Basic Concepts of Nursing1 . nursing
a. understanding nursing
Nursing is a form of health care professionals who are part of the internal health care , based on nursing science and troubleshooting services to the shape of biological , psychological , social , and community both healthy and diseased , and covers the entire process of human life ( MOH , 2000) .
b . The purpose of nursing
1 ) . Helping people become free of perceived health problems and encourage individuals and communities to participate in improving health status .
2 ) . Indivudu help develop their potential in maintaining optimum health in order not to depend on others in maintaining health.
3 ) . Helping individuals to obtain optimal health status .
2 . Nursing process
a. Understanding the Nursing Process
The nursing process is a system in which nursing care plan has four stages , namely the assessment , planning , implementation or implementation , and evaluation . Another alternative of the nursing process consists of five phases which include assessment , diagnosis , planning , implementation and evaluation ( Lismidar , 2005) .
b . The purpose of the Nursing Process
The end result of this process is to write down a plan of nursing . The nursing process is a systematic problem-solving process in providing nursing care . The nursing care plan is a guideline in providing nursing care .
c . Nursing Process Steps
There are five steps in the nursing process in five steps are all interrelated and influence each other , namely assessment , nursing diagnosis , planning , implementation and evaluation that form a chain as follows .
1 ) . Nursing Assessment .
Assessment is an initial step in the nursing process . A careful assessment is needed to identify the patient's problems , in order to give direction to nursing actions . With the aim to gather information and create a data base of patients .
Assessment measures the following data :
a) Data collection
Data collection is done since entering the hospital , for patients treated continuously and made to add to and complement the existing data . Based on the data source , distinguished by assessment data ; Primary data is data obtained directly from the patient or the patient's family , while secondary data is data obtained from physical examination ( inspections , palpation , percussion , Aulkutasi ) . In general, there are several ways of collecting data that is anamnesis , including: a) . The identity of the client : name , age , gender , address , religion , language spoken , marital status , education , occupation , ethnicity, blood type , registration number , date and time of hospital admission ( MRS ) , and medical diagnostics , b ) . Main complaints generally hepatitis are nausea vomiting , c ) . History of present illness , review the chronological occurrence of nausea and vomiting and relief that has been obtained for , alleviate complaints , d ) . Past medical history : Has there ever been treated in hospital if ever , what pain ? Pulmonary Tuberculosis is there any disease , pankresitis , types , which can interfere with liver function , e ) . Family history of family disease associated with hepatitis whether there is a family suffering from hepatitis due to hepatitis can be contracted quickly , f ) . Psychosocial and spiritual history , examine the emotional response to the illness of suffering client , the client 's role in the family and society , and the response or effects in everyday life , both in the family and society , g ) . Patterns of Health functions include: 1 ) the pattern of perception and self-concept : anxiety and shame arising due to whole body iktrus that happened , anxiety , a sense of inability to perform activities optimally and views against him is wrong ( disorder self-image ) , 2 ) sensory and cognitive patterns : review of long-term memory and short-term if the disorientation of time and place , 3 ) penggulangan pattern of stress : anxiety arises about the situation himself , which raised fears of disability on self and body functions . , 4 ) patterns and values confidence: the client with hepatitis can not practice their religion well , this is caused by pain and limitation of motion of clients, 5 ) . Nutrition and metabolic patterns : a client with hepatitis should consume more nutrients everyday needs , such as calcium , iron , protein , vitamin C , and others to help the healing process , 6 ) . The pattern of elimination client will be impaired . Nevertheless it needs to assess the frequency , consistency , color and smell of feces and the elimination pattern Alvi . It also should review the frequency , sensitivity , color , odor , and amount of the urinary elimination pattern , the second pattern also examined the difficulty or not , 7 ) . Activity patterns arise because of pain , limited motion . All forms to be reduced client activity and client require a lot of help from others . Another thing that needs to be studied adalal form of client activity especially client work , 8 ) . Rest and sleep patterns . All clients with hepatitis pain and limited movement so that it can interfere with sleep patterns and needs of the client . In addition it is necessary to study the amount of sleep , the atmosphere , sleep habits , sleep difficulties , and the use of sleeping pills . h ) Physical Examination : a) . Eye , the sclera iktrus and pale , showing the reflection of hemolysis anemia , cirrhosis , or neoplasm , b ) . Ekstermitas : skinny may be associated with cirrhosis , c ) . Parotid gland , the parotid gland was enlarged , d ) . Skin : the skin examination in the presence of iktrus found throughout the body , e ) . Mental status : on examination stus mental and neurological functions will be found and intellectual decline personality changes , f ) . On abdominal examination in the presence of ascites were found along with periumbilical veins were dilated and showed cirrhosis and an extensive portal collateral circulation . On palpation there is enlargement of the liver and liver cirrhosis downsizing occurs .
