DIAGNOSIS KEPERAWATAN NANDA-I 2009-2011

Domain 1 Promosi Kesehatan................................................................................................................................................................................................................................

1. Ketidakefektifan Pemeliharaan Kesehatan (00099) ............................................................................................................................................. 67
2. Ketidakefektifan Manajemen Kesehatan Diri (00078) .......................................................................................................................................... 68
3. Hambatan Pemeliharaan Rumah (00098)............................................................................................................................................................ 72
4. Kesiapan Meningkatkan Status Imunisasi (00186) .............................................................................................................................................. 73
5. Pengabaian Diri (00193) ...................................................................................................................................................................................... 75
6. Kesiapan Meningkatkan Nutrisi (00163) .............................................................................................................................................................. 79
7. Ketidakefektifan Manajemen Regimen Terapeutik Keluarga (00080) .................................................................................................................. 80
8. Kesiapan Meningkatkan Manajemen Kesehatan Diri (00162) ............................................................................................................................................. 81

Domain 2 Nutrisi .................................................................................................................................................................................................................. 83

9. Ketidakefektifan Pola Makan Bayi (00107) .......................................................................................................................................................... 85
10. Ketidakseimbangan Nutrisi: Kurang dari Kebutuhan Tubuh (00002) ................................................................................................................... 86
11. Ketidakseimbangan Nutrisi: Lebih dari Kebutuhan Tubuh (00001) ...................................................................................................................... 87
12. Risiko Ketidakseimbangan Nutrisi: Lebih dari Kebutuhan Tubuh (00002) ........................................................................................................... 88
13. Gangguan Menelan (00103) ................................................................................................................................................................................ 89
14. Risiko Ketidakstabilan Kadar Glukosa Darah (00179) ......................................................................................................................................... 91
15. Ikterik Neonatus (00194) - ................................................................................................................................................................................... 92
16. Risiko Gangguan Fungsi Hati (00178) ................................................................................................................................................................. 94
17. Risiko Ketidakseimbangan Elektrolit (00195) ...................................................................................................................................................... 95
18. Kesiapan Meningkatkan Keseimbangan Cairan (00160) ..................................................................................................................................... 96
19. Kekurangan Volume Cairan (00027) ................................................................................................................................................................... 97
20. Kelebihan Volume Cairan (00026) ....................................................................................................................................................................... 98
21. Risiko Kekurangan Volume Cairan (00028) ......................................................................................................................................................... 99
22. Risiko Ketidakseimbangan Volume Cairan (00025) ........................................................................................................................................... 100

Domain 3 Eliminasi dan Pertukaran ................................................................................................................................................................................. 103

23. Inkontinensia Urinarius Fungsional (00020) ...................................................................................................................................................... 105
24. Inkontinensia urinarus aliran berlebih ............................................................................................................................................................... 106
25. Inkontinensia urinarus reflex.............................................................................................................................................................................. 108
26. Inkontinensia urinarus stress ............................................................................................................................................................................. 109
27. Inkontinensia urinarus dorongan ....................................................................................................................................................................... 111
28. Risiko Inkontinensia urinarus dorongan ............................................................................................................................................................. 113
29. Gangguan eliminasi urinarus ............................................................................................................................................................................ 114
30. Kesiapan meningkatkan eliminasi urinarus ........................................................................................................................................................ 115
31. Retsnsi urinarius ................................................................................................................................................................................................ 116
32. Inkontinensia defekasi ....................................................................................................................................................................................... 117
33. Konstipasi .......................................................................................................................................................................................................... 118
34. Persepsi konstipasi............................................................................................................................................................................................ 120
35. Resiko konstipasi .............................................................................................................................................................................................. 121
36. Diare .................................................................................................................................................................................................................. 123
37. Disfungsi motilitas gastrointestinal .................................................................................................................................................................... 124
38. Resiko Disfungsi motilitas gastrointestinal ........................................................................................................................................................ 126
39. Gangguan pertukaran gas ................................................................................................................................................................................. 128

Domain 4 aktivitas / istirahat............................................................................................................................................................................................. 129

