METEODOLOGI KEPERAWATAN PLANNING, IMPLEMENTASI,

EVALUASI DAN DOKUMENTASI

BAB I
PENDAHULUAN

A. Latar Belakang
Adanya tuntutan terhadap kualitas pelayanan keperawatan dirasakan sebagai suatu fenomena
yang harus di respon oleh perawat. Pelayanan keperawatan secara professional perlu
mendapatkan perhatian dalam pengembangan dunia keperawatan. Salah satu strategi untuk
mengoptimalkan peran dan fungsi perawat dalam pelayanan keperawatan adalah melakukan
manajemen keperawatan dengan harapan adanya faktor kelola yang optimal dan mampu meningkatkan
keefektifan pembagian pelayanan keperawatan sekaligus lebih menjamin kepuasan klien
terhadap pelayanan keperawatan.
Keperawatan didasarkan pada suatu teori yang sangat luas. Proses keperawatan adalah
metode dimana suatu konsep diterapkan dalam praktik Keperawatan. Hal ini dapat disebut
sebagai suatu pendekatan untuk memecahkan masalah (problem-solving) yang memerlukan
ilmu, teknik, dan keterampilan interpersonel yang bertujuan untuk memenuhi kebutuhan klien,
keluarga, dan masyarakat. Proses keperawatan terdiri atas lima tahap yang berurutan dan saling
berhubungan, yaitu pengkajian, diagnosis, perencanaan, implementasi, dan evaluasi (Iyer et al.,
1996). Tahap-tahap tersebut berintegrasi terhadap fungsi intelektual problem-solving dalam
mendefinisikan suatu asuhan keperawatan.

B. Tujuan
Tujuan proses keperawatan secara umum adalah untuk menyusun kerangka konsep
berdasarkan keadaan individu (klien), keluarga, dan masyarakat agar kebutuhan mereka dapat
terpenuhi. Yura dan Walsh (1983) menyatakan proses keperawatan adalah suatu tahapan desain
tindakan yang ditujukan untuk memenuhi tujuan keperawatan, yang meliputi mempertahankan
keadaan kesehatan klien yang optimal, apabila keadaanya berubah menjadi suatu kuantitas dan
 kualitas asuhan keperawatan terhadap kondisinya guna kembali ke keadaan yang normal. Jika
kesehatan yang optimal tidak dapat tercapai, proses keperawatan harus dapat memfasilitasi
kualitas kehidupan yang maksimal berdasarkan keadaanya untuk mencapai derajat kehidupan
yang lebih tinggi selama hidupnya (Iyer et al., 1996).
Proses keperawatan mempunyai tujuan yang jelas melalui suatu tahapan dalam
meningkatkan kualitas asuhan keperawatan kepada klien.
C. Manfaat
Bagi Penulis
Mengembangkan kemampuan penulis dalam hal menyusun suatu laporan dan menambah
wawasan penulis tentang perencanan, implementasi dan evaluasi.
Bagi Pembaca
Dapat menambah wawasan dan pengetahuan pembaca dalam hal perencanaan, implementasi dan
evaluasi dalam keperawatan.
 BAB II
PEMBAHASAN
A. PERENCANAAN/ PLANNING
Langkah ketiga dari proses keperawatan adalah perencanaan. Dalam perencanaan
keperawatan, perawat menetapkannya berdasarkan hasil pengumpulan data dan rumusan
diagnosa keperawatan yang merupakan petunjuk dalam membuat tujuan dan asuhan keperawatan
untuk mencegah, menurunkan, atau mengeliminasi masalah kesehatan klien.
a. Pengertian Planning/Perencanaan
Perencanaan adalah kategori dari perilaku keperawatan dimana tujuan yang berpusat pada
klien dan hasil yang diperkirakan ditetapkan dan intervensi keperawatan dipilih untuk mencapai
tujuan tersebut. (Potter & Perry, 2005).
Menurut Kozier et al. (1995) perencanaan adalah sesuatu yang telah dipertimbangkan secara
mendalam, tahap yang sistematis dari proses keperawatan meliputi kegiatan pembuatan
keputusan dan pemecahan masalah.
Tahap perencanaan memberi kesempatan kepada perawat, klien,keluarga, dan orang
terdekat klien untuk merumuskan rencana tindakan keperawatan guna mengatasi masalah yang
dialami klien.
Perencanaan merupakan petunjuk tertulis yang menggambarkan secara tepat rencana
tindakan keperawatan yang dilakukan terhadap klien sesuai dengan kebutuhannya berdasarkan
diagnosa keperawatan.

b. Langkah-langkah intervensi keperawatan :

1. Menetapkan Prioritas
Setelah merumuskan diagnosa keperawatan spesifik, perawat menggunakan ketermpilan
berpikir kritis untuk menetapkan prioritas diagnosa dengan membuat peringkat dalam urutan
kepentingannya. Prioritas ditegakkan untuk mengidentifikasi urutan intervensi keperawatan
ketika klien mempunyai masalah atau perubahan multiple. (Carpenito, 1995).
Penetapan prioritas bertujuan untuk mengidentifikasi urutan intervensi keperawatan yang
sesuai dengan berbagai masalah klien (Carpenito, 1997). Penetapan prioritas dilakukan karena
tidak semua masalah dapat diatasi dalam waktu yang bersamaan. Salah satu metode dalam
menetapkan prioritas dengan mempergunakan hirarki kebutuhan menurut Maslow. Prioritas
dapat diklasifikasi menjadi tiga tingkatan, antara lain high priority, intermediate priority, dan
low priority. Dalam menetapkan prioritas perawat juga harus memperhatikan nilai dan
kepercayaan klien terhadap kesehatan, prioritas klien, sumber yang tersedia untuk klien dan
perawat, pentingnya masalah kesehatan yang dihadapi, dan rencana pengobatan medis.

2. Menetapkan Tujuan
Setelah mengkaji, mendiagnosis, dan menetapkan prioritas tentang kebutuhan perawatan
kesehatan klien, perawat merumuskan tujuan dan hasil yang diperkirakan dengan klien untuk
setiap diagnosa keperawatan (Gordon,1994).
Tujuan ditetapkan dalam bentuk tujuan jangka panjang dan jangka pendek. Tujuan jangka
panjang dimaksudkan untuk mengatasi masalah secara umum atau sasaran yang diperkirakan
untuk dicapai sepanjang periode waktu yang lebih lama, biasanya lebih dari satu minggu atau
berbulan-bulan (Carpenito, 1995 ). Sedangkan tujuan jangka pendek dimaksudkan untuk
mengatasi etiologi guna mencapai tujuan jangka panjang atau sasaran yang diharapkan tercapai
dalam periode waktu yang singkat, biasanya kurang dari satu minggu (Carpenito, 1995).

Tujuan keperawatan harus SMART artinya:

S Specific = Rumusan tujuan harus jelas
M Measurable = Dapat diukur
A Achievable = Dapat dicapai
R Realistic = Dapat tercapai dan nyata
T Timing = Harus ada target waktu
Penetapan tujuan menegakkan kerangka kerja untuk rencana asuhan keperawatan. Melalui
tujuan, perawat mampu untuk memberikan asuhan yang bersinambungan dan meninngkatkan
penggunaan waktu serta sumber yang optimal.

