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 A legislação e a sistematização da assistência de enfermagem

2011 ◽  
Vol 1 (2) ◽  
pp. 63-65 ◽  
Author(s):  
Alba Lucia Bottura Leite De Barros ◽  
Juliana De Lima Lopes
Keyword(s):  
Data Collection ◽  
Nursing Care ◽  
Nursing Process ◽  
Nursing Diagnosis ◽  
Nursing Data ◽  
Professional Care ◽  
Planning Implementation ◽  
Nursing Professionals ◽  
Nursing Professional ◽  
Or History

O processo de enfermagem é o método utilizado para sistematizar a assistência de enfermagem no Brasil. Dessa forma, é imprescindível que os profissionais de enfermagem conheçam e apliquem as normas regulamentadoras do exercício. A Resolução Cofen 358/2009 estabelece que o processo de enfermagem deve ser realizado de modo deliberado e sistemático em todos os ambientes públicos ou privados em que ocorre o cuidado profissional de enfermagem. Ainda destaca as cinco etapas: coleta de dados (ou histórico), diagnóstico, planejamento, implementação e avaliação.Descritores: Enfermagem, Ética de Enfermagem, Legislação de Enfermagem.The legislation and the systematization of nursing careThe nursing process is the method used to systematize the nursing care in Brazil. This way, it is necessary that the nursing professionals know and apply the rules of the actions. The resolution Cofen 358/2009 establishes that the nursing process must be carried out deliberately and systematic in all public or private environments where there is a nursing professional care. Yet, it emphasizes the five stages: nursing data collection (or history), nursing diagnosis, nursing planning, implementation and nursing evaluation.Descriptors: Nursing, Nursing Ethic, Nursing Legislation.La legislación y la sistematización de la asisténcia de enfermeríaEl proceso de enfermería es el método utilizado para sistematizar la asisténcia de enfermería en Brasil. Desta forma, es imprescindible que los profesionales de enfermería conoscan y apliquem las normas reglamentadoras del ejercício. La Resolución Cofen 358/2009 estableces que el Proceso de enfermería deba ser realizado de modo deliberado y sistemático en todos los ambientes públicos ou privados en que ocurre el cuidado profesional de enfermería. Aunque destaca las cinco etapas: colecta de datos, diagnóstico, planeamiento, implementación y evaluación de enfermería.Descriptores: Enfermería, Ética de Enfermería, Legislación de Enfermería.

scholarly journals Diagnósticos de enfermagem para pacientes com tuberculose

2021 ◽  
Vol 95 (35) ◽  
Author(s):  
Maiana Evillyn Silva Santos ◽  
Luana Nunes Santos ◽  
Danielly Cardoso Mesquita ◽  
Joseilze Santos Andrade. ◽  
Lígia Mara Dulce Lemos ◽  
...  
Keyword(s):  
Nursing Care ◽  
Nursing Process ◽  
Nursing Diagnosis

Objetivo: sintetizar a produção científica sobre diagnósticos de enfermagem para pacientes com tuberculose. Método: trata-se de um estudo bibliográfico, descritivo, tipo revisão integrativa da literatura, sem limite temporal, realizado por meio das bases de dados:  LILACS, BDENF, IBECS, PUBMED, Portal Periódicos Capes e na Biblioteca Virtual SciELO. Utilizou-se os descritores: “tuberculosis”; “nursing diagnosis”, “nursing process” e “nursing care”. Resultados: foram identificadas 875 publicações; após o processo de seleção resultaram três artigos como amostra final. Seguida a análise dos estudos, verificou-se 60 diagnósticos de enfermagem relacionados aos pacientes com tuberculose. Em dois artigos avaliados, a Teoria das Necessidades Humanas Básicas foi o embasamento teórico do processo de enfermagem. Constatou-se que dentre as classificações de linguagens padronizadas de enfermagem, a mais utilizada foi a CIPE, seguida pela NANDA. Houve a predominância de estudos desenvolvidos em nível de assistência terciária e de estudo de caso. Considerações finais: O enfermeiro ao aplicar o seu julgamento clínico tem autonomia de levantar para os pacientes com tuberculose diversos diagnósticos de enfermagem, utilizando-se desse instrumento de trabalho para elaboração de planos de cuidados eficazes para o público-alvo em questão.

scholarly journals The Most Commonly Determined Nursing Diagnoses According to NANDA-I Taxonomy and Difficulties Using the Nursing Process in COVID-19 Outbreak

2021 ◽  
pp. 105477382110515
Author(s):  
Hale Tosun ◽  
Ayşe Tosun ◽  
Birgül Ödül Özkaya ◽  
Asiye Gül
Keyword(s):  
High School ◽  
Nursing Care ◽  
High School Graduates ◽  
Cross Sectional Study ◽  
Nursing Process ◽  
Sectional Study ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Acute Confusion ◽  
Nursing Diagnoses

