Intervensi Keperawatan :

NANDA NIC NOC (NNN)

Dewi Baririet Baroroh
Proses Dokumentasi Keperawatan (semester 2)
PSIK FIKES UMM
April 2011
Based on NIC and NOC book
Taxonomy Nomenclature :
NANDA NIC NOC (NNN)
13 domain 47 kelas 206 diagnosa
7 domain 31 kelas 385 kriteria
7 domain 31 kelas 542 intervensi
TRADISIONAL :
Tujuan jangka panjang dan jangka pendek
Tujuan dan kriteria hasil
Perencanaan


NANDA DIAGNOSE
Find a Diagnose :
1. Identifikasi keluhan
2. Masukkan domain
3. Masukkan kelas
4. Lihat definisi
5. Lihat batasan karakteristik


Contoh :
1. Identifikasi keluhan : sering terbangun
jika tidur tidak tahu penyebabnya
2. Masukkan domain : 4
3. Masukkan kelas : 1
4. Lihat definisi : insomnia
5. Lihat batasan karakteristik : insomnia
Components of
a Nursing Diagnosis
1. Label or Name and definition
(Axis 1 2 3)
2. Related Factors OR Risk Factors
3. Defining Characteristics


Axis 1 7
Penulisan axis lengkap, mempermudah NOC NIC

Contoh
1. Aktual : Ketidakefektifan (axis 3) bersihan jalan nafas
(axis 1), individu (axis 2, jika individu tdk ditulis),
kardiopulmonal (axis 4), dewasa (axis 5), kronis (axis 6),
aktual (axis 7) b.d mukus dalam jumlah berlebih ditandai
dengan wheezing, sianosis, dispnea
2. Aktual : Ketidakefektifan (axis 3) bersihan jalan nafas
(axis 1) individu (axis 2, jika individu tdk ditulis) b.d
mukus dalam jumlah berlebih ditandai dengan wheezing,
sianosis, dispnea
3. Aktual : Ketidakefektifan bersihan jalan nafas b.d mukus
dalam jumlah berlebih
Contoh
4. Resiko : Resiko Infeksi b.d penyakit
kronis (kanker paru)
5. Promosi : Kesiapan meningkatkan
(axis 3) rasa nyaman (axis 1) keluarga
(axis 2)
6. Kesejahteraan : Diare b.d keracunan
makanan (petis)

Dx Medis dan Dx Keperawatan

CLINICAL SITUATIONS DIAGNOSTIC CONCEPT
POSSIBLE NURSING
DIAGNOSES
SYSTEMIC ARTERIAL
HYPOTENSION
Cardiac output Decreased cardiac output
HYPOVOLEMIA Fluid balance Deficient fluid volume
PAIN Pain Acute pain
METABOLIC ACIDOSIS Tissue perfusion
Tissue perfusion:
cardiopulmonary,
ineffective
WOUND DRAINAGE Skin integrity Impaired skin integrity
SYSTEMIC ARTERIAL
HYPERTENSION
Tissue perfusion
Tissue perfusion:
cardiopulmonary,
ineffective
OLIGURIA Urinary elimination Impaired urinary elimination
POLYURIA Urinary elimination Impaired urinary elimination
HYPERTHERMIA Body temperature Hyperthermia
HYPOCALCEMIA Cardiac output Decreased cardiac output
Prioritas diagnosa
Standar asuhan keperawatan : (1) mengancam kehidupan,
(2) mengancam kesehatan, (3) mempengaruhi perilaku
manusia
DEPKES RI ; (1) aktual, (2) potensial/resiko
Maslow : (1) fisiologis, (2) aman&nyaman, (3) cinta&kasih
sayang, (4) harga diri, (5) aktualisai diri
Per sistem : B1, B2, B3, B4, B5, B6
NOC
(Nursing Outcomes Classification)
Kriteria hasil (dan indikator)
NOC
The nursing outcomes classification (NOC) is a
classification of nurse sensitive outcomes
NOC outcomes and indicators allow for
measurement of the patient, family, or
community outcome at any point on a continuum
from most negative to most positive and at
different points in time. ( Iowa Outcome Project,
2008)
SEJARAH
Tidak ada kriteria pasien sembuh. Kematian,
kesakitan dan gejala kesakitan ditentukan dg
tradisional, dikira kira.
Kriteria sembuh kinerja perawat dalam
memberikan asuhan keperawatan.
Beragam respon pasien dan beragam
kemampuan perawat

SEJARAH
1973 : Hover dan Zimmer membagi kriteria
sembuh dalam 5 domain
ANA (american nurses association) : kriteria
sembuh meningkatkan angka kesembuhan,
menurunkan unit cost dan meningkatkan angka
kesehatan negara
1982 : NANDA menyeragamkan kriteria
sembuh dalam keperawatan NOC
Bekerjalah kalian, maka Allah dan RasulNya serta
orang-orang mukmin akan melihat amal-amal
kalian itu, dan kamu akan dikembalikan kepada
Allah Yang Maha Mengetahui akan yang ghaib dan
yang nyata, lalu diberitakanNya kepada kamu apa
yang telah kamu kerjakan
QS. At Taubah (9) : 105
SEJARAH
Cita-cita luhur keperawatan : Bermanfaat
untuk manusia
Jika tolak ukur kriteria sembuh hanya berasal
dari profesi lain, rasa dari asuhan
keperawatan tidak dapat diukur.
Memacu perawat untuk memberikan asuhan
keperawatan yang benar dan tepat.

