Domain 3

Eliminasi dan Pertukaran

DOMAIN 3. Eliminasi dan pertukaran

Sekresi dan ekskresi produk limbah dari tubuh

Kelas 1. Fungsi kemih

Proses sekresi, reabsorpsi, dan ekskresi urin
Code Diagnosa Page
00016 Gangguan eliminasi urin 183
00166 Kesiapan untuk meningkatkan eliminasi urin 184
00020 Inkontinensia kencing fungsional 185
00176 Overflow inkontinensia urin 186
00018 Inkontinensia urin refleks 187
00017 Stres inkontinensia urin 188
00019 Mendorong inkontinensia urin 189
00022 Risiko untuk mendesak inkontinensia urin 190
00023 Retensi urin 191
Kelas 2. Fungsi gastrointestinal

Proses penyerapan dan ekskresi produk akhir dari pencernaan

Code Diagnosa Page

00011 Sembelit 192
00015 Resiko sembelit 194

NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017,

Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru.
© 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd.
Companion website: www.wiley.com/go/nursingdiagnoses
Kelas 2. Fungsi gastrointestinal (lanjutan)

Code Diagnosa Page

00235 Konstipasi fungsional kronis 196
00236 Resiko sembelit fungsional kronis 198
00012 Sembelit yang dirasakan 199
00013 Diare 200
00196 Motilitas gastrointestinal disfungsional 201
00197 Resiko motilitas gastrointestinal disfungsional 202
00014 Inkontinensia usus 203
Kelas 3. Fungsi integumen
Proses sekresi dan ekskresi melalui kulit
Tidak ada saat ini
Kelas 4. Fungsi pernafasan
Proses pertukaran gas dan pemindahan produk akhir metabolisme
Code Diagnosa Page
00030 Gangguan pertukaran gas 204

182 Domain 3: Elimination and Exchange

 Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00016
Gangguan eliminasi urin
(1973, 2006; LOE 2.1)

3. Elimination and Exchange

Definisi

Disfungsi dalam eliminasi urine.

Mendefinisikan Karakteristik
■ Disuria ■ Retensi urin
■ Sering batal ■ Urin urgensi
■ Keraguan
■ Nokturia
■ Inkontinensia urin

Related Factors
■ Obstruksi anatomis ■ Kerusakan motorik sensorik
■ Beberapa kausalitas ■ Infeksi saluran kemih

Original literature support available at www.nanda.org

183 Domain 3: Elimination and Exchange Class 1: Urinary Function 183

Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00166

Kesiapan untuk meningkatkan eliminasi urin (2002, 2013; LOE 2.1)

Definisi
Pola fungsi urin untuk memenuhi kebutuhan eliminatory, yang dapat
diperkuat.

Mendefinisikan Karakteristik

■ Mengungkapkan keinginan
untuk meningkatkan
eliminasi urin
Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00020
Inkontinensia kencing fungsional
(1986, 1998)

Definisi
Ketidakmampuan orang benua biasa untuk mencapai toilet pada
waktunya untuk menghindari hilangnya air seni secara tidak disengaja.

Mendefinisikan Karakteristik
■ Sepenuhnya
mengosongkan kandung
kemih sepenuhnya
■ Inkontinensia urin di pagi
hari
■ Sensasi kebutuhan untuk
batal
■ Waktu antara sensasi dorongan
dan kemampuan mencapai toilet
terlalu pendek
■ Membatalkan sebelum
mencapai toilet

Related Factors
■ Perubahan fungsi kognitif
■ Perubahan faktor
lingkungan
■ Gangguan penglihatan
■ Kerusakan neuromuskular
■ Kelainan psikologis
■ Melemahnya struktur pelvic
pendukung
 Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00176
Overflow inkontinensia urin
(2006; LOE 2.1)

