NAMA : YOSI EKA DAMAYANTI

NIM : 01.2.17.00631
TUGAS : BIG P.YOYOK

Chapter 3
NURSING INTERVENTION
& IMPLEMENTATION
Activity 7 - Working in a Pair

Finish this conversation, and practice with a partner.

Case : Two nurses need to give an IV to the patient.

Nurse : Good morning mom

Patient : Morning nurse

Nurse : How are you today

Patient : My current situation is still dizzy, nurse

Nurse : you are still dizzy. Either you. Now I want to put the IV, will you sit or lie on the sofa
and I will put on the right hand.

Patient : Sure.

Nurse : You will now see this vein (tourniquet) wrapped around him and his hand for help on
his fist

Patient : good nurse

Nurse : I'll do this and it hurts a little bit huh

Patient : Ouch!

Nurse : Don't move when I insert the needle OK.

There he is. Done.

Patient : Thank you Nurse.

Nurse : You're welcome.

Activity 8

Nurse : Good morning, please introduce me to nurse Yosi who will be on duty this morning,
from 08:00 to 14:00 noon, can you mention the name and place of birth date?

Patient : My name is Yusuf Alfatoni, my place of birth is Jombang, 15 January 1997

Nurse : Yes, the name is correct, here I will carry out an infusion of the lady according to the
doctor's advice which aims to meet the fluid needs

Patient: yes

Nurse : The time I spent for the infusion was around 10-15 minutes, was Miss willing?

Patient : Yes, I do

Nurse : Fine, my lady will prepare the tools first, okay?

Patient : Yes

Work Stage: Action: wash hands, bring the appliance closer.

Nurse : OK, Miss. I will put the infusion in your right hand, Miss. By inserting the needle, it
hurts a little, and when I insert it, you can't pull her hand. (Prepare fluids and infusion
tube and hang it on the standard infusion, determine the puncture area and attach the
base)

Patient : Yes

Nurse : Miss can lie on your back, I will pair tourniket

Patient : Fine

Nurse : I will clean the area where the IV needle was inserted, you can clench her fists.

Patient : Good nurse

Nurse : In the third count I will start to insert the needle, Miss can catch a breath. Miss, don't be
afraid, it will only hurt for a moment. You can close your eyes if you are afraid. (After
the needle is inserted into the vein, connect it with an IV line, fix it and cover the
insertion area with a pelster)

Patient : Good nurse

Nurse : My lady has finished the infusion

Patient : Thank you

Nurse : You're welcome

Activity 16

Conversation 1
Instruction Label

Nurse : good morning ..

Client : Morning nurse

Nurse : what's her name? And how old

Patient : Duvan Nurse, I am 15 years old

Nurse : oo yes .. what do you feel?

Client : I have flu, nurse, runny nose all day

Nurse : okay, let me check it first ..

Client : yes please

Nurse : body temperature = 37.5 C, respiration = 20x / m, pulse = 80, TD = 120/80.

you are in a fever condition

Client : then how about a nurse ..

Nurse : let's consult a doctor ..

Client : OK
Peawat : the doctor said that you yourself have a cold and flu .. and this is the doctor's
prescription.

Client : what drug is this?

Nurse : this is a medicine for colds and fever, how to take 2 tablets a day morning and
night after meals. This drug has a side effect that can make you drowsy. how
does duvan understand?

Client : yes, I understand

Nurse : not after taking the medicine, joni should take a break first ... can I travel first?

Client : Thank you, beautiful nurse

Nurse : yes, joni is the same

Conversation 2
Instruction Label

Nurse: Good evening

Client: evening ..
Nurse: Can you say name and age
Client: My name is Yusak and I am 21 years old
Peawat: what are you complaining about?
Client: I kept coughing, until I had a sore throat, I experienced this after I traveled ..
Nurse: OK, any more complaints?
Client: My stomach is bloated ..
Nurse: OK, I'll check it out
Client: Fine
Nurse: temperature = 36.5 C P = 18x / m, N = 80 x / m, TD = 100/70
Client: then how is the nurse?
Nurse: come with me to the doctor's room for further examination.
Client: OK ..
Nurse: Yusak what is coughing shivering because he has a cold huh ... this is syrup for Dion
Client: how to use it?
Nurse: drink 1 to 2 teaspoons Can be repeated in 4 hours, if necessary, but not more than 4 times
in 24 hours
Nurse: How do you understand it
Client: thank you good nurse
Nurse: You're welcome

Conversation 3
Instruction Label

Nurse : “Hallo Ms, How are you?”

Client : “I’m Not Fine, Nurse”

Nurse : “ Ok, have you taken the medicine?”

Client : “Not Yet”

Nurse : “Here are some spray”

Client : “How to use these spray?”

Nurse : “Please take this for adult is a one time or twice in each nostril with head upright.
Squeeze bottle quickly and firmly. And for Children is Spray once.”

Ms T : “Ok Nurse, Thank You”

Nurse : “You’re Welcome”

Activity 22

Bekerja dalam Pasangan Terjemahkan ke Bahasa Indonesia. Tentukan apakah formulir -ing
adalah Present Participle atau Gerund, atau tidak termasuk keduanya.