2 ) . Nursing Diagnosis .
Some nursing problems that may arise in patients with hepatitis by Carpenito L. J (1999 ) , as follows :
1 ) Changes in nutrition less than body requirements related to , the feeling of discomfort in the right upper quadrant , impaired absorption and digestion of food metabolism , input failure to meet the metabolic demands due to anorexia , nausea and vomiting , 2 ) . Impaired sense of comfort ( pain ) associated with swelling of the liver is inflamed liver and portal vein dam , 3 ) . Hypertermi associated with invasive agent in the blood circulation secondary to inflammation of the liver , 4 ) . Fatigue associated with chronic inflammatory process secondary to hepatitis , 5 ) . High risk of skin integrity and tissue damage associated with pruritus secondary to the accumulation of the pigment bilirubin in the bile salts , 6 ) . A high risk of transmission of infection associated with the infectious nature of the virus agent .
3 ) . Implementation Measures of Nursing .The implementation is to implement what has been formulated in the intervention and step - lngkah in the implementation , including the preparation and implementation of clients in receiving nursing care . nurses need to pay attention to communication skills in supervision , leadership motivation in making decisions .In step implementation of activities , in addition to nurses carry out efforts to achieve the goal , the nurse must also consider the legal and ethical aspects as well as trying to prevent the complications that arise in the nursing care given .
4 ) . Evaluation of Nursing .
Evaluation is an activity that is intentional and involves continuous with patients and other health team members . Evaluation is a systematic comparison of the patient's nursing plan , with defined objectives and a continuous effort , involving patients , nurses and other health care team .
The purpose of the evaluation is to determine whether the expected results achieved or not and to find out if a new problem arises after the act of nursing .
There are two kinds of evaluation criteria , namely criteria and process outcomes. Criteria for evaluating the course of the process according to the situation and needs of the patient's condition while criteria for evaluating the results of outcomes after implementing nursing actions in the form of assessment " SOAP " . S or expression based on the patient's subjective outcome . O or objective that nurses know the results of the observations client's condition , A is the result of the assessment is an assessment analysis of existing problems whether resolved or not resolved , and P or Planning ( plan ) is the next stage of planning or implementing cessation .
a. understanding nursing
Nursing is a form of health care professionals who are part of the internal health care , based on nursing science and troubleshooting services to the shape of biological , psychological , social , and community both healthy and diseased , and covers the entire process of human life ( MOH , 2000) .
b . The purpose of nursing
1 ) . Helping people become free of perceived health problems and encourage individuals and communities to participate in improving health status .
2 ) . Indivudu help develop their potential in maintaining optimum health in order not to depend on others in maintaining health.
3 ) . Helping individuals to obtain optimal health status .
2 . Nursing process
a. Understanding the Nursing Process
The nursing process is a system in which nursing care plan has four stages , namely the assessment , planning , implementation or implementation , and evaluation . Another alternative of the nursing process consists of five phases which include assessment , diagnosis , planning , implementation and evaluation ( Lismidar , 2005) .
b . The purpose of the Nursing Process
The end result of this process is to write down a plan of nursing . The nursing process is a systematic problem-solving process in providing nursing care . The nursing care plan is a guideline in providing nursing care .
c . Nursing Process Steps
There are five steps in the nursing process in five steps are all interrelated and influence each other , namely assessment , nursing diagnosis , planning , implementation and evaluation that form a chain as follows .
1 ) . Nursing Assessment .
Assessment is an initial step in the nursing process . A careful assessment is needed to identify the patient's problems , in order to give direction to nursing actions . With the aim to gather information and create a data base of patients .