Definisi
3. Hilangnya urin tanpa disengaja yang terkait dengan
Eli overdistention kandung kemih.
mi
na
tio
n Defining Characteristics
an ■ Distensi kandung kemih ■ Kebocoran volume urin tanpa
d ■ Volume residu post-void disengaja
Ex ■ Nocturia
ch
yang tinggi
an
ge
Related Factors
■ Obstruksi outlet kandung ■ Impaksi feses
kemih ■ Prolaps panggul yang parah
■ Detrusor disfusi sfingter ■ Rejimen pengobatan
eksternal ■ Obstruksi Uretral
■ Detrusor hypocontractility

Original literature support available at www.nanda.org

Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00018

Inkontinensia urin refleks

3. Elimination and Exchange

(1986, 1998)

Definisi
Hilangnya urin secara sukarela pada interval yang dapat diprediksi saat volume
kandung kemih tertentu tercapai.

Mendefinisikan Karakteristik
■ Tidak adanya sensasi
kepenuhan kandung kemih
■ Tidak adanya keinginan
untuk membatalkan
■ Pengosongan kandung kemih
yang tidak lengkap dengan lesi di
atas pontine micturition center
■ Pola mati yang bisa diprediksi

■ Tidak adanya sensasi ■ Sensasi kepenuhan kandung

voiding kemih
■ Sensasi urgensi untuk batal
■ Ketidakmampuan untuk
tanpa penghambatan sukarela
secara sukarela
kontraksi kandung kemih
menghambat kekosongan
■ Ketidakmampuan untuk
secara sukarela memulai
voiding

Related Factors
■ Kelainan neurologis di atas ■ Kerusakan neurologis di atas
tingkat pusat kebutaan pontine tingkat penguburan sakral pusat
■ Kerusakan jaringan
 Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00017

Stres inkontinensia urin

(1986, 2006; LOE 2.1)

3.
Definisi
Eli Kebocoran mendadak urin dengan aktivitas yang meningkatkan
mi tekanan intra abdomen.
na
tio
n
an Defining Characteristics
d ■ Kebocoran volume urin tanpa
Ex ■ Kebocoran volume urin disengaja tanpa adanya kontraksi
ch detrusor
secara tidak disengaja (mis.,
an
Batuk, tertawa, bersin, saat ■ Kebocoran volume urin tanpa
ge
beraktivitas) disengaja tanpa adanya
kandung kemih yang terlalu
banyak

Related Factors
■ Perubahan degeneratif ■ Defisiensi sfingter uretra intrinsik
pada otot panggul ■ Otot pelvis yang lemah
■ Kenaikan tekanan intra-
abdomen

Original literature support available at www.nanda.org

Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00019

Mendorong inkontinensia urin

(1986, 2006; LOE 2.1)

3. Elimination and Exchange

Definisi
Bagian urin yang tidak disengaja terjadi segera setelah rasa
urgensi kuat untuk batal.

Mendefinisikan Karakteristik
■ Ketidakmampuan untuk
mencapai toilet pada
waktunya untuk menghindari
kehilangan air kencing
■ Kehilangan urin secara tidak
disengaja dengan kejang kandung
kemih
■ Urin urgensi

■ Kehilangan urin tanpa

disengaja dengan kontraksi
kandung kemih

Faktor Terkait
■ Konsumsi alkohol ■ Turunkan kapasitas kandung
■ Atetik uretritis Vaginitis kemih
atrofi ■ Detrusor hyperactivity dengan
■ Infeksi kandung kemih gangguan kontraktilitas kandung
■ Asupan kafein kemih
■ Impaksi feses
■ rejimen pengobatan

Original literature support available at www.nanda.org

 Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00022
Risiko untuk mendesak inkontinensia urin
(1998, 2008, 2013; LOE 2.1)

Definisi
Rentan terhadap urin yang tidak disengaja terjadi segera
3. setelah sensasi atau urgensi kuat untuk batal, yang dapat
Eli membahayakan kesehatan.
mi
na
tio Risk Factors
n ■ Konsumsi alkohol ■ Kelainan kandung kemih yang
an
d ■ Atetik uretritis Vaginitis atrofi terganggu
Ex ■ Detrusor hyperactivity dengan ■ Kebiasaan buang air kecil yang
ch gangguan kontraktilitas kandung tidak efektif
an kemih ■ Relaksasi sfingter spontan
ge
■ Impaksi feses ■ Kapasitas kandung kemih kecil
■ rejimen pengobatan

Original literature support available at www.nanda.org

Domain 3. Eliminasi dan Pertukaran Kelas 1. Fungsi Urin
00023

Retensi urin
(1986)

Definisi
Pengosongan kandung kemih tidak lengkap.

