scholarly journals Analysis of Standardized Nursing Languages Application in the Context of Nursing Diagnosis in Hospital in Indonesia

2021 ◽  
Vol 9 (T6) ◽  
pp. 173-178
Author(s):  
Irman Somantri ◽  
Nanan Sekarwana ◽  
Ati Surya Mediawati ◽  
Vimala Ramoo ◽  
Nor Aziyan Yahaya ◽  
...  
Keyword(s):  
Nursing Care ◽  
Simple Random Sampling ◽  
Professional Organizations ◽  
P Value ◽  
Standard Language ◽  
Nursing Diagnosis ◽  
Open Questions ◽  
Nursing Services ◽  
Nursing Diagnoses ◽  
Nursing Professional

Background. Documentation of nursing care is important in applying care to patients, in terms of their workload coming into the context of indirect nursing care. The focus of his study is to assess the application of nursing diagnoses in hospitals. The phenomenon that occurs in the order of nursing services was found that nurses only focused on documenting nursing assessments, but formulating nursing diagnoses was not clearly illustrated and there are still different perceptions in relation to writing a nursing diagnosis phrase. Objective. The purpose of this study is to identify the application of Standardized Nursing Languages in the context of nursing diagnoses in hospitals in Indonesia. Method. This study uses a descriptive correlation design using simple random sampling and obtained 132 nurse respondents. Closed questions (with answer choices prepared by the researcher) and open questions (in the form of frequently used diagnostic questions) were used. The instrument was first tested for validity and content validity with a CVI (0.9) and CVR (0.85) value, which means that the instrument is relevant and important to use. Results. It was found that almost half of the respondents (48.49%) nurses did not use a standard diagnosis. Only the level of education has a relationship with the application of the use of standard language nursing in Indonesia (p-value = 0.006) where the higher the education of nursing will have an impact on accuracy in diagnosing. Whereas for other variables such as gender, career ladder level and position in nursing were found no relationship with the ability in the accuracy of writing diagnoses. Conclussion. As the results shows that the use of the standard language of nursing is not fully used by nurses in Indonesia. Standardization and equalization of perception by nursing professional organizations are needed to be a guide for all nurses in carrying out documentation of nursing care

scholarly journals PENGARUH PELAKSANAAN PRE DAN POST CONFERENCE TERHADAP PENDOKUMENTASIAN ASUHAN KEPERAWATAN

2019 ◽  
Vol 2 (1) ◽  
pp. 21
Author(s):  
Fitrianola Rezkiki ◽  
Wiwit Febrina ◽  
Devi Anggraini
Keyword(s):  
Nursing Care ◽  
Simple Random Sampling ◽  
Internal Space ◽  
P Value ◽  
Sampling System ◽  
Before And After ◽  
Preliminary Study ◽  
Nursing Diagnoses ◽  
Responsible Manner ◽  
Smirnov Test

<p><em>Nursing documentation is a record that contains all the data needed to determine nursing diagnoses, planning, actions and evaluations that are arranged in a systematic, valid, and morally and legally responsible manner. Based on a preliminary study with a sample of 10 documentation of internal space medical records taken randomly only 4 (40%) were completely filled and 6 (60%) incomplete. This study aims to determine the effect of pre and post conference services on documenting nursing care. This study uses a pre-experimental design with one-group pretest-posttes design. The method of data collection is using observation sheets. Samples are taken with a simple random sampling system of 10 samples. The results of the study based on the Kolmogrov-smirnov test observations were carried out before and after being given a pre and post conference treatment of 10 statuses obtained a p-value of 0,000. The conclusion of this study is that there is an influence of the implementation of pre and post conference on the documentation of nursing care.</em></p><p><em><br /></em></p><p><strong>Keywords: </strong><em>Documentation, Pre and post conference</em></p><p><em><br /></em></p>

scholarly journals Analysis of Nurses' Knowledge in Determining Diagnosis of Islamic Spiritual Nursing Care in Sharia Hospitals

