The Nurses’ Nursing Diagnosis Identification in Public Hospital, Indonesia

Abstract

The nursing process is a pivotal action in nurses’ clinical practice. It enquires appropriate assessment and

critical thinking with several steps of data analysis. One step in the nursing process is the nursing diagnosis

establishment. Nursing diagnosis is the nurse’s clinical decision for patients’ response in the level of individual,

family, group and community. The aim of this study was to identify the nursing diagnosis identification in

RSUP H. Adam Malik Hospital, Medan. The study sample was 90 nurses who were taken randomly with

a convenience sampling technique. The instrument consists of two instruments that are the demographic

data and the list of 245 NANDA-International (NANDA-I) nursing diagnoses labels 2015-2017.The result

showed that all the nurses identified all the NANDA-I nursing diagnoses as nursing diagnosis. And, there

are 10 nursing diagnoses were frequently used by nurses in Adam Malik Hospital. The diagnosis was:

activity intolerance (88.8%), impaired comfort (86.6%), decreased cardiac output (81.1%), anxiety (78.8%),

impaired gas exchange (77.7%), impaired physical mobility (75.5%), impaired skin integrity (74.4%), risk

for infection (72.2%), acute pain (71.1%), and sleep pattern disturbance (71.1%). It is recommended in the

future to explore more the main nursing diagnosis among the patients in order to implement the appropriate

nursing interventions in clinical practice.