Development of Nursing Diagnosis and Intervention Instrument Based on Standardized Nursing Language (Nanda-I, Noc, Nic)

Abstract

Nursing diagnosis and intervention standards, in this case was using standardized nursing language, was still a problem in the nursing profession. In order to produce a good quality of nursing diagnosis and intervention, need to be supported by good quality of instruments. The purpose of this research was to development of nursing diagnsois and intervention instrument based on Standardized Nursing Language (NANDA-I, NOC, NIC)This study was action reserach carried out in 2 phases. Participants for FGD and sample selected using purposive sampling techniques with participants were 15 and sample were 7. Participants for FGD phase 2 and sample selected with purposive sampling technique with 13 participants and 8 samples to try using instrument nursing diagnosis and intervention. Analyze data using descriptive analysis, statistical analysis Pearson Product Moment Correlation for validity test and Cronbach alpha for reliability test. The result show that the r count validity value of nursing diagnosis instruments was 0,862 and nursing intervention was 0,911. The r count reliability value of nursing diagnosis instruments was 0,862 and nursing intervention was 0,875. The development of nursing diagnosis and intervention instrument based on the Standardized Nursing Language) with an average overall instrument r count > r table (0.754) declared valid and reliableRecommendations for the Amelia Hospital Pare Kediri was always evaluate routintly the nursing diagnosis and intervention instrument appropriate with the patient condition.

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

“…Proses dalam pelaksanaan dokumentasi yang buruk terjadi karena dokumentasi keperawatan dianggap membuang waktu dan merupakan beban kerja tambahan (3) . Masalah tambahan yang masih sering muncul pada pelaksanaan dokumentasi adalah dokumentasi keperawatan yang sesuai standar bahasa keperawatan (Standarized Nursing Language), khususnya keseragaman dalam menggunakan bahasa diagnosis dan intervensi keperawatan (4) .…”

“…Penelitian di Indonesia, hasil wawancara dengan 4 dari 13 perawat (30%) Ruang Rawat Inap Teratai RS Amelia Pare Kediri, yaitu dari 4 perawat menyatakan bahwa kadang mereka belum sempat menulis pada format yang telah disediakan karena banyaknya tindakan yang harus dilakukan kepada pasien daripada menulis pada format yang ada. (4) Dokumentasi keperawatan merupakan bagian integral dari perawatan pasien, pentingnya dokumentasi keperawatan berhubungan dengan kepatuhan melaksanakan syarat dokumentasi yang merupakan aspek kunci profesionalisme perawat (8) . Dokumentasi keperawatan yang berkualitas dapat meningkatkan komunikasi yang efektif dengan tim kesehatan lain tentang pasien dan perawatannya (9) .…”