Name : Taupik Rohman

NPM : 16.156.01.11.072

Kelas : 1b Keperawatan

A. Nursing Intruction

Nursing Intruction is specific to be implemented by nurse to assist clien achieving the

result of nursing.
Criteria Intuction
Specific
Observable
Measurable
Realistic
B. Nursing Process

A systematic way to plan, implement and evaluate care for individuals, families, groups
and communities

Diagnosis
The nursing diagnosis is the nurses clinical judgment about the clients response to actual
or potential health conditions or needs. The diagnosis reflects not only that the patient is in
pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict
within the family, or has the potential to cause complicationsfor example, respiratory
infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the
nurses care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short-
and long-range goals for this patient that might include moving from bed to chair at least three
times per day; maintaining adequate nutrition by eating smaller, more frequent meals;
resolving conflict through counseling, or managing pain through adequate medication.
Assessment data, diagnosis, and goals are written in the patients care plan so that nurses as
well as other health professionals caring for the patient have access to it.

C. Nursing Procedure

A nursing procedure is a course of action intended to achieve a result in the delivery of

health care. A medical procedur with the intention of determining, measuring, or diagnosing a
patien condition or parameter is also called a medical test. Other common kinds of procedure of
procedures are therapeutic, such as surgical and physical rehabilitation procedures.
 D. Nursing assessment

Nursing Assessment to collect and analyze data about a client, the first step in delivering
nursing care. Assessment includes not only physiological data, but also psychological,
sociocultural, spiritual, economic, and life-style factors as well. For example, a nurses
assessment of a hospitalized patient in pain includes not only the physical causes and
manifestations of pain, but the patients responsean inability to get out of bed, refusal to eat,
withdrawal from family members, anger directed at hospital staff, fear, or request for more pain
mediation.

D. Physical examination

A nursing assessment includes a physical examination: the observation or measurement

of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can
be felt by the patient.

The techniques used may include Inspection, Palpation, Auscultation and Percussion in addition
to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and further
examination of the body systems such as the cardiovascular or musculoskeletal systems.[9]

clinical examination

Physical examination or clinical examination is a process of a medical expert examining the

patient's body to find clinical signs of the disease.

medical examination

Conduct a medical examination is recommended to prevent the development of some diseases

so as not to deteriorate further

E. Nursing intervention

Nursing intervention is measures designed to assist in the process from the current level
of health to the desired level in the expected results.

The things that should be considered in determining the plan of nursing intervention are:

1. Identify alternative actions.

2. Establish and master the techniques and procedures of nursing to be performed.
3. Involves the client and his family.
4. Engage other health team members.
5. Know the client's cultural and religious background.
6. Must be able to guarantee the client's sense of security.
7. Leads to the objectives and criteria of the results to be achieved.
F. Implementation
Implementation is the management and manifestation of the nursing plan that has been
compiled at the planning stage. Steps of nursing intervention provided to clients related to
support, treatment for family action, or action for future health problems.

Purpose of nursing Implementation :

1. Implement the results of the nursing plan for subsequent evaluation to determine the health
condition of patients in a short period
2. Maintain endurance
3. Preventing complications
4. Finding body system changes
5. Provide a comfortable environment for clients
6. Implementation of doctor's message

G. Evaluation
Evaluation in nursing is an activity in assessing predetermined nursing actions, to know
the fulfillment of client needs optimally and measure the results of the nursing process

The objectives of the evaluation include:

1. To determine the client's health development.

2. To assess the effectiveness, efficiency, and productivity of the nursing actions that have
been given.
3. To assess the implementation of nursing care.
4. Get feedback.
5. As a responsibility and responsibilities in the implementation of nursing services.