Diagnosa Keperawatan Dari Beberapa Penelitian Yang Diterapkan Di Rumah Sakit

AbstrakIndikator klinis yang akurat diperlukan untuk memvalidasi diagnosa keperawatan yang ditegakkan. Keakuratan indikator klinis ditentukan dengan kemunculan batasan karakteristik dan faktor yang berhubungan (etiologi). Diagnosa keperawatan yang valid sangat penting untuk mengurangi risiko kesalahan mendiagnosis. Penegakan diagnosis keperawatan yang sesuai standar bahasa keperawatan masih merupakan masalah di dalam dokumentasi keperawatan. Supaya bisa menghasilkan dokumentasi keperawatan yang baik, perlu didukung dengan adanya instrumen dokumentasi yang baik pula.Kata Kunci:Diagnosa KeperawatanAbtractAccurate clinical indicators are needed to validate the establishment of nursing diagnosis. The accuracy of clinical indicators is determined by the presence of defining characteristics and related factors (etiology). A valid nursing diagnosis is essential to reduce the risk of misdiagnosis. The maintenance of nursing diagnose that appropiate with standard nursing language is the problem in nursing documentation. To produce the good nursing documentation, it also needs supporting with good instrument documentationKeywords : nursing diagnose

Standar nursing language berbasis NANDA, NOC, dan NIC terhadap kualitas pengisian dokumentasi keperawatan

Pendahuluan: Perawat Indonesia harus dapat memberikan asuhan keperawatan yang komprehensif, mandiri (independen), sehingga pelaksanaannya dapat dipertanggungjawabkan dan dipertanggunggugatkan. Penelitian ini bertujuan untuk mengetahui pengaruh penerapan standar nursing languageterhadap kualitas pengisian dokumentasi keperawatan. Metode:Penelitian ini menggunakan metode kuantitatif dengan desain quasi eksperimen dengan jenis non equivalen without control group, after only design. Seluruh pasien dan perawat ruang Flamboyan dan Cempaka sebagai subjek penelitian. Teknik pengambilan sampel dengan total sampling. Instrumen yang digunakan adalah kuesioner dan dianalisis menggunakan uji non parametrik Wilcoxon test. Hasil:Terdapat peningkatan skor kualitas pengisian dokumentasi keperawatan setelah dilakukan pelatihan dan pendampingan dalam pengisian dokumentasi keperawatan. Hasil penelitian menunjukkanp-value0,000. Simpulan: Ada pengaruh yang signifikan terhadap peningkatan kualitas pengisian dokumentasi keperawatan berbasis NANDA, NOC dan NIC setelah dilakukan Penerapan Standard Nursing Language. RS diharapkan dapat menetapkan standard an melakukan monitoring secara berkala terhadap proses dokumentasi keperawatan.

Faktor-Faktor yang Mempengaruhi Kualitas Dokumentasi Keperawatan: A Systematic Review

