The fourth step in the nursing process is implementation. Implementation involves the execution of the nursing plan of care derived during the planning phase. It consists of performing nursing activities that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing interventions to other persons assigned to care for the client—for example, the licensed practical nurses and unlicensed assistive personnel.
Implementation involves many skills. The nurse must continue to assess the client’s condition before, during, and after the nursing intervention. Assessment prior to the intervention provides the nurse with baseline data. Assessment during and after the intervention allows the nurse to detect positive or negative responses the client may have to the intervention. If negative responses occur during the procedure, the nurse must take appropriate action. If positive responses occur, the nurse adds this information to the database for use in evaluating the efficacy of the intervention. The nurse must also possess psychomotor skills, interpersonal skills, and critical thinking skills to perform the nursing interventions that have been planned. Continue reading IMPLEMENTATION AND EVALUATION IN NURSING CARE

Termination Phase

The termination phase is the third and final stage of the of the therapeutic relationship. It focuses on the evaluation of goal achievement and effectiveness of treatment. It is important that the client has been prepared for the final stage of the relationship by encouraging discussion of feelings. Some clients welcome this final phase, whereas other clients who have become overly dependent on their nurse will be more resistant to saying goodbye. Planning for termination is actually initiated during the beginning of the relationship. A relationship that ends abruptly is likely to place the client at risk for difficulties such as increased:
• Anxiety levels
• Frustration
• Suspiciousness
• Unwillingness to engage in future relationships with health care providers
Evaluation is the primary goal for the client and nurse in the third stage of the nurse-client relationship. Continue reading Termination Phase


1. Ketidakefektifan Pola Nafas b.d Infeksi Paru
Karakteristik : batuk (baik produktif maupun non produktif) haluaran nasal, sesak nafas, Tachipnea, suara nafas terbatas, retraksi, demam, diaporesis, ronchii, cyanosis, leukositosis
Tujuan :
Anak akan mengalami pola nafas efektif yang ditandai dengan :
Suara nafas paru bersih dan sama pada kedua sisi
Suhu tubuh dalam batas 36,5 – 37,2OC
Laju nafas dalam rentang normal
Tidak terdapat batuk, cyanosisi, haluaran hidung, retraksi dan diaporesis