; proposta inicial de resultados e intervenções, elaboração de um planode cuidados e validação por especialista, implementação e avaliação do plano. Resultados: Elaborou-se, implementoue avaliou um plano de cuidados contendo cinco diagnósticos (mobilidade física prejudicada; dor crônica; sofrimentoespiritual; memória prejudicada; eliminação urinária prejudicada) cinco metas, cinco intervenções e 21 atividadesde enfermagem. Conclusões: Nota-se que a aplicabilidade do processo de enfermagem direciona as necessidadesprioritárias à paciente, permitindo uma linguagem homogênea e cientifica entre os profissionais de enfermagem.Palavras-chave: Esclerose Múltipla; Processos de Enfermagem; Cuidados de Enfermagem. ABSTRACTObjective: To develop, validate, implement and evaluate a plan of nursing care to a patient with multiple sclerosis.Methodology: This is a methodological intervention study in a patient of a Teaching Hospital in the capital ofNortheast Brazil, from June 2014. This was followed by the following steps: preparation of nursing diagnoses;Initial proposed outcomes and interventions, preparation of a plan of care and expert validation, implementationand plan evaluation. Results: We elaborated, implemented and evaluated a care plan with five diagnoses (impairedphysical mobility, chronic pain, spiritual pain, impaired memory, impaired urinary elimination) five goals, fiveinterventions and 21 nursing activities. Conclusions: It is clear that the application of the nursing process directsthe priority needs the patient, allowing a homogeneous and scientific language among nursing professionals.Keywords: Multiple Sclerosis; Nursing Process; Nursing Care.

Planned Nursing Care - A Main Element of Health Care Management for Ischemic Stroke Patients

2020 ◽  
Vol 13 (1) ◽  
pp. 35-40
Author(s):  
Meglena M. Balaburova ◽  
Makreta T. Draganova
Keyword(s):  
Health Care ◽  
Ischemic Stroke ◽  
Nursing Care ◽  
Care Management ◽  
Care Plan ◽  
Main Element ◽  
Nursing Interventions ◽  
Nursing Process ◽  
The European Union ◽  
Personalized Health Care

Summary Morbidity and mortality rate for stroke and ischemic stroke (IS), in particular, have ranked Bulgaria at a top place in the European Union. In the acute recovery stage of the disease, patients need continuous and personalized health care. The assessment of individual needs and adequate planning for nursing interventions, known as nursing process stages, are the basis of effective care management for patients, surviving ischemic stroke (PSIS). Therefore, the study and application of the nursing process in practice have proved to be an objective prerequisite for improving the quality and development of nursing care for PSIS. The objective of the study was to analyze the opinion of nurses working in clinics/departments of Neurology and Physiotherapy and Rehabilitation in three towns in Northern Bulgaria, on health care (HC) planning for PSIS and the required documentation. A direct anonymous inquiry was carried out, using specially designed questions to investigate the opinion of the respondents on the problems studied. Of the 81 individuals approached, 75 (93%) responded. Of these, 52 (69%) were familiar with the main points of the nursing plan concept, and 34 (65%) had heard about the concept during their basic training in the speciality. According to 67 (89%) of the respondents, a care plan was necessary to increase the health care (HC) efficiency in IS patients. Our results showed that healthcare professionals considered care planning an important tool to ensure continuity, evaluation and control of the care provided. According to the respondents, documenting health care and evaluating the activities performed will contribute to improve the quality of nursing care and promote research into nursing care.

scholarly journals Nursing care systematization: perceptions and knowledge of the Brazilian nursing

2019 ◽  
Vol 72 (6) ◽  
pp. 1547-1553
Author(s):  
Marcos Renato de Oliveira ◽  
Paulo César de Almeida ◽  
Thereza Maria Magalhães Moreira ◽  
Raimundo Augusto Martins Torres
Keyword(s):  
Nursing Care ◽  
Descriptive Study ◽  
Care Practice ◽  
Nursing Process ◽  
Planning Step ◽  
The Face ◽  
The Subject ◽  
Level Of Training

