Model documentation of assessment and nursing diagnosis in the practice of nursing care management for nursing students

 
 
 
  • Abstract
  • Keywords
  • References
  • PDF
  • Abstract


    Model documentation of assessment and nursing diagnosis in the practice of nursing care management is an integration model in nursing care records, especially records nursing assessment and diagnosis in one format. This model can reduce the duration of the recording in nursing care, and make it easier for students to understand the nursing diagnosis, so that nursing interventions more effective. The purpose of this paper was to describes the form integration documentation of nursing assessment and diagnosis of nursing in nursing care management for nursing students. This literature review was done by searching the following search engine: Pubmed, Midline, EBSCO, and Google Scholar. Data in the synthesis from nursing diagnoses of NANDA-I were incorporated into the of nursing assessment form using Gordon’s functional health pattern. Types of articles included: original research, and literature review. This review of article includes 1) introduction 2) form of nursing assessment documentation 3) implementation of nursing diagnosis documentation 4) the implementation strategy documentation of assessment and nursing diagnosis 5) recommendation for nursing education 6) conclusion.


  • Keywords


    Nursing Assessment; Nursing Care Managament; Nursing Diagnosis; Nursing Student; and Nursing Documentation.

  • References


      [1] Herdman,TH (2008). Nursing Diagnosis: Is It for a New Definition?.International Journal of Nursing Termnologies and Classifications, 19 (1), 2-13. http://dx.doi.org/10.1111/j.1744-618X.2007.00073.x.

      [2] Herdman,TH (2008). Nursing Diagnosis: Definitions & Classifications 2012-2014. USA: Wiley Blackwell Publishing.

      [3] Karmawati, IA (2001). Nurses’ Perception through the assessment documentation in hospital room RSUD Rebo Market Jakarta: Abstract Research, University of Indonesia. Available at: http://www.digilib.ui.ac.id/opac/themes/libri2 (accessed 17 May 2012).

      [4] Kurashima, S, Kobayashi,K, Toyabe,S, Akazawa,K (2008). Accuracy and Efficiency of Computer-Aided Nursing Diagnosis.International Journal of Nursing Termnologies and Classifications, 19 (3), 95-301. http://dx.doi.org/10.1111/j.1744-618X.2008.00088.x.

      [5] Kusumawaty, I (2001). The relationship between understanding of nursing process and function of supervision with documentation competencies of nursing process in hospital of Karya Bhakti Bogor: Abstract Research, University of Indonesia. Available at: http://www.digilib.ui.ac.id/opac/themes/libri2/detail.jsp?id=71558 (accessed 17 May 2012)

      [6] Krogh, GV (2006). An Examination of the NANDA Interntional Taxonomy for Domain Completeness, Ontological Homogeneity, and Clinical Functionality.International Journal of Nursing Termnologies and Classifications, 19 (2), 65-75. http://dx.doi.org/10.1111/j.1744-618X.2008.00083.x.

      [7] Meyer, G (2007). Is it Time for a New Category of Nursing Diagnosis?.International Journal of Nursing Termnologies and Classifications, 180 (2), 45-50. http://dx.doi.org/10.1111/j.1744-618X.2007.00049.x.

      [8] Muller-Staub, M, Needham,I, Odenbreit, M, Lavin,MA, Achterberg, TV (2007). Improved Quality of Nusring Documentation: Results of a Nursing Diagnoes, Interventions, and Outcomes Implementation Study.International Journal of Nursing Termnologies and Classifications, 18 (1), 5-17. http://dx.doi.org/10.1111/j.1744-618X.2007.00043.x.

      [9] Muller-Staub, M, Needham,I, Odenbreit,M,Lavin,MA, Achterbag,TV (2008). Implementing nursing diagnosis effectively: cluster Randomized trial.Journal of Advanced Nursing, 63 (3), 291-301. http://dx.doi.org/10.1111/j.1365-2648.2008.04700.x.

      [10] Muller-Staub M (2009). Evaluation of the Implementation of Nursing Diagnosis, Interventions, and Outcomes.International Journal of Nursing Termnologies and Classifications. 20 (1), 9-15. http://dx.doi.org/10.1111/j.1744-618X.2008.01108.x.

      [11] Paganin, A, Moraes, MA, Pokorski, S, Rabelo, ER (2008). Factors that Inhibit the Use of Nursing Langeage.International Journal of Nursing Termnologies and Classifications. 19 (4), 150-157. http://dx.doi.org/10.1111/j.1744-618X.2008.00103.x.

      [12] Scroggins, LM (2008). The Development Process for NANDA International Nursing Diagnoses. International Journal of Nursing Termnologies and Classifications, 19 (2), 57-64. http://dx.doi.org/10.1111/j.1744-618X.2008.00082.x.

      [13] Sumitra (2001). Related Factors with documentation of nursing assessment by nurses in hospital room RSUD Karawang : Abstract Research, Unversity of Indonesia. Available at: http://www.digilib.ui.ac.id/opac/themes/libri2/detail (accessed 17 May 2012).

      [14] Widyantoro, W (2002). The relationship of the using of nursing information system with the completeness of nursing documentation in Fatmawati Hospital: Abstract Research, University of Indonesia. Available at: http://www.digilib.ui.ac.id/opac/themes/ libri2/detail.jsp?id=97376 (accessed 17 May 2012).

      [15] Wilkinson,JM (2006). Nursing diagnosis handbool: with NIC Interventions and NOC Outcomes. New Jersey: Pearson Education, Inc.


 

View

Download

Article ID: 5116
 
DOI: 10.14419/ijans.v4i2.5116




Copyright © 2012-2015 Science Publishing Corporation Inc. All rights reserved.