PENGGUNAAN NANDA, NIC & NOC (NNN)

dalam

PRAKTEK KEPERAWATAN KOMUNITAS

IKATAN PERAWAT
KESEHATAN KOMUNITAS INDONESIA
(IPKKI) , 2014

LATAR BELAKANG
Asuhan keperawatan komunitas ditujukan
ke: individu, keluarga, kelompok dan
masyarakat
Pendekatan Proses keperawatan
Asuhan harus terdokumentasi baik:
dokumen askep, legal aspek, harapan
berlakunya sistem reward / imbal jasa
perawat Perkesmas/ komunitas
Penerapan: terkendala rumusan
diagnosis, intervensi, tujuan, evaluasi
belum seragam

LATAR BELAKANG
Diagnosis dikembangkan belum dapat
diadopsi langsung
Sistem klien (individu, keluarga, kelompok,
komunitas) sangat unik dipengaruhi
lingkungan
Kualifikasi pendidikan perawat perkesmas/
komunitas bervariasi: SPK, AMK, Ners dan
Spesialis
Butuh telaah lebih dalam

UPAYA ORGANISASI PROFESI

(IPKKI)
Melakukan telaah diagnosis keperawatan di
area praktik keperawatan komunitas
Mereview teori terkait dgn para pakar
Keilmuan Keperawatan Komunitas (Kolegium)
Diskusi dengan perawat Komunitas pada
level pengambil kebijakan (KEMENKES RI)
Mendengarkan masukan para perawat
praktisi
Mensosialisasikan hasil telaah dalam Konas II
IPKKI di Yogyakarta , rumusan draft askep
Menetapkan rumusan standar draft askep
integrasi NANDA, ICNP, NIC, NOC

NANDA, NIC, NOC (NNN)

NANDA: North American Nursing Diagnosis
Association
Exists to develop, refine, and promote
terminology that accurately reflects
nursesclinical judgments. This unique,
evidence-based perspective includes social,
psychological, and sipritual dimensions of
care
NANDA International Taxonomy (Classification)
II , 2012-2014

NANDA International Taxonomy II

(3 level)
1. Domains : 13
2. Classes : 47
3. Nursing diagnosis: 217
Axis : 7
Code structure (recommendation National
Library of Medicine/ NLM)

Domain
(a sphere of knowledge, influence, inquiry)
Health Promotion, nutrition,
elimination/ exchange, activity/ rest,
perception/ cognition, self perception,
role relationships, sexuality, coping/
stress tolerance, life principles, safety
protection, comfort,
growth/development

CLASSES
(a group, set )
Health awareness, health
management, ingestion, digestion,
absorption, metabolism, hydration,
urinary function, gastrointestinal
function, integumentary function,
respiratory function, sleep/rest,
activity exercise, energy balance,
cardiovascular/ pulmonary responses,
self care,

AXIS
Axis 1: Diagnostic focus respon manusia
Axis 2: subjek diagnosis (individu, keluarga,
kelompok, masyarakat)
Axis 3: judgment (gangguan,
ketidakefektifan, penurunan,
peningkatan)
Axis 4: Lokasi: (otak, telinga, kandung kemih)
Axis 5: Usia: bayi, anak, dewasa
Axis 6: waktu: kronik, akut, intermittent)
Axis 7: Status diagnosis (aktual, risiko, health
promotion)

Domain- Classes
Domain

Health
Promotion

Class 1

Health
Awareness

Class 2

Health
Manage
ment

LABEL?
Aktual
Potensial Promosi Kesehatan/ sejahtera/
wellness
Risiko

NURSING DIAGNOSIS/
DIAGNOSIS KEPERAWATAN
Clinical judgment about individual, family, or
community experiences/ responses to actual or
potential health problem/life process.
A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse has accountability
(Approved at the ninth NANDA Conference, 2009).