Mendefinisikan Karakteristik
■ Keluarnya urin tidak
ada
■ Distensi kandung kemih
■ Dribbling urin
■ Disuria Sering voiding
■ Inkontinensia overflow
■ Sisa urin Sensasi kepenuhan
kandung kemih
■ Kekosongan kecil

Related Factors
■ Penyumbatan pada ■ Refleks hambatan busur
saluran kemih ■ Sfingter kuat
■ Tekanan uretra tinggi
 Domain 3. Penghapusan dan Pertukaran Kelas 2. Gastrointestinal
Fungsi
00011
Constipation
(1975, 1998)

3. Definisi
Eli Turunkan frekuensi buang air besar yang normal disertai dengan bagian
mi tinja yang sulit atau tidak lengkap dan / atau bagian dari tinja kering
na yang terlalu keras.
tio
n Mendefinisikan Karakteristik
an ■ Abdominal pain ■ Headache
d ■ Abdominal tenderness with
Ex ■ Hyperactive bowel sounds
ch palpable muscle resistance ■ Hypoactive bowel sounds
an ■ Abdominal tenderness without ■ Inability to defecate
ge palpable muscle resistance ■ Increase in intra-abdominal
■ Anorexia pressure
■ Atypical presentations in older ■ Indigestion
adults (e.g., changes in mental ■ Liquid stool
status, urinary incontinence, ■ Pain with defecation
unexplained falls, elevated ■ Palpable abdominal mass
body temperature) ■ Palpable rectal mass
■ Borborygmi ■ Percussed abdominal dullness
■ Bright red blood with stool ■ Rectal fullness
■ Change in bowel pattern ■ Rectal pressure
■ Decrease in stool frequency ■ Severe flatus
■ Decrease in stool volume ■ Soft, paste-like stool in
■ Distended abdomen rectum
■ Fatigue ■ Straining with defecation
■ Hard, formed stool ■ Vomiting

Related Factors
Functional ■ Habitually ignores urge to
■ Abdominal muscle defecate
weakness ■ Inadequate toileting habits
■ Average daily physical activity ■ Irregular defecation habits
is less than recommended for ■ Recent environmental change
gender and age
 Mechanical
■ Electrolyte imbalance
■ Hemorrhoids
■ Hirschprung’s disease
Neurological impairment
■ Prostate enlargement
■ Rectal abscess
■ Rectal anal fissure
Rectal anal stricture

3. Elimination and Exchange

■ ■
(e.g., positive EEG, head ■ Rectal prolapse
trauma, seizure disorders) ■ Rectal ulcer
■ Obesity ■ Rectocele
■ Postsurgical bowel obstruction ■ Tumor
■ Pregnancy

Pharmacological
■ Laxative abuse ■ Pharmaceutical agent

Physiological
■ Decrease in gastrointestinal ■ Inadequate dentition
motility ■ Inadequate oral hygiene
■ Dehydration ■ Insufficient dietary habits
■ Eating habit change (e.g., ■ Insufficient fiber intake
foods, eating times) ■ Insufficient fluid intake

Psychological
■ Confusion ■ Emotional disturbance
■ Depression

193 Domain 3: Elimination and Exchange Class 2: Gastrointestinal Function 193

 Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00015
Risk for constipation
(1998, 2013)

