Assessment is an effort to collect data in a complete and systematic way to be studied and analyzed so that health and nursing problems faced by patients both physically, mentally, socially and spiritually can be determined. This stage includes three activities, namely data collection, data analysis, and
determination of health and nursing problems.
1) Data collection
Goals:
Obtained data and information regarding health problems that exist in patients so that actions can be determined that must be taken to overcome these problems involving physical, mental, social and spiritual aspects as well as environmental factors that influence them. The data must be accurate and easy to analyze. Types of data include objective data, namely data obtained through a measurement, examination, and observation, such as body temperature, blood pressure, and skin color. Subjective data, namely data obtained from complaints felt by the patient, or from the patient's family / other people, for example; headache, pain, and nausea.
The focus in data collection includes:
- Past and present health status
- Past and present coping patterns
- Previous and current status function
- Response to medical therapy and nursing actions
- Risk for potential problems
- Things that become the client's encouragement or strength
2) Data analysis
Data analysis is the ability to develop the ability to think rationally in accordance with the scientific background.
3) Problem formulation
After analyzing the data, several health problems can be formulated. There are health problems that can be intervened with nursing care (nursing problems) but some are not and require more medical action. Furthermore, nursing diagnoses are arranged according to priorities. The priority of the problem is determined based on important and immediate criteria. It is important to cover the emergency and if not treated it will cause complications, while immediately covering the time, for example in stroke patients who are unconscious, action must be taken immediately to prevent more severe complications or death. Priority problems can also be determined based on Maslow's hierarchy of needs, namely: Life-threatening conditions, health-threatening conditions, perceptions of health and nursing.
Nursing Diagnosis
Nursing diagnosis is a statement that describes the human response (health status or risk of changing patterns) of an individual or group where nurses can responsibly identify and provide definite interventions to maintain health status to reduce, limit, prevent and change (Carpenito, 2000). nursing diagnoses :
- Actual: describes the current real problem according to the clinical data found.
- Risk: explaining the real health problems that will occur if no intervention is carried out.
- Possibility: explains that additional data are needed to confirm possible nursing problems.
- Wellness: clinical decisions about the state of an individual, family, or community in transition from a certain level of well-being to a higher level of well-being.
- Syndrome: a diagnosis consisting of a group of actual and high-risk nursing diagnoses that are thought to arise/arise due to a particular event or situation.
Planning
All actions taken by nurses to help clients move from their current health status to health status are described in the expected results (Gordon, 1994). Are written guidelines for client care. The care plan is organized so that each nurse can quickly identify the treatment actions to be administered. A properly formulated nursing care plan facilitates continuity of care from one nurse to another. As a result, all nurses have the opportunity to provide consistent, high-quality care. Written nursing care plans govern the exchange of information by nurses in service exchange reports. A written treatment plan also includes long-term client needs (Potter, 1997).
Implementation
It is an initiative of an action plan to achieve a specific goal. The implementation phase begins after the action plan is prepared and is aimed at nursing orders to help clients achieve the expected goals. Therefore a specific action plan is implemented to modify the factors that affect the client's health problem.
The stages in nursing action are as follows :
Stage 1: preparation
The initial stage of this nursing action requires the nurse to evaluate what was identified at the planning stage.
Stage 2: intervention
The focus of the implementation phase of treatment actions is the activities and implementation of actions from planning to meet physical and emotional needs. Nursing action approach includes actions: independent, dependent, and interdependent.
Stage 3: documentation
The implementation of nursing actions must be followed by complete and accurate recording of an incident in the nursing process.
Evaluation
The evaluation plan contains the criteria for the success of the process and the success of nursing actions. The success of the process can be seen by comparing the process with the guidelines/plan for the process. While the success of the action can be seen by comparing the level of independence of the patient in daily life and the level of progress of the patient's health with the goals that have been previously formulated. The evaluation targets are as follows:
- The process of nursing care, based on the criteria/plans that have been prepared.
- The results of nursing actions, based on the success criteria that have been formulated in the evaluation plan.
Evaluation result
There are 3 possible evaluation results, namely:
- The goal is achieved, if the patient has shown improvement / progress in accordance with the criteria that have been set.
- The goal is partially achieved, if the goal is not achieved optimally, so it is necessary to find the cause and how to overcome it.
- The goal is not achieved, if the patient does not show any change/progress at all and even new problems arise. In this case the nurse needs to examine in more depth whether there are data, analyzes, diagnoses, actions, and other factors that are not appropriate for the patient. causes of non-achievement of goals.
After a nurse performs the entire nursing process from assessment to evaluation of the patient, all actions must be properly documented in the nursing documentation.
