scholarly journals Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan

2020 ◽  
Vol 3 (2) ◽  
pp. 739-751
Author(s):  
Dheni Koerniawan ◽  
Novita Elisabeth Daeli ◽  
Srimiyati Srimiyati

This study aims to look at the quality of nursing care documentation at Myria Hospital Palembang. Analytic surveys are used to obtain an overview of nursing documentation as secondary data. Nursing care documents used were 105 documents by cluster sampling and measured using Q-DIO instruments, and analyzed descriptively. The results showed most of the medium quality in all dimensions, namely diagnosis as a process of 70 documents (67%), diagnosis as a product as many as 56 documents (53%), intervention as many as 66 documents (63%), and nursing outcomes as many as 67 documents (64%). The conclusions in this study indicate that 67% of records have moderate quality on the dimensions of diagnosis as a process, 53% of documents have a reasonable condition on the aspects of diagnosis as a product, 63% of records have moderate quality on the dimensions of intervention, and 64% of documents have average quality on the dimensions of output nursing. The results of the nursing process that have been obtained in this study illustrate the change or improvement in the improvement of symptoms that have a moderate quality to integrate with the nursing process.   Keywords: Diagnosis, Documentation, Intervention, Output

2019 ◽  
Vol 9 (11) ◽  
pp. 85
Author(s):  
Youko Nakano ◽  
Tetsuya Tanioka ◽  
Rozzano Locsin ◽  
Misao Miyagawa ◽  
Tomoya Yokotani ◽  
...  

Contemporary and future nursing practices are increasingly being designed with nursing theories as to its foundation. The aim of this article is to describe an in-service education program for nursing administrators centered on the theory of Technological Competency as Caring in Nursing (TCCN). This theory is framed chiefly within the concepts of technology, caring, nursing, and technological competency. Influencing the significance of in-service education is theory-based practice with advancing technologies in human caring. The in-service education program was organized as a five-month, one-hour a month lecture and discussion series. In each session, educational contents are focused on the nursing process as caring based on the theory of TCCN. This education is a plan that will gradually educate the nurse manager group, the mid-level nursing staff group, and finally to the staff nurse group. This hierarchically organized in-service educational plan aims to systematically improve their knowledge and practice situation for three years. During each session, theory content included “knowing persons as caring” as the nursing process based on the theory of TCCN. Participating in these lectures are envisioned to increase knowledge about TCCN for the purpose of improving the overall quality of nursing care outcomes. An organized educational plan will improve the quality of nursing care as influenced by the use of the theory of TCCN in the practice of nursing.


2019 ◽  
Vol 5 (2) ◽  
pp. 15-20
Author(s):  
Kencho Zangmo ◽  
Tshering Dema ◽  
Bhagawat Acharya ◽  
Sonam Sonam ◽  
Tshering Choden ◽  
...  

Introduction: Whether it is a written documentation or an oral communication, the practice and delivery of healthcare is debated to be critically dependent on effective and efficient communication. Nursing documentation is one of the principal sources of information about patient care and an important tool for communication. This descriptive study assessed both quantitative completeness and quality of nursing documentation by major in-patient units of Jigme Dorji Wangchuck National Referral Hospital. Methods: This cross-sectional study used D-catch tool. Data of randomly selected 317 patient records from six major in-patient units were entered into EpiData file. Using STATA version IC/14, descriptive statistics and multi variable analysis were carried out. Results: Overall quantitative completeness (M-3.4, SD-.59) of the nursing documentation was higher compared to the quality of the documents maintained (M-2.8, SD-.79). The basic and less time-consuming information such as admission data and vital signs charting are documented better compared to the more time consuming and complex documentation such as nursing care process. Conclusion: Systems should not only be in place to enhance documentation quantitatively but also consider uplifting the quality of the documents maintained. Initiating centralized admission system in the hospital may reduce nurses’ burden of clerical documentation, which will allow them to focus on quality nursing documentation and overall nursing care of patients.


2021 ◽  
Author(s):  
Chia-Hui Chu ◽  
Shu-Hui Weng

Nursing interruptions can suspend the nursing process and distracting the nurses’ attention. In a nursing information system, there are lots of pop-up windows to notify the nurses to complete the nursing records. These notifications can also interrupt the original work. We proposed an “Integrated Reminders of Nursing Written Assignment” system to reduce the number of interruptions from the nursing information system. The result showed that the number of pop-up windows decreased from 489.48 to 0 per shift. The completeness of the nursing records raised from 97.3% to 100%. The “Integrated Reminders of Nursing Written Assignment” can effectively reduce the frequency of nursing interruptions and improve the quality of nursing records.


Curationis ◽  
1989 ◽  
Vol 12 (1/2) ◽  
Author(s):  
Susanne W. Booyens ◽  
Leana R. Uys

An investigation was undertaken with the aim o f establishing standards for the documentation o f nursing care. Nursing care records in the medical and surgical units o f private and general hospitals in the PWV-area and the Cape Peninsula were audited. A considerable number o f deficiencies were identified in the daily record keeping o f nursing care.


2019 ◽  
Vol 13 (2) ◽  
pp. 538
Author(s):  
Jane Keyla Souza dos Santos Macedo ◽  
Isadora Pereira Farias ◽  
Thayse Gomes Almeida ◽  
Raquel Ferreira Lopes ◽  
Beatriz Alves Torres ◽  
...  