2020 ◽  
Vol 4 (1) ◽  
pp. 73
Author(s):  
Inggriane Puspita Dewi ◽  
Nurohmah Suwandi ◽  
Fikri Rizki Fadlurrahman
Keyword(s):  
Nursing Care ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Hospital Staff ◽  
Further Education ◽  
Cross Sectional ◽  
Average Value ◽  
Nursing Diagnosis ◽  
Level Of Knowledge ◽  
Nursing Diagnoses

One of the standards that must be met by sharia hospitals is to provide comprehensive Islamic spiritual services, by all hospital staff, including in nursing services. Determination of Islamic spiritual nursing diagnosis in sharia hospital services is the main thing that must be known by nurses. This study aims to analyze the level of knowledge of nurses in determining the diagnosis of Islamic spiritual nursing care in a Sharia hospital in Bandung, through a correlational research method with a cross sectional approach. The sampling technique used was simple random sampling, a total of 50 adult inpatient nurses who met the inclusion and exclusion criteria. The results showed that the average value obtained by nurses after filling out a questionnaire about determining spiritual nursing diagnoses was 44.16, the level of knowledge of nurses in determining spiritual nursing diagnoses in sharia hospitals was a sufficient category (42%), but on average they were not able to differentiate (C3) definitions between spiritual nursing diagnoses (≥50%). Spiritual care education and training have a close relationship with the knowledge level of nurses, with a significant value <0.0001 and a correlation coefficient of 1.00. The results of the research can be used as a reference for training and further education for nurses so that their knowledge can increase and become basic data for further research. Keywords: Knowledge, Nursing diagnosis, , Spiritual

scholarly journals Hubungan Karakteristik Perawat Dengan Pelaksana Asuhan Keperawatan Spiritual Islami Di Ruang Inap Dewasa Rumah Sakit Kabupaten Bandung

2020 ◽  
Vol 7 (2) ◽  
pp. 125
Author(s):  
Inggriane Dewi ◽  
Rahmat Sastro ◽  
Suryadi Alamsyah
Keyword(s):  
Nursing Care ◽  
Spiritual Care ◽  
Direct Action ◽  
Spiritual Needs ◽  
P Value ◽  
Training Experience ◽  
Cross Sectional ◽  
Care Nurse ◽  
Data Collection Technique ◽  
Nursing Diagnoses

