Taxonomy Nomenclature :
47 kelas
206 diagnosa
7 domain
31 kelas
385 kriteria
7 domain
31 kelas
542 intervensi
TRADISIONAL :
NANDA DIAGNOSE
Find a Diagnose :
1.
2.
3.
4.
5.
Identifikasi keluhan
Masukkan domain
Masukkan kelas
Lihat definisi
Lihat batasan karakteristik
Contoh :
Components of
a Nursing Diagnosis
Axis 1 7
Contoh
Contoh
4. Resiko : Resiko Infeksi b.d penyakit
DIAGNOSTIC CONCEPT
POSSIBLE NURSING
DIAGNOSES
SYSTEMIC ARTERIAL
HYPOTENSION
Cardiac output
HYPOVOLEMIA
PAIN
Fluid balance
Pain
METABOLIC ACIDOSIS
Tissue perfusion
WOUND DRAINAGE
Skin integrity
SYSTEMIC ARTERIAL
HYPERTENSION
Tissue perfusion
OLIGURIA
Urinary elimination
POLYURIA
Urinary elimination
HYPERTHERMIA
Body temperature
Hyperthermia
HYPOCALCEMIA
Cardiac output
Prioritas diagnosa
NOC
(Nursing Outcomes Classification)
Kriteria hasil (dan indikator)
NOC
SEJARAH
SEJARAH
SEJARAH
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
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
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
Not
Comprised
5
5
5
5
5
5
5
5
5
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
FENOMENA
Apa yang dilakukan perawat ?
Apakah kegiatan perawat mempengaruhi
tingkat kesembuhan ?
Efektifkah kegiatan perawat dalam
pengurangan biaya ?
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
Activities (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 lowcarbohydrate 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
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)