Data / Karakterisitik
An H mengeluh batuk dan sering
demam sejak sekitar 6 bulan
yang lalu
sering mengeluh sesak nafas
sering terbangun karena batuk
membuang dahak,
dada sering terasa sakit dan
panas,
tidur dengan menggunakan dua
bantal
nafsu makan berkurang,
Pada pemeriksaan fisik An H, TD
100/60 mmHg, S 37,20 , N 92
x/mnt, RR 38 x/mnt, BB 40 Kg, TB
165 cm
Ada ronchi dan weezing di
kedua paru.
An H tampak sering batuk dan
mengeluarkan dahak kental
warna kehijauan

DX
NANDA

Domain : 3 Elimination and

Exchange
Secretion and secretion of
waste from the body

Class: 4 Respiratory Function

Impaired Gas Exchange

(00030)

Data / Karakterisitik
An H mengeluh batuk dan sering
demam sejak sekitar 6 bulan
yang lalu
sering mengeluh sesak nafas
sering terbangun karena batuk
membuang dahak,
dada sering terasa sakit dan
panas,
tidur dengan menggunakan dua
bantal
nafsu makan berkurang,
Pada pemeriksaan fisik An H, TD
100/60 mmHg, S 37,20 , N 92
x/mnt, RR 38 x/mnt, BB 40 Kg, TB
165 cm
Ada ronchi dan weezing di
kedua paru.
An H tampak sering batuk dan
mengeluarkan dahak kental
warna kehijauan
ada retraksi dinding dada dan

DX
NANDA

Domain : 3 Elimination and

Exchange
Secretion and secretion of
waste from the body

Class: 4 Respiratory Function

Rumusan Diagnosis Keluarga:

Gangguan Pertukaran
Gas pada anak AH
(Konas IPKKI, 2011)

Catatan:
NANDA International Taxonomy
(Classification) II , 2012-2014: belum
optimal mengakomodasi diagnosis
keperawatan di area Keperawatan
Komunitas kelompok dan Masyarakat
Digunakan juga rumusan diagnosis dari
International Classifications for Nursing
Practice (ICNP)

Mengapa NANDA, NIC, NOC?

Disusun oleh scientists nurse, clinician
expertises nurse di seluruh dunia, berdasarkan
high quality evidence based nursing care
Diterjemahkan hampir ke seluruh bahasa /
negara didunia
Memiliki : Diagnosis Development Committee
review diagnosis setiap tahun
Saat ini, Indonesia belum memiliki ada
peluang untuk mengembangkan sendiri

NURSING INTERVENTION CLASSIFICATION

(NIC)

NIC
Comprehensive standardized classifications of
interventions that nurses perform
Useful for : care planning, clinical documentation,
communication of care across setting, integration
of data across systems and settings,
effectiveness research, productivity
measurement, competency evaluation,
reimbursement, teaching and curricular design

NIC
Includes the interventions that nurses do
on behalf of patient,
Both independent and collaborative
interventions,
Both direct and indirect care,
Used in all setting: acute care to intensive
care units, to home care, to hospice
care, to primary care, and all specialties
(critical care, occupational health nursing,
gerontological nursing).

NIC
Domain : 7, Class Interventions
1). Physiological: Basic, 2). Physiological: Complex,3). Behavioral,
4). Safety, 5).Family, 6).Health System, 7).Community
554 interventions
Nearly 13.000 activities

NIC, 6 th ed, 2013

NIC, 6 th ed, 2013

Contoh:DOMAIN: Physiological: Basic

CLASSES
Activity and Exercise Management
Elimination Management
Immobility Management
Nutrition Support
Physical Comfort Promotion
Self Care Facilitation

INTERVENTIONS

INTERVENTIONS ?
Any treatment , based upon clinical judgment
and knowledge, that a nurse performs to
enhance patient/client outcomes
Although an individual nurse will have expertise
in only a limited number of interventions
reflecting her or his specialty