1. Melanjutkan pemantauan tekanan darah, pernapasan, dan refleks harus dimasukkan

dalam rencana perawatan wanita pascapartum. (Not included)
2. Seorang dewasa telah menerima satu unit sel darah merah setelah mengalami trauma
parah pada kakinya dengan pendarahan yang banyak.( Present Participle)
3. Perawat menyarankan agar kunjungan keluarga bergiliran selama jam kunjungan normal,
karena klien perlu tidur.(gerund)
4. Manakah dari intervensi keperawatan berikut yang menunjukkan kurangnya tuntutan di
pihak perawat terkait perawatan yang tepat untuk tukak tekan? ( Gerund)
 5. He is complaining of burning, crushing pain in his amputated food. ( Present Participle)
6. Saat menilai seorang wanita, perawat mendapatkan data yang menunjukkan bahwa klien
telah mengembangkan hipertiroidisme.( Gerund )

Activity 23

Implementation
- Assessing the client's preferred fluids within the dietary limits
- Planning a target for fluid intake for each shift, (eg 1000 ml day, 800 ml afternoon and 200
ml night.
- Assess client's understanding of reasons for maintaining adequate hydration.
- Record output intake
- Monitor oral intake, at least 1500 ml / 24 hours
- Monitor urine specific gravity.

2. Anxiety related to breathing difficulties and worries about work and parenting.
Diagnosis Goals Nursing Rational
Intervention
Anxiety is related to: After intervention for Anxiety reduction Observation:
- Needs are not met 1 x 24 hours, then the (I.09314): 1. To determine the
- Threats to death anxiety level Observation: client's ability to
- Family system (L.09093) was 1. Identify the ability make decisions
dysfunction improved with the to make decisions 2. In order to know
following criteria: 2. Monitor for signs the signs indicated by
1. Verbalize of anxiety (verbal the client
confusion and nonverbal) Therapeutic:
2. Verbalization of Therapeutic: 1. So that patients
worry due to the 1. Create a can trust the nurse
conditions at hand therapeutic 2. So that the
3. Restless behavior atmosphere to patient's anxiety can
4. Tense behavior cultivate trust be reduced
2. Accompany the 3. To be able to find
patient to relieve out what the patient
anxiety, if possible feels
3. Understand the 4. So that the patient
situation that causes can trust and have
anxiety. Listen confidence in the
attentively nurse.
4. Use a calm and Education:
reassuring approach 1. So that the patient
Education: can understand what
1. Describe the the procedure will be
procedure, including 2. So that the
any sensations that patient's anxiety
may be experienced problems can be
 2. Instruct family to reduced
stay with patient, if 3. In order to divert
necessary client anxiety
3. Practice distraction 4. In order to reduce
activities to reduce anxiety
tension Collaboration:
4. Practice relaxation 1. In order to treat
techniques patient anxiety.
Collaboration:
1. Collaboration of
antianastesity drugs,
if necessary

implementation
- Identify the ability to make decisions
- Monitor signs of anxiety (verbal and nonverbal)
- Teaches clients to reduce tension
- Train clients to do relaxation techniques

3. Altered nutrition: less than body requirements associated with decreased appetite,
nausea, and increased metabolism secondary to disease processes.
Diagnosis Goals Nursing Rational
Intervention
Nutritional deficits After intervention for Nutrition Observation:
related to: 1 x 24 hours, then the management 1. In order to know
- Inability to digest nutritional status (I.03119): the patient's
food (L.03030) was Observation: nutritional status
- Inability to absorb improved with the 1. Identification of 2. In order to find out
nutrients following criteria: nutritional status the patient's favorite
1. The portion that is 2. Identify the food
consumed preferred food 3. In order to know
3. Identify calorie whether the patient's
needs and nutrient calorie and
types nutritional needs
4. Monitor food have been met or not
intake 4. To find out what
5. Monitor weight intake the client
Therapeutic: consumes
1. Take oral hygine 5. In order to find out
before meals, if the weight reduction
necessary in clients
2. Serve food in an Therapeutic:
attractive manner and 1. So that the patient
 at a suitable can eat with clean
temperature hands
3. Provide foods high 2. So that the patient
in calories and can eat
protein 3. So that the
Education: patient's calorie and
1. Encourage a sitting protein needs can be
position, if able fulfilled
Collaboration: Education:
1. Collaborate with a 1. So that the patient
nutritionist to can eat well
determine the Collaboration:
number of calories 1. So that the
and types of nutrients patient's nutritional
needed, if necessary. intake can be
fulfilled properly

Implementation
- Identification of nutritional status
- Monitor weight
- Checking the food intake consumed by the patient

4. Self-care deficit (level 2) associated with activity intolerance secondary to ineffective

airway clearance and disturbed sleep patterns.
Diagnosis Goals Nursing Rational
Intervention
Self-care deficits After intervention for Self-care support Observation:
related to: 1 x 24 hours, then the (I.11348): 1. To know the
- Weakness self-care (L.11103) Observation: patient's self-care
- Neuromuscular was improved with 1. Identify age- habits
disorders the following criteria: appropriate self-care 2. To determine the
1. The ability to activity habits level of
shower 2. Monitor level of independence of the
2. Ability to wear independence patient
clothes Therapeutic: Therapeutic:
3. Ability to toilet 1. Prepare personal 1. So that patients
(BAB / BAK) needs (for example can easily perform
4. Verbalize the perfume, toothbrush, self-care
desire for self-care and bath soap) independently
5. Interest in self-care 2. Assist in self-care 2. In order to assist
until independent clients in self-care
Education: Education:
1. Encourage 1. So that patients
 consistent self-care can be independent
according to ability to do self-care
according to their
abilities

Implementation
- Monitor patient self-care activities
- Prepare personal needs (for example perfume, toothbrush, and bath soap)
- Assist in self-care until they are independent