FORMULATION PROCESS NURSING DIAGNOSIS
1. Classification and Data Analysis
Grouping the data is grouped client data or a particular situation where the client has health problems or nursing based on the criteria of the problem. grouping data can be compiled based on the pattern of human response (NANDA taxonomies) and / or patterns of health functions (Gordon, 1982);
Human Response (NANDA Taxonomy II):
a. Exchange
b. Communication
c. Related
d. Values
e. Options
f. Moving
g. Interpretation
h. Knowledge
i. Feeling
Function Health Patterns (Gordon, 1982):
a. Perceptions of health: health management pattern
b. Nutrition: the pattern of metabolism
c. Pattern of elimination
d. Activities: training patterns
e. Sleep: the pattern of resting
f. Cognitive: perceptual patterns
g. Perception of self: self-concept pattern
h. Role: the pattern of relationships
i. Sexuality: patterns of reproductive
j. Köping: stress tolerance pattern
k. Value: patterns of belief
2. Identify client problems
Client is a state issue or a situation where clients need help to maintain or improve their health status, or died peacefully, which can be done by nurses according to their ability and authority he has
Identification of client problems are divided into: patients are not a problem, patients who may have a problem, patients who have a potential problem that most likely have a problem and patients who have actual problems.
a. Determining the excess clients
If the client meets the criteria standards of health, nurses and concluded that the client has the advantage of certain things. Excess funds can be used to improve or help solve problems facing clients.
a. Determining the client’s problem
If the client does not meet the standard criteria, then the client is experiencing limitations in terms of health and I need help.
a. Determining problems experienced by clients
At this stage, it is important to determine the client’s potential problems. For instance found any signs of wound infection in clients, but the lab test results, do not indicate a disorder. In accordance with the theory, then the infection will occur. The nurse then concluded that the immune system the client is not able to fight infection.
a. Determination of the decision
- No problem, but needs to improve the status and function (welfare): there is no indication of the response of nursing, increased health status and habits, and her health promotion initiatives to ensure the presence or absence of the alleged problem.
- Issues likely (possible problem): the pattern of data collected to ensure the complete presence or absence of problems allegedly
- Actual problems, risk, or syndrome: not able to care for clients’ problems and refused treatment, began to design the planning, implementation, and evaluation to prevent, reduce, or solve problems.
- Collaborative problem: consult your professional health workers and ompeten working collaboratively on these issues. Collaborative problem is physiological complications resulting from pathophysiology, associated with treatment and other situations. The task is to monitor the nurse, to detect the status of clients and collaborative with medical personnel to the appropriate treatment.
3. Validate nursing diagnosis
Is connected with the classification of symptoms and signs which then refers to the completeness and accuracy of data. For completeness and accuracy of data, cooperation with clients is very important to trust each other, so getting the right data.
At this stage, nurses validate existing data accurately, is done with the client / family and / or the community. Validation was conducted by asking questions or reflective statement to the client / family about the clarity of data interpretation. Once the nursing diagnosis made, then the validation should be done.
4. Establishing nursing diagnoses according to the priorities
After the nurse group, identify, and validate the data significantly, then the duty nurse at this stage is to formulate a nursing diagnosis. Nursing diagnosis can be actual, risk, syndrome, the possibility and wellness.
Establishing nursing diagnoses should be ordered by the berlandaskabn needs Maslow’s hierarchy (except for cases kegawat daruratan – use priority based on “life threatening”):
a. Based on Maslow’s hierarchy: physiological, safety, comfort, safety, love and belonging, self-esteem and self-actualization
b. Griffith-Kenney Christensen: the threat of life and health, resources and funds available, the role and the client, and the scientific principles and practice of nursing.
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