Data / Karakterisitik
An H mengeluh
batuk,sering demam sejak
sekitar 6 bulan yang lalu
sering mengeluh sesak
nafas
sering terbangun karena
batuk membuang dahak,
dada sering terasa sakit
dan panas,
tidur menggunakan dua
bantal
nafsu makan berkurang,
Pada pemeriksaan fisik An
H, TD 100/60 mmHg, S
37,20 , N 92 x/mnt, RR 38
x/mnt, BB 40 Kg, TB 165 cm
Ada ronchi, wheezing di
kedua paru.
An H tampak sering batuk
dan mengeluarkan dahak
kental warna kehijauan
ada retraksi dinding dada

DX
NANDA
Domain : 3
Elimination and
Exchange
Secretion and
secretion of
waste from the
body

Class: 4 Respiratory
Function

Impaired Gas
Exchange
(00030)

NIC
Level 1 Domains: 2.
Physiological :
Complex
Care that Support
Homeostatic
Regulation
Level 2 Classes : K
Respiratory
Management
Interventions to
promote airway
patency and gas
exchange
Level 3 Interventions:
3140- Airway
management
3230- Chest
Physiotherapi
3250- Cough
Enhancement

NIC
Problem

Intervensi (contoh)

Individu
al

Physiological

Acid-Base Management

Psychosocial

Anxiety Reduction

Illness
Treatment

Hyperglycemia Management

Illness
Prevention

Fall Prevention

Health
Promotion

Exercise Promotion

Family Integrity

Family Integrity Promotion

Community

Environmental Management:
Community

Family

Commun
ity

V
V

NURSING OUTCOMES CLASSIFICATION

(NOC)

NOC
Standardized terminology for nursing sensitive outcomes
for use by nurses across specialties, and practice to
capture changes in patient status after intervention
Each outcome represents a concept that can be used to
measure the state of patient, care giver, family, or
community before and after intervention
The outcomes have been developed for use by nurse,
but other disciplines may find them helpful for
evaluating the effectiveness of the intervention they
provide independently or in collaboration with
nurses.

Outcome = Tujuan Khusus

A Nursing- sensitive patient outcome is an individual,
family, or community state, behavior, or perception that is
measured along a continuum in response to nursing
intervention(s).
Bagaimana mengukurnya? .A five point Likert type
scale (1- 5) is used with all outcomes and indicators
Apa yang diukur?..= Fungsi organ, pengetahuan,
kemampuan caregiver sesuai dengan domain yang
akan diukur.
Apa saja domainnya? = Functional health, Physiologic
health, Psychososial health, Health Knowledge &
behavior, Perceived health, Family Health, Community
health (7 domain)

NOC

7 domain
32 classes
490 outcomes
17 measurement scales

NOC, 5 th ed (2013)

Data / Karakterisitik
An H mengeluh batuk dan
sering demam sejak sekitar
6 bulan yang lalu
sering mengeluh sesak
nafas
sering terbangun karena
batuk membuang dahak,
dada sering terasa sakit
dan panas,
tidur dengan
menggunakan dua bantal
nafsu makan berkurang,
Pada pemeriksaan fisik An
H, TD 100/60 mmHg, S
37,20 , N 92 x/mnt, RR 38
x/mnt, BB 40 Kg, TB 165 cm
Ada ronchi dan weezing di
kedua paru.
An H tampak sering batuk
dan mengeluarkan dahak
kental warna kehijauan

DX
NANDA
Domain : 3
Elimination and
Exchange
Secretion and
secretion of
waste from the
body

Class: 4 Respiratory
Function

Impaired Gas
Exchange
(00030)

NOC
Level 1 (2)
Domain II:
Physiologic Health
Level 2
Classes:
Outcomes that
describe an
individuals cardiac
pulmonary,
circulatory, or
tissue perfusion
status
Level 3 Outcomes:
0414Cardiopulmonary
status
0401- Circulation
status
0415- Respiratory
status: airway
patency

