8/10/2013

1
UNIVERSITAS
AIRLANGGA
PLANNING THE NURSING
INTERVENTION
Ninuk Dian k
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING PROCESS
Process uses to identify, diagnose, and treat
human responses to health and illness (ANA,
2003)
8/10/2013
2
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
FIVE-STEPS NURSING PROCESS

Assess-Gather
information
about the clients
conditions
Diagnose. Identify
the clients
problems
Plan. Set goals of
care and desired
outcomes and
identify appropriate
nursing actions
Implement.
Perform the
nursing actions
identified in the
planning
Evaluate. Determine
if goals met and
outcome achieved
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING CARE PLANS
The nursing care plan consists of a nursing diagnosis
with defining characteristics (subjective and objective
data that support the diagnosis), related factors or risk
factors, expected outcomes/goals, and nursing
interventions.

8/10/2013
3
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NCP
In agreement with the client, the nurse addresses each of
the problems identified in the diagnosing phase. When
there are multiple nursing diagnoses to be addressed, the
nurse prioritizes which diagnoses will receive the most
attention first according to their severity and potential
for causing more serious harm. For each problem a
measurable goal/outcome is set. For each goal/outcome,
the nurse selects nursing interventions that will help
achieve the goal/outcome.

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NCP
A common method of formulating the expected
outcomes is to use the evidence-based Nursing Outcomes
Classification to allow for the use of standardized
language which improves consistency of terminology,
definition and outcome measures. The interventions
used in the Nursing Interventions Classification again
allow for the use of standardized language which
improves consistency of terminology, definition and
ability to identify nursing activities, which can also be
linked to nursing workload and staffing indices
8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CHARACTERISTICS OF NURSING CARE
PLANS
Its focus is holistic, and is based on the clinical judgment of the
nurse, using assessment data collected from a nursing
framework.
It is based upon identifiable nursing diagnoses (actual, risk or
health promotion) - clinical judgments about individual, family,
or community experiences/responses to actual or potential
health problems/life processes.
It focuses on client-specific nursing outcomes that are realistic
for the care recipient
It includes nursing interventions which are focused on the
etiologic or risk factors of the identified nursing diagnoses.
It is a product of a deliberate systematic process.
It relates to the future.
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
PLANNING
Planning is a category of nursing behaviours in which client-
centered-goals and expected outcome are specifically chosen to
resolve the clients problem and achieve the goals and
outcomes.
Is dynamic, will change as the clients need are met or as new
needs are identified
It requires a nurse to use deliberate decision making and
problem solving skills to design care for each client.
Priorities are set during planning because a client often has
more than one nursing diagnosis and variety of proposed
interventions.
To establish a plan: collaborate with client and family, consult
with other member of health care team, review pertinent
literature
8/10/2013
5
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
ESTABLISHING PRIORITIES
Priority setting involves ranking nursing diagnoses in
order of importance
Helps nurse attend to the clients most important needs
and assist nurse in organising ongoing care activities
Priorities help nurse anticipate and sequence nursing
interventions when a client has multiple problems or
alterations
Nurse and client select mutually agreed-on-priorities
based on the urgency of the problem, the client safety
and desires, the nature of treatment indicated, and the
relationship among the diagnosis.
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
PRIORITIES CLASSIFICATION
High
Intermediate
Low
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CRITICAL THINKING AND
ASSESSMENT PROCESS
Assessme
nt
Diagnosi
s
Plannin
g
Impleme
ntation
Evaluatio
n
Knowledge
Underlying disease process
Normal growth and
development
Normal psychology
Normal assessment findings
Health promotion
Assessment skills
Communication skills
Attitudes
Perseverance
Fairness
Integrity
Confidence
Creativity
Standard
Scope of nursing practice
Specialty standards of practice
Intellectual standard of
measurement
Experience
Previous client care
experience
Validation of assessment
findings
Observation of assessment
techniques
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING DIAGNOSIS
A nursing diagnosis is part of the nursing process and
is a clinical judgment about individual, family, or
community experiences/responses to actual or potential
health problems/life processes. Nursing diagnoses are
developed based on data obtained during the nursing
assessment.

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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT..
Actual diagnosis - "A clinical judgment about human
experience/responses to health conditions/life processes
that exist in an individual, family, or community". An
example of an actual nursing diagnosis is: Sleep
deprivation.
Risk diagnosis - "Describes human responses to health
conditions/life processes that may develop in a
vulnerable individual/family/community. It is supported
by risk factors that contribute to increased vulnerability."
An example of a risk diagnosis is: Risk for shock.

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT..
Health promotion diagnosis - "A clinical judgment
about a persons, familys or communitys motivation and
desire to increase wellbeing and actualize human health
potential as expressed in the readiness to enhance
specific health behaviors, and can be used in any health
state." An example of a health promotion diagnosis is:
Readiness for enhanced nutrition.
Syndrome diagnosis - "A clinical judgment describing
a specific cluster of nursing diagnoses that occur
together, and are best addressed together and through
similar interventions." An example of a syndrome
diagnosis is: Relocation stress syndrome

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
PROCESS OF DIAGNOSIS
Conduct a nursing assessment - collection of
subjective and objective data relevant to the care
recipient's (person, family, group, community) human
responses to actual or potential health problems / life
processes.
Cluster and interpret cues/patterns - Assessment
data must be clustered and interpreted before the nurse
can plan, implement or evaluate a plan to support
patient care
Generate Hypotheses - possible alternatives that
could represent the observed cues/patterns.

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT..
Validation & Prioritization of Nursing Diagnoses
- taking necessary steps to rule out other hypotheses, to
confirm with the patient(s) the validity of the
hypotheses, and to prioritize the list of diagnoses. A
focused assessment may be needed to obtain data for one
or more diagnoses
Planning - Determining appropriate (realistic) patient
outcomes and interventions most likely to support
attainment of those outcomes through evidence-based
practice

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT..
Implementation - Putting the plan of care (nursing
diagnoses - outcomes - interventions) into place,
preferably in collaboration with the care recipient(s)
Evaluation - Movement toward identified outcomes is
continually evaluated, with changes made to
interventions as necessary. When no positive movement
is occurring, reassessment to reevaluate appropriateness
of diagnoses and/or achievability of outcomes must
occur.

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING DIAGNOSIS
Activity intolerance
Anxiety
Risk for respiration
Bowel incontinence
Etc

Nomenclature:
PE
PES
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10
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING INTERVENTION
Are not selcted haphazardly, when choosing an
intervention, a nurse deliberates abut six important
factors:
Characteristic of the nursing intervention
Expected outcome
Research base
Feasibility
Acceptability to the client
Capability of the nurse

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING INTERVENTION
Interventions must be directed toward altering the
etiological factors associated with the dx
When the etiological factor cannot change, the
interventions must be directed toward treating the signs
and symptoms
For risk, interventions must be aimed at
altering/eliminating the risk factors
8/10/2013
11
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
GOAL
The goal as established in a nursing care plan in terms
of observable client responses is what the nurse hopes
to achieve by implementing nursing orders. It is a
desired outcome or change in the client's condition. The
terms goal and outcome are often used interchangeably,
but in some nursing literature, a goal is thought of as a
more general statement while the outcome is more
specific. For example, a goal might be that a patient's
nutritional status will improve overall, while the outcome
would be that the patient will gain five pounds by a
certain date
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
EXPECTED OUTCOMES
Must be specified before selecting an intervention
The language can assist the intervention due to it is
stated in term used to evaluate the effectiveness of
intervention
Nursing intervention classification is designed to show
the link to nursing outcomes classification
8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
GOAL
Has to be written clearly so that all members of the
nursing team understand a clients plan of care and are
able to collaborate in achieving the sane goals and
outcomes.

