BACKGROUND OF STUDY

The nursing profession is one of the jobs that is deeply involved service sector. In
providing services to clients, a nurse certainly can not be separated from the name nursing care .
(Law No. 38 of 2014). Nursing Care itself is a series of interactions between nurses and clients
and their environment to achieve the goals of meeting the needs and independence of clients in
caring for themselves. (Law No. 38 of 2014).
In providing Nursing Care, nurses must prepare a Nursing Care Plan, namely how nurses
plan a nursing action in order to treat patients effectively and efficiently and are written
instructions that describe precisely the plan of action taken against the client in accordance with
their needs based on nursing diagnoses (Nursalam, 2015).
In Indonesia, a study conducted by the Mataram Health Service in West Nusa Tenggara
Province in 2013 showed that 71.60% of nursing documentation was incomplete (West Nusa
Tenggara Health Service, 2013). Based on data from Wahadi (2008) at Dr. Soetomo Surabaya
nursing care which is documented correctly and completely on average 56.93% of what should
be 100%. Evaluation results of documentation of nursing care in July to November 2015 as in
the table below :
No. Description June July August September October Nopember
1. Assessment 72,5% 75% 90% 93,7% 67,5% 72,5%
2. Diagnosis 86,7% 84,3% 87,8% 89,9% 71,7% 73,3%
3. Intervention 86% 92% 86% 97,5% 75% 73%
4. Implementation 86,7% 86,7% 73,3% 100% 70% 70%
5. Evaluation 93,3% 100% 93,3% 96,7% 70% 73%
6. Nursing Care record 95% 100% 100% 87% 80% 80%
Based on the data above shows that the documentation of nursing care is still not optimal,
where the results of the evaluation of nursing care documentation about nursing interventions in
October 75% and November 73% while the standard of the Ministry of Health of Indonesia is
80% to 100%.
It is hoped that the assignment of this paper can help facilitate nurses in making and
compiling Nursing Care Plans to the correct patients so that effective and efficient energy,
thought, time and infrastructure are achieved.
 DISCUSSION
1. Nursing Intervention And Activities
1.1. Definition
Nursing planning is an internal process problem solving which is the initial
decision about what something will be done, how it will be done, when done, who does
all the actionsnursing (Generous, 2012).
Nursing planning is part of the phase organizing in the nursing process as a guide
to direct nursing actions in business help, alleviate, solve problems or to meet the needs
of patients (Setiadi, 2012)
Nursing planning is a series of activities determining the steps of solving
problems and their priorities, formulation of goals, action plans and assessment of
nursing care to the patient or client based on data analysis and nursing diagnoses
(Kemenkes RI, 2017).
1.2. Purpose
The objectives of nursing planning nursing documentation are (Kemenkes RI,
2017) :
1) To identify the focus of nursing to the client or group
2) To distinguish nurses' responsibilities from other health professions
3) To provide a criterion for repetition and evaluation of Nursing
4) To provide client classification criteria
5) Provides a guideline in writing
1.3. Stage of Composing Nursing Intervention
In making a nursing plan, there are several things that need to be considered as
follows (Kemenkes RI, 2017) :
1) Determine Priority of Problems
2) Determine Goals and Results Criteria
3) Determine the Action Plan
4) Documentation
1.4. Activities on Nursing Intervention
Nursing planning steps according to Kemenkes RI (2017) is as follows:
1) Stage 1: Determine Priority of Problems.
 The priority of the problem is the nurse's attempt to identify the patient's
response to health problems, both actual and potential. To set priorities the problem is
often used in a hierarchy of basic human needs. In fact nurses are unable to solve the
patient's problems simultaneously, therefore it required efforts to prioritize the
problem. Diagnosis priority is distinguished by Important diagnoses are as follows:
 Priority diagnosis is a nursing diagnosis, if not addressed at this time it will
adversely affects the condition of the patient's health function status. Emergency
health problems in the form of health threats and threats life; level of problems
based on actual, risk, potential and prosperity up to syndrome; patient's wishes.
 Determining priority nursing diagnoses are used Maslow's priority priority
requirements, as follows:
 Priority 1 : problems related to needs physiological like respiration,
circulation, nutrition, hydration, elimination, temperature and physical gaps.
 Priority 2 : issues that affect safety and security.
 Priority 3 : problems that affect love and a sense of belonging.
 Priority 4 : problems that affect self-esteem.
 Priority 5 : problems that affect ability achieve personal goals or
self-actualization.
2) Stage 2 : Determine Goals and Results Criteria
The goal of treatment is the desired result of the expected nursing care can be
achieved with patients and plan to reduce the problem that has been identified in the
diagnosis nursing.
Treatment objectives based on the SMART concept are:
 S: Specific (not giving a double meaning)
 M: Measurable (can be measured, seen, heard, touched, felt or helped)
 A: Achievable (realistically achievable)
 R: Reasonable (scientifically responsible)
 T: Time (has a time limit in accordance with the conditions of the client).
Example: After doing nursing care for 1 x 24 hours, the problem of taste
disturbance comfortable: pain can be overcome.
Characteristics of the results criteria that need attention are:
  Related to the stated treatment goals
 Can be achieved
 Specific, real and measurable
 Write positive words
 Determine the time
 Using verbs
 Avoid using the words 'normal, good', but the size limit is written down specified
or appropriate.
3) Stage 3 : Determine the Action Plan
The action plan that will be given to patients is written specifically, clearly and
can be measured. The treatment plan is aligned with the medical plan, so that they
complement each other in improving the patient's health status.
In formulating an action plan that needs to be considered are:
a) The nursing action plan is a specific intervention design that helps the client
achieve the expected outcomes
b) Documentation of the action plan that has been implemented must be written in a
format so that it can help nurses to process the information obtained during the
nursing and diagnostic stages of nursing
c) Planning is indivisual according to the conditions and needs of the patient
d) Collaborate with patients in planning interventions
4) Stage 4 : Documentation
Documentation Format for Nursing Action Plans
Priority Diagnosis Purpose and Results Plan Action Name and
Criteria initial
2. WRITING CARE PLAN BASED ON NANDA NIC NOC
a) Acute Pain
1) Characteristic limits