Background: Nursing documentation is the most important part of the nursing profession, providing structured, consistent and effective communication to give quality services to patients based on professional and legal standards. Objective: To identify scientific evidence about the factors that influence the quality of nursing documentation. Methods: This systematic review was compiled based on study of literature from various journal data bases in the last 5 years, including Scopus, Sciencedirect, Proquest, and Google Scolar by conducting a comprehensive review using the PRISMA guidelines. Keywords used were "nursing documentation" OR "Standard Nursing Language" OR "quality of nursing documentation" AND "Quality Diagnosis Intervention Outcome". The articles used to compile this systematic review were 13 original articles on data base identification. Results : the factors affecting the quality of documentation were the level of knowledge, abilities, facilities, patient and nurse ratios, workplace climate, leadership and organizational models, training in nursing process standards, nursing language standards and accreditation. Conclusion: The quality of documentation increased when the affecting factors were improved. Suggestion: This systematic review can be used as a guideline in implementing nursing documentation in hospitals with the aim of producing quality nursing documentation. Keywords: nursing documentation; quality ABSTRAK Latar Belakang: Dokumentasi keperawatan merupakan bagian terpenting pada profesi keperawatan, menyediakan komunikasi secara terstruktur, konsisten dan efektif untuk memberikan pelayanan yang berkualitas pada pasien berdasarkan standar profesional dan legal. Tujuan: Untuk mengidentifikasi bukti ilmiah tentang faktor-faktor yang mempengaruhi kualitas dokumentasi keperawatan. Metode: Systematic review ini disusun berdasarkan studi literatur dari berbagai data base jurnal pada 5 tahun terakhir, meliputi Scopus, Science Direct, Proquest, dan Google scholar dengan melakukan review secara komprehensif menggunakan pedoman PRISMA. Kata kunci yang digunakan "nursing documentation" OR "Standard Nursing Language" OR "quality of nursing documentation" AND "Quality Diagnosis Intervention Outcome". Artikel yang digunakan untuk menyusun systematic review ini berjumlah 13 artikel original pada. Hasil: Faktor-faktor yang mempengaruhi kualitas dokumentasi adalah tingkat pengetahuan, kemampuan, fasilitas, rasio pasien dan perawat, iklim tempat kerja, model kepemimpinan dan organisasi, pelatihan standar proses keperawatan, standar bahasa keperawatan dan akreditasi. Kesimpulan: Kualitas dokumentasi meningkat apabila faktor-faktor yang mempengaruhi tersebut ditingkatkan dan diperbaiki. Saran: Systematic review ini dapat digunakan sebagai pedoman dalam pelaksanaan dokumentasi keperawatan di Rumah Sakit dengan tujuan menghasilkan dokumentasi keperawatan yang berkualitas. Kata kunci: dokumentasi keperawatan; kualitas

Terms of specialized nursing language for chronic renal patients undergoing conservative treatment

ABSTRACT Objectives: to validate the terms of the specialized nursing language used in the care of people with chronic kidney disease undergoing conservative treatment identified in the literature by mapping them with terms of the International Classification for Nursing Practice, version 2019, and representing them by means of a mandala. Methods: descriptive, documentary and methodological study. The terms were collected in 53 scientific articles, standardized and mapped with the terminology. The validation was performed by six nurses through a focus group. The Content Validity Index was used and terms with a value ≥ 0.80 were validated. Results: the normalization resulted in 957 relevant terms, of which 499 were constant and 458 not included in the terminology. Terms were validated when Content Validity Index was between 0.86 and 1.0. Conclusions: the study allowed the validation of terms that will contribute to unify the professional language of nursing in the care of people with chronic kidney disease.

Terms of specialized nursing language for people with pressure injury

ABSTRACT Objective: to validate the terms of the specialized nursing language used in care for hospitalized patients with Pressure Injury, identified in nurses’ records, mapping them with the terms of the International Classification for Nursing Practice (ICNP® 2017). Methods: methodological study, carried out at a School Hospital in 2018. It was performed: extraction of terms of medical records; normalization; cross-mapping between extracted terms and those in ICNP®; distribution in the seven axes; theoretical definition and validation of terms. Results: 27,756 terms were extracted. The normalization resulted in 370 relevant terms, being: 225 listed and 145 not listed in the ICNP®, being 60 similar, 13 more comprehensive, 38 more restricted and 34 without agreement, all of which are validated. Conclusion: this study identified and validated terms used by nurses to assist people with Pressure Injury. These may contribute to the unification of professional nursing language in care for these clients.

Specialized nursing terminology for the care of people with spinal cord injury

ABSTRACT Objective: To develop a bank of terms of specialized nursing language based on the International Classification for Nursing Practice (ICNP®) for the care of the person with spinal cord injury. Method: Descriptive, quantitative study guided by the guidelines of terminological studies. Terms were extracted from an official document of the Ministry of Health through use of a computer tool, and were standardized and mapped with the ICNP® Version 2015. Results: We identified 446 relevant terms, of which 265 were equal, 68 were similar, 23 were more comprehensive, 66 were more restricted, and 24 were not in concordance with terms of the ICNP®. Terms classified as equal and similar were considered as constant. Thus, the bank of terms consisted of 333 constant terms and 113 not contained in the classification. Terms included in the Focus, Action, Means and Location axes predominated. Conclusion: The bank of terms will contribute to the construction of the ICNP® terminology subset for the care of people with spinal cord injury.