3. Definition
Eli
Vulnerable to a decrease in normal frequency of defecation accompa-
mi
na nied by difficult or incomplete passage of stool, which may compromise
tio health.
n
an
d
Ex Risk Factors
ch
an Functional
ge
■ Abdominal muscle weakness ■ Habitually ignores urge to
■ Average daily physical activity defecate
is less than recommended for ■ Inadequate toileting habits
gender and age ■ Irregular defecation habits
■ Recent environmental change

Mechanical
■ Electrolyte imbalance ■ Prostate enlargement
■ Hemorrhoids ■ Rectal abscess
■ Hirschprung’s disease ■ Rectal anal fissure
■ Neurological impairment ■ Rectal anal stricture
(e.g., positive EEG, head ■ Rectal prolapse
trauma, seizure disorders) ■ Rectal ulcer
■ Obesity ■ Rectocele
■ Postsurgical bowel obstruction ■ Tumor
■ Pregnancy

Pharmacological
■ Iron salts ■ Pharmaceutical agent
■ Laxative abuse
Physiological
■ Decrease in gastrointestinal
motility
■ Dehydration
■ Eating habit change
(e.g., foods, eating times)

194 Domain 3: Elimination and Exchange

■ Inadequate dentition ■ Insufficient dietary habits
■ Inadequate oral hygiene ■ Insufficient fiber intake
■ Insufficient fluid intake

3. Elimination and Exchange

Psychological ■ Emotional disturbance
■ Confusion
■ Depression

195 Domain 3: Elimination and Exchange

 Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00235
Chronic functional constipation
(2013; LOE 2.2)

3. Definition
Eli
Infrequent or difficult evacuation of feces, which has been present for
mi
na at least three of the prior 12 months.
tio
n
an
d Defining Characteristics
Ex ■ Abdominal distention ■ CHILD ≥4 years: Presence of
ch
■ ADULT: Presence of ≥2 of the ≥2 criteria on Roman III
an
ge following symptoms on Rome Pediatric classification system
III classification system: for ≥2 months: * ≤2 defecations
* Lumpy or hard stools in ≥25% per week; * ≥1 episode of fecal
defecations; * Straining incontinence per week; * Stool
during ≥25% of defecations; retentive posturing; * Painful
* Sensation of incomplete or hard bowel movements;
evacuation for ≥25% of * Presence of large fecal mass
defecations; * Sensation of in the rectum; * Large diameter
anorectal obstruction/blockage stools that may obstruct the
for ≥25% of defecations; toilet
* Manual manuevers to ■ Fecal impaction
facilitate ≥25% of defecations ■ Fecal incontinence
(digital manipulation, pelvic (in children)
floor support); * ≤3 ■ Leakage of stool with digital
evacuations per week stimulation
■ CHILD ≤4 years: Presence of ≥2 ■ Pain with defecation
criteria on Roman III Pediatric ■ Palpable abdominal mass
classification system for ≥1 ■ Positive fecal occult blood test
month: * ≤2 defecations per ■ Prolonged straining
week; * ≥1 episode of fecal ■ Type 1 or 2 on Bristol Stool
incontinence per week; * Stool Chart
retentive posturing; * Painful
or hard bowel movements;
* Presence of large fecal mass
in the rectum; * Large-
diameter stools that may
obstruct the toilet
Related Factors
■ Amyloidosis
■ Anal fissure
Anal stricture
■ ■
■ Autonomic neuropathy
■ Cerebral vascular accident
■ Chronic intestinal pseudo-
obstruction
■ Chronic renal insufficiency
■ Colorectal cancer
■ Dehydration
■ Dementia
■ Depression
■ Dermatomyositis
■ Diabetes mellitus
■ Diet disproportionally high in
protein and fat
■ Extra intestinal mass
■ Failure to thrive
■ Habitually ignores urge to
defecate
■ Hemorrhoids
■ Hirschprung’s disease
■ Hypercalcemia
■ Hypothyroidism
■ Impaired mobility
Original literature support available at www.nanda.org
■ Inflammatory bowel disease
■ Insufficient dietary intake
3. Elimination and Exchange
Insufficient fluid intake
■ Ischemic stenosