Skripsi
GAMBARAN KESESUAIAN PENERAPAN DIAGNOSIS KEPERAWATAN BERDASARKAN STANDAR DIAGNOSIS KEPERAWATAN INDONESIA (SDKI) DI RUMAH SAKIT UMUM NEGERI KOTA PALEMBANG
Nursing diagnosis is a fundamental component of the nursing process and must be formulated based on standardized guidelines to ensure consistency in terminology and accuracy in nursing documentation. The Indonesian Nursing Diagnosis Standard (Standar Diagnosis Keperawatan Indonesia/SDKI) has been established as a national reference for determining nursing diagnoses; however, in clinical practice, nursing diagnoses are still frequently found to be inconsistent with the SDKI. This study aimed to describe the appropriateness of nursing diagnosis implementation based on the Indonesian Nursing Diagnosis Standard (SDKI) at the Regional Public Hospital of Palembang City. This study employed a descriptive observational design. The sample consisted of 658 inpatient medical records from patients hospitalized at the Regional Public Hospital of Palembang City during the period of January to December 2024. Samples were selected using probability sampling with a proportionate stratified random sampling technique. Data were collected using an observation checklist instrument. The results showed that the appropriateness of nursing problem formulation according to the SDKI reached 91.79%, while appropriateness for etiology was 12.03%, signs and symptoms 8.52%, and risk factors 39.58%. These findings indicate that most nurses were able to formulate nursing problems in accordance with the SDKI; however, they still encountered difficulties in identifying etiologies, signs and symptoms, and risk factors in line with SDKI standards. This condition suggests that the implementation of nursing diagnoses based on the SDKI has not yet been fully optimal. The findings imply the need for improving nurses’ competencies through continuous training, supervision, and professional development to ensure comprehensive and consistent implementation of nursing diagnoses in accordance with the SDKI.
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