TujuAn Penyeragaman Outcomes
Memudahkan pengaturan sistem informasi
keperawatan
Memberikan definisi sama pada setiap
intepretasi data
Mengukur kualitas asuhan keperawatan
Mengukur efektifitas asuhan keperawatan
Meningkatkan inovasi keperawatan

Pernyataan/Kalimat Outcomes :
Konsisten
Memberikan pengertian yang sama terhadap
sebuah istilah
Bukan menjelaskan kegiatan perawat
Bukan diagnosa keperawatan
Dapat diukur
Dapat dimengerti
Spesifik
Outcomes Vs Intervention :
Intervensi keperawatan harus :
Menghasilkan O positif
Mengarah pada O positif
Berdasarkan O positif
Meningkatkan O positif
Mempertahankan O positif
Mencegah perburukan O
Dilakukan sebelum evaluasi O
Diganti bila O negatif
Kapan Outcome diUKUR:
Saat mengkaji pasien
Saat akan dilakukan intervensi
Saat dilakukan intervensi
Saat setelah dilakukan intervensi
Saat jatuh tempo
NOC component
A neutral label or name used to
characterize the behavior or patient status
A list of indicators that describe client
behavior or patient status.
A five point scale to rate the patients status
for each of the indicators
Label : Immune Status (0702)
Definition: Natural and acquired appropriately
targeted resistance to internal and external
antigens.
Skala : 1=severely compromised thru 5= not
compromised
Indikator :
Absolute WBC values WNL
Differential WBC values WNL
Skin integrity
Mucosa integrity
Body temperature IER
Gastrointestinal function

Scale
Extremely compromised 1
Substantially compromised 2
Moderately compromised 3
Mildly compromised 4
Not compromised 5
_____________________________________________________
Severe 1
Substantial 2
Moderate 3
Mild 4
None 5

Features of NOC
Fluid Balance 0601
Balance of water in the intracellular and extracellular compartments of the body
Extremely Substantially Moderately Mildly Not
Compromised Compromised Compromised Compromised Comprised
1 2 3 4 5
Indicators:
BP IER
1 2 3 4 5
Mean arterial pressure IER
1 2 3 4 5
Pulmonary wedge pressure IER
1 2 3 4 5
Peripheral pulses palpable
1 2 3 4 5
Ascites not present
1 2 3 4 5
Neck vein distention not present
1 2 3 4 5
Peripheral edema not present
1 2 3 4 5
Sunken eyes not present
1 2 3 4 5
Confusion not present
1 2 3 4 5
NANDA/NOC Linkage
Each nursing Diagnosis is followed by a list
of suggested outcomes to measure whether
the chosen interventions are helping the
identified problem
Each outcome can be individualized to the
patient or family by choosing the
appropriate indicators or adding additional
indicators as necessary
Membuat NOC
Tanpa NNN
1. Tentukan diagnosa
2. Masukkan domain
3. Masukkan kelas
4. Pilih kriteria
5. pilih indikator
6. Tentukan skala
Dengan NNN
1. Tentukan diagnosa
2. Pilih kriteria
3. Pilih indikator
4. Tentukan skala

NIC NOC Judith M
Wilkinson

NIC
(Nursing Intervention Classification)
Intervensi
NIC
The nursing interventions classification
(NIC) is a comprehensive, standardized
language describing treatments that nurses
perform in all settings and in all
specialties. (Iowa Intervention Project,
2008)
FENOMENA
Apa yang dilakukan perawat ?
Apakah kegiatan perawat mempengaruhi
tingkat kesembuhan ?
Efektifkah kegiatan perawat dalam
pengurangan biaya ?
Tujuan Penyeragaman NIC :
Standarkan intervensi
Memberikan definisi yang sama tentang diagnosa
Mempermudah sistem informasi keperawatan
Memudahkan pengajaran
Mengukur biaya keperawatan
Memudahkan perencanaan administrasi/unit cost
Meminimalkan kesalah fahaman antar perawat