Kesenjangan antara pemenuhan kebutuhan spiritual oleh perawat dengan yang diterima oleh pasien rawat inap dewasa di rumah sakit Kabupaten Bandung ini mendorong sebuah penelitian dengan tujuan menganalisis implementasi asuhan keperawatan spiritual muslim di ruang rawat inap dewasa. Desain penelitian yang digunakan dalam penelitian ini adalah deskriptif korelatif, dengan pendekatan Cross Sectional sampel dalam penelitian ini adalah semua perawat pelaksana yang melakukan tindakan langsung kepada pasien yaitu sebanyak 39 orang dan pasien yang telah dirawat di ruangan ≥ 3 hari. Teknik pengambilan data dengan menggunakan kuesioner bagi perawat dan pasien, selain itu peneliti melakukan observasi terhadap dokumentasi asuhan spiritual Islami yang telah dilakukan perawat serta wawancara pada perawat.Hasil penelitian menunjukan pelaksanaan spiritual care Islami di ruang rawat inap dewasa ini, sebagian besar belum terlaksana (53%), data didukung oleh pernyataan pasien (68%) mengatakan kurang mendapatkan asuhan spiritual dari perawat serta aspek pendokumentasian yang kurang (33%) untuk pengkajian dan penegakan diagnosa keperawatan, sementara untuk perencanaan, implementasi dan evaluasi 100% tidak terdokumentasi. Terdapat hubungan antara jenis kelamin, pelatihan dan lama kerjaperawat  dengan pelaksanaan asuhan keperawatan spiritual Islami (nilai P = 0,000) dan terdapat hubungan jenis kelamin dan lama kerja perawat dengan pendokumentasian asuhan keperawatan spiritual Islami dengan (nilai P 0,000).Kata kunci                : asuhan keperawatan spiritual islami; perawat; dokumentasiTHE CORRELATION BETWEEN NURSE CHARACTERISTICS AND THE IMPLEMENTATION OF ISLAMIC SPIRITUAL NURSING CARE IN ADULT WARD OF BANDUNG DISTRICT HOSPITAL Abstract  The gap between the fulfillment of spiritual needs by nurses and those received by adult inpatients room at Bandung Regency hospital encourages a study with the aim of analyzing the implementation of Muslim spiritual nursing care in adult inpatients. The research design used in this study was descriptive correlative, with a cross sectional approach. The sample in this study were all nurses who took direct action on the patient, as many as 39 people and patients who had been treated in the room ≥ 3 days. The data collection technique used a questionnaire for nurses and patients. In addition, the researcher made observations on the documentation of Islamic spiritual care that had been carried out by nurses and interviews with nurses. The results of the study show that the implementation of Islamic spiritual care in inpatient rooms today has not largely been implemented (53%), the data is supported by statements of patients (68%) saying they do not get spiritual care from nurses and lack of documentation (33%) for assessment and enforcement of nursing diagnoses, while for planning, implementation and evaluation they are 100% undocumented. There is a relationship between gender, training experience and length of work of nurses with the implementation of Islamic spiritual nursing care (value P = 0.000) and there is a relationship between gender and length of work of nurses with documentation of Islamic spiritual nursing care with (P value 0,000).. Keywords: islamicspiritual nursing care;nurse; documentation

scholarly journals Hubungan Karakteristik individu dan Perilaku Caring Perawat Dengan Kepuasan pasien di Ruang Rawat Inap RSUD Abdul Manap Jambi Tahun 2019

2020 ◽  
Vol 20 (3) ◽  
pp. 996
Author(s):  
Ernawati Ernawati ◽  
Bettywati E Tumanggor
Keyword(s):  
Nursing Care ◽  
Individual Characteristics ◽  
Bivariate Analysis ◽  
P Value ◽  
Caring Behavior ◽  
Nursing Services ◽  
Chi Square Analysis ◽  
Relationship Of ◽  
The Relationship

Nursing services have a big role to play in improving and determining the quality of health care. caring is an important component in nursing and is at the core of nursing practice because it contains humanistic values, respects human freedom of choice, emphasizes on improving ability and self-reliance, increasing knowledge and respecting every human being. Nurses who have value and caring spirit will have work behaviors that are in accordance with the principles of ethics due to the care of nurses who view clients as humanistic beings so motivated to provide high quality nursing services. This study is a quantitative study with a design description of correlation with a cross sectional approach to view the relationship of individual characteristics and caring behavior of nurses as independent variables and patient satisfaction as variable dependent. The goal is to know the relationship of individual characteristics and behavior of caring nurses with the satisfaction of inpatients of Abdul Manap Jambi Hospital. Samples of patients treated in the first and VIP inpatient rooms, how to take samples by accidental sampling. Data processing with chi-square analysis. Based on the results of the study the characteristics of individuals are mostly: male gender respondents (56.7%), low education (83.3%), age over 46 years (56.7%), and work (61.7%). Caring behavior of nurses is mostly well behaved (73.3%) and 70% of patients are satisfied with the services provided in the inpatient room of RsUD Abdul Manap Kota Jambi. The results of bivariate analysis there is no relationship of individual characteristics with the satisfaction of inpatients and there is a relationship of caring behavior of nurses with the satisfaction of inpatients in Abdul Manap Hospital Jambi City (p value 0.018). The results of the study are expected to improve the quality of nursing services, especially in providing nursing care by taking into account caring aspects to improve the satisfaction of inpatients. For nurses in the inpatient room consistently and further improve caring application in providing nursing care to patients especially in the fulfillment of basic needs and health education in the inpatient room.