 Expressing behavior such as anxiety, whining, crying, alert

 Changes in physiological parameters such as blood pressure, heart rate, respiratory
rate, oxygen saturation, and end tidal carbon dioxide (CO2)
 Changes in position to avoid pain
2) Nursing Outcomes Classification (NOC)
a) Anxiety Level
Indicator information 1 2 3 4 5
121105 Restless Feeling
121120 Increased Pulse Frequency
121129 Sleep Disturbance
121131 Change to Diet
Information :
1. Weight
2. Quite heavy
3. Medium
4. Light weight
5. Nothing
b) Movement
Indicator information 1 2 3 4 5
201001 Control of Symptom
201004 Comfortable position
201009 Energy Level
2010011 Airway Compliance
Information :
1. Very disturbed
2. Much disturbed
3. Quite disturbed
4. Slightly disturbed
5. Not disturbed
 c) Vital Sign
Indicator information 1 2 3 4 5
080201 Body Temperature
080204 Respiratory Rate
080210 Respiratory Rhythm
080209 Pulse Pressure
Information :
1. Severe deviation from the normal range
2. A fairly severe deviation from the normal range
3. Medium deviation from the normal range
4. Mild deviation from the normal range
5. There is no deviation from the normal range
3). Nursing Intervention Classification (NIC )
a). Pain Management
 Perform a comprehensive pain assessment that includes location,
characteristics, onset or duration, frequency, quality, intensity or severity of
pain and precipitating factors
 Determine the frequency requirements for assessing patient discomfort and
implementing a monitoring plan
 Select and implement various actions such as pharmacology,
nonpharmacology, interpersonal to facilitate pain reduction as needed
 Collaboration with patients, closest people and other health teams to select and
implement nonpharmacological pain reduction measures as needed
b). Distraction
 Individual motivation to choose the desired transfer technique
 Suggest diversion techniques that are appropriate for energy levels, abilities,
age suitability, developmental levels, and effectiveness in the use of diversion
in the past
 Encourage the participation of family and other closest people and provide the
necessary teaching
 Evaluate and document the patient's response to the transfer activity
c). Position Adjustment
 Monitor the patient's oxygenation status before and after position changes
 Immobilize or support the affected body parts appropriately
 Do not place the patient in a position that can increase pain
 Minimize movement and injury when positioning and turning the patient's
body
 CONCLUTION
From the discussion above we can conclude that planningand nursing action is the stage
in the nursing process based on the actual client, the purpose of establishing priority problems is
identifying the sequence of nursing interventions when the client has problems in setting
priorities not only paying attention to physiological aspects but also aspects of client desires,
needs, and safety. Nursing actions are distinguished based on authority and responsibilities of
nurses in a professional manner as contained in nursing practice standards, including
independent, interdependent, and dependent.
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