ABSTRACT Objective: to present the perception and knowledge of Brazilian nursing nurses and academics regarding Nursing Care Systematization. Method: a descriptive study, carried out in the first half of 2018. Results: of the 596 respondents, 86% perceived Nursing Care Systematization as very important, but only 60.9% used it in their care practice. Its use was statistically associated with a higher level of training. Non-utilization was associated with the perception that it is irrelevant and with little knowledge on the Nursing Process, even in the face of recognition of its obligation. Among professionals who wish to learn more about the subject, understanding the application of the process, especially the planning step, is perceived as a necessity. Conclusion: the relevance perception of systematization and levels of knowledge of the professional/academic are directly related to the use or not of Nursing Care Systematization principles.

scholarly journals PELAKSANAAN PEMERIKSAAN FISIK OLEH PERAWAT RUMAH SAKIT ADVENT BANDAR LAMPUNG

2016 ◽  
Vol 2 (1) ◽  
pp. 13
Author(s):  
Novita Verayanti Manalu
Keyword(s):  
Problem Solving ◽  
Physical Examination ◽  
Nursing Care ◽  
Nursing Process ◽  
Health Records ◽  
Purposive Sampling ◽  
Surgical Department ◽  
Important Stage ◽  
A Value

ABSTRAK Pendahuluan: Perawat masa kini dituntut untuk dapat mengaplikasikan metode pendekatan pemecahan masalah dalam memberikan asuhan keperawatan kepada klien. Pengkajian merupakan tahap yang paling utama dalam proses keperawatan, dimana pada tahap ini perawat melakukkan pengkajian data yang diperoleh dari hasil wawancara/anammesis, catatan kesehatan lain dan pemeriksaan fisik. Tujuan penelitian ini adalah untuk mengetahui kualitas pemeriksaan fisik oleh perawat diruang rawat inap medikal bedah dewasa di Rumah Sakit Advent Bandar Lampung. Metode: Deskriptif dengan melakukan observasi yang menggunakan checklist blangko yang berisi 69 butir pelaksanaan pemeriksaan fisik yang di adaptasi dari prosedur pemeriksaan fisik menurut Estes (2006). Populasi dalam penelitian ini adalah perawat di ruang rawat inap medikal bedah dewasa Rumah Sakit Advent Bandar Lampung yang berjumlah 46 orang dipilih secara purposive sampling. Pengukuran dilakukan dengan menghitung persentase. Hasil: Hasil pelaksanaan pemeriksaan fisik oleh perawat diruang medikal bedah dewasa Rumah Sakit Advent Bandar Lampung secara keseluruhan adalah 47,29% dengan kategori rendah. Aspek yang paling sering dilaksanakan adalah aspek pra-prosedur dengan nilai 68,2%, yang dikategorikan sedang. Sedangkan aspek yang kurang dilakukan adalah intra-prosedur(43.3%) dikategorikan kurang. Diskusi: Kualitas pemeriksaan fisik oleh perawat diruang medikal bedah dewasa di Rumah Sakit Advent Bandar Lampung termasuk dalam kategori rendah dengan interpretasi bahwa perawat kurang melakukan pemeriksaan fisik dengan benar yang mengakibatkan pengidentifikasian masalah kurang dan proses asuhan keperawatan tidak maksimal. ABSTRACT Introduction: Nurses today are required to be able to apply the methods of approach to problem solving in providing nursing care to clients. Assessment is the most important stage of the nursing process, which at this stage nurse doing analysis of data obtained from the interviews/anamnesis , other health records and the results of a physical examination . The purpose of this study was to determine the quality of a physical examination by a nurse in inpatient adult medical-surgical department in Bandar Lampung Adventist Hospital. Result: The results of the implementation of a physical examination in a medical-surgical wards by nurses in Bandar Lampung Adventist Hospital overall was 47.29% with the low category. The aspect most often implemented is the aspect of the pre-procedure with a value of 68.2%, which is average. While aspects less to do is intra-procedure (43.3%) were categorized less. Methode: Descriptive by observation that use blank checklist containing 69 statements of the implementation of the physical examination was adopted from the physical examination procedures by Estes (2006 ). The population in this study were nurses in inpatient adult medical-surgical Bandar Lampung Adventist Hospital totaling 46 people selected by purposive sampling . Measurement is done by calculating the percentage. Discussion: Quality physical examination rendered by nurses in an adult medical-surgical wards in Bandar Lampung Adventist Hospital is in the low category with the interpretation that the nurses less doing right physical examination resulting in unidentified problems and lack of nursing care was not optimal.

