According to Carpenito (1998), the nursing diagnosis is a clinical assessment of actual or potential responses from individuals, families, or communities against health problems/life processes. The outline of the diagnosis of IE Problems (P) related to Etiology (E) and both are causal relationships exist scientifically. Formulation of nursing diagnosis refers to the tree of soul problem that’s been created. For example, in the tree above, then the problem can be formulated as the following diagnosis.
- As the principal diagnosis, that is, the main problem being the etiology, i.e., the risk of injuring yourself, others and the environment associated with auditory hallucinations.
- Change of remote perception: auditory hallucinations related to pull away.
- Social isolation: withdraw associated with chronic low self-esteem.
On the formulation of nursing diagnosis that use single typology of diagnosis, then the formula is to use the diagnosis of the etiology of course. Based on the problems above, the tree formula following diagnosis are as follows;
- Change remote perceptions: hallucination.
- Social isolation: withdraw.
- The concept of self disorders: chronic low self-esteem.
Nursing Action Plan
Nursing action plan consists of four components, namely, general purpose, specific goals, the plan of action of nursing, and rational. General purpose focused on solving the problem (P). This goal can be achieved if the specified special purpose has been achieved. Special purpose focuses on solving the etiology (E). The purpose of this formula is the ability of the patient to be achieved. This ability is generally composed of three aspects, i.e. as follows;
- Cognitive ability needed to complete the etiology of nursing diagnosis.
- Psychomotor abilities required for the etiology can be completed.
- Affective capabilities need to be owned so that the patient believed in the ability to resolve problems.
Nursing action plan is a series of actions that can be implemented to achieve each goal. While rational scientific reasons why the action was given. The reason for this can be obtained from the literature, research results, and practical experience. Plan of action used in mental health order is adjusted to the standards of nursing care of the soul of Indonesia. Nursing standard United States there are four kinds of nursing actions, namely (1) the care of self help, (2) collaborative, (3) health education, and (4) follow-up observations.
Nursing action should describe the actions of an independent nursing, as well as working with patients, families, groups, and collaboration with other mental health team.
Given the difficulty of creating a plan of action on the patient’s psychiatric, students are advised to make a preliminary Report and strategy Implementation (LPSP), which describes the process of implementing the actions and strategies of nursing planned. Nursing process referred to in this short blurb is LPSP about one problem found, consisting of the subjective, objective data, valuation (assessment), and planning (planning) (SOAP). One of the planned actions to make strategy implementation (SP), consisting of the orientation phase, this phase of the work, and termination.
The orientation phases of implementation action describe a situation that will be done, the contract time and the purpose of the meeting was expected. This phase of the work contains some of the questions to be submitted for assessment information, additional studies, the discovery of problems with, and/or the completion of the action. Termination phase is the time for the evaluation of the actions that have been undertaken, assess the success or failure of, and planning for the next meeting time contracts.
By arranging LPSP, students are expected to have no trouble when the interview or carry out nursing intervention in psychiatric patients. This happens because of all the questions to be asked are already designed, and the purpose of the meeting and the anticipation has been made if the action or the interview did not work. Here’s one example of the form of the LPSP.