scholarly journals Penerapan Supervisi Klinik Model Group dalam Pendokumentasian Asuhan Keperawatan di RSUD Indrasari Rengat

2020 ◽  
Vol 11 ◽  
pp. 53
Author(s):  
Deswita Deswita ◽  
Yulastri Arif ◽  
Supiyah Supiyah
Keyword(s):  
Clinical Supervision ◽  
Nursing Care ◽  
Random Sampling ◽  
Simple Random Sampling ◽  
Group Supervision ◽  
Regional Hospital ◽  
P Value ◽  
Group Model ◽  
Model Group ◽  
Clinical Model

Documentation of nursing care is one indicator of the quality of nursing services at the hospital. Documentation of nursing care at Indrasari Rengat Hospital 40% still does not meet the standards, both in completeness standards, implementation standards and relevance standards. The low achievement in documenting nursing care is due to the supervision factor, where supervision is carried out at Indrasari Rengat Regional Hospital is still not optimal, there is no feedback from the head of the room for documentation of nursing care. In this study, researchers applied group model clinical supervision at Indrasari Rengat Regional Hospital, with the aim of seeing the effectiveness of clinical model group supervision of nursing care documentation. This research was carried out from 20 January to 10 August 2015, with a quasi-experimental design, One-Group pretest-Posttest Design. The sample of this study was in the form of 35 patient documents in the inpatient room with simple random sampling technique. The results found a significant difference between documenting nursing care before and after the implementation of clinical model group supervision with p value <0.05. An increase in documentation of nursing care after the implementation of the group model clinical supervision at Indrasari Rengat District Hospital. Keywords: clinical model group supervision; documentation; nursing care ABSTRAK Dokumentasi asuhan keperawatan merupakan salah satu indikator mutu pelayanan keperawatan di Rumah Sakit. Pendokumentasian asuhan keperawatan di RSUD Indrasari Rengat 40% masih belum memenuhi standar, baik dalam standar kelengkapan, standar pelaksanaan dan standar relevansi. Rendahnya pencapaian pendokumentasian asuhan keperawatan disebabkan oleh faktor supervisi, dimana supervisi yang dilakukan di RSUD Indrasari Rengat masih belum optimal, tidak ada feed back dari kepala ruangan terhadap pendokumentasian asuhan keperawatan. Pada penelitian ini, peneliti menerapkan supervisi klinik model group di RSUD Indrasari Rengat, dengan tujuan untuk melihat efektifitas supervisi klinik model group terhadap pendokumentasian asuhan keperawatan. Penelitian ini telah dilaksanakan dari tanggal 20 Januari sampai 10 Agustus 2015, dengan disain quasi experiment, One-Group pretest-Posttest Design. Sampel penelitian ini berupa dokumen pasien di ruang rawat inap sebanyak 35 dokumen dengan tehnik pengambilan sampel simple random sampling. Hasil penelitian didapatkan perbedaan yang signifikan antara pendokumentasian asuhan keperawatan sebelum dan sesudah penerapan supervisi klinik model group dengan p value < 0,05. Terjadi peningkatan pendokumentasian asuhan keperawatan setelah penerapan supervisi klinik model group di RSUD Indrasari Rengat. Kata kunci: supervisi klinik model group; dokumentasi; asuhan keperawatan

scholarly journals The Implementation Of 3S (SDKI, SIKI, SLKI) to The Quality Of Nursing Care Documentation In Hospital’s Inpatient Rooms

2020 ◽  
Vol 9 (2) ◽  
pp. 1323-1328
Author(s):  
Wiwin Sulistyawati ◽  
Susmiati Susmiati
Keyword(s):  
Nursing Care ◽  
Nursing Intervention ◽  
P Value ◽  
Hospital Inpatient ◽  
Chi Square ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Chi Square Test ◽  
Quality Of Nursing