3. Kriteria Hasil atau Hasil Yang Diharapkan

Hasil yang diharapkan adalah sasaran spesifik, langkah demi langkah yang mengarah pada
pencapaian tujuan dan penghilangan etiologi untuk diagnose keperawatan. Suatu hasil adalah
perubahan dalam status klien yang dapat diukur dalam berespons terhadap asuhan keperawatan
(Gordon, 1994; Carpenito, 1995). Hasil adalah respons yang diinginkan dari kondisi klien dalam
dimensi fisiologis, sosial, emosional, perkembangan atau spiritual.
Untuk menentukan hasil yang diharapkan, ada beberapa pedoman yang harus diperhatikan,
yaitu :
a. Faktor yang berpusat pada klien
Karena asuhan keperawatan diarahkan dari diagnose keperawatan, maka tujuan dan hasil
yang diperkirakan difokuskan pada klien. Pernyataan ini mencerminkan perilaku dan respons
klien yang diperkirakan sebagai hasil dari intervensi keperawatan.
b. Faktor Tunggal
Setiap penetapan tujuan atau hasil yang diperkirakan harus menunjukkan hanya satu
respons perilaku. Kemungkinan ini memberikan metoda yang lebih tepat untuk mengevaluasi
respons klien terhadap tindakan keperawatan.
c. Faktor yang dapat diamati
Hasil yang diharapkan dari asuhan keperawatan harus dapat diamati. Melalui pengamatan
perawat mencatat bahwa telah terjadi perubahan. Perubahan yang dapat diamati dapat terjadi
dalam temuan fisiologis, tingkat pengetahuan klien, dan perilaku. Hasilnya dapat dicapai dengan
menanyakan secara langsung klien tentang kondisi atau dapat diamati dengan menggunakan
keterampilan pengkajian. Faktor yang dapat diamati ini kita dapati dari data subjektif.
d. Faktor yang dapat diukur
Tujuan dan hasil yang diharapkan ditulis untuk memberi perawat standar yang dapat
digunakan untuk mengukur respons klien terhadap asuhan keperawatan. Faktor yang dapat
diukur ini kita dapat dari data obektif.
e. Faktor batasan waktu
Batasan waktu untuk setiap tujuan dan hasil yang diharapkan menunjukkan kapan respons
yang diharapkan harus terjadi. Batasan waktu membantu perawat dan klien dalam menentukan
bahwa kemajuan sedang dilakukan dengan kecepatan yang jelas.
f. Faktor Mutual
Penetapan tujuan dan hasil yang diharapkan secara mutual memastikan bahwa klien dan
perawat setuju mengenai arah dan batasan waktu dari perawatan. Penetapan tujuan secara mutual
dapat meningkatkan motivasi dan kerja sama klien.
g. Faktor realistik
 Tujuan dan hasil yang diharapkan yang singkat dan realistic dapat dengan cepat memberikan
klien dan perawat suatu rasa pencapaian. Sebaliknya, rasa pencapaian ini dapat meningkatkan
motivasi dan kerja sama klien. Ketika menetapkan tujuan dan hasil yang diharapkan yang
realistik, perawat, melalui pengkajian, harus mengetahui sumber-sumber fasilitas perawatan
kesehatan, keluarga, dan klien.

4. Intervensi Keperawatan
Intervensi, strategi, atau tindakan keperawatan dipilih setelah tujuan dan hasil yang
diharapkan ditetapkan. Intervensi keperawatan adalah tindakan yang dirancang untuk membantu
klien dalam beralih dari tingkat kesehatan saat ini ke tingkat kesehatan yang diinginkan dalam
hasil yang diharapkan (Gordon, 1994).
Tipe intervensi terbagi 3, yaitu :
a. Intervensi perawat
Intervensi perawat adalah respons perawat terhadap kebutuhan perawatan kesehatan dan
diagnose keperawatan klien. Sebagai contoh, intervensi untuk meningkatkan pengetahuan klien
tentang nutrisi yang adekuat atau aktivitas kehidupan sehari-hari yang berhubungan dengan
hygiene ini adalah tindakan keperawatan mandiri. Intervensi perawat tidak membutuhkan
instruksi dari dokter atau profesi lainnya.
b. Intervensi dokter
Intervensi dokter didasarkan pada respons dokter terhadap diagnose medis, dan perawat
menyelesaikan instruksi tertulis dokter (Bulechek & McCloskey, 1994). Sebagai perawat untuk
menyelesaikan insruksi tersebut dan untuk mengkhususkan pendekatan tindakan. Setiap
intervensi dokter membutuhkan tanggung jawab keperawatan spesifik dan pengetahuan
keperawatan tehnik spesifik.

c. Intervensi kolaborasi
Intervensi kolaborasi adalah terapi yang membutuhkan pengetahuan, keterampilan, dan
keahlian dari berbagai professional perawatan kesehatan. Intervensi perawat, dokter dan
kolaborasi membutuhkan penilaian keperawatan yang kritis dan pembuatan keputusan. Ketika
menghadapi intervensi dokter, atau intervensi kolaboratif, perawat tidak secara otomatis
 mengimplementasikan terapi, tetapi harus menentukan apakah intervensi yang diminta sesuai
untuk klien.
Pemilihan intervensi
Ketika memilih intervensi, perawat menggunakan keterampilan membuat keputusam klinis
yang menunjukkan tentang enam faktor untuk memilih intervensi keperawatan pada klien
spesifik, yaitu :
a. Karakteristik diagnosa keperawatan
1) Intervensi harus diarahkan pada pengubahan etiologi atau tanda dan gejala yang berkaitan
dengan label diagnostik.
2) Intervensi diarahkan pada pengubahan atau menghilangakan faktor-faktor risiko yang
berkaitan dengan diagnosa keperawatan faktor risiko.

b. Hasil yang diharapkan

1) Hasil dinyatakan dalam istilah yang dapat diukur dan digunakan untuk mengevaluasi
keefektifan intervensi.

c. Dasar riset
1) Tinjauan riset keperawatn klinis yang berhubungan dengan label diagnostik dan masalah klien.
2) Tinjauan artikel yang menguraikan penggunaan temuan riset dalam situasi dan lingkungan
klinis yang serupa.

d. Kemungkinan untuk dikerjakan

1) Interaksi dan intervensi keperawatan dengan tindakan yang sedang diberikan oleh profesional
kesehatan lain.
2) Biaya. Apakah intervensi mempunyai nilai yang efektif baik secara klinis maupun biaya?
3) Waktu. Apakah waktu dan sumber tenaga tertangani dengan baik ?

e. Penerimann klien
1) Rencana tindakan harus selalu dengan tujuan klien dan nilai perawatan kesehatan klien.
2) Tujuan keperawatan yang diputuskan secara mutual.
3) Klien harus mampu melakukan perawatan diri atau mempunyai orang yang dapat membantu
dalam perawatan kesehatan tersebut.

f. Kompetensi dari perawat

1) Berpengetahuan banyak tentang rasional ilmiah intervensi.
2) Memiliki keterampilan fisiologis dam psikomotor yang diperlukan untuk menyelesaikan
intervensi.
3) Kemampuan untuk berfungsi dalam lingkungan dan secara efektif dan efisien menggunakan
sumber perawatan kesehatan.