Komponen intervensi :
Pengkajian/Diagnostik/Observasi
Tindakan Mandiri perawat/terapeutik
Pendidikan kesehatan/health education
Kolaborasi/(LIMPAHAN) tindakan medis
NIC component
Name or label
A definition
A set of activities the nurse does to carry out
the intervention
Example : Diagnose : Risk for Infection
NOC yang di pilih :
6550 infection protection
1100 nutrition management
3590 skin surveillance
6650 surveillance
3660 wound care
Infection Protection 6550
Definition: Prevention and early detection of
infection in a patient at risk
Activities:
Monitor for systemic and localized s & sx of
infection (central line site check every 4 hours.)
Monitor WBC, and differential results (qd or qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors


Infection Protection (Cont.)
Activities (Cont.)
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for redness,
extreme warmth or drainage (q4 hours)
Inspect condition of surgical incision ( central line
insertion site q 4 hours)
Obtain cultures, as needed (Blood cultures prn
T>38.3 C q 24 hours) (Drainage @ Central line site)
Promote Nutritional intake (1500 kcal per day, Pt.
likes cereal)


Infection Protection (cont.)
Activities (cont.)
Encourage fluid intake (1225 cc per day, Pt likes orange
Gatorade)
Encourage rest (naps every afternoon from 1-3 PM, bedtime
at 2030)
Monitor for change in energy level/malaise
Instruct patient to take anti-infective as prescribed
(Bactrim BID, po, MTW and Nystatin 5cc,s & s, TID)
Teach Family about s & sx of infection and when to report
them to HCP
(NIC, 2008)



Features of NIC
ELECTROLYTE MANAGEMENT 2000
Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormal
or undesired serum electrolyte levels
Activities:
- Monitor for manifestations of electrolyte imbalance
- Maintain patent IV access Administer fluids, as prescribed, if appropriate
- Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate
- Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate
- Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate
- Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as prescribed, if appropriate
- Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels)
- Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound
drainage, and diaphoresis)
- Irrigate nasogastric tubes with normal saline
- Provide diet appropriate for patient's electrolyte imbalance (e.g., potassium-rich, low-sodium, and low-
carbohydrate foods)
- Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate
- Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen
- Monitor patient's response to prescribed electrolyte therapy
- Place on cardiac monitor, as appropriate



NANDA/NIC Linkage
Each NANDA diagnosis is followed by a list
of suggested interventions for resolving the
identified problem
Interventions and activities should be
chosen to meet the individual clients needs
Activities can be further individualized by
adding client specific information
Additional activities may be added if
appropriate
PENULISAN NNN
Sample Care Plan using Case Study
NANDA Nursing Diagnoses NOC Outcomes and Indicators NIC Intervention Label and select nursing activities
Risk for infection related to
immunosuppression
secondary to chemotherapy,
inadequate primary defenses
(central venous catheter),
chronic disease (ALL) and
developmental level.
0702Immune Status
Definition: Natural and acquired appropriately
targeted resistance to internal and external antigens.
1=severely compromised thru 5= not compromised
Absolute WBC values WNL(within normal limits)
1 2 3 4 5
Differential WBC values WNL(within normal limits)
1 2 3 4 5
Skin integrity
1 2 3 4 5
Mucosa integrity
1 2 3 4 5
Body temperature IER( in expected range)
1 2 3 4 5
Gastrointestinal function
1 2 3 4 5
Respiratory Function
1 2 3 4 5
Genitourinary Function
1 2 3 4 5
1= severe thru 5= None
Recurrent Infections
1 2 3 4 5
Weight Loss
1 2 3 4 5
Tumors (Immature
WBCs)
1 2 3 4 5
(NOC, 2008 p.399)
6550 infection protection
Definition: Prevention and early detection of infection in a patient at risk
Activities:
Monitor for systemic and localized signs & symptoms of infection (central line
site check every 4 hours.)
Monitor WBC, and differential results (qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for redness, extreme warmth or
drainage (q4 hours)
Inspect condition of surgical incision
(central line insertion site q 4 hours)
Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage
@ Central line site)
Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
Monitor for change in energy level/malaise
Instruct patient to take anti-infective as prescribed
(Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
Teach Family about s & symptoms of infection and when to report them to
HCP
-Teach patient and family how to avoid infections
(NIC, 2008)
Sample Blank Careplan
Nanda
Nursing
Diagnosis
NOC Outcome
Label(s) and
indicators
Rationale for NOC
chosen
and indictor score
NIC Intervention
label(s) and
nursing activities
Rationale for
NIC Chosen
Complete
NANDA
Nursing Dx
Statement
including
related or
risk factors
and defining
characteristic
NOC label and
appropriate
indicators and
rating on scale
with date (s)
Describe your
rationale for
choosing this NOC
label and the
indicator ratings that
you chose for this
patient.
NIC label and
appropriate
activities with
individualized
information
added.
Describe your
rationale for
choosing this
NIC label
Jazakumullah khoiron katsir..