CHAPTER I

INTRODUCTION

A. Background
In the medical world that are involved in the world of nursing is known for recording the things
that are important to the interests of all parties, both from nurses, doctors, patients and patients'
families. Documenting performed after the execution of each phase of the nursing process is
done and adjusted family time sequence. The benefits of such documentation as a means of
communication between other health team members, as an official document in the healthcare
system, as a means of accountability and accountability of nursing care given to patients
(Effendi, 1995). Some things to consider in documenting according Potter and Perry in Nursalam
(2001), provides guidance as instructions on how to properly documenting that:

a. Do not remove the type -x or cross out the wrong article. The correct way is to create a
line on the wrong paper, write the word "wrong" and initialed and write a note that is
true.
b. Do not post comments that are critical of the client or other health professionals. Just
write an objective description of the client's behavior and actions carried out by health
personnel.
c. Error correction as soon as possible.
d. Record only facts must be accurate and realible records.
e. Do not let the nurses final note empty.
f. All records must be legible, written in ink and using straightforward language.
g. Record only for yourself because the nurse is responsible and accountable for the
information that is written.
h. Avoid writing a general nature. Posts must be complete, concise, solid and objective.
i. Begin recorded documentation with time and ends with the signature.

Thus nursing documentation must be objective, accurate and describes the state of the client as
well as what happens to the client. So that, if necessary, this documentation may indicate that the
nurse has recorded correctly and does not conflict with policies or regulations of health care
providerinstitutions.
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B. Problem Formulation
1. What is the intervention?
2. The purpose of the intervention?
3. Any type Intervention?
4. Nursing Action Plan?
5. Principles of Effective Writing Action Plan?
6. What are the criteria for planning?

C. Purpose
1. To find out what it was intervention
2. To determine the purpose of the intervention
3. Knowing the type Intervention
4. Nursing Action Plan
5. Principles of Effective Writing Action Plan
6. To determine Planning Criteria

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 CHAPTER II
DISCUSSION

A. Definition
The document is a record that can be proven or used as evidence in legal matters ". While
documentation is a work record or record of events and objects and activities providing services
(services) that are considered valuable and important (Tungpalan, 1983).
Traditionally, intervention or care plan is defined as a document handwritten in solving the
problem, objectives, and interventions. As mentioned earlier, the nursing plan is a method of
communication about nursing care to clients. Every client who requires nursing care need a good
planning.

For example, all clients require a postoperative observation of fluids and pain management so
that all nursing actions must be standardized. Planning includes the development of strategies
designed to prevent, reduce or correct the problems identified in the nursing diagnosis. This stage
begins after determining nursing diagnosis and concluded the plan documentation (Iyer,
Taptich&bernocchi-Losey, 1996). Picture planningNursing documentation starting from data
collection and analysis problems. Then the nurse include this information in maintenance records
to devise a plan of care. Priority issues and the type of client based on the maintenance actions
that provide corrections to the way nurses work for the achievement of objectives. Determination
of a complete treatment plan is the mechanism of the nursing process.Documentation of nursing
actions Planning and nursing action is the stage in the process keperwatan based on actual
problems of the client.The purpose of the intervention is as an introduction to set or design
maintenance actions based client response to health problems, with the goal to prevent, eliminate
or minimize the causes which affect health status.

Documentation purposes the planning stage:

As a framework for the implementation of nursing
It is the core of nursing documentation problem-oriented
As a reference in the nursing plan modifications melkukan

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 Means of communication in the nursing team delegation of tasks / nursing instruction
As the cornerstone of ilmiahyang logical and systematic in doing nursing care to patients.
For all the plan of action could have been adjusted so that the client's condition effectively.

B. Purpose of intervention
The purpose of the plan of care is to provide nursing actions based on client response to health
problems, and prevent new problems that will arise. Planning and nursing action is a step in the
nursing process is based on the actual problems of the client.The purpose of the intervention is as
an introduction to set or design maintenance actions based client response to health problems,
with the goal to prevent, eliminate or minimize the causes which affect health status.

Documentation purposes the planning stage:

As a framework for the implementation of nursing

It is the core of nursing documentation problem-oriented
As a reference in making modifications to the nursing plan
Means of communication in the nursing team delegation of tasks / nursing instruction
As the cornerstone of ilmiahyang logical and systematic in doing nursing care to patients.
For all the plan of action could have been adjusted so that the client's condition effectively.