Contoh bentuk intervensi :

No Tanggal Diagnosa Tujuan Kriteria hasil Intervensi
keperawatan
1. 21 Nov Gangguan mobilitas Untuk dapat
1. 1. Dapat 1. Mengajarkan
2011 fisik berhubungan Menyeimbangkan
2. klien
dengan inflamasi fisik : berdiri menggunakan alat bagaimana cara
pada lutut : tidak seimbang dengan bantu selama satu menggunakan
mampu kaki kiri minggu. alat
berdiri seimbang 3. bantu.
dengan kaki kiri. 2. Berdiri tanpa ada
bantuan asisten
selama sebulan. 2. Membimbing
klien
agar terlepas
dari
ketergantungan
terhadap alat
bantu.
 BAB III
PENUTUP
Kesimpulan

Dari bab pembahasan di atas dapat disimpulkan:

1. Proses Keperawatan adalah metode pengorganisasian yang sistematis dalam melakukan asuhan
keperawatan yang berfokus pada identifikasi dan pemecahan masalah dari respon pasien.
2. Proses Keperawatan digunakan untuk membantu perawat melakukan praktik keperawatan
secara sistematis dalam memecahkan masalah keperawatan.
3. Manfaat Proses Keperawatan untuk perawat adalah dapat merencanakan asuhan keperawatan
dan membantu mengembangkannya melalui hubungan professional, untuk memberikan
kepuasan bagi pasien dan perawat,dan untuk memberikan kerangka kerja bagi perawat dalam
melaksanakan asuhan keperawatan.
4. Proses keperawatan terdiri dari tiga proses yaitu Pengkajian, diagnose keperawatan, perencanaan
atau planning, Implementasi dan Evaluasi/Dokumentasi.

