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

2016 ◽  
Vol 2 (1) ◽  
pp. 13
Author(s):  
Novita Verayanti Manalu

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.

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,


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 ...


10.3823/2365 ◽  
2017 ◽  
Vol 10 ◽  
Author(s):  
Louise Passos Vigolvino Macêdo ◽  
Alyne Fernandes Bezerra ◽  
Aran Rolim Mendes De Almeida ◽  
Thayana Rose de Araújo Dantas ◽  
Rafaella Felix Serafim Veras ◽  
...  

Objective: Investigate the understanding of nurses who work at a teaching hospital, in relation to NCS and the nursing process; ascertain facilities/difficulties related to the applicability of the nursing process in that service; and verify the opinions of those professionals for the improvement and/or effectiveness of the nursing process at the hospitalization units of the hospital. Method: Exploratory, descriptive study, with a qualitative approach. The sample consisted of 42 nurses who answered a questionnaire. The empirical material was analyzed and categorized based on the content analysis technique and discussed in the light of the literature. Results: From the participants' discourses, two categories of analysis emerged: 1) understanding of NCS as a tool to organize the Nursing work process and improve the quality of care; and 2) applicability of the nursing process at the various hospitalization units of the institution. Conclusion: The implementation and applicability of that method depend on not only the knowledge and motivation of the nursing professionals, but also on a strategic planning involving management and staff, from the recognition of their importance in order to obtain adherence and effective operationalization in practice. Descriptors: Nursing; Nursing Process; Professional Practice.


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 ◽  
...  

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.


2017 ◽  
Vol 16 (4) ◽  
pp. 46-51
Author(s):  
Marlena Padykuła ◽  
Ewa Czaja ◽  
Urszula Pieczyrak-Brhel ◽  
Maria Kózka

AbstractIntroduction. An essential part of specialized nursing care is a physical examination. In neurological nursing, its aim is to identify the symptoms that result from damage to the nervous system. There is no literature on the use of physical examination in neurological nursing.Aim. The aim of this work is to present the significance of the use of physical examination in the work of a neurological nurse.Summary. Performing physical examination by nurses in neurological departments requires specialized knowledge, as it allows you to make proper nursing diagnoses, define goals and plan nursing interventions. It contributes to the improvement of the therapeutic team cooperation and to the quality of nursing care provided.


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 1 (2) ◽  
pp. 91-97
Author(s):  
Rani Damanik

Sistem informasi merupakan salah satu atribut yang bermanfaat dalam meringankan proses dokumentasi dalam perawatan sekaligus menciptakan sejumlah tantangan dokumentasi baru. Sistem informasi dalam proses asuhan keperawatan dengan menggunakan Visual Basic 6.0 (VB) and Microsoft SQL Server 2000 yang dihubungkan dengan database. Standar proses dokumentasi asuhan keperawatan NIC, NOC, dan NANDA dengan tahapan, penelitian ini adalah untuk mengidentifikasi kepuasan perawat pada pelatihan sistem informasi dalam proses dokumentasi asuhan keperawatan di Rumah Umum Imelda Pekerja Indonesia Medan. Tehnik pengambilan data menggunakan desain penelitian quasy experiment, dengan uji paired sample t test. Populasi penelitian adalah perawat di Ruangan Melati Rumah Sakit Umum Imelda Pekerja Indonesia. Tehnik pengambilan sampel dilakukan dengan menggunakan rumus Cohen’s d melalui pendekatan purposive sampling maka diperoleh jumlah sample sebanyak 22 orang. Hasil penelitian yaitu ada perbedaan kepuasan perawat antara sebelum dan sesudah pelatihan sistem informasi dalam proses dokumentasi asuhan keperawatan di Rumah Sakit Umum Imelda Pekerja Indonesia dengan nilai (p=0.00), sehingga (p<0.05), dengan kata lain (Ha: μx1≠μx2), maka Ha diterima dan Ho ditolak. System information is one of the attributes that are useful in relieving the documentation process in the treatment of a number of challenges while creating new documentation. The nursing process based information systems is aimed to manage patient records based on the needs of the patients, using design Visual Basic 6.0 (VB) and Microsoft SQL Server 2000 as the database link. The steps in the nursing process, such as: assessment, diagnosis formulation, intervention, implementation and evaluation of nursing, then in doing the nursing process standards covering all aspects of nursing is done through a system of classification as NIC, NOC, and NANDA. The purpose of this study was to identify the statisfaction of information systems in the process of documentation of nursing care in Imelda Hospital. The study design was quash experiment, the population was nurses in Jasmine Room of Imelda Hospital. The samples were 22 respondents, taken by using Cohen's d formula, with a purposive sampling technique. The data were collected by using questionnaires and analyzed by paired sample t test. The test results showed that there were differences in effectiveness between before and after the application of information systems in the process of documentation of nursing care in a private hospitals in Medan with p-value = 0.00 (p <0.05) and Ha: μx1 ≠ μx2 which indicated that Ha was accepted and Ho was rejected.