The implementation of 3S (SDKI, SIKI, and SLKI) is a benchmark used as a guideline for the enforcement of nursing diagnosis, nursing intervention, and a nursing outsider to provide safe, effective, and ethical nursing care. This study aims to analyze the implementation of 3S on the quality of documentation in hospital inpatient rooms. Research design correlation analysis with the cross-sectional approach. The research sample of implementing nurses in hospital inpatient rooms who have implemented 3S. Sampling techniques use sampling quotas. Based on Chi-Square test results obtained, p-value = 0.001 < α 0.005 . It means there is a relationship of application of 3S to the quality of nursing care documentation in hospital inpatient rooms. Based on the results of this study, the Head of Nursing is expected to implement 3S to improve the quality of nursing care documentation, which will have an impact on improving the quality of nursing services

scholarly journals THERAPEUTIC TOY IN PRIMARY CARE: CONTRIBUTIONS FOR THE SYSTEMATIZATION OF NURSING CARE

2021 ◽  
Vol 30 ◽  
Author(s):  
Letícia Roberta Pedrinho ◽  
Bianca Machado Cruz Shibukawa ◽  
Gabrieli Patrício Rissi ◽  
Roberta Tognollo Borotta Uema ◽  
Maria de Fátima Garcia Lopes Merino ◽  
...  
Keyword(s):  
Nursing Care ◽  
Multiple Case Study ◽  
The North ◽  
Coping Process ◽  
Nursing Diagnosis ◽  
Multiple Case ◽  
Nursing Diagnoses

ABSTRACT Objective: to analyze the role of the therapeutic toy as a tool for the nursing diagnosis in the setting of care for the child with diabetes. Method: a qualitative multiple-case study conducted with children diagnosed with Type 1 Diabetes mellitus and living in the inland of Paraná. The data were collected in 2018 through interviews, field diary and sessions using the therapeutic toy. Nursing diagnoses were elaborated according to the North American Nursing Diagnosis Association Taxonomy I and a targeted content analysis was performed, resulting in four categories. Results: using the dramatic therapeutic toy allows the child to show their perception of the disease and of the care provided. The sessions with the dramatic therapeutic toy made it possible to identify five nursing diagnoses, which were later worked on by means of an instructional therapeutic toy. Conclusion: systematization of assistance mediated by the use of the toy allows nurses to establish bonds with the child with diabetes and their family, revealing their perceptions of the disease and treatment, thereby stimulating a more active participation of the binomial in the management of this coping process.

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 Kepatuhan Perawat dalam Melakukan Dokumentasi Asuhan Keperawatan

2020 ◽  
Vol 3 (1) ◽  
pp. 17-23
Author(s):  
Ni Kadek Erna ◽  
Ni Luh Putu Thrisna Dewi
Keyword(s):  
Nursing Education ◽  
Nursing Care ◽  
Self Efficacy ◽  
P Value ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
Nursing Services ◽  
Cross Sectional Design ◽  
Spearman Test

Introduction: Nurses' lack of understanding and non-compliance in nursing documentation resulted in low quality of documentation and nursing services. One of factors which affects nursing documentation is self-efficacy. The purpose of this study was to know the correlation of self-efficacy and the compliance of nurses in the nursing documentation. Methods: This research used cross-sectional design with the descriptive documentation approach. The sample of the study was 23 nurses in a hospital recruiting with a nonprobability technique type i.e. total sampling. The inclusion criteria in this study were nurses who were willing to be respondents and had at least a diploma in nursing education. The instrument used was a self-efficacy questionnaire and the nursing care documentation compliance observation sheet. Data analysis used Rank Spearman test with the meaning level 0.05. Results: Most of nurses had high self-efficacy (69.9%) and majority nurse obey in nursing care documentation (73.9%). The statistic test showed p value = 0.000 < (0.05) with r = 0.898. Conclusion: This result confirmed that there is a relation between self-efficacy and the compliance of nurses in nursing documentation at hospital.

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.

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