Contoh: A five point Likert type scale

Extremely
compromised

Substantially
compromised

Moderately
compromised

Mildly
Compromised

Not
compromised

Extreme
deviation
from
expected
range

Substantially
deviation
from
expected
range

Moderate
Mild deviation
deviation from from expected
expected range range

No deviation
from
expected
range

Dependent,
does not
participate

Requires
person &
devise

Requires
assistive
person

Independent
with assistive
device

Completely
independent

No motion

Limited
motion

Moderate
motion

Substantial
motion

Full motion

Contoh: Self Care Hygiene

Domain: Functional Health (1) Class-Self Care (D)

Definition: Personal actions to maintain own personal cleanliness and kempt
appearance independently with or without assistive device
OUTCOME TARGET RATING: Maintain: _____ Increase to:______
Indicat
ors

Severe
ly
compr
omised

Subst
antiall
y
compr
omise
d

Moder
ately
compr
omise
d

MiLdly
compr
omised

Not
comp
romis
ed

030501

Washes
hands

NA

030506

Maintains
Oral
Hygiene

NA

030512

Cares for
fingernail

NA

NIC atau NOC terlebih dulu?

Di institusi pendidikan: tetapkan diagnosis outcomes
(NOC) indicators select the interventions (NIC)
appropriate activities implements outcomes
Situasi tertentu berbeda situasi kegawatdaruratan:
NIC NOC
Kriteria waktu? Lihat NIC tabel 1, hal: 449, contoh:
Intervention

Code
No

Educational
level

Time Request

Diarrhea Management

4240

RN Basic

15 minutes or
less

Parent Education

5566

RN Basic

16-30 minutes

Communicable
Disease Management

8820

RN Basic

46-60 minutes

DRAFT PENERAPAN STANDAR ASUHAN

KEPERAWATAN INDIVIDU, KELUARGA,
KELOMPOK, KOMUNITAS
DI INDONESIA
dikembangkan berdasarkan :
integrasi diagnosis NANDA, International Classification
for Nursing Practice (ICNP), NIC, NOC, pengalaman
lapangan para penyusun
Mempermudah para praktisi dan Ners pendidik
melakukan askep: Keluarga, Komunitas, Gerontik, serta
mendokumentasikan: askep: efektif, ringkas,
komprehensif
Fasilitasi para pimpinan menilai kinerja dan
pemberian reward perawat Perkesmas di dalam dan
di luar gedung Puskesmas

Contoh aplikasi NNN di area

Keperawatan Komunitas
Asuhan Keperawatan Individu
Asuhan Keperawatan Keluarga
Asuhan Keperawatan Komunitas

Individu
Data

Domain:
Diagnosa

NOC

NIC

Data Pendukung
masalah ISPA
Demam
Dada sering terasa
sakit dan panas
Tachycardia
Cyanosis
Dsypneu
Pernafasan
abnormal (ritme,
rate, kedalaman)
Retraksi dinding
dada
Nyeri kepala
Mudah sensitive
(balita)

Domain : 3 hal
191
Eliminasi dan
pertukaran
Diagnosis
Gangguan
pertukaran Gas
(00030)
hal 214

0414 status
pulmonary
0401 status sirkulasi
0402 status respirasi
: pertukaran gas
0403 status ventilasi
0408 perfusi
jaringan pulmonary
0802 vital sign

3320 Terapi
Oksigen hal
281
6680 Vital Sign
Monitoring hal
53
3140 Manajemen
jalan nafas hal
76
3350 Monitoring
pernafasan hal
326
3230 Fisioterapi
dada hal 120
1130
Aromaterapi
(inhalasi) hal
84