40. Insomnia ............................................................................................................................................................................................................ 131
41. Deprivasin tidur ................................................................................................................................................................................................. 134
42. Kesiapan meningkatkan tidur ............................................................................................................................................................................ 135
43. Resiko sinrome disuse ...................................................................................................................................................................................... 137
44. Defisiensi aktivitas pengalih .............................................................................................................................................................................. 138
45. Gaya hidup kurang gerak .................................................................................................................................................................................. 139
46. Hambatan mobilitas ditempat tidur .................................................................................................................................................................... 140
47. Hambatan mobilitas fisik .................................................................................................................................................................................... 141
48. Hambatan mobilitas berkursi roda .................................................................................................................................................................... 143
49. Kelamabatan pemulihan pasca bedah ............................................................................................................................................................... 145
50. Hambatan kemampuan berpindah ..................................................................................................................................................................... 147
51. Hambatan berjalan ............................................................................................................................................................................................ 152
52. Gangguan medan energy ........................................................................................................................................................................................
53. Keletihan .................................................................................................................................................................................................................
54. Intoleransi aktivitas ..................................................................................................................................................................................................
55. Resiko Intoleransi aktivitas ......................................................................................................................................................................................
56. Resiko perdarahan ..................................................................................................................................................................................................
57. Ketidak efektifan pola nafas ....................................................................................................................................................................................
58. Penurunan Curah Jantung (00029) ................................................................................................................................................................... 162
59. Ketidakefektifan Perfusi Jaringan Perifer (00204) ............................................................................................................................................. 164
60. Risiko Penurunan Perfusi Jaringan Jantung* (00200) ....................................................................................................................................... 166
61. Risiko Ketidakefektifan Perfusi Jaringan Otak* (00201) .................................................................................................................................... 168
62. Risiko Ketidakefektifan Perfusi Gastrointestinal* (00202) .................................................................................................................................. 170
63. Risiko Ketidakefektifan Perfusi Ginjal* (00203) ................................................................................................................................................. 172
64. Risiko Syok (00205) .......................................................................................................................................................................................... 173
65. Gangguan Ventilasi Spontan (00033) ................................................................................................................................................................ 174
66. Disfungsi Respons Penyapihan Ventilator (00034) ............................................................................................................................................ 175
67. Kesiapan Meningkatkan Perawatan Diri (00182) ............................................................................................................................................... 177
68. Defisit Perawatan Diri: Mandi* (00108) .............................................................................................................................................................. 179
69. Defisit Perawatan Diri: Berpakaian* (00109) ..................................................................................................................................................... 180
70. Defisit Perawatan Diri: Makan (00102) .............................................................................................................................................................. 182
71. Defisit Perawatan Diri: Eliminasi* (00110) ......................................................................................................................................................... 183

Domain 5 Persepsi/Kognisi ............................................................................................................................................................................................... 185

72. Kealpaan Tubuh Unilateral (00123) ................................................................................................................................................................... 187
73. Sindrom Gangguan Interpretasi Lingkungan (00127) ........................................................................................................................................ 190
74. Keluyuran (00154) ............................................................................................................................................................................................. 191
75. Gangguan Sensori Persepsi (Tipe: Penglihatan, Pendengaran, Kinestetik, GustatQri, Taktil, Olfaktori) (00122) .............................................. 193
76. Konfusi Akut (00128) ......................................................................................................................................................................................... 194
77. Konfusi Kronik (00129) ...................................................................................................................................................................................... 198
78. Risiko Konfusi Akut (00173) .............................................................................................................................................................................. 199
79. Defisiensi Pengetahuan (00126) ....................................................................................................................................................................... 203
80. Kesiapan Meningkatkan Pengetahuan (00161) ................................................................................................................................................. 204
81. Kerusakan Memori (00131) .............................................................................................................................................................................. '205
82. Kesiapan Meningkatkan Pembuatan Keputusan (00184) .................................................................................................................................. 206
83. Ketidakefektifan Perencanaan Aktivitas (00199) ............................................................................................................................................... 208
84. Hambatan Komunikasi Verbal (00051) .............................................................................................................................................................. 210
85. Kesiapan Meningkatkan Komunikasi (00157) .................................................................................................................................................... 212

Domain 6 Persepsi Diri ...................................................................................................................................................................................................... 213

86. Risiko Pelemahan Martabat (00174) ................................................................................................................................................................. 215
87. Keputusasaan .................................................................................................................................................................................................... 126
88. Ganggaun identifikasi personil .......................................................................................................................................................................... 217
89. Resiko kesepian ................................................................................................................................................................................................ 219
90. Kesiapan meningkatnya daya ............................................................................................................................................................................ 220
91. Ketidakberdayaan .............................................................................................................................................................................................. 222
92. Resiko Ketidakberdayaan .................................................................................................................................................................................. 224
93. Kesiapan meningkatkan konsep diri .................................................................................................................................................................. 225
94. Harga diri rendah situasional ............................................................................................................................................................................. 226
95. Harga diri rendah kronik .................................................................................................................................................................................... 227
96. Resiko harga diri rendah situasioal ................................................................................................................................................................... 230
97. Gangguan citra tubuh ........................................................................................................................................................................................ 231