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.


2020 ◽  
Vol 14 (1) ◽  
pp. 17-28
Author(s):  
Tomy Suganda ◽  
Rr Tutik Sri Hariyati

Paper‐based versus electronic‐based of health records in quality of nursing documentation: A literature review study.Background: Many technological developments in nursing services have emerged, one of them is electronic-based nursing documentation. The electronic nursing documentation has a good impact which increases the quality of service. But the readiness is still questionable.Purpose: Describing the quality comparison of electronic-based nursing documentation and paper-based nursing documentation.Method: This study uses a PRISMA literature review. Through the remote-lib.ui.ac.id database that is connected to various scientific publication pages such as, Scopus, Ebsco, PROQUEST Scholar-Articles with several key words such as electronic nursing documentation, nursing paper documentation, management information systems.Results: Electronic-based documentation has a higher level of quality documentation than paper-based documentation in terms of efficiency, effectiveness, patient focus and timeliness.Conclusion: Electronic-based documentation offers the optimization of nursing care, effective and efficient documentation, integrated nursing care and cost-effective through (paperless). Strong support from hospital institutions, organizations and government at the beginning of the nurse adaptation system and process is a challenge so that the application of electronic nursing documentation is realized properly.Keywords: Paper‐based; Electronic‐based; Health records; Quality; Nursing documentation.Pendahuluan: Pengembangan teknologi dalam pelayanan keperawatan banyak bermunculan, salah satunya dokumentasi keperawatan berbasis elektronik. Dokumentasi keperawatan elektronik memberikan dampak baik yang luarannya meningkatkan kualitas pelayanan. Namun kesiapan masih dipertanyakan.Tujuan: Menggambarkan perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan dokumentasi keperawatan berbasis kertas.Metode: Penelitian ini menggunakan tinjauan pustaka PRISMA. Melalui Database remote-lib.ui.ac.id yang terhubung dengan berbagai macam laman publikasi ilmiah seperti, Scopus, Ebsco, PROQUEST, Scholar-Artikel dengan beberapa kata kunci seperti dokumentasi keperawatan elektronik, dokumentasi keperawatan kertas, sistem informasi manajemen.Hasil: Dokumentasi berbasis elektronik memiliki tingkat kualitas dokumentasi lebih dibandingkan dokumentasi berbasis kertas secara efesiensi, efektifitas, fokus pada pasien maupun ketepatan waktu.Simpulan: Dokumentasi berbasis elektronik menawarkan keoptimalan melakukan asuhan keperawatan, dokumentasi efektif dan efesien, asuhan keperawatan terintegrasi serta cost-effective melalui (paperless). Dukungan kuat dari institusi rumah sakit, organisasi maupun pemerintah dalam permulaan sistem dan proses adaptasi perawat menjadi tantangan, agar penerapan dokumentasi keperawatan elektronik terealisasi dengan baik.


Sign in / Sign up

Export Citation Format

Share Document