RESUMOObjetivo: identificar os requisitos necessários para a construção de um checklist voltado para a segurança em eletrocirurgia. Método: trata-se de um estudo quantitativo, descritivo, para a produção tecnológica, a ser desenvolvida em duas etapas. Identificar-se-ão, na primeira, os requisitos necessários, por meio de revisão integrativa, para o apoio ao processo de Enfermagem (cuidados de Enfermagem) em paciente submetidos a procedimentos cirúrgicos com o uso de eletrocirurgia. Desenvolver-se-á, na segunda etapa, um checklist de apoio ao processo de Enfermagem a partir dos requisitos identificados e eleitos na etapa anterior. Resultados esperados: pretende-se disponibilizar um checklist que sirva de ferramenta para o uso seguro do bisturi elétrico, assim como contribuir para a melhoria da qualidade da assistência de Enfermagem e, ainda, diminuir o número de injúrias causadas pelo mau uso desta tecnologia. Descritores: Eletrocirurgia; Enfermagem; Saúde; Cuidados de Enfermagem; Enfermagem Perioperatória; Eletrodos.ABSTRACT Objective: to identify the necessary requirements for the construction of a checklist for safety in electrosurgery. Method: this is a quantitative, descriptive study for technological production, to be developed in two stages. The first one will identify the necessary requirements, through an integrative review, to support the nursing process (nursing care) in a patient undergoing surgical procedures with the use of electrosurgery. A checklist of support to the Nursing process will be developed in the second stage, based on the requirements identified and elected in the previous stage. Expected results: it is intended to provide a checklist that serves as a tool for the safe use of the electric scalpel, as well as to contribute to the improvement of the quality of Nursing care and also to reduce the number of injuries caused by the misuse of this technology. Descriptors: Electrosurgery; Nursing; Cheers; Nursing care; Perioperative Nursing; Electrodes.       RESUMENObjetivo: identificar los requisitos necesarios para la construcción de un checklist orientado a la seguridad en electrocirugía. Método: se trata de un estudio cuantitativo, descriptivo, para la producción tecnológica, que se desarrollará en dos etapas. Se identificará, en la primera, los requisitos necesarios, por medio de revisión integrativa, para el apoyo al proceso de Enfermería (cuidados de Enfermería) en paciente sometidos a procedimientos quirúrgicos con el uso de electrocirugía. Se desarrollará, en la segunda etapa, un checklist de apoyo al proceso de Enfermería a partir de los requisitos identificados y elegidos en la etapa anterior. Resultados esperados: se pretende disponer un checklist que sirva de herramienta para el uso seguro del bisturí eléctrico, así como contribuir a la mejora de la calidad de la asistencia de Enfermería y, además, disminuir el número de injurias causadas por el mal uso de esta tecnología. Descriptores: Electrocirugía; Enfermería; Salud; Cuidados de enfermería; Enfermería perioperatoria; Electrodos.


2019 ◽  
Vol 5 (5) ◽  
pp. 180-191
Author(s):  
Enny Eko Setyaningrum ◽  
Intansari Nurjannah ◽  
Anik Rustiyaningsih

Background: The existing standard of nursing language consists of NANDA-I for diagnostic language standard, Nursing Intervention Classification (NIC) for nursing intervention, and Nursing Outcome Classification (NOC) for nursing outcomes. One way to improve the quality of nursing care documentation is to provide training in the documentation system.Objectives: To determine the effect of providing NANDA-I, NIC, and NOC (NNN) nursing care documentation systems training on the quality of nursing documentation.Methods: This was a pre-experimental study with pretest posttest design without a control group.  Twenty-one nurses and eighty-six Medical Records (MR) of patients who were treated in the perinatal ward of Yogyakarta Regional Public Hospital were used as samples selected using purposive sampling. Those nurses were trained in the nursing care documentation system. The quality of nursing care documentation was measured using modified Quality of Diagnoses, Interventions and Outcomes (Q-DIO) instrument. Data were analyzed using Independent samples t-test with a confidence level of 95%.Results: The average of the scores of the quality of nursing documentation before training was lower (1.91) than the average after training (2.78). There was a significant difference in the quality of nursing documentation before and after training (p < 0.001).Conclusion: Training of NNN nursing documentation system could improve the quality of nursing documentation in the perinatal ward of Yogyakarta Regional Public Hospital.


2020 ◽  
Author(s):  
Kristin Natal Riang Gea

AbstrakManajemen asuhan keperawatan merupakan suatu proses keperawatan yang menggunakan konsep manajemen secara umum didalamnya seperti perencanaan, pengorganisasian, pengarahan dan pengendalian atau evaluasi. Peningkatan mutu pelayanan adalah derajat memberikan pelayanan secara efisien dan efektif sesuai dengan standar profesi, standar pelayanan yang dilaksanakan secara menyeluruh sesuai dengan kebutuhan pasien, memanfaatkan teknologi tepat guna dan hasil penelitian dalam pengembangan pelayanan kesehatan/ keperawatan sehingga tercapai derajat kesehatan yang optimal. Kualitas pelayanan keperawatan di rumah sakit tidak akan berjalan dengan baik apabila proses keperawatan yang dilaksanakan tidak terstruktur dengan baikKata Kunci : Manajemen Keperawatan, Kualitas Pelayanan,.standar proses keperawatanAbstract Nursing care management is a nursing process that uses general management concepts in it such as planning, organizing, directing and controlling or evaluation. Improving the quality of service is the degree of providing services in an efficient and effective in accordance with professional standards, service standards are implemented thoroughly in accordance with the needs of patients, utilizing appropriate technology and research results in the development of health services / nursing to achieve optimal health. The quality of nursing care in the hospital will not run properly if the nursing process does not properly implemented.Keywords: Management of Care of Nursing, Quality of Service, standard nursing process,


2005 ◽  
Vol 14 (10) ◽  
pp. 1260-1261 ◽  
Author(s):  
Hsu Nanly ◽  
Brian T.-H. Chen ◽  
Lay-lan Lee ◽  
Min-huey Chung ◽  
Pi-chu Lin

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