C. Type of Intervention

The intention is to find an appropriate documentation as an overview of nursing interventions

that include:

a) Therapeutic Intervention
Therapeutic action is a direct nursing care in accordance with the state of the client. Nursing
plan that more than one must be done sincerely in order of priority problems in nursing
diagnoses.

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b) Intervention stabilization / observation
This process requires the sharpness of observation nurses including evaluating skills are right
at the top. The program is more than a very decisive client's health. Nurses should be able to
see the development of good and bad of clients such as :
- Observe vital signs.
- Awareness
- Production of urine
- Monitor blood sugar
- Nursing Diagnosis
- The act of Nursing (Therapeutic)
- Therapy Medicus
- The lack of effectiveness of airway clearance
- Anxious
- Decrease in Cardiac output
- Set the position for the provision of Oxygen
- Suction if there are no contraindications
- Teaching techniques cough
- Take a sample of arterial blood gas
- Physical examination of the heart, lung and others
- Observation emotional (behavioral, communication and others)
- Monitoring Heart
- Monitoring respiration
- Monitoring Fetal
- Teach activities to reduce stress
- Set up a safe environment
- Diverting reality orientation
- Adjust the position fowler / semi-Fowler
- Reduce movement
- Set a stimulating environment
- Manage the Oxygen

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 - Giving expectorant drugs
- Checking sputum
- Measuring arterial blood gas
- Provide transquilizer sedative drugs
- Reducing diet containing sodium
- The infusion liquid electrolyte according BB
- Provide drugs to increase cardiac output.

An important component in Intervention Documentation

Documentation of intervention identified, why something happens to the client, what happened,
when, how, and who intervened.

Why: should explain the reason action must be carried out and the existing data on the results of
the assessment and documentation of nursing diagnoses.
What: clearly written summary of the treatment / actions in the form of Action Verbs.
When: contains important aspect of intervention documentation. Recording time to implement
interventions are very important in terms of legal liability and effectiveness of specific
actions
How: actions implemented in the addition of more detailed records. For example, "tilted right /
left with the help of a nurse" denotes a scientific and rational principles of the plan of
action. This method will be able to increase the effort - an effort the use of appropriate
nursing procedures.
Who: who carry out the intervention should always be written in the documentation as well as
accountability signature.
Interventions that requires a specific documentation

Procedure"Invasive"
Invasive measures are an important part of the nursing process, as it requires knowledge of
science and technology is high. For the advanced knowledge needed in order to increase
responsibility in the delivery of interventions. For example, nurses provide blood transfusions,

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chemotherapie, installing cathether. The above actions will bring a high risk for complications of
the client, which is certainly necessary informed consent prior to the actions implemented.

Intervention educate clients

Nurses play an important role in identifying learning needs of clients. In a plan to educate clients
and maintain its activity report need education. This activity is carried on - constantly so that
clients fully understand and change attitudes and behavior. If the plan can not be implemented
then it will continue at the next meeting.

Examples of educational plan as opposed to education implemented by chance can be seen in the
table below:

Education educationalplan implemented by chance

1. Incidentally learn the ins and outs 1. Provide general advice and encouragement that
of patients including learning
objectives and teaching strategies

2. Activities carried out on schedule 2.Memberikan opportunity during the meeting to get
to know how study

3. Implement continuous care about 3. Know the lesson that less and require a formal
personal hygiene after returning home plan learning

D. nursing action plan include:

1. Nursing Diagnosis
Nursing diagnoses should be a priority to take care of the client. It must involve directly at the
client's life-threatening situation.

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2. Criteria results
Each nursing diagnoses hartus have at least one criterion results. Expected outcomes can be
measured with the expected goals that reflect the client's problem.

3. Plan of nursing action

Nursing action is to obtain a standalone Java responsibility, especially by nurses who worked
with the medical order based maslaah client and the client is dterimaantuan the expected
results. Each client problems and expected results obtained at least two plans of action.

