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PAPER

“ASSESSMENT, NURSING DIAGNOSIS, NURSING

INTERVENTION AND IMPLEMENTATION”

COURSES: ENGLISH

LECTURER : Yoyok Febrijanto, A.Md.Kep, M.Pd

Arranged by:

Millitio (01.2.19.0069
Christiantoro 7)
 HIGH SCHOOL OF HEALTH SCIENCE RS. BAPTISM
KEDIRI

UNDERGRADUATE NURSING STUDY PROGRAM

2021/2022

FOREWORD

We thank God Almighty, because with His love and will we

were able to complete the paper entitled "Assessment, Nursing
Diagnosis, Nursing Intervention and Implementation".

We also take this opportunity to thank MrYoyok Febrijanto,

A.Md.Kep, M.Pdwho has helped us a lot in the preparation of this
paper.

Although we have collected several references to support the

preparation of this paper, we feel that there are still many
shortcomings in this paper. Therefore, we look forward to suggestions
and input that can benefit us in future assignments.

And we hope that this paper can provide benefits for readers, so
that readers can understand the concept of home care and journal
analysis related to it

Compiler
 Kediri, 09 May 2022

TABLE OF CONTENTS

TITLE PAGE...............................................................................i

FOREWORD...............................................................................ii

TABLE OF CONTENTS..........................................................iii

CHAPTER I INTRODUCTION................................................1

1.1 Background........................................................................1

1.2 Problem Formulation........................................................1

1.3 Purpose of Writing............................................................1

CHAPTER II DISCUSSION......................................................3

2.1 Assessment.........................................................................3

2.2 Nursing Diagnosis..............................................................9

2.3 Nursing Intervention.........................................................9

2.4 Nursing Implementation...................................................9

CHAPTER III CLOSING........................................................11

3.1 Conclusion........................................................................11

3.2 Suggestions.......................................................................11

BIBLIOGRAPHY.....................................................................12
 PIG

PRELIMINARY

1.1Background
Today's health services have become the main health service
industry where every hospital is accountable to the recipients of health
services. The existence and quality of health services provided is
determined by the values and expectations of the recipients of these
services. In addition, the emphasis on high quality services must be
achieved at a cost that can be accounted for.
Thus, all service providers are pressured to reduce service costs but
service quality and client satisfaction as consumers are still the main
benchmarks for the success of the health services provided.
The nursing service team provides services to clients in accordance
with professional beliefs and established standards. This is intended so
that the nursing services provided are always safe services and can meet
the needs and expectations of clients.
Quality nursing care can be achieved if the implementation of
nursing care is perceived as an honor held by nurses in showing it as an
honor that nurses have in demonstrating their right to provide care that is
humane, safe, and in accordance with the standards and ethics of the
nursing profession on an ongoing basis. and consists of activities of
assessment, planning, implementation of plans, and evaluation of nursing
actions that have been given.

1.2Formulation of the problem

1.2.1 What is the stage of nursing assessment?
1.2.2 What is the stage of the nursing diagnosis?
1.2.3 What is the nursing planning stage?

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 1.2.4 What are the stages of nursing implementation?
1.3Problem Goal
1.3.1 Know how the assessment stage in the nursing process?

1.3.2 Know how the stages of diagnosis in the nursing process?

1.3.3 Know how the planning stage in the nursing process?

1.3.4 Know how the implementation stage in the nursing process?

CHAPTER II

DISCUSSION

2.1Assessment
The assessment stage is a systematic process of collecting data from
various sources to evaluate and identify the client's health status. Nursing
assessment activities include:

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1) Data collection
Data collection is the process of obtaining information about the
client's health status. It is significant, systematic, and reflects changes
in the client's health status.
1. Data Type
The type at the time of data collection was in the form of
Subjective Data (data obtained from patients in the form of
complaints expressed from patients at that time), and Objective
Data (data obtained by nurses directly and could be
measured/viewed).
2. Data Characteristics
Data collected to support nursing diagnoses must have
complete, accurate, real and relevant characteristics.
3. Data source
Data sources can be either primary or secondary. Primary data
comes from the client himself, while secondary data can be
obtained from people closest to the client, client records, disease
history, consultation, diagnostic examination results, medical
records and other members of the health team, from other
nurses and from the library.