Domain 7 hubungan peran ................................................................................................................................................................................................ 233

98. Ketegangan peran pemberi asuhan ................................................................................................................................................................... 235

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99. Resiko Ketegangan peran pemberi asuhan ....................................................................................................................................................... 238
100. Ketidakmampuan menjadi orang tua ................................................................................................................................................................. 240
101. Resiko Ketidakmampuan menjadi orang tua ..................................................................................................................................................... 243
102. Resiko gangguan perlekatan ............................................................................................................................................................................. 244
103. Disfungsi proses keluarga ................................................................................................................................................................................. 246
104. Gangguan proses keluarga ............................................................................................................................................................................... 247
105. Kesiapan meningkatkan proses keluarga .......................................................................................................................................................... 250
106. Keefektifan pemberian ASI ................................................................................................................................................................................ 252
107. Konflik peran menjadi orang tua ........................................................................................................................................................................ 253
108. Kesiapan meningkatkan hubungan .................................................................................................................................................................... 254
109. Ketidak efektifan performa peran....................................................................................................................................................................... 256
110. Hambatan interaksi social ................................................................................................................................................................................. 257

Domain 8 seksualitas
111. Disfungsi seksual ....................................................................................................................................................................................................
112. Ketidakefektifan pola seksualitas ............................................................................................................................................................................
113. Kesiapan meningkatkan proses kehamilan persalinan ............................................................................................................................................
114. Resiko gangguan hubungan ibu/Janin .....................................................................................................................................................................

Domain 9 Koping/Toleransi Stres 273

115. Sindrom Pascatrauma (00141) ......................................................................................................................................................................... 275
116. Risiko Sindrom Pascatrauma (00145) .............................................................................................................................................................. 277
117. Sindrom Trauma Perkosaan (00142) ................................................................................................................................................................ 278
118. Sindrom Stres Akibat Perpindahan (00.114) .................................................................................................................................................... 279
119. Risiko Sindrom Stres Akibat Perpindahan (00149) .......................................................................................................................................... 280
120. Ansietas (00146) .............................................................................................................................................................................................. 281
121. Ansietas Kematian (00147) .............................................................................................................................................................................. 284
122. Perilaku Kesehatan Berisiko* (00188) : ............................................................................................................................................................ 287
123. Penurunan Koping Keluarga (00074) ............................................................................................................................................................... 290
124. Koping Defensif (00071) ................................................................................................................................................................................... 292
125. Ketidakmampuan Koping Keluarga (00073) ..................................................................................................................................................... 295
126. Ketidakefektifan Koping (00069) ....................................................................................................................................................................... 297
127. Ketidakefektifan Koping Komunitas (00077) ..................................................................................................................................................... 299
128. Kesiapan Meningkatkan Koping (00158) .......................................................................................................................................................... 300
129. Kesiapan Meningkatkan Koping Komunitas (00076) ........................................................................................................................................ 301
130. Kesiapan Meningkatkan Koping Keluarga (00075) ........................................................................................................................................... 302
131. Penyangkalan Tidak Efektif (00072) ................................................................................................................................................................. 303
132. Ketakutan (00148) ...................................................................................................................................................................................................
133. Dukacita* (00136) ....................................................................................................................................................................................................
134. Dukacita Terganggu* (00135) ..................................................................................................................................................................................
135. Risiko Dukacita Terganggu* (00172) ......................................................................................................................................................................
136. Gangguan Penyesuaian Individu (00210) ................................................................................................................................................................
137. Kesiapan Meningkatkan Penyesuaian (00212) .......................................................................................................................................................
138. Risiko Gangguan Penyesuaian (00211) ..................................................................................................................................................................
139. Kepedihan Kronis (00137) .....................................................................................................................................................................................
140. Stres Berlebihan (00177) ........................................................................................................................................................................................
141. Disrefleksia Autonomik (00009) ..............................................................................................................................................................................
142. Risiko Disrefleksia Autonomik (00010) ...................................................................................................................................................................
143. Disorganisasi Perilaku Bayi (00116). ......................................................................................................................................................................
144. Risiko Disorganisasi Perilaku Bayi (00115) ............................................................................................................................................................
145. Kesiapan Meningkatkan Perilaku Bayi (00117) .......................................................................................................................................................
146. Penurunan Kapasitas Adaptif Intrakranial (00049) ..................................................................................................................................................