Keluarga
Data

Domain:
Diagnosa

NOC

NIC

Data Objektif:
TTV: 1. TD: >
130/90 mmHg,
Nadi : 100x/mnt,
tachikardi

Data Subjektif:
Data individu
Nyeri tengkuk
Nyeri kepala
Susah tidur/
sering terbangun
Penglihatan
kadang buram
Merasa
gelisah/cemas
Mudah marah

Domain 12:
comfort
Kelas 1:phsycal
comfort
Acute pain
(00132)
Chronic pain
(00133)

Keluarga mampu
mengenal
masalah:

Level 1
Domain IV:
health knowledge
& behavior

Level 2
Kelas S:
Health knowledge
(1821) knowledge
conceptions
prevention
(1803)
knowledge:
disease process
(1805)
knowledge: health
behavior
(1823)

Keluarga mampu
mengenal
masalah :

Level 1
Domain 1 :
Physiological
Basic

Level 2
Kelas E :
Physical comfort
promotion.

Level 3 ;
Interventions
(1320)
Acupressure
(1330)
Aromatherapy
(1390) Healing
Touch

Kelompok/ Komunitas
Data

Domain:
Diagnosa

NOC

NIC

Kemudahan akses
web/situs
khususnya situs
porno.
Pergaulan bebas
yang terjadi di
masyarakat,
nyaris tanpa
kontrol.
Pola asuh yang
tidak efektif
(sebagian besar
orang tua lemah
dalam mengatur
pergaulan dan
komunikasi)
Sebagaian besar
remaja di kota
besar melakukan
perilaku seksual

Promosi
kesehatan;
Problematic
Sexual
Behaviour
(10001274)/ICN
P

Prevensi primer :
Domain 4,
(Pengetahuan dan
perilaku
kesehatan)

Prevensi primer :
Kategori
Health education
hal 10 (5510)
Support spiritual
kategori
emosional
(11027067)
Family
involvement
promotion
491(NIC)
Pemantauan
kebijakan (7970)
(BKR, PKPR,
POKJA)
Assessing health
social care needs
( 10030618 ),
kategori
assement
Support group hal

Class S
level 3
1805 :
pengetahuan
:kesehatan
1823 :
pengetahuan
:promosi
kesehatan
1815 :
pengetahuan :
fungsi seksual

Panduan Penyusunan?
1. Lakukan pengkajian klien (individu, keluarga, kelompok/ komunitas
secara komprehensif) diperoleh data/ batasan/ karakteristik,
2. Lihat/ identifikasi NANDA, tetapkan kemungkinan DOMAIN
berdasarkan data,
3. Lihat/ identifikasi Class
4. Proses berfikir, analisis .
5. Tetapkan Diagnosis NANDA
6. Link Diagnosis dengan NOC, berdasarkan domain (NOC) yang
sesuai proses berfikir, analisis..
7. Lihat NOC hal 737 751 cari kata kunci untuk NOC sesuai
diagnosis
8. Link Diagnosis dengan NIC, berdasarkan domain (NIC) yang
sesuai proses berfikir, analisis..
9. Lihat NIC hal 579 608 cari kata kunci untuk NIC sesuai
diagnosis

KESIMPULAN
Asuhan Keperawatan harus
terdokumentasi baik: dokumen askep,
legal aspek, harapan berlakunya sistem
reward / imbal jasa perawat Perkesmas/
komunitas
Sistem klien (individu, keluarga, kelompok,
komunitas) sangat unik dipengaruhi
lingkungan diagnosis Keperawatan

KESIMPULAN
Penggunaan NANDA, ICNP, NIC, NOC,
harus disesuaikan dengan situasi kondisi
di area praktek keperawatan Komunitas di
Indonesia (letak geografis, budaya,
bahasa, SDM, kebijakan pemerintah/
perkesmas)
Evidence -based sangat dibutuhkan untuk
memperkaya variasi diagnosis
keperawatan di area keperawatan
Komunitas di Indonesia.

TERIMAKASIH, SEMOGA
BERMANFAAT