Assessment measures the following data :
a) Data collection
Data collection is done since entering the hospital , for patients treated continuously and made to add to and complement the existing data . Based on the data source , distinguished by assessment data ; Primary data is data obtained directly from the patient or the patient's family , while secondary data is data obtained from physical examination ( inspections , palpation , percussion , Aulkutasi ) . In general, there are several ways of collecting data that is anamnesis , including: a) . The identity of the client : name , age , gender , address , religion , language spoken , marital status , education , occupation , ethnicity, blood type , registration number , date and time of hospital admission ( MRS ) , and medical diagnostics , b ) . Main complaints generally hepatitis are nausea vomiting , c ) . History of present illness , review the chronological occurrence of nausea and vomiting and relief that has been obtained for , alleviate complaints , d ) . Past medical history : Has there ever been treated in hospital if ever , what pain ? Pulmonary Tuberculosis is there any disease , pankresitis , types , which can interfere with liver function , e ) . Family history of family disease associated with hepatitis whether there is a family suffering from hepatitis due to hepatitis can be contracted quickly , f ) . Psychosocial and spiritual history , examine the emotional response to the illness of suffering client , the client 's role in the family and society , and the response or effects in everyday life , both in the family and society , g ) . Patterns of Health functions include: 1 ) the pattern of perception and self-concept : anxiety and shame arising due to whole body iktrus that happened , anxiety , a sense of inability to perform activities optimally and views against him is wrong ( disorder self-image ) , 2 ) sensory and cognitive patterns : review of long-term memory and short-term if the disorientation of time and place , 3 ) penggulangan pattern of stress : anxiety arises about the situation himself , which raised fears of disability on self and body functions . , 4 ) patterns and values confidence: the client with hepatitis can not practice their religion well , this is caused by pain and limitation of motion of clients, 5 ) . Nutrition and metabolic patterns : a client with hepatitis should consume more nutrients everyday needs , such as calcium , iron , protein , vitamin C , and others to help the healing process , 6 ) . The pattern of elimination client will be impaired . Nevertheless it needs to assess the frequency , consistency , color and smell of feces and the elimination pattern Alvi . It also should review the frequency , sensitivity , color , odor , and amount of the urinary elimination pattern , the second pattern also examined the difficulty or not , 7 ) . Activity patterns arise because of pain , limited motion . All forms to be reduced client activity and client require a lot of help from others . Another thing that needs to be studied adalal form of client activity especially client work , 8 ) . Rest and sleep patterns . All clients with hepatitis pain and limited movement so that it can interfere with sleep patterns and needs of the client . In addition it is necessary to study the amount of sleep , the atmosphere , sleep habits , sleep difficulties , and the use of sleeping pills . h ) Physical Examination : a) . Eye , the sclera iktrus and pale , showing the reflection of hemolysis anemia , cirrhosis , or neoplasm , b ) . Ekstermitas : skinny may be associated with cirrhosis , c ) . Parotid gland , the parotid gland was enlarged , d ) . Skin : the skin examination in the presence of iktrus found throughout the body , e ) . Mental status : on examination stus mental and neurological functions will be found and intellectual decline personality changes , f ) . On abdominal examination in the presence of ascites were found along with periumbilical veins were dilated and showed cirrhosis and an extensive portal collateral circulation . On palpation there is enlargement of the liver and liver cirrhosis downsizing occurs .
2 ) . Nursing Diagnosis .
Some nursing problems that may arise in patients with hepatitis by Carpenito L. J (1999 ) , as follows :
1 ) Changes in nutrition less than body requirements related to , the feeling of discomfort in the right upper quadrant , impaired absorption and digestion of food metabolism , input failure to meet the metabolic demands due to anorexia , nausea and vomiting , 2 ) . Impaired sense of comfort ( pain ) associated with swelling of the liver is inflamed liver and portal vein dam , 3 ) . Hypertermi associated with invasive agent in the blood circulation secondary to inflammation of the liver , 4 ) . Fatigue associated with chronic inflammatory process secondary to hepatitis , 5 ) . High risk of skin integrity and tissue damage associated with pruritus secondary to the accumulation of the pigment bilirubin in the bile salts , 6 ) . A high risk of transmission of infection associated with the infectious nature of the virus agent .
3 ) . Implementation Measures of Nursing .The implementation is to implement what has been formulated in the intervention and step - lngkah in the implementation , including the preparation and implementation of clients in receiving nursing care . nurses need to pay attention to communication skills in supervision , leadership motivation in making decisions .In step implementation of activities , in addition to nurses carry out efforts to achieve the goal , the nurse must also consider the legal and ethical aspects as well as trying to prevent the complications that arise in the nursing care given .
4 ) . Evaluation of Nursing .
Evaluation is an activity that is intentional and involves continuous with patients and other health team members . Evaluation is a systematic comparison of the patient's nursing plan , with defined objectives and a continuous effort , involving patients , nurses and other health care team .
The purpose of the evaluation is to determine whether the expected results achieved or not and to find out if a new problem arises after the act of nursing .
There are two kinds of evaluation criteria , namely criteria and process outcomes. Criteria for evaluating the course of the process according to the situation and needs of the patient's condition while criteria for evaluating the results of outcomes after implementing nursing actions in the form of assessment " SOAP " . S or expression based on the patient's subjective outcome . O or objective that nurses know the results of the observations client's condition , A is the result of the assessment is an assessment analysis of existing problems whether resolved or not resolved , and P or Planning ( plan ) is the next stage of planning or implementing cessation .
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