PROSES

INTERVENSI KEPERAWATAN

Taufan Arif, S.Kep., Ns., M.Kep

 CONTENT
Penjelasan perencanaan dan intervensi/implementasi keperawatan
• Langkah-langkah Perencanaan
• Prioritas Masalah
• Standar Intervensi Keperawatan Indonesia (SIKI)
• Komponen rencana keperawatan
• Penentuan rencana keperawatan berdasarkan NANDA NOC dan NIC
The Nursing Process
Standard Nursing Process
Component
1. Standard 1 Assessment
2. Standard 2 Diagnosis
3. Standard 3 Outcomes
Identification
4. Standard 4 Planning
5. Standard 5 Implementation
6. Standard 6 Evaluation
Collaborative healthcare Team

A nursing diagnosis
can be problem-
focused, or a state
of health
promotion or
potential risk
 NURSING DIAGNOSIS
• Problem-focused diagnosis – a clinical judgment concerning an
undesirable human response to a health condition/life process that exists
in an individual, family, group, or community
• Risk diagnosis – a clinical judgment concerning the vulnerability of an
individual, family, group or community for developing an undesirable
human response to health conditions/life processes
• Health promotion diagnosis – a clinical judgment concerning motivation
and desire to increase well-being and to actualize human health potential.
These responses are expressed by a readiness to enhance specific health
behaviors, and can be used in any heath state. Health promotion responses
may exist in an individual, family, group, or community
Planning for Nursing Care
• The nursing assessment and the formulations of
nursing diagnoses are essential to the planning step

• Planning is a category of nursing behaviors in which

the client-centered goals and expected outcomes
are established and nursing interventions are
selected to achieve the goals and outcomes of care
 Definition
Once the nursing diagnoses have been identified, the
planning component is established in accordance with the
steps of the nursing process:
1. Assigning priorities to the diagnoses
2. Specifying the immediate, intermediate, and longterm goals of learning
3. Identifying specific teaching strategies appropriate for attaining goals
4. Specifying the expected outcomes
5. Documenting the diagnoses, goals, teaching strategies, and expected
outcomes of the teaching plan
 Nursing Diagnosis Priority
• High-priority nursing diagnoses need to be identified (i.e.,
urgent need, diagnoses with a high level of congruence
with defining characteristics, related factors, or risk
factors)
 Establishing priorities
• Priority selection is the method the nurse and the client use to
mutually rank the diagnoses in order of importance based on the
client’s desires, needs, and safety. For example: Maslow’s hierarchy
of needs
• Priorities are classified as high, intermediate, or low, depend on
the urgency of the problem.
• High priority: if the nursing diagnoses were untreated, it could
result in harm to the client or others (include both physiological
and psychological dimensions)
• Intermediate priority: involve the non-emergent, non-life
threatening needs of client
• Low priority: client needs that may not be directly related to a
specific illness or prognosis
MENENTUKAN PRIORITAS
Establishing Goals and Expected Outcomes
• Before giving any form of nursing care, the nurse must
decide what the end point of nursing care should be for
the client
• Goals and expected outcomes are specific statements
used to indicate client behavior or responses from nursing
care
• The purposes: to provide direction for individualized
nursing interventions and to set standard of determining
the effectiveness of the interventions
 TUJUAN DAN KRITERIA HASIL