Domain 10: Prinsip-Prinsip Hidup, ................................................................................................................................................................................... 335

147. Kesipana meningkatkan harapan ............................................................................................................................................................................
148. Kesiapan meingkatkan kesejahteraan spiritual ........................................................................................................................................................
149. Konflik keputusan ....................................................................................................................................................................................................
150. Distress moral .........................................................................................................................................................................................................
151. Ketidakpatuhan........................................................................................................................................................................................................
152. Hambatan religiositas ..............................................................................................................................................................................................
153. Kesiapan meingkatkan religiositas ..........................................................................................................................................................................
154. Resiko hambatan religiositas ...................................................................................................................................................................................
155. Distress spiritual ......................................................................................................................................................................................................
156. Resiko sistress spiritual ...........................................................................................................................................................................................

Domain 11: Keamanan/Perlindungan .....................................................................................................................................................................................

157. Resiko infeksi ..........................................................................................................................................................................................................
158. Ketidakefektifan bersihan jalan nafas ......................................................................................................................................................................
159. Resiko aspirasi ........................................................................................................................................................................................................
160. Resiko syndrome kematian bayi mendadak ............................................................................................................................................................
161. Kerusakan gigi .........................................................................................................................................................................................................
162. Resiko jatuh .............................................................................................................................................................................................................
163. Resiko cidera ...........................................................................................................................................................................................................
164. Resiko cidera akibat kondisi perioperatif .................................................................................................................................................................
165. Kerusakan membrane mukosa oral .........................................................................................................................................................................
166. Resiko disfungsi neurovascular perifer ....................................................................................................................................................................
167. Ketidakefektifan perlindungan .................................................................................................................................................................................
168. Kerusakan integritas kulit ........................................................................................................................................................................................
169. Resiko Kerusakan integritas kulit ............................................................................................................................................................................
170. Resiko asfiksia ........................................................................................................................................................................................................
171. Kerusakan integritas jaringan ..................................................................................................................................................................................
172. Resiko trauma .........................................................................................................................................................................................................
173. Resiko trauma vascular ...........................................................................................................................................................................................
174. Menciderai diri .........................................................................................................................................................................................................
175. Resiko Menciderai diri .............................................................................................................................................................................................
176. Resiko bunuh diri .....................................................................................................................................................................................................
177. Resiko perilaku kekerasan terhadap orang lain .......................................................................................................................................................
178. Resiko perilaku kekerasan terhadap diri sendiri ......................................................................................................................................................
179. Kontaminasi (00181) ......................................................................................................................................................................................... 387
180. Risiko Kontaminasi (00180). .............................................................................................................................................................................. 392
181. Risiko Keracunan (00037) ................................................................................................................................................................................. 395
182. Respons Alergi Lateks (00041) ......................................................................................................................................................................... 396
183. Risiko Respons Alergi Lateks (00042) ............................................................................................................................................................... 398
184. Risiko Ketidakseimbangan Suhu Tubuh (OOQ05) ............................................................................................................................................. 399
185. Hipertermia (00007) ........................................................................................................................................................................................... 400
186. Hipotermia (00006) ............................................................................................................................................................................................ 401
187. Ketidakefektifan Termoregulasi (00008) ............................................................................................................................................................ 402

Domain 12: Kenyamanan ................................................................................................................................................................................................... 403

188. Kesiapan Meningkatkan Rasa Nyaman (00183) ................................................................................................................................................ 405
189. Gangguan Rasa Nyaman (00214) ..................................................................................................................................................................... 407
190. Mual (00134) ..................................................................................................................................................................................................... 408
191. Nyeri Akut (00132)............................................................................................................................................................................................. 410
192. Nyeri Kronis (00133).......................................................................................................................................................................................... 411
193. Isolasi Sosial (00053) ........................................................................................................................................................................................ 412

Domain 13 Pertumbuhan/Perkembangan ......................................................................................................................................................................... 415

194. Kegagalan Orang Dewasa untuk Tumbuh (00101) ............................................................................................................................................ 417
195. Keterlambatan Pertumbuhan dan Perkembangan (00111) ................................................................................................................................ 419
196. Risiko Pertumbuhan Tidak Proporsional (00113) .............................................................................................................................................. 420
197. Risiko keterlambatan Perkembangan (00112) ................................................................................................................................................... 421

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