ASKING AND TELLING ABOUT A

MEASUREMENT

GROUP 9

1. EVIARTY
2. LIA AFRINA
3. META SUSANTI
4. TRISNA WIRAYUDA
1. EXPLAINING INTERVENTION TO THE PATIENTS

Nursing interventions are guidelines for specific behaviors

expected of clients, or actions that nurses should take.
Interventions are carried out to help clients achieve the
expected results (Deswani, 2009).
The planning stage focuses on prioritizing problems,
determining expected goals and outcomes, make the
nursing instruction, and document nursing care plan.

Step-by-Step Planning Nursing

1. A Priority Problem
Priority problem is the method used nurses and
patients to make a diagnosis ranked in order of
importance based on the desires, needs and patient
There are 5 levels of priority :

Self
actu
aliz
atio
n
self-esteem

love ( own and be owned )

sense of security and protection

physiological needs
There are 3 priority levels in nursing planning:
• Height Patients will be disrupted if the nursing diagnoses
are not met.
• Medium The patient's condition is not an emergency if his
needs are not met.
• Low If the patient's needs are not met, it will not interfere
with the patient's specific disease.

2. DETERMINING EXPECTED GOALS AND OUTCOMES

The goals and expected outcomes are specific statements of the
patient's behavior or response to nursing care.
The benefits of writing objectives:
a. Provide direction for individual nursing interventions.
b. Determine the effectiveness of the intervention.
Guidelines for writing goals and expected results :
1 
1 Client-centered factors

2 Single Factor
3 Observable factors
4 Measurable factors
5 Time limitation factor
6 Mutual factors
7 Realistic / attainable
4
factors
3. NURSING INTERVENTIONS
There are 3 types of nursing interventions,
namely:
• Nurse interventions
Include aspects of professional nursing
practice that has licensed and legal.
• Doctor's Intervention
The doctor's response to the medical
diagnosis and the nurse completes the
doctor's instructions
• Collaborative Intervention
Therapy that requires the knowledge, skills,
and expertise of a wide range of health
nursing professionals
4. WRITING NURSING CARE PLAN
In planning writing using 5 columns :
 Column 1: contains accurate data with related
nursing diagnoses.
 Column 2: contains predefined objectives.
After that, the nurse makes short-term and
long-term goals in the action plan.
 Column 3: is the implementation column
containing the action plan.
 Column 4: contains a nurse's rational
understanding of specific interventions
 Column 5: contains defined and previously
identified outcome criteria from the nursing
care plan
2. GIVING INSTRUCTIONS TO THE PATIENTS
( IMPLEMENTATION )
• Implementation is an initiative of a nursing action
plan to achieve a specific goal.
The implementation stage begins after an action plan is
drawn up and aimed at nursing orders to help patients
achieve the expected goals.
• The objectives of nursing implementation:
 Helping patients achieve the goals that have been
set
 Includes health improvements
 Includes disease prevention
 Covers health restoration
• Types of nursing implementation Broadly speaking, there are
three categories of nursing implementation (Craven and Hirnle,
2000), namely:
a. Cognitive implementations.
Includes teaching or education, linking the client's level of
knowledge with daily life activities, making strategies for
clients with communication dysfunction, providing feedback,
supervising the nursing team, supervising the appearance of
clients and families, and creating an environment as needed,
and so on.
b. Interpersonal implementations.
Includes coordinating activities, improving services, creating
therapeutic communication, setting personal schedules,
c. Technical implementations.
Includes providing skin hygiene care, performing
routine nursing activities, finding changes
from client baseline data, organizing abnormal
client responses, performing independent
nursing actions, collaboration, and referrals,
and others.
Types of nursing implementation
Meanwhile, in implementing nursing, nurses can
do it in accordance with the nursing plan and the
type of nursing implementation.
• In its implementation, there are three types of nursing
implementation, including:
a. Independent implementations.
b. Interdependent / Collaborative implementations.
c. Dependent implementations.
• Factors that influence the implementation of the mental health
nursing process
1. Level of education
2. Knowledge
3. Motivation
4. Mental Health Nursing Process Assessment Form
5. Technical Guidance (Juknis) of Filling Mental Health
Nursing Process.
6. Work Fixed Procedure (Protap)
• How to measure implementation in the work phase
To measure the implementation of the guidelines is the
applicable nursing care standards, therefore knowledge of
nursing standards must absolutely be possessed. To measure
each parameter that must be measured, you can use interviews,
Examples of intervention and implementation in
patients with chronic renal failure

NO Diagnosis (SDKI) objectives and intervention (SIKI) Implementation

outcome criteria
(SLKI)
1 Less nutrients After the intervention • identify nutritional • Ask the family or the
associated with nausea 2 x 24 hours, the status patient whether the
and vomiting nutritional status patient spent 1
improved, with the portion of his food
criteria • Identify food allergies • Ask the patient
result: Meals that are whether or not there
consumed quite a lot • Identify preferred is a food allergy
foods • Ask the patient what
his favorite food
examples of conversations between nurses and
patients, for the provision of nursing instructions
• Nurse: Good morning, sir!
With Mr. A, 55 years old, address berok ulu,
right sir?
• Patient : That's right
• Nurse: How are you today?
• Patient : Still unwell miss
• Nurse: What is the problem?
• Patient : I feel like throwing up.
• Nurse: did you finish your breakfast ?
• Patient : No, I just ate a few spoons.
• Nurse : why don't you finish your breakfast?
• Patient : I have no appetite for food.
• Nurse: Do you have any food allergies and what is your
favorite food?
• Pasient : I can't eat nuts and I like soup
• Nurse : OK, I'll ask the doctors and nutritionists.
Can you eat soup or not? if doctors and
nutritionists let you eat it, maybe this afternoon
you will have soup for lunch.
But if you can't eat it, then you shouldn't ask your
family to bring the food to the hospital.
Means the food is not good enough for your
health at this time.
• Patient : Ok miss, Thanks for your attention.
• Nurse: You're welcome, any other problems?
• Patient : nothing miss
• Nurse: If there is no more, I will leave the room. OK, sir?
• Patient : please miss
Thank You