Subjek Memiliki
harus target
spesifik waktu

Menggunakan
kata kerja yg
dapat Kriteria
diukur/positif pencapaian
Hasil yang
“mampu” yg relevan
dicapai
dan rasional
nyata
Goals of care
• A client-centered goal: a specific, measurable
objective
• it require active involvement by the client
• Goals should be realistic and based on client needs
and resources
• Have a time target
• Short-term and long-term goal could be developed
depend on the client’s need/problem and the
nursing services provided
 Expected outcomes
• An outcome is a measurable change of the client’s status in
response to nursing care
• Outcomes are the desired responses of client’s condition in
physiological, social, emotional, developmental or spiritual
dimensions
• This change in condition is documented through observable
or measurable client responses
Nursing Outcome Classification (NOC)
• Nursing diagnoses are used to identify outcomes of care
and plan nursing-specific interventions sequentially.
• A nursing outcome refers to a measurable behavior or
perception demonstrated by an individual, family, group,
or community that is responsive to nursing intervention.
• Nursing Outcome Classification (NOC) is a system that can
be used to select outcome measures related to nursing
diagnosis.
Guidelines for writing goals and
expected outcome
•NDx: Airway clearance, ineffective related to Retained secretions
•Goals: After 3x24 hours nursing care, the client Tn X will maintain
adequate of the airway clearance
•Expected outcomes:
- Respiratory frequency between 15-20 times per minute
- Regular breathing rhythm
- The ability to take out secretions and effective cough
- There are no additional breath sounds
- There is no dyspnea
Step 1
Step 2
Step 3
Step 4
Nursing Interventions Classification (NIC)
• An intervention is defined as “any treatment, based upon
clinical judgment and knowledge, that a nurse performs
to enhance patient/client outcomes”
• The Nursing Interventions Classification (NIC) is a
comprehensive, evidence-based taxonomy of
interventions that nurses perform across various care
settings.
 Cara Menentukan NIC (1)
1. LIHAT DIAGNOSA KEPERAWATAN PADA BUKU NIC
LANGKAH
2
 LANGKAH 3

Lihat Lihat
Classification
NIC pada
daftar isi.
 CONTOH PERUBAHAN MASALAH
PRIORITAS KEPERAWATAN
Pasien pada awalnya ditangani dengan diagnosa
keperawatan : Intoleransi aktivitas.
Setelah mengkaji pasien kembali, perawat
memperhatikan bahwa pasien tidak bisa batuk dan
dada terasa berat saat digunakan bernafas, RR 30
x/menit dan dangkal, terdengar bunyi ronkhi saat di
auskultasi di lobus kanan bawah paru.
Diagnosa keperawatan yang muncul baru adalah :
Bersihan jalan nafas tidak efektif, dan dijadikan
diagnosa prioritas.
 JENIS-JENIS INTERVENSI
KEPERAWATAN
Intervensi Diagnostik :
Mengkaji kemajuan pasien ke arah pencapaian
kriteria hasil dg pemantauan aktivitas px scr
langsung

Intervensi Terapeutik :
Intervensi Rujukan :
Menunjukkan tindakan o/
Menekankan peran perawat
perawat yg secara
sbg koordinator dan
langsung mengurangi,
manager dalam perawatan
memperbaiki atau
pasien dlm anggota tim
mencegah eksaserbasi
perawatan kesehatan
masalah

Intervensi promkes:
Meningkatkan perawatan diri pasien dg
membantu individu utk memperoleh tingkah
laku baru yg mempermudah resolusi masalah
 TIPE INTERVENSI
1. tipe diagnostik : menilai kemungkinan klien ke arah pencapaian kriteria hasil dengan observasi
secara langsung.
Ex : kaji rentang gerak ekstremitas atas klien
2. Tipe terapeutik : menggambaran tindaan yang dilakukan oleh perawat secara langsung untuk
mengurangi, memperbaiki, dan mencegah kemungkinan masalah.
Ex : Lakukan ROM aktif pada kaki kiri klien
3. Tipe penyuluhan : digunakan untu meningatkan perawatan diri klien dengan membantu klien
memperoleh tingkah laku individu yang mempermudah pemecahan masalah.
Ex : ajarkan klien menggunakan walker
4. Tipe rujukan : menggambarkan peran perawat sebagai koordinator dan manajer perawatan
klien dalam anggota tim kesehatan.
Ex : kolaborasi dengan fisiotherapi untuk mobilisasi klien.
TUGAS INDIVIDU TERSTRUKTUR
• Buatlah Intervensi Keperawatan dari salah satu diagnose
keperawatan yang ANDA pilih..
• Setiap Mahasiswa Harus berbeda diagnose keperawatan
yang diangkat.. (perlu dikoordinasikan oleh PJMK terkait
pembagian diagnose keperawatan).
• Tugas ditulis tangan dan di kumpulkan Besok hari
maksimal pukul 15.00.