The study was planned to determine the most common nursing diagnoses according to NANDA International (NANDA-I) taxonomy and difficulties experienced in using of nursing process in COVID-19 outbreak. The sample of the descriptive cross-sectional study consisted of nurses cared for patients with COVID-19 ( n = 114). Average age of nurses is 26.86 ± 6.68. Commonly determined nursing diagnoses according to NANDA-I taxonomy in patients with COVID-19 were imbalanced nutrition (66.7%), impaired gas exchange (40.4%), insomnia (21.1%), acute confusion (31.6%), hopelessness (96.5%), difficulty playing caregiver (84.2%), anxiety (38.6%) willingness to strengthen religious bond (71.9%), risk for infection (64.9%), nausea (49.1%). Twenty-four-years old and younger, high school graduates, caring for intubated patients, and those who stated that they did not use nursing diagnosis had more difficulty in using nursing process (<0.05). The use of nursing diagnoses and process for patients with COVID-19 is extremely important in ensuring individual and qualified nursing care.

Processo de enfermagem fundamentado na teoria do autocuidado de Orem a um paciente submetido à cirurgia bariátrica

2009 ◽  
Vol 3 (4) ◽  
pp. 814 ◽  
Author(s):  
Lidiany Galdino Felix ◽  
Maria Miriam Lima da Nóbrega ◽  
Maria Júlia Guimarães de Oliveira Soares
Keyword(s):  
Bariatric Surgery ◽  
Nursing Care ◽  
Clinical Case ◽  
Self Care ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Qualified Individual ◽  
Case Type ◽  
Nursing Diagnoses

Objective: to apply the nursing process fundament on the Theory of Orem’ Self-care, through the conduct of a report of clinical case, with a patient submitted to bariatric surgery. Methods: this is about a descriptive study, from qualitative approach, report of clinical case type, performed in a patient with morbid obesity, included in Bariatric Surgery Group of a teaching hospital in João Pessoa-PB city. For data collection was used a script adapted to Theory of Orem’ Self-care, which led to the identification of deficits of self-care and therefore to nursing diagnoses. It was then developed the plan of nursing care, with the determination of goals, objectives, method of assistance, type of system and nursing interventions. This study has been approved by the Research Ethics Committee of the Hospital of the Federal University of Paraiba (054/07). Results: from the identification of nursing diagnoses was established and implemented the plan of nursing care with the aim of restoring the patient to prevent postoperative complications, promote recovery and prepare you for the self-care. Conclusion: it is considered that the application of the nursing process, based on Theory of Orem’ Self-care, enabled the provision of assistance and qualified individual, encouraging the patient to participate actively in their treatment, but also to increase their responsibility in the outcome of care. Descriptors: nursing; nursing process; self care; bariatric surgery.

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 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 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.

scholarly journals Nursing Care of Patient with Acromegaly Disease — Case Report

2019 ◽  
Vol 8 (4) ◽  
pp. 162-169
Author(s):  
Seçil Melikoğlu ◽  
◽  
Yeliz Çulha ◽  
Hatice Kaya ◽  
Necmettin Tanrıöver ◽  
...  
Keyword(s):  
Nursing Care ◽  
Psychological Health ◽  
Pituitary Tumors ◽  
Signs And Symptoms ◽  
Nursing Process ◽  
Negative Effects ◽  
Systemic Complications ◽  
Individualized Care ◽  
Nursing Diagnosis ◽  
Disease Case

Pituitary tumors are the most common tumors of benign brain tumors, accounting for about one-fifth of all intra cranial tumors. Pituitary tumors include; nonfunctional adenomas and prolactinomas are followed by tumors that secrete growth hormone or acromegaly. Physical changes and systemic complications caused by acromegaly have negative effects on the bio-physiological, psychological and social dimensions of individuals. Diagnosis, treatment, care and follow-up of the disease; It requires a approach to multidisciplinary from endocrine to neurosurgery. The nurse should know the signs and symptoms of the disease, treatment, side effects that may be caused by the treatment, complications and the care interventions to solve the problems that arise and should plan the individualized care to improve the psychological health and quality of life by increasing the individual’s biophysiological functions. The use of the nursing process for the scientific and systematic realization of the care, as well as the use of the nursing process to get her with a model/theory, guide the nurse in the provision of individualized care. In this context, individualized care of the patient who is planned to be operated due to acromegaly, a rare disease, is discussed by integrating with the Model of Nursing. (JNNN 2019;8(4):162–169) Key Words: acromegaly, nursing care, nursing diagnosis

scholarly journals ELECTRONIC NURSING PROCESS PROGRAM IN NURSING CARE PLANNING: A SYSTEMATIC REVIEW

2021 ◽  
Author(s):  
Elif GÜNAY İSMAİLOĞLU ◽  
Seda ŞAHAN ◽  
Kemal YILMAZ ◽  
Serkan TİMUÇİN ◽  
Oğuzhan TAŞKIN
Keyword(s):  
Systematic Review ◽  
Nursing Care ◽  
Care Planning ◽  
Nursing Process
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