SARAN
Semoga hasil makalah ini dapat dipergunakan sebagai bahan pertimbangan, data awal
untuk melakukan proses keperawat. Serta dapat meningkatkan pengetahuan, sikap dan kemauan
perawat untuk melakukan tanggung jawabnya di rumah sakit nantinya
NURSING METHODOLOGY PLANNING, IMPLEMENTATION, EVALUATION AND DOCUMENTATION
PRINCESS DIANA 20@GMAIL.COM
PART I
PRELIMINARY
A. Background
Demands on the quality of nursing care perceived as a phenomenon that must be responded by nurses.
Professional nursing services should receive more attention in the development of the nursing world.
One strategy to optimize the role and function of nurses in the nursing service is to conduct nursing
management in the hope of factors and optimal management can improve the effectiveness of nursing
care division once more ensure client satisfaction on nursing services.
Nursing is based on a theory that is very broad. The nursing process is a method in which a concept is
applied in the practice of nursing. It can be called as an approach to problem solving (problem-solving)
that require science, engineering, and skills interpersonel which aims to meet the needs of the client,
family, and community. The nursing process consists of five successive phases and interconnected, ie
assessment, diagnosis, planning, implementation, and evaluation (Iyer et al., 1996). The stages integrate
the function of intellectual problem-solving in defining a nursing care.
B. Purpose
Nursing process in general goal is to develop a conceptual framework based on individual circumstances
(client), families, and communities so that their needs can be met. Yura and Walsh (1983) states the
nursing process is an action aimed at the design stage to meet the objectives of nursing, which includes
maintaining an optimal state of health of the client, if the condition turns into a quantity and quality of
nursing care for the condition to return to the normal state. If optimal health can not be achieved, the
nursing process should facilitate maximum quality of life based on the condition to achieve a higher
degree of life during his lifetime (Iyer et al., 1996).
The nursing process has a clear objective through a stage in improving the quality of nursing care to
clients.
C. Benefits
For Authors
Develop the ability of authors in preparing a report and broaden the author of planning, implementation
and evaluation.
For Readers
Can add insight and knowledge of the reader in terms of planning, implementation and evaluation in
nursing.
CHAPTER II
DISCUSSION
A. PLANNING / PLANNING
The third step of the nursing process is the planning. In the planning of nursing, nurse set it based on the
results of data collection and formulation of nursing diagnoses that are clues to make goals and nursing
care to prevent, decrease, or eliminate the client's health problems.
a. Definition of Planning / Planning
Planning is the category of nursing behavior where client-centered objectives and expected results set
and nursing interventions chosen to achieve these objectives. (Potter & Perry, 2005).
According Kozier et al. (1995) planning is something that has been considered in depth, systematic
phases of the nursing process includes the decision making and problem solving. The planning stage
gives an opportunity to the nurses, clients, family, and the people closest to the client to formulate a
nursing action plan to address the problems experienced by the client. Planning is the written
instructions that describe accurately plan nursing actions performed to clients according to their needs
based on nursing diagnoses.
b. Steps nursing interventions:
1. Setting Priorities
After formulating specific nursing diagnosis, the nurse uses critical thinking ketermpilan to set priorities
by making diagnosis rank in order of importance. Priority is established to identify the sequence of
nursing interventions when clients have multiple problems or changes. (Carpenito, 1995).
Prioritization aims to identify appropriate nursing interventions sequence with a variety of client
problems (Carpenito, 1997). Priority setting is done because not all problems can be solved at the same
time. One of the methods for setting priorities by using a hierarchy of needs Maslow. Priority can be
classified into three tiers, including high priority, intermediate priority, and low priority. In setting
priorities nurse must also consider the client's values and beliefs on health, client priorities, resources
available to clients and nurses, the importance of health issues faced, and the medical treatment plan.
2. Setting Goals
After studying, diagnosing, and set a priority on the health care needs of clients, nurses formulate
objectives and results are expected by the client for each nursing diagnosis (Gordon, 1994).
Objectives set out in the form of long-term goals and short-term. Long-term goals are intended to
address the issue in general or targets that are expected to be achieved over a period of time longer,
usually more than one week or months (Carpenito, 1995). While the short-term goals intended to
address the etiology in order to achieve long-term goals or objectives expected to be achieved in a short
period of time, usually less than one week (Carpenito, 1995).
Nursing objectives should be SMART means: S] Specific = formulation of objectives must be clear M]
Measurable = Can be measured A] Achievable = Can be reached R] Realistic = Can be reached and the
real T] Timing = There should be a target date
Determination purpose of enforcing a framework for nursing care plan. Through goals, the nurse is able
to provide the ongoing care and at enhancing the use of time and resources optimally.
3. Criteria Results or Results Expected
The expected result is a specific target, step by step towards achieving the goals and removal etiology
for nursing diagnosis. One result is a change in the status of clients that can be measured in respond to
the nursing care (Gordon, 1994; Carpenito, 1995). The result is the desired response from the client's
condition in dimensions physiological, social, emotional, or spiritual development.
To determine the expected results, there are some guidelines that should be considered, namely:
a. Factors client-centered
Because nursing care directed from nursing diagnoses, the objectives and results are expected to be
focused on the client. This statement reflects the client's behavior and responses are expected as a
result of nursing interventions.
b. Single Factor
Each setting goals or expected results should show only one behavioral response. This gives the
possibility of a more appropriate method to evaluate the client's responses to nursing actions.
c. Factors that could be observed
The expected outcome of nursing care must be observed. By observing the nurses noted that there have
been changes. Observable changes can occur in physiological findings, the level of client knowledge and
behavior. The result can be achieved by directly asking clients about the conditions or it can be observed
using the skills assessment. Factors that could be observed we find on subjective data.
d. Factors that can be measured
Objectives and expected results are written to give nurses a standard that can be used to measure the
client's response to nursing care. Factors which can be measured we can from the data obektif.
e. Factors time limit
The time limits for any purpose and expected outcomes indicate when a response is expected to be the
case. The time limits helps the nurse and the client to determine that progress is being made at a pace
that clearly.
f. Factors Mutual
Setting goals and expected outcomes mutually ensuring that clients and nurses agree on the direction
and limits the time of treatment. Mutually goal setting can increase motivation and collaboration client.
g. Factors realistic
Objectives and expected outcomes are concise and realistic can quickly provide clients and nurses a
sense of achievement. Instead, a sense of achievement can increase motivation and collaboration client.
When setting goals and expected results are realistic, nurses, through assessment, must know the
sources of health care facilities, family, and clients.
4. Nursing Interventions
Intervention, strategy, or action of nursing was chosen after objectives and expected results set. Nursing
intervention is an action designed to help clients to switch from the current health level to the desired
level of health in the expected results (Gordon, 1994).
Divided into 3 types of intervention, namely:
a. Intervention nurses
Nurse nurse intervention was a response to the needs of health care and nursing diagnosis of clients. For
example, interventions to improve client knowledge about adequate nutrition or daily life activities
related to hygiene are independent nursing actions. Intervention nurses do not need instructions from a
doctor or other professional.
b. Intervention doctor
Interventions based on the physician's response to the diagnosis of medical doctors, and nurses
completed the written instructions the doctor (Bulechek & McCloskey, 1994). As a nurse to complete
the insruksi and specialized approach to action. Each physician intervention requires specific nursing
responsibilities and specific knowledge of nursing techniques.
c. Intervention collaboration
Collaboration is a therapeutic intervention that requires knowledge, skill, and expertise of a wide range
of health care professionals. Interventions nurses, doctors and nursing collaboration requires a critical
assessment and decision-making. When facing the physician intervention, or collaborative intervention,
the nurse does not automatically implement the therapy, but must determine whether the requested
intervention is appropriate for the client.
Selection intervention
When selecting interventions, using the skills of nurses make clinical keputusam show about six factors
to select nursing interventions on specific clients, namely:
a. Characteristics of nursing diagnoses
1) Interventions should be aimed at changing etiology or signs and symptoms associated with a
diagnostic label.
2) Interventions aimed at changing or menghilangakan risk factors associated with nursing diagnosis risk
factors.
b. Expected results
1) The result is expressed in terms that can be measured and used to evaluate the effectiveness of
interventions.
c. Basic research
1) Overview keperawatn clinical research related to diagnostic label and the client's problem.
2) Review article describes the use of research findings in the clinical situation and the environment
alike.
d. Possibility to do
1) Interaction and nursing interventions with actions that are being given by other health professionals.
2) Cost. Is has a value of effective interventions, both clinically and cost?
3) Time. Is the time and energy sources handled properly?
e. Penerimann client
1) The action plan must be always with the client's goals and values of health care clients.
2) The purpose of nursing to be decided mutually.
3) The client must be able to perform self-care or to have people who can help in the health care.
f. Competence of nurses
1) Become knowledgeable about the scientific rational intervention.
2) Have a physiological dam psychomotor skills needed to complete the intervention.
3) Ability to function in the environment and the effective and efficient use of health care resources.
Examples of intervention:
No.
Date
Nursing diagnoses
Aim
Expected outcomes
Intervention
1.
21 Nov
2011
Impaired mobility
Physical touch
with inflammation of the knee: not afford
standing balance
with the left foot.
To be able
Physical balance: stand
by
Left Foot
1. 1. Can
2. use the tools for one week.
3.
2. Stand without any
aid assistant
for a month.
1. Teach clients
How to
use tool
aids.
2. Guiding clients
to escape from dependence
to tool
aids.
B. IMPLEMENTATION
a. Understanding Implementation Implementation of nursing is a set of activities performed by nurses to
help clients of the problems facing the health status kestatus good health that describes the criteria
expected results (Gordon, 1994, in Potter & Perry, 1997). The size of the nursing interventions provided
to clients related to support, treatment, measures to improve the conditions of education for the client-
family, or measures to prevent health problems that arise in the future.
For the successful implementation of the order in accordance with the implementation of nursing care
plan, the nurse must have the cognitive ability (intellectual) ability in interpersonal relationships, and
skills in action. The implementation process of implementation should be centered on the needs of the
client, other factors that affect the needs of nursing, nursing implementation strategy and
communications activities. (Kozier et al., 1995).
In the implementation of nursing actions requires several considerations, among others:
1) Individuality clients, by communicating the basic meaning of an implementation of nursing to be
performed.
2) Involve the client taking into account the energy of his illness, the nature of the stressor, a state of
psycho-socio-cultural understanding of the disease and intervention.
3) prevention of complications that may occur.
4) Maintaining the condition of the body so that the disease does not become more severe as well as
health improvement efforts.
5) Efforts to security and assistance to clients in meeting kebutuhannnya.
6) Appearance wise nurse of all activities performed to clients.
b. Type Implementation
According to Craven and Hirnle (2000) broadly there are three categories of implementation of nursing,
among others:
1.Cognitive implementations, includes teaching / education, linking the level of knowledge of clients
with activities of daily living, create strategies for clients with communication dysfunction, provide
feedback, overseeing the nursing team, overseeing the appearance of clients and families, as well as
creating an environment as needed, and etc.
2.Interpersonal implementations, including the coordination of activities, improve service, creating
therapeutic communication, set a personal timetable, expression of feelings, providing spiritual support,
acting as a client advocate, role model, and others.
3.Technical implementations, including the provision of hygiene skin care, perform routine activities of
nursing, found the change from baseline clients, organize an abnormal response to the client,
independent nursing action, collaboration, and referral, and others.
Whereas in the implementation of nursing, nurses can do so in accordance with the plan of nursing and
nursing type of implementation. In practice there are three types of implementation of nursing, among
others:
1.Independent implementations, is implementing its own initiated by nurses to assist clients in
addressing the problem in accordance with the needs, for example: assist in meeting the activity daily
living (ADL), provide care themselves, adjusting the sleeping position, creating a therapeutic
environment, provide a boost motivation , the fulfillment of psycho-socio-spiritual, treatment of invasive
tool used client, document, and others.
2.Interdependen / Collaborative implementations are nursing actions on the basis of cooperation with
fellow nursing or other health care team, such as doctors. For example in the case of oral drug delivery,
drug injection, infusion, urinary catheters, naso gastric tube (NGT), and others. Linkages in cooperative
action, for example in drug delivery injection, type of medication, dosage, and side effects are the
responsibility of the doctor but the right medication, the accuracy of the schedule of administration, the
accuracy of administration, the accuracy of the dosage, and the accuracy of the client, and the client's
response after the administration is the responsibility and to the attention of a nurse.
3.Dependent implementations are nursing actions on the basis of referrals from other professionals,
such as nutritionists, physiotherapies, psychologists and so on, for example in the case of: providing
nutrition to clients in accordance with the diet that was created by nutritionists, physical exercise
(physical mobilization) in accordance with the recommendation of the physiotherapy department.
c. Stage to Look For In Implementation
Operationally things that need to be considered in the implementation of the implementation of nursing
nurses are: 1. In the preparation phase. a.Menggali feelings, analysis of the strengths and limitations of
its own professionals. b.Memahami nursing plan well. c.Menguasai technical skills of nursing.
d.Memahami scientific rationale of the action to be performed. e.Mengetahui the necessary resources.
f.Memahami code of ethics and legal aspects applicable in nursing services. g.Memahami nursing clinical
practice standards for measuring success. h.Memahami side effects and complications that may arise.
i.Penampilan nurses have to convince. 2. During the implementation phase. a.Mengkomunikasikan /
inform the client about the decision nursing actions to be performed by nurses. b.Beri an opportunity
for clients to express their feelings to the explanation given by nurses. c.Menerapkan intellectual
knowledge, the ability of human relations and technical capabilities of nursing in the implementation of
nursing actions given by nurses. d.Hal things that need to be considered when implementing client's
action is energy, prevention of accidents and complications, security, privacy, the condition of the client,
the client's response to the actions that have been given. 3. At the termination stage. a.Terus attention
to the client's response to nursing actions that have been given. b.Tinjau client progress of nursing
actions that have been given. c.Rapikan equipment and the client environment and do termination.
d.Lakukan documentation.
d. Approach Implementation Measures In nursing action requires several considerations, among others:
1) Individuality clients, by communicating the basic meaning of an implementation of nursing to be
performed.
2) Involve the client taking into account the energy of his illness, the nature of the stressor, a state of
psycho-socio-cultural understanding of the disease and intervention.
3) prevention of complications that may occur.
4) Maintaining the condition of the body so that the disease does not become more severe as well as
health improvement efforts.
5) Efforts to security and assistance to clients in meeting kebutuhannnya.
6) Appearance wise nurse of all activities performed to clients.
e. Principles of Implementation Some guidelines or principles in the implementation of the
implementation of nursing (Kozier et al ,. 1995) are as follows:
1) Based on client responses.
2) Based on the science, the results of nursing research, professional service standards, legal and ethical
codes of nursing.
3) By the use of the resources available.
4) In accordance with the responsibilities and accountability of the nursing profession.
5) Understand clearly the existing orders in the plan of nursing interventions.
6) Must be able to create adaptations to the client as an individual in an effort to increase participation
to care for themselves (Self Care).
7) Emphasizing aspects of prevention and efforts to improve health status. Can keep a sense of security,
dignity and protect the client.
8) Provide education, support and assistance.
9) As a holistic.
10) Cooperation with other professions.
11) Perform documentation
f. Methods of Implementation
1. Helps In Daily Life Activities Daily Life Activities (AKS) is an activity usually performed throughout the
day / normal, these activities include: ambulation, eating, dressing, bathing, brushing teeth, and which
resulted in the need AKS berhias.Kondisi can be acute, chronic, temporary, permanent, for example,
postoperative clients who are unable to independently menyelesaikansemua AKS, while constantly
switch passes postoperative period, the client gradually less dependent on nurses to complete the AKS.
2.Konseling
Counseling is a method of implementation that helps clients use the problem-solving process to
mengelani and handle the stress and facilitates interpersonal relationships between clients, their
families and care teams kesehatan.klien with psychiatric diagnosis requiring treatment by a nurse who
has expertise in psychiatric nursing by social workers, psychiatrists and psychologist
3.Penyuluhan
Used presents the principles, procedures and techniques of health care for clients and to inform the
client about his health ststus.
4.Memberikan direct nursing care
To achieve the therapeutic objectives of clients, nurse intervention to reduce adverse reactions to the
use of precautionary and preventive measures in providing care.
COMPENSATION FOR ADVERSE REACTIONS
An adverse reaction is a harmful effect or unwanted effects of the medication. Examination of
diagnostic, or therapeutic intervention. Adverse reactions requiring nursing interventions independent,
dependent or interdependent. Mengopensasi nursing actions adverse reactions reduce or face
reactions. To do so nurses must have knowledge of the potential unintended effects. For example, when
delivering medication. Nurses understand the side effects of the known and potential of the drug. After
delivering medication nurse assess a client against any adverse effects. Nurses should know the drugs
that can fight side effects. For example, a client may have not known hypersensitivity to penicillin and
may experience wheals and itching after receiving three doses of penicillin. The nurse noted that the
reaction occurs and stop further administration of drugs.
When treating clients who will undergo or have to undergo certain diagnostic examinations. Nurses
must understand the inspection and any potential adverse effects. For example, the client does not
defecation within 24 hours after a barium enema. Nurses also have to learn about potential side effects,
recognizing the existence of adverse reactions and handle it according to the situation.
PREVENTIVE MEASURES
Preventive nursing actions aimed at health promotion and disease prevention to avoid the need for
treatment of acute or chronic rehabiliatif. Prevention includes the assessment and promotion of health
potential clients. Application of the measures required deperti immunization, health education, and
early diagnosis. Preventive nursing actions be used to meet the client's therapeutic purposes. Through
preventive action the nurse is able to help clients get the highest level of welfare.
RIGHT TECHNIQUE IN CARE GIVING CLIENTS AND PREPARING FOR THE PROCEDURE
Nursing care requires nurses experienced in many techniques is the method to be followed in
performing specific procedures such as giving medications, changing dressings or put a catheter folley
clients. Nurse clients, especially in the home and in the hospital, involving a lot of techniques. Each
procedure the nurse do for a client is done with a specific method. To run the procedure, the nurse must
have knowledge about the procedure itself. Frequency, measures and expected results. At the hospital
the nurses complete many procedures each day. Some of these procedures may be new, so before
making a new procedure nurse assess personal competence and determine the need for assistance, new
knowledge or skills.
ACTION TO SAVE THE SOUL
This action is applied when the physiological and psychological state of the client in danger. The purpose
of the life-saving action is to restore the balance of physiology and psychology. Such measures include
providing emergency medication, perform cardiopulmonary resuscitation, meresterain clients who
experience confusion or clients with violence and get immediate counseling from a crisis center for
clients who are very agitated. Doing this action is an important component of nursing practice. As with
the other procedures. Nurses should have knowledge about the life-saving procedure sendari. Steps and
expected results. If the nurses were not experienced a situation that requires emergency action.
Appropriate nursing actions may be to call the experienced professionals.
PURPOSE OF TREATMENT
Nurse destination client can be achieved by providing an environment that is conducive to meeting
those goals. Nurse adjusts based on client needs expressed or indicated; stimulate and motivate clients.
Nurses are also able to create a health care environment that is conducive to achieving the client's goals.
Ideally, the nurse creates an environment that gives adequate privacy for clients to meet their basic
needs and enable them to feel comfortable and beabas to interact with the health care team. An early
step in establishing a suitable environment is to orient clients and their families in health care
institutions. And they have to do cleaning in environments in homes, hospitals, health centers, and
other health-conducive maintained that feels safe and free from the environment is not clean.
MONITORING and evaluate OTHER STAFF MEMBERS WORKING from
Nurses who develop treatment plans often do not do all the nursing interventions. Some interventions
may be delegated to other health nursing team members. For example, non-invasion interventions such
as skin care, range of motion exercises, ambulation, ornate and hygiene measures can be assigned to
nursing assistants. In the case of a licensed practical nurse, medication administration and assessment of
vital signs can be delegated. The nurse who gave the task is responsible for ensuring that each task is
assigned accordingly and completed in accordance with the standards of care.
g. Documentation Implementation Examples Implementation Nursing Documentation Format:
COLLABORATIVE PROBLEM NO.DIAGNOSIS
DATE / TIME
ACTION
Format initials Charging Guidelines Implementation Measures of Nursing
1. Number of nursing diagnosis / problem collaboratively.
Write the number of nursing diagnosis / problem collaborative accordance with problems that have
been identified in the nursing diagnosis format.
2. Date / hour
Write the date, month and hour implementing nursing actions.
3.Tindakan
Write down the serial number of the action
The act is written in order of implementation of the action
Write dilakuakn actions and their results or clear response
Do not forget to write your name / type of drug, dosage, how memberikat, and other medical
instructions clearly
Do not write a term often, small, large, or other terms that can lead to different perceptions or still
raises questions. Example: feeding more often than usual. Better write at any hour feeding and in how
many servings of food given
To write health education measures "do penkes about penkes report attached
When penkes done briefly write down the actions and responses of patients after penkes clearly
4.Paraf
Write the initials and name light
Examples of problems Mr. Antony, a man aged 75 years, entered in the surgical unit of the recovery
room after the installation of the pen on the hips. History shows that Mr. Antony sendrian live in an
apartment. His wife died 10 years ago. Mr. Antony had many friends and was involved in NGOs. He likes
the way and ride a bicycle. This time she was hospitalized Because of falling off the bike. Postoperative
medical program for Tn.Antony is as follows.
foley catheters for drainage density.
2% NaCldengan KCL20 mEq for infuskan for 8 hours.
Morphine sulfate 6-8, IM every 3-4 hours, when pain.
Trapese above the headboard.
NO. COLLABORATIVE PROBLEM DIAGNOSIS
DATE / TIME
ACTION
Initials
24-03-2011 / 07:30
08:00
8:15
08:20
09:00
09:30
10:00
10:30
11:00
Measuring the level of consciousness:
GCS 1-1-1, pupillary reaction to light (+) isokor.
38C temperature, pulse 94 X / minute, blood pressure of 180 / 120mmHg
Making beds, tables and clothes client
Monitoring fluid infusion: NaCl 0.9% 20 drops / minute
Measuring temperature and pulse 38,9C 100X / min
Collaborated with the doctor during the visit: a plan for the CT scan, the therapy remains laen
Doing injection
Give an explanation to the family of the final client's condition and needs a CT scan.keluarga approved
and signed an informed concent
Escort clients to the CT scan room.
C. EVALUATION
a. Understanding evaluation
Stage assessment or evaluation is a comparison of systematic and deliberate about the health of its
clients with its intended purpose, carried out by means of ongoing, involving clients and other health
professionals.
In the act of nursing, nursing need to be evaluated. Evaluation of nursing is the final stage of a series of
nursing process which is useful if the purpose of nursing actions that have been done achieved or need
another approach.
In accordance with the action plan that has been granted, an assessment to see its success. If it is not or
has not been successful, needs to be drawn up new plans accordingly. All nursing action may not be
carried out in a single visit to the family. To that can be implemented in stages according to the time and
the willingness of the family.
Assessment in nursing is an activity in implementing the plan of action has been determined, to
determine the optimal fulfillment of client needs and measure the results of the nursing process.
Nursing assessment is mungukur the success of the plan and implementation of nursing actions
performed in meeting client needs. Assessment is a stage that determines whether the destination is
reached.
b.

