TASK 2 : CASE STUDY

NURSING INTERVENTION

By :

SALWA APRILIA
089 STYC 17

ISLAMIC HOSPITAL FOUNDATION OF NUSA TENGGARA BARAT

HIGH SCHOOL OF HEALTH SCIENCE YARSI MATARAM
STUDY NURSING LEVEL S.1
MATARAM
2020
 NURSING INTERVENTION

A. Intervention Definition (Planning)

Planning is the preparation of a nursing action plan that will be implemented to
repeat the problem in accordance with the nursing diagnosis that has been determined
with the fullest purpose of the client's needs (Maryam, 2008).
Nursing interventions according to Dochterman & Bulechek are all treatments that
are based on clinical judgment and nurse knowledge to improve patient / client
outcomes. Based on nursing priorities, an example of intervention in a case that is
effective airway clearance is related to secret accumulation. The author carries out a
treatment plan for 1x24 hours expected to clear the airway effectively with the criteria of
patent airway results with clean breath, clean breathing, facetular lung sound (Wilkinson,
2011). Interventions or plans to monitor vital signs to determine the client's health status
(Suparman, 2012). Examination of vital signs include: blood pressure, pulse, perifri, and
apical pulse (HR), respiration (RR), and body temperature. Give chest physiotherapy to
remove the secret, collaboration with doctors to accelerate the healing process (Riksani,
2012).
The planning stage can be referred to as the core or main point of the nursing
process because planning is an initial decision that gives direction to the goals to be
achieved, things to be done, including how, when, and who will carry out nursing
actions. Therefore, in preparing a nursing action plan for clients, family and the closest
people need to be involved maximally
B. Intervention Objectives
The aim is to anticipate the possibility of re-emergence of problems by analyzing
internal and external environmental conditions that refer to efforts to achieve goals (Mc
Namara, 2010).
C. Types of Nursing Interventions
According to Walkinson (2007) nursing interventions consist of three types:
1. Independent intervention (independent intervention)
This type of intervention is the type in which nurses are allowed to prescribe,
carry out or delegate interventions based on nurses' knowledge and skills.
2. Intervention of dependency (dependent intervention)
This type of intervention is the type in which the intervention is prescribed by
the doctor and carried out by the nurse. Medical orders usually include orders for
 medication, IV therapy, diagnostic tests, treatments, diet and activities. The nurse is
responsible for explaining, assessing, the need for this intervention, and carrying out
medical orders.
3. Interdependent interventions
This type of intervention is also called collaborative which is done in
collaboration with other health team members. For example phsycal therapy, social
workers, nutritionists and doctors. Interventions here illustrate overlapping
responsibilities.
D. Stages in Intervention
The stages in intervention (planning) according to (Flores, 2009) are:
1. Must conduct an assessment first
2. Prioritize problems
3. Setting goals
4. Analyzing obstacles and limitations
5. Make a schedule of activities (set activities, personnel involved, facilities and
infrastructure, financial support, and stages).
E. Examples of Interventions
Day/Dat No Objectives and outcome criteria Intervention
e DX (SLKI Edition 1 Issue II, 2019) (SIKI Edition 1 Prints II 2018)
After nursing action, it is expected 1. Monitor frequency, rhythm,
that the pertukran gas disturbance depth and breathing efforts
can be overcome with the result 2. Monitor breathing patterns (such
criteria: as bradycardia, tachypnea,
1. Dyspnea decreases hyperventilation etc.)
2. Dizziness decreases 3. Monitor for airway obstruction
3. PCO2 improves 4. Monitor oxygen flow velocity
4. PO2 improves 5. Palpate symptom of pulmonary
5. The tachycardia improves expansion
6. Additional breath sounds 6. Auscultation of breath sounds
decrease 7. Adjust respiration monitoring
7. Cyanosis improves interval according to the patient's
8. Restless anxiety decreases condition
9. Nasal lobe breath decreases 8. Teach patients and families how
10. Improved breathing patterns to use oxygen at home
11. 11. Awareness increases 9. Collaboration in determining the
oxygen dose