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
GOALS AND EXPECTED OUTCOMES
Client centered: reflect the client behaviour and responses
expected as a result of nursing intervention.
Singular goal/outcome: each goal/expected outcome should
only address one behaviour or response
Observable: the nurse must be able to determine through
observation if the change has taken place
Measurable: goal and expected outcome are written to give the
nurse a standard against to measure the clients response to
nursing care
Time limited: the time frame indicates when the expected
response should occur
Mutual factors: ensure both nurse and client agree on the
direction and time limits of care
Realistic: can be achieved

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING INTERVENTION-RESEARCH
BASE
Research in support of a nursing intervention will
indicate the effectiveness of using the intervention with
certain types of clients
Refer to research articles or EBP protocols the describe
the utilisation of research findings in similar clinical
situations and settings
When research is not available, use scientific principles
(e.g. Infection control) or consult a clinical expert about
your client population
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
FEASIBILITY
A specific intervention may have the potential for
intracting with other interventions chosen by the nurse
or other health care providers
The nurse must be knowledgeable of the total plan of
care
Consider cost: is the intervention clinically effective and
cost effective?
Consider time: are time and personnnel resources
available?
8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
ACCEPTABILITY OF CLIENT
The intervention must be acceptable to the client and
family and congruent with the clients goals, health care
values, and culture
To faciliatte informed choice, a client must know how
he/sge is expected to participate and the anticipated
effect of the intervention
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CAPABILITY OF THE NURSE
Nurse must be able to carry out the intervention
Nurse must be knowledgeable of the scientific rationale
of the intervention
Nurse must possess the necessary psychosocial and
psychomotor skills to complete the intervention
Nurse must be able to function within the particular
setting to effectively use health care resources
8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
TYPES OF NURSING INTERVENTION
Nurse-initiated intervention

Independent response of the nursee to the clients health
care needs and nursing diagnoses
Nurse is able to act within his/her own scope of practice
to intervene on a clients behalf
Autonomous actions based on scientific rationale that is
expected to benefit client
Do not require a physicians or NP or other health
professional orders

e.g. Instructing clients to manage their activities of daily
living
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
PHYSICIAN-INITIATED
INTERVENTION
Based on physician response to treat medical diagnoses

E.g. Dressing care, administer medication, invasive
procedures, prepare client for dx tests
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
COLLABORATIVE INTERVENTION
Therapies that require the knowledge, skill, and expertise
of multiple health care professionals
E.g. Care of client with multiple fracture and dementia
Client require interventions from multiple health care
professionals that all directed toward the long term goal
of maintaining the client present level of health
Client will require nursing intervention to prevent
pressure ulcers
Physical therapy to prevent musculoskeletal changes
from immobility
Occupational interventions for eating and hygiene needs
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING ORDER
Nursing orders are instructions for the specific
activities that will perform to help the patient achieve the
health care goal. How detailed the order is depends on
the health personnel who will carry out the order.
Nursing orders will all contain:
The date
An action verb like "monitor," "instruct," "palpate," or
something equally descriptive
A content area that is the where and the what of the
order, for example, placing a "spiral bandage on the left
leg from ankle to just below the knee"
A time element will define how long or how often the
nursing action will occur
The signature of the prescribing nurse, since orders are
legal documents.

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NURSING INTERVENTION
Ax: fever (t=40C), diaphoresis, poor skin turgor, no skin
breakdown noted, unconscious, bed rest.
Dx: risk for impaired skin integrity r.t. physical
immobility
Goal: skin remains intact through discharge
Expected outcomes:
Client is afebrile in 24hr, skin colour returns to normal
inn 48hr, skin turgor returns to normal in 48 hr
Intervention: turn client every 1 as follow: 8 am
supine, 9.30 am 30 degree left lateral position, 11 am 30
degree right lateral position, 12.30 supine. Continue as
aforementioned cycle; keep HOB < 30 elevation,
administer IV fluid as ordered, apply air fluidized bed
until body fluids are contained.
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NCP
Activity Intolerance
Alteration in Bowel Elimination: Constipation
Alteration in Bowel Elimination: Diarrhea
Alteration in Comfort: Pain
Alteration in Patterns of Urinary Elimination:
Incontinence
Alteration in Patterns of Urinary Elimination: Retention
Alterations in Cardiac Output: Decreased


8/10/2013
18
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
NCP
Disuse Syndrome
Fluid Volume Deficit
Fluid Volume Excess
Impaired Gas Exchange
Impaired Physical Mobility
Impaired Skin Integrity
Impaired Social Interaction
Impaired Verbal Communication
Ineffective Airway Clearance
Ineffective Breathing Patterns
Self Care Deficit: Bathing
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
EXERCISE
Formulate goal, expected outcomes and nursing
intervention for the following case studies
8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CASE I
Mr Andrew 42 years old, trauma patient is brought to the
ED in an ambulance. He was the driver in a motor
vehicle collision and was not wearing seat belt. The
passenger in the car was dead at the scene. The
paramedics stated that there was significant damage to
the car on the passenger side.

Subjective data: Is awake, Complains of shortness of
breath and abdominal pain

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT
Objective data: Physical Examination:
4 cm head laceration
Badly deformed right lower leg without pulses
Unequal pupils
Decreased breath sounds on left side of chest
Asymmetric chest movement
Vital signs: BP 90/40, HR 130 beats/min, RR 36
breaths/min.
O2 saturation 82%

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CASE II
John, 34 years old man, was admitted to the emergency
department after his wife found him comatose in his
apartment.

Subjective Data
Was diagnosed with diabetes mellitus 12 months ago
Was taking 48 U of insulin daily: 12 U of regular insulin
plus 20 U of NPH before breakfast, 8 U of regular insulin
before dinner, and 8 U of NPH at bedtime.
Has history of flu for 1 week with vomiting and anorexia.
Stopped taking insulin 2 days ago when he was unable to
eat.


UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CONT..
Objective Data
Physical Examination
Breathing is deep and rapid
Acetone smell on breath
Skin flushed and dry

Diagnostic studies
Blood glucose level of 730 mg/dl (40.5 mmol/L)
Blood pH of 7.26

8/10/2013
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UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CASE III
Susan is a 16-year-old high school student who sustained a
C7 spinal cord injury when she dove into a lake while
swimming with her friends. Susan is admitted directly to
the ICU.
Subjective Data: Has patchy sensation in her upper
extremities
Objective Data
Very weak bicep and triceps strength bilaterally
Bowel and bladder control present
Moderate strength in both of lower extremities
X-rays show no fracture dislocation of the spine
Placed on bed rest with a hard cervical collar
Methylprednisolone administered per protocol

UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
CASE IV
Ms. Patricia was bought to the first aid tent provided for
participants in a charity marathon. She is a diabetic well
maintained on regimen of self-monitoring of blood glucose,
insulin and diet.
Subjective Data
States she feels cold, has a headache and her fingers feel numb
Took her usual insulin dose this morning but was unable to eat
her entire breakfast due to lack of time
Completed the entire marathon in a personal-best time
Objective Data
Has slurred speech and unsteady gait, Pulse 120 beats/min,
Appears confused
Capillary blood glucose level 48 mg/dl (2.7 mmol/L)

8/10/2013
22
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
HOW TO ADDRESS THE CASSE
STUDIES
Write down the diagnoses and the evidence (subjective
and objective data)
Write the goal
Write the expected outcomes
Write the interventions
e.g. Case II: fluid volume deficit r.t. ......
As evidence by:
Subjective data.....
Objective data.....
Goal:
Expected outcome
Interventions:
UNIVERSITAS
AIRLANGGA
EXCELLENCE WITH MORALITY
ninuk.dk@fkp.unair.ac.id