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d.

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No.

Action

O.
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CHAPTER III
CLOSING

C. EVALUATION

a. Understanding evaluation
Stage assessment or evaluation is a comparison of systematic and deliberate about the health of its
clients with its intended purpose, carried out by means of ongoing, involving clients and other health
professionals.
In the act of nursing, nursing need to be evaluated. Evaluation of nursing is the final stage of a series of
nursing process which is useful if the purpose of nursing actions that have been done achieved or need
another approach.
In accordance with the action plan that has been granted, an assessment to see its success. If it is not or
has not been successful, needs to be drawn up new plans accordingly. All nursing action may not be
carried out in a single visit to the family. To that can be implemented in stages according to the time and
the willingness of the family.
Assessment in nursing is an activity in implementing the plan of action has been determined, to
determine the optimal fulfillment of client needs and measure the results of the nursing process.
Nursing assessment is mungukur the success of the plan and implementation of nursing actions
performed in meeting client needs. Assessment is a stage that determines whether the destination is
reached. Evaluation is always related to the purpose. If the assessment turns out goals are not achieved,
it is necessary to find the cause. This can occur due to several factors:
The aim is unrealistic
nursing improper action
There are environmental factors that can not be overcome.

Dimensions in the assessment:

Y The success of nursing actions associated with the achievement of objectives
Y efficiency associated with costs whether in the form of money, time, tanaga and material / equipment
needed
Y Compatibility, associated with the ability of the measures taken to solve the problem properly
according to the professional judgment
Y Adequacy, offensive completeness of action if all the measures implemented to achieve the desired
results.
b. Evaluation stage
Evaluation prepared using SOAP operationally with summative (done during the process of nursing care)
and formative (with the process and the final evaluation).
Evaluation can be divided into 2 types:
1. Evaluation of running (summative)
Genius evaluation is done in the form filling format with the progress notes oriented to the problems
experienced by the family. format used is SOAP format.
2. The final evaluation (formative)
This type of evaluation is done by comparing the objectives to be achieved. When there is a gap
between them, perhaps all stages of the nursing process needs to be revisited, in order to obtain the
data, problems or plans that need to be modified.
c. Evaluation methods
The method used in the evaluation include:
Direct observation is directly observe the changes that occur in the family.
Interviews family, related to a change in attitude, whether it has run the advice given nurse.
Checking the report, can be seen from nursing care plans are made and actions are implemented
according to plan.
stimulation exercises, is useful in determining the development of the ability to implement nursing
care.
d. Measuring achievement of goals family
Factor evaluated there are several components, among others:
a) Cognitive (knowledge)
The scope of the cognitive evaluation is:
family knowledge about the disease
Controlling symptoms
Treatment
diet, activity, inventory tools.
The risk of complications
symptoms should be reported
Prevention
This information can be obtained by:
a. Interview, by:

* To Ask the family to recall some facts that have been taught
* To Ask the family to declare specific information with the words of his own family (the family's own
opinion)
* For Inviting hypothesis family situations and ask appropriate action against what is being asked.
b. Paper and pencil
Nurses use paper and pencil to evaluate the knowledge of the family of the things that have been
taught.
c. Affective (emotional status), by means of direct observation, that is by observation of facial
expression, posture, tone of voice, verbal content of the message at the time doing interviews.
d. Psychomotor, namely by looking at what the family in accordance with what is expected.
e. The decision on the determination of the evaluation phase
There are 3 possible decisions at this stage:
* The family has achieved results that are determined in purpose, so that the plan may be discontinued
* The family is still in the process of achieving results that are determined, so it needs additional time,
resources, and intervention before the destination successfully
* Families can not achieve a predetermined outcome, so it is necessary:
1) Reviewing the issue or more accurate response
2) Creating a new outcome, the first outcome may be unrealistic or family may not want to the
objectives drawn up by nurses.
3) nursing intervention must be evaluated in terms of accuracy to achieve the goal earlier.

f. AIM
General purpose :

Guaranteeing optimal nursing care

Improving the quality of nursing care.

Special purpose :

Ending a nursing action plan

State whether the nursing objectives have been achieved
Forward the action plan of nursing
Modify the action plan of nursing
Can determine if the cause of the nursing care objectives have not been achieved

g. BENEFITS:
To determine the development of the client's health
To assess the effectiveness, efficiency and productivity of nursing care given
To assess the implementation of nursing care
As feedback to improve or construct a new cycle in the nursing process
Supporting accountability and responsibility in the implementation of nursing

h. Reason The importance of assessment

Y Stop the actions / activities that are not useful
Y To increase the efficiency of nursing actions
Y As evidence of the results of care measures
Y For the development and improvement of nursing practice.

i. STEPS EVALUATION:
! Determine the criteria, standards and evaluation questions
! Gather new data on the client
! Interpreting the new data
! Comparing the new data to the applicable standards
! Summarizes the results and make conclusions
! Implement appropriate action based on the conclusions

j. EVALUATION RESULT :
1) Objectives achieved: if the client shows the changes in accordance with established standards
2) The purpose is achieved in part: if the client shows some of the changes to the standards and criteria
that have been ditetapan
3) The purpose is not achieved: if the client does not show the changes and progress at all and even new
problems arise.

k. SOME THINGS NEED QUESTIONABLE IN EVALUATION:

1. Sufficiency of information
2. Relevance factors related
3. Priority issues compiled
4. Compliance with the issue plan
5. Consideration of factors unique Fator
6. Attention to the medical plan for therapy
7. The logic of the expected results
8. Explanation of nursing actions undertaken
9. The success of the plan that has been drawn up
10. The quality of planning
11. The emergence of new problems.
The evaluation is based on how effective intervention-intervention undertaken by the families, nurses
and others. Effectiveness is determined by looking at the family's response and the result, not the
interventions implemented.
Although the evaluation of the client-centered approach is the most relevant, often frustrating because
of the difficulties in making objective criteria for the desired result. The treatment plan contains a
framework for evaluation. Evaluation is a continuous process that occurs every time a nurse renew the
nursing care plan. Before plannings developed, a nurse with the family need to see tindakantindakan
tertenu care whether these measures really helped.
Here are questions to ponder when evaluating:
a. Is there a consensus among the families and other health care team members in terms of the
evaluation?
b. What additional data should be collected to evaluate progress?
c. Are there hidden the results of which need to be developed?
d. If the behavior and perceptions of the family stated that the problem in the intention is not
satisfactorily resolved, then what is the reason?
e. Is nursing diagnoses, objectives and approaches are accurate?
The most important factor is that the method should be tailored to the objectives and interventions
being evaluated.
Evaluation format
No. Dx

Date / Time

Action

TT Nurses

Date / hour

Note Developments

TT nurses

S.
O.
A.
P.

l. CRITERIA
1. Criteria Process (evaluation process): assess the course of implementation of the nursing process in
accordance with the circumstances, conditions and needs of the client. The evaluation process should
be implemented as soon as the planning of nursing implemented to assist the effectiveness of the
action.
2. Criteria for success (evaluation results / summative): assesses the results of which are shown
eperawatan care to change the client's behavior. This evaluation is carried out by the end nursing
actions in the plenary.
D. Documentation

a. Definition Documentation
Documentation in general is an authentic record, or all of the original script that can be proved or be
used as evidence in legal matters. While nursing documentation is proof of registration and report held
nurses in care record that is useful to the interests of clients, nurses, and health care team in providing
basic health services with accurate and complete communication in writing to the nurse's responsibility.

b. The concept for the model documentation

In understanding the various concepts for the model of nursing documentation, there are three
components of the model are mutually brhubungan documentation, interdependence and dynamic;
namely communication, the nursing process and documentation standards. The third component has a
specific skill that can be learned and used mainly by nurses. These three components are known as a
model Fisbach (uniflying model). Each component has a specific skill that can be learned and used by
nurses.
Written communication skills are the skills of nurses in notes with clear, easy to understand, and
contains accurate information that would be appropriately interpreted by others.
Skills documentation of the nursing process is the skill of nurses in the recording of the nursing process
as the skills to document when assessing the patient, the skills to identify problems and needs for care,
skill documenting the implementation of nursing, skill documenting nursing plans, skills documented
evaluation of the patient's response to treatment, and the skills to communicate the results of the study
patients to nurses or other health team members.
Standard documentation skills are skills to be able to meet and implement documentation standards
that have been established to keep. Such skills include skills in meeting documentation standards
assessment, diagnosis, planning, implementation and evaluation of nursing.
c. Documentation Standards
Documentation standard is a standard that can be used to provide direction and guidance for the
nursing process documentation.
In the standard documentation, there are several characteristics, including:
1) Characteristic documentation standards seen from various viewpoints nurses
2) Characteristics of documentation standards from the perspective of the client

d. Usefulness Documentation
1. As a communication tool
Documentation in providing nursing care will be coordinated to avoid or prevent repetitive information.
Errors will also be reduced so as to improve the quality of nursing care. In addition, communication can
also be used effectively and efficiently.
2. As an accountability mechanism
Standard documentation contains rules or regulations on the implementation of documentation.
Therefore, the quality of documentation standards truth will easily dipertanggungjawaban and apat
used on the lawsuit because it already has the legal standards
3. Methods of data collection
Documentation can be used to view patient data on the progress or development of asien objectively
and detect trends may occur. Can also be used as research material, because the data is authentic and
verified. In addition, the documentation can be used as statistical data.
4. Means nursing services individually
This objective is the integration of various aspects of the clients about the need for nursing services that
include the needs of bio, psycho, social and spiritual so that individuals can experience the benefits of
nursing care
5. Means evaluation
The end result of nursing care that has been documented is the evaluation of matters relating to the
actions of nursing actions in providing nursing care