scholarly journals NURSING PROCESS FOR PATIENTS DIAGNOSED WITH ACCIDENTAL TETANUS

2021 ◽  
Vol 6 ◽  
Author(s):  
Cássio Baliza Santos ◽  
Deíze Carvalho Pereira ◽  
Ricardo Bruno Santos Ferreira ◽  
Elaine de Oliveira Souza Fonseca
Keyword(s):  
Infectious Disease ◽  
Nursing Care ◽  
Public Hospital ◽  
Descriptive Study ◽  
Care Plan ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Human Needs ◽  
Human Need ◽  
Basic Human Needs

Introduction: Accidental tetanus is an infectious disease with systemic repercussions and high lethality. Due to the complexity surrounding the care for these patients, nursing care must be conducted in a systematic, scientific and individualized way. Objective: To report the experience of systematization of nursing care to a patient affected by accidental tetanus in the light of the Basic Human Needs theory. Outline: This is a descriptive study, an experience report, developed in March 2019 after nursing care for a patient diagnosed with accidental tetanus, admitted to an intensive care unit (ICU) of a public hospital. Results: The elaboration of the care plan included information about the risk diagnosis and real diagnosis, nursing interventions and expected results, associated with the affected basic human need. Implications: It is well known that the provision of qualified care in the admission of patients with suspected accidental tetanus as well as their proper referral to the ICU contributes to a better prognosis.

scholarly journals Proposta de plano de cuidados de enfermagem para paciente queimado: estudo de caso

2019 ◽  
Vol 80 (18) ◽  
Author(s):  
Richardson Augusto Rosendo da Silva ◽  
Vinicius Lino de Souza Neto ◽  
Olga Alice Alencar Moreira ◽  
Fernanda Rafaela dos Santos ◽  
Rafael Medeiros dos Santos ◽  
...  
Keyword(s):  
Data Collection ◽  
Nursing Care ◽  
Public Hospital ◽  
Technical Assistance ◽  
Northeastern Brazil ◽  
Care Plan ◽  
Nursing Interventions ◽  
Burn Patients ◽  
Nursing Process

A Sistematização da Assistência de Enfermagem é caracterizada por ser uma ferramenta utilizada pelo enfermeiropara aprimorar os saberes da prática, otimizando, aperfeiçoando e aprimorando as técnicas assistenciais a partirdas novas evidências científicas. O estudo teve como objetivo elaborar e validar um plano de cuidados parapaciente queimado. Trata-se de um estudo de caso realizado no Centro de Tratamento de Queimados de umhospital público no nordeste do Brasil, no período de abril a maio de 2016. As etapas metodológicas do estudoforam estas: coleta de dados; elaboração dos diagnósticos, resultados e intervenções de enfermagem; elaboraçãoe validação do plano de cuidados. Após a análise dos dados, foi realizada a elaboração e a validação de umplano de cuidados com quatro diagnósticos, resultados e 24 intervenções de enfermagem. Diante disso, o estudopermitiu identificar os diagnósticos, resultados e intervenções de enfermagem para a aplicação na prática clínica,corroborando para o cuidado científico e direcionado as necessidades prioritárias.Palavras-chave: Processos de Enfermagem; Enfermagem; Queimaduras. ABSTRACTThe Systematization of Nursing Care is characterized by being a tool that nurses use to improve the practicalknowledge, optimizing, enhancing and improving the technical assistance will from the new scientific evidence.The study aimed to develop and validate a plan of care for burn patients. This is a case study in the Burn TreatmentCenter of a public hospital in northeastern Brazil, from April to May 2016. The methodological stages of thestudy were these: data collection; preparation of diagnoses / outcomes and nursing interventions; preparationand care plan validation. After analyzing the data produced and validated a care plan with four diagnostic / 24results and nursing interventions. Thus, the study identified the diagnoses / outcomes and nursing interventionsto implement in clinical practice.Keywords: Nursing process; Nursing; Burns.

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