Model of Nursing Documentation

Source Oriented Record (SOR)

Everyone is a traditional Notes / sections / resource has its own record or separately. Consisting of five components:

1. Admission sheet
2. Doctor's instruction sheet
3. Medical history sheet
4. Note nurses
5. Notes and special reports
6. Graphics card / records

Problem Oriented Record (POR)

Is an effective tool to assist health care teams (Introduced by Dr. Lawrence Weed, USA). Identify patient problems, plan therapy, diagnosis and counseling and evaluating and reviewing progress.

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Family Nursing Process

Nursing process will be relatively different families who become focus of treatment. The difference depends on keonseptualisasi focus the family of the nurse in practice. If he sees the family as background or context of a patient-oriented individuals, as in traditional. In practice, most nurses worked well with family and individual family members. This means that family caregivers will use the nursing process in the two circles are the individual level and family. In this Hali, pengakjian diagnosis, planning, intervention, and evaluation will become more extensive and complicated. Family care is very specialized and only work on the family as a system. And on the other hand, an understanding of each family member inadequate can not be achieved regardless of such member in primary groups-family context. The second approach this level, which is used to assess and implement family nursing portrayed in the picture below which describe the steps in the process of family nursi...

The concept of Basic Human Needs According to Abraham Maslow

Based on the concept of basic needs, the nurse in charge in meet the basic needs of the client. Nurses are expected to view the client as a unique creature comprehensive in providing care. 1.Actualization Self Esteem 2.Belonging Self 3.Safety /Security Need Comprehensive means that in meeting basic needs of the client, not just focusing on meeting the physical needs or psychological only, but all aspects of the responsibility of the nurse.

NANDA Nursing Diagnosis Domain Nutrition

Ingestion. Imbalanced nutrition: less than body requirements (Nursing care Plan). Readiness for enhanced nutrition. Insufficient breast milk production. Ineffective breastfeeding (Nursing care Plan). Interrupted breastfeeding (Nursing care Plan). Readiness for enhanced breastfeeding. Ineffective adolescent eating dynamics. Ineffective child eating dynamics. Ineffective infant feeding dynamics. Ineffective infant feeding pattern (Nursing care Plan). Obesity, Overweight, Risk for overweight, and Impaired swallowing (Nursing care Plan). Risk for unstable blood glucose level (Nursing care Plan).Neonatal hyperbilirubinemia. Risk for neonatal hyperbilirubinemia. Risk for impaired liver function. Risk for metabolic imbalance syndrome.

Nursing

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