E. Principles of Effective Writing Action Plan

1) Before writing action plans, review all existing data sources satisfy the data include:
Assessment as a client in the hospital. Nursing diagnosis during hospital admission. The
main complaints of the client ataualasan in berhuungan with health services. Supporting
investigation. Socio-cultural background. Medical history and physical examination.
Observations of other health team.
2) List and type of actual problems and possible risks. Give priority to the actual issue which
threatens health.
3) To simplify and understandable in memubuat give ganbaran action plan and illustration:
(Example) if possible diagnoses especially helpful when advanced technology is used to
perawtan client or when describing the anatomical location.
4) Write clearly specific, measurable, expected outcomes for mentapakan problem ogether
with clients determine cognitive skills, affective and psychomotor that require attention.
5) Always signed and dated plan of action, it is because a nurse profesionalakanperting
responsible and accountable for melaksananertanggung action plan that has been written.
6) Start using the action plan tindakandenganverb.Catat vital signs every turn dines. Weigh
BB every day
7) Reasons principle specivity to write nursing diagnoses .: What is the procedure to be
carried out. When and how long. Briefly describe the purpose of what needs to be met,
including the stages of action.
8) Give the rationale of the plan of action.

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 9) The plan of action must always be in writing and signed
10) The plan of action should be recorded seagai permanent thing
11) Client and family if possible be included in the planning
12) The plan of action should be in accordance with the time yangditentukan and endeavored
to always modified example dines every turn, every day, or at any time required.

F. Criteria planning
1) Formulation of objectives
Focusing on society
Clear and concise
Can be measured and observed
Realistic
There is a target date
Involving community participation

2) Plan of action
Set techniques and procedures to be used.
Lead on the objectives to be achieved.
Realistic
Compiled sequentially and no rational

3) Criteria results
Using the right verb
Can be modified
Specific

The importance of nursing care plan documentation:

a) It contains important information and clear
b) As a means of communication between nurses and nurse
c) Facilitate melaaksanakan issue, sustainable nursing.
d) Documentation exclusively for the recording of expected results for the patient.\

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Benchmark Documentation
Treatment planning illustrates the freedom and lack of freedom of action of nurses
on the client as part of personal health maintenance. Benchmark represents the work of
nursing practice decisions based on knowledge, attitudes and skills worthy and
dikombinasika to establish a plan in accordance with the client's condition.

Interventions that require a special dokumnetaction. There are two dokumnetasi

require special documentation, namely:

1. Invasive Procedures
Invasive measures are an important part of the nursing process, Due requires
knowledge of science and technology is high. For the advanced knowledge needed in
order to increase responsibility in the delivery of interventions. For example, a nurse
gives transfusions, chemotherapy, put a catheter. These actions it carries a high risk for
complications of the client, which of course needs to Information and Media consent
before action is implemented.

2.Intervensi educate clients

Nurses play an important role in identifying learning needs of clients in a plan to
educate clients and maintain its activity report. Requires Education. Examples of
Education plan from the education the opposite to that implemented by chance as
follows: Education Education Plan implemented by chance.
a) The need to learn the ins and outs of patients including learning objectives and
teaching strategies
b) Activities carried out on schedule
c) Implement a continuous secar care about personal hygiene after returning home
d) Meneberikan advice and general encouragement of sustainable
e) Provide an opportunity during the meeting to get to know the car study
f) Know the lesson that less and require a formal learning plan

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3. The implementation phase or nursing Actions
Focus pelakanaan stage nursing actions are activities pelakanaan act of planning to
meet the physical needs and emosional.pemenuhan physical and emotional needs are
variations, depending on the individual and specific problem.

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 CHAPTER III
CLOSING

A. Conclusions
From the above discussion we can conclude that the Planning and nursing action is the stage
in the nursing process based on actual problems of the client. The intention is to find an
appropriate documentation as an overview of nursing interventions that include therapeutic
intervention, stabilization intervention / observation, there is no documentation that require
special dokumnetasi namely invasive procedure and Intervene educate clients.The purpose of
the plan of care is to provide care measures based on client response to health problems, and
prevent new problems that will arise

B. Suggestions
Documentation should be made that intervention should really fit the prescribed standards and
completely regarding to the action that was done, no engineering.

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 BIBLIOGRAPHY

HidayatAlimulAzis.A. (2007), Introduction to Basic Concepts of Nursing Edition 2,

SalembaMedika, Jakarta
Http: // olifdwiaja. com / 2011/11 / documentation-intervention-keperawatan.html
Http://www.docstoc.com/docs/6850312/Dokumentasi nursing.

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