6. Means of improving cooperation between the health team

Through documentation, doctors, nutritionists, physiotherapists, and medical personnel, will be
mutually cooperation in delivering the actions associated with the client. Because only through
authentic evidence of the actions that have been carried out, these activities will be run professionally.
7. Means of further education.
Evidence has the better education system and directed in accordance with the client's desired program.
Specifically for health workers, such evidence can be used as a tool to improve further education of
nursing services.
8. Used as nursing care audi
Documentation is useful for monitoring the quality of nursing care that has been given in connection
with competence in carrying out nursing care.

e. Documentation Assessment
Documentation of the assessment is a record of the results of assessments conducted to collect
information from the patient, making the basic data about the client, and make notes about the client's
health response.
a) Assessment Documentation Type
1. Preliminary Assessment (initial assessment)
Performed when the patient entered the hospital. Forms of documentation usually refers to the basic
data maintenance. During a general assessment, the nurse identifies health problems experienced by
clients, to collect data both general and specific assessments to facilitate nursing.
2. Continuous Assessment (Ongoing assessment)
Is the development of basic data. Information obtained from patients during the initial assessment and
additional information (in the form of diagnostic tests and other sources) is required to enforce data.
3. reexamined (Reassesment)
An assessment of the information obtained during the evaluation. Reassessment means nurses evaluate
the progress of the data from the patient's problems or the development of basic data as additional
information of the patient.
b) Form of Assessment Documentation Format
1. FAQ
Is one form of documentation format that can be achieved through various means. Done by asking
questions directly on the client.
2. Checklist
Form of checklists can be a list that has been provided or made such that, with the purpose of collecting
the data used for the organizational framework. Format checklists can minimize the time in writing the
data assessment, which questions require only a "yes" or "no".
3. Format Questionnaire
This format is the most widely used mainly in ambulatory environments to obtain information about
medical history.

f. Documentation of Nursing Diagnosis

Nursing diagnosis is a clinical judgment about a person, family, or society as a result of health problems
or life processes are actual or potential (NANDA, 1990)
a) Categories Nursing Diagnosis
1. The actual nursing diagnoses
According to Nanda is presenting clinical situation that has been validated through karatteistik major
constraints identified. Diagnosis actual keperawtan possess four components are: Label, definition,
characteristics and limitations related factors.
2. Nursing diagnosis risk or high risk
According to NANDA is a clinical judgment about individual, family or community that is highly
susceptible to experiencing problems than individuals or other groups in the same situation or nearly
the same.
3. Nursing diagnosis possibilities
According to NANDA, adlah tntang statement alleged health problems still require additional data in the
hope still needed to ensure the signs and symptoms of major risk factors.
4. Nursing Diagnosis prosperous
According to NANDA, go round the clinical provisions regarding individuals, groups or communities in
the transition from level to level specific health better health.

g. Plan Nursing Documentation

Nursing Plan Documentation is a record of the preparation "keprawatan action plan" to be performed.
a) type of plan documentation of nursing
1. Traditionally designed care plans
Using the three approaches, namely the diagnosis, keperawtan, expected outcomes and nursing
interventions or care instructions
2. Standarlized care plans
Using standard nursing practice in documenting that:
1) printed nursing plan based diagnostic medical or special procedures such as cardiac catheterization
procedures, surgery and others. This type anticipate responses to procedures performed
2) The treatment plan is based on nursing diagnoses. It is used based on the examination of patients
that support the diagnosis treatment.
3) Plans of nursing created by using a computer. Treatment can select client issues from the menu on
the computer.

b) Care Instructions
Is a form of action that menunujukkan care and specialized treatment.
Type of Care Instructions
1. Diagnostic Type
This type is assessing the possibility of the client toward achievement of expected outcomes with direct
observation.
2. Therapeutic Type
Menggambrkan actions taken by nurses directly to reduce, repair, and prevent possible problems.
3. Type extension
Used to improve patient care by helping clients obtain the behavior of individuals who facilitate
troubleshooting.
4. Type reference
This illustrates the type of care instructions perawtan role senagai coordinator and manager of client
care within the health care team members.

h. Documentation of Nursing Interventions

Documentation is a record of the actions of intervention given nurse.
a) type of nursing intervention
According to Bleich and Fischbach:
1. Intervention therapeutic treatment
These interventions provide treatment directly to the problems experienced by the patient, prevent
complications, and maintain health status.
2. Intervention Surveillance
These interventions stated on the survey data by looking back common data and validate the data. In
other words, nature is not directly because it provides the data first.

i. Documentation Evaluation
Documentation is a record of the evaluation of the patient's indication of progress toward an achievable
goal.
a) Type Evaluation documentation
There are two types of documentation that evaluation
1) Formative Evaluation
Stating evaluations conducted during interventions with immediate response.
2) Summative Evaluation
Is a recapitulation of observations and analysis of the patient's status at any given time.

k. Format and device documentation

Nursing documentation system is a way to collect the data into the format, records and operating
procedures that can provide a complete picture (an input data).
a) Technical Documentation Nursing:
1. Source Oriented Record
Dokumetasi technique is made by each member of the health team. In action, they do not rely on other
teams.
2. Kardex
This documentation technique uses a series of cards and make important data on the client using the
client's summary of the problem and therapies such as those used on an outpatient basis.
3. Problem-oriented record
An effective technique to document nursing care system oriented to client problems. 4 Components:
1) Data Base
Is a collection of information received from the client tentan diunit health services.
2) The list of problems
Is the result of the interpretation of the data base or the results of the analysis of data changes
3) The original plan
A plan that can be developed specifically for each issue includes three components, namely Diagnostics,
case management and health education
4) Note the development
Is a record of the development of state of the client based on each client's problems encountered.

b) Documentation Format
1. Format narrative
2. The format of SOAP
3. Format FOCUS
4. Format DAE
5. Notes concise development

CHAPTER III
CLOSING
Conclusion

From chapter discussion above it can be concluded:

1. The Nursing Process is a method of organizing systematic in doing nursing care that focuses on
identifying and solving the problem of the patient's response.
2. Nursing Process is used to help nurses perform nursing practice systematically in solving the problem
of nursing.
3. Benefits Nursing Process for the nurse is able to plan nursing care and help develop them through
professional relationships, to provide satisfaction for patients and caregivers, and to provide a
framework for nurses in performing nursing care.
4. The nursing process consists of three processes namely assessment, nursing diagnosis, planning or
planning, Implementation and Evaluation / Documentation.

SUGGESTION
Hopefully the results of this paper can be used as consideration, the initial data to perform the process
keperawat. And can improve knowledge, attitude and willingness of nurses to perform their
responsibilities at the hospital later