4. Method of collecting data

Data can be collected by interviewing the client, by observation
or by performing a physical examination.
In addition, the problems that may occur when collecting data
that nurses should also avoid are:
1. The inability of nurses in organizing data.
2. Loss of data that has been obtained.
3. The data obtained are not relevant.

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 4. There is duplication of data.
5. Misperception of data
6. Incomplete data.
7. There is interpretation of data in observing behavior.
8. Failure to retrieve the most recent baseline.
2) Data validation
Data validation is an attempt to justify the data that has been collected
by comparing the subject data and object data obtained from various
sources based on standard normal values.
Data that needs to be validated is data that is abnormal / its validity is
doubtful.
3) Data Organization
Data organization is grouping data based on a framework that can
help identify problems.
How to group data:
1. Based on body system
2. Based on basic needs (Maslow)
3. Based on nursing theory
4. Based on functional health pattern
4) Pattern/problem identification
Problem identification is the last step of the assessment phase by
conducting data processing / data analysis, which is an intellectual
process that includes: tabulating, selecting, clarifying, interpreting and
drawing conclusions.
The results of the data analysis will get a "Nursing Diagnosis"
statement.
Data collection format:
1) Client Identity
Includes registration number, name, age, gender,

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 ethnicity/nation, marital status, religion, education, address,
date of hospital admission (MRS), date of assessment, health
insurance and person in charge.
2) Nursing/Health History
Includes chief complaint, current medical history, past medical
history, family medical history (genogram), environmental
health history, psychosocial history, growth history,
immunization history and childbirth history.
3) Health Function Pattern
Includes health perception-maintenance patterns, exercise-
activity patterns, nutrition-metabolism patterns, elimination
patterns, rest-sleep patterns, cognitive-perceptual patterns,
stress-tolerance-coping patterns, self-perception-self-concept,
sexual-reproductive patterns, relationship patterns- role, pattern
of belief values.
4) Inspection
Includes a physical examination and ancillary examinations.
5) The reviewing nurse's signature and date.

2.2Nursing Diagnosis
Nursing diagnosis is a clinical decision regarding individual responses
(clients and society) about actual or potential health as the basis for
selecting nursing interventions to achieve nursing care goals in
accordance with the nurse's authority.
1) Purpose of Nursing Diagnosis
1. Provide a common language for nurses so that
information can be formed in a shared perception.

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 2. Improve the identification of appropriate goals so that the
selection of interventions is more actual and becomes a
guide in conducting evaluations.
3. Creating standards of nursing practice.
4. Provide a basis for improving the quality of nursing
services.
2) Nursing Diagnosis Components
1. Problem (P) or Diagnostic Label: describes the client's
health problem or response to therapy by the nurse.
2. Etiology (E) or Associated Factors. Identify one or more
possible causes, provide direction to nursing therapy as
needed and enable nurses to provide individualized care.
3. Defining Characteristics is a group of signs and
symptoms / signs & symptoms (S) that indicate the
presence of a diagnostic label.
3) Types of Nursing Diagnosis
1. Actual Diagnosis
is a client problem that is present during a nursing
assessment. Based on the signs and symptoms.
Component : P + E + S
Example: Acute pain related to joint inflammation
process is marked by the patient saying "My knee has
been sore since yesterday afternoon"
2. Nursing Diagnosis Risk
is the clinical judgment that the problem does not exist,
but the presence of risk factors indicates that a problem is
likely to develop unless the nurse intervenes.
Component : P + E
Example: Risk of infection related to infusion

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 3. Welfare Nursing Diagnosis (Wellness)
describes the responses of individuals, families or
communities to higher levels of well-being that have a
readiness for improvement. Component : P (diagnostic
label)
Example: Potential for Increasing Spiritual Well-being
4. Possible Nursing Diagnosis
Possibility is something where the presence of a health
problem is incomplete or unclear, requires more data to
support it. Component : P + E
Example: The possibility of impaired mobility related to
the installation of the infusion.

5. Syndrome Nursing Diagnosis

is a diagnosis that consists of a group of other nursing
diagnoses.
Component : P
Example: Disuse syndrome. (This diagnosis consists of:
risk of infection, risk of skin tissue damage, risk of
activity intolerance, risk of injury, risk of constipation,
etc.)
4) Collaborative Problem
All collaborative (multidisciplinary) problems begin with the
label “Potential Complications (PK). The nurse should write
down either the complications that will occur with the disease
or the actions that will cause it.
Example: Potential Complications of Head Trauma: Increased
intracranial pressure

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 When monitoring a group of complications, the nurse states the
disease followed by a list of complications
Example: Potential Complications of Pregnancy-with
Hypertension: seizures, fetal distress, pulmonary edema,
liver/kidney failure, premature birth, intracranial hemorrhage
5)
a.
2.3Nursing Intervention
1) Component
1. Determining the Priority of Nursing Diagnosis
- Based on the severity level
a) High Priority = life-threatening situation
b) Priority Moderate = condition that threatens health
c) Low Priority = something that increases from normal
developmental needs, or requires little nursing assistance.
- Can use Maslow's theory
2. Determining Goals and Expected Results
Goal conditions = observable.
Objective component = subject, measurable verb, result, criteria,
target time.
Some literature distinguishes between Goals and Outcomes
Criteria.
- Goal --> is the result to be achieved to overcome the problem of
nursing diagnosis.
- Outcome Criteria --> is an evaluation standard which is a
description of the factors that can give an indication that the
objectives have been achieved or not (more specific).
Example:

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 - Goal: Client is able to remove pulmonary secretions without
assistance on 9-7-2018
- Outcome criteria: good, irregular, regular breathing, no
additional breath sounds, no stones/shortness, no cyanosis,
temperature: 36-37 degrees Celsius, RR: 16-20 x/minute, LabRo
improved.
3. Determine the Action Plan
Requirements in writing intervention:
a. Date
b. Verbs that can be measured, seen, heard, felt.
c. Results
d. subject.
e. Target date.
f. Nurse's name and signature.
2) Types of Instructions Used in the Intervention
1. Diagnostic Instructions, assesses the client's progress towards
achieving the outcome criteria by monitoring the client's activities
directly. Diagnostic instructions can be used to gather information
in an attempt to fill in the missing information.
2. Therapeutic Instructions, indicate actions by nurses that directly
reduce, correct, prevent exacerbation of the problem.
3. Counseling Instructions improve client self-care by helping
individuals acquire new behaviors that facilitate the resolution of
client problems.
4. Referral Instructions, emphasizes the nurse's role as coordinator
and manager in client care in health care members.
2.4Nursing Implementation
1) Component

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 1. Independent Nursing Actions: actions that can be implemented by
nurses without a doctor's order and are still within the limits of
nursing authority.
2. Collaborative Nursing Action, collaborative nursing action is
implemented when the nurse works with other members of the
health care team in making joint decisions that aim to address the
client's problems.
Example:
a. Assessing TTV, cough, frequency, rhythm, breath sounds of the
client
b. Perform chest physio therapy on clients 2 times a day
c. Teach clients to breathe deeply and cough effectively

CHAPTER III

CLOSING

3.1Conclusion

The nursing process is an organized activity using a systematic method in

providing nursing care to individuals, groups, families and communities
for health problems experienced.

3.2Suggestion

1. Nurses must have professional skills in carrying out assessments,

because data assessment is the main basis for implementing the nursing
process.

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2. Nursing assessments must be carried out systematically to obtain
accurate data.
3. In determining the diagnosis must be adjusted to the needs of the
client.
4. The data obtained must be accurate and not a nurse's conclusion.
5. The nurse should not immediately make decisions about the client's
condition.

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 BIBLIOGRAPHY

public health. (2013, January 23). Nursing Care Documentation Application.

Retrieved from Public Health:
http://www.indonesian-publichealth.com/application-documentation-
keperawatan/ .(accessed July 07, 2018)
Wantika, R. (2015, September 26). Nursing Process. Retrieved from
WordPress: https://ruryuswantika.wordpress.com/ .(accessed July 07,
2018)

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