Nursing Process for Child

Andi Yudianto

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If you should die before me, ask if you could bring a friend.

If you live to be a hundred, I want to live to be a hundred minus one day, so I never have to live, without you.

True friendship is like sound health; the value of it is seldom known until it is lost.

Peran Perawat Anak PHC

Pembinaan hubungan terapeutik Pembela Anak/Keluarga Promosi Penc. Primer Pendidik Konseling Pelaksana Koordinator Perujuk Pembuat perawat etis
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Disease Prevention
Primary prevention protection from a disease while still in a healthy state.
Secondary prevention early detection and treatment of disease. Tertiary prevention prevent complications and to maintain health once the disease process has occurred.

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Primary Health Care For Child

Primer : menjaga kesehatan supaya tidak sakit, mis promosi kesehatan, gizi
Sekunder : menurunkan / meminimalkan komplikasi, mis anak yg sudah sakit tidak ber tambah sakit dengan penyakit lain. Tertier : menurunkan kecacatan dan rehabilitasi (terjadi kecacatan yg lebih lanjut).
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Pendekatan Respon manusia/ANA - NANDA

Exchanging saling take and give Communicating komunikasi terapiutik Relating ikatan/pertalian Valuing penghargaan Choosing alternatif pemilihan Moving pergerakan Perceiving penerimaan Knowing pengetahuan Feeling perasaan

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M. Gordon; 11 pola fungsi kesehatan:

Pola pengelolaan sehat dan persepsi sehat Pola metabolit nutrisi Pola eliminasi Pola Aktivitas dan kegiatan Pola Istirahat dan tidur Pola Persepsi kognitif dan daya nalar Pola Konsep diri dan persepsi diri Pola Hubungan sosial dan peran Pola Reproduksi dan seksual Pola Toleransi terhadap stress koping Pola Nilai Belief

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The Nursing Process

An organizational framework for the practice of nursing
Orderly, systematic

Central to all nursing care

Encompasses all steps taken by the nurse in caring for a patient

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A real friend is one who walks in when the rest of the world walks out

My father always used to say that when you die, if you've got five real friends, then you've had a great life.;

Definition of the Nursing Process

An organized sequence of problemsolving steps used to identify and to manage the health problems of clients
It is accepted for clinical practice established by All Nation Nurses Association

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Assessment
Data base assessment comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment the data you gather to determine the status of a specific condition.

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Sources of Data
Primary source: Client
Secondary source: Clients family, reports, test results, information in current and past medical records, and discussions with other health care workers

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ASSESSMENT
Observation
Interview Types of questions Environment (physical and emotional) Spiritual conciderations Examination
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Types of Data To Collect:

Objective data-observable and measurable facts (Signs)
Subjective data-information that only the client feels and can describe (Symptoms)

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Sumber-sumber Data
Interview/riwayat kesehatan Anak Keluarga Individual Significant Observasi Interaksi Sosial Pengkajian Perkembangan Pengkajian Fisik Data Laboratorium Konsultasi Profesi Kesehatan Lain

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Pengkajian Yang Lengkap

Data tentang anak dan kelas
Kebutuhan perawatan kesehatan diuvaluasi

Penyebabfungsi anak dan kelas terganggu

Susun masalah-masalah yang mungkin ada.

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Interpretasi dan membuat keputusan tentang data yang dikumpulkan

Tidak ada masalah kesehatan, tidak ada intervensi
Potensial disfungsi kesehatan , intervensi untuk menfasilitasi promosi kesehatan Aktual disfungsi kesehatan, intervensi meminimalkan disf (x) max kes naik

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Diagnosa Keperawatan
Pernyataan klinis tentang respon individu, keluarga, masyarakat terhadap masalah kesehatan / proses kehidupan baik aktual / potensial

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Diagnostic Statements

Name of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase related to, and the signs and symptoms are identified with the phrase as manifested (or evidenced) by
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3 Komponen : P. E . S. PROBLEM
P Menggambarkan respon anak terhadap berkurangnya pola kesehatan anak, keluarga dan masyarakat.
Respon

Gangguan proses kehidupan

Gangguan pola Gangguan F (x) Gangguan perkembangan

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ETIOLOGI
E Faal, situasi, maturasi yang menyebabkan masalah /pengaruh terhadap perkembangan
Menggunakan kategori diagnostik NANDA Bervariasi penting untuk tindakan intervensi

Selalu melihat Etiologi Co/ : Non compliance in dieatary restriction Etiologi yang mungkin : < pengetahuan

Menolak sakit
Sumber ekonomi lemah / rendah Konflik budaya
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SIMPTOM
S : Derifat dari pengkajian pasien Merujuk pada defisiensi karakteristik (membantu membedakan kategori diagnostik)
Masalah : Kesehatan yang aktual Katagore diagnostik berhubungan dengan F (x) dan koping keluarga Definisi karakteristik
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Cara prioritaskan masalah :

Fokus ancaman kehidupan

Fokus kepada keluhan / masalah Fokus pada akibat dari masalah utama

Fokus kepada kebutuhan

Perawat harus bisa berkomunikasi dengan anak dan keluarga

.
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PERENCANAAN Perbedaan standar dengan

Asesment - Informasi khusus hanya masalah
Dx Perawatan - Semua masalah dengan etiologi yang umum Planning - Tujuan luas dan menggambarkan tujuan pasien Implementasi - Intervensi keperawatan luas dan bisa diterapkan u/ sebagian besar Pasien dengan masalah Evaluasi - Kemajuan pasien diharapkan bisa diidentifikasi.
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PERENCANAAN
Mengembangkan rencana dan tujuan.
Hasil kesehatan

* Meningkatkan status

* Kondisi klinik * Tingkah laku

Standar care plan

Individualised care plan

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Pada anak > dipakai individualised care plan Individualised

Informasi spesifik identitikan masalah anak dan keluarga
Khusus untuk anak dan keluarga rencana asuhan langsung kepenyakit Tujuan khusus dan menggambarkan tujuan pasien Kemajuan pasien secara aktual bisa diidentifikasi
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DOMAIN OF PROFESIONAL NURSING OF PEDIATRIC

Dependent Perawat dalam melakukan tindakan sesuai medical order yang didapat
Interdependent Implementasi melibatkan 2 disiplin ilmu Independent Wewenang utuh perawat untuk melakukan tindakan keperawatan

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The Nursing Process

Nursing Diagnosis
Judgment or conclusion about the risk foror actualneed/problem of the patient NANDA format

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DIAGNOSIS
Sort, cluster, analyze information
Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition

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Nursing Diagnosis (cont.)

Potential for effective breastfeeding related to knowledge level and support system
Prioritize the problems Not a medical diagnosis

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NANDA North American Nursing Diagnosis Association

Identifies nursing functions
Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance

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Planning
Establish the goals, interventions and outcomes

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General Guidelines for Setting Priorities

1. Take care of immediate life-threatening issues.
2. Safety issues.

3. Patient-identified issues.
4. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.
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Nurse Identified Priorities

Composite of all patients strengths and health concerns.
Moral and ethical issues.

Time, resources, and setting.

Hierarchy of needs. Interdisciplinary planning.

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Identifying Client-centered Outcomes

State what the patient will do or experience at the completion of care.
Give direction to the patients overall care. Patient behaviors not nurse behaviors!! The patient will
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Steps for deriving outcomes from Nursing Diagnosis

Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure.
The client will demonstrate no signs or symptoms of infection.

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Components of Outcomes

Subject: who is the person expected to achieve the outcome?

Verb: what actions must the person take to achieve the outcome?

Condition: under what circumstances is the person to perform the actions?

Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions?
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Nursing Interventions

1. 2. 3. 4. 5.

Road maps directing the best ways to provide nursing care.

Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.

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Interventions
Direct interventions: actions performed through interaction with clients.
Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

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Predict, Prevent, and Manage

Focus on early intervention
Based on research Predict and anticipate problems Look for risk factors

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Collaborative Problems-Nurses Responsibility

Correlating medical diagnoses or medical treatment measures with the risk for unique complications
Documenting the complications for which clients are at risk Making pertinent assessments to detect complications

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Continued
Reporting trends that suggest development of complications
Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes

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Documenting the Plan of Care

To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.
Consists of:

1.
2.

Prioritized nursing statements.

Outcomes.

diagnostic

3.

Interventions.

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Documentation
Clear and concise
Appropriate terminology Usually on a designated form Physical assessment Usually by Review of Systems

Overview of symptoms
Diet

Each body system

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Documentation
Use patients own words in subjective data enclose in ___ (quotation marks)
Avoid generalizations be specific Dont make summative statements describe - e.g. patient is being ornery should be patient resists instruction or patient states Dont talk to me, I dont care about that
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Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement

3. Deciding whether to continue, modify, or terminate the plan

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If all my friends were to jump off a bridge, I wouldn't jump with them, I'd be at the bottom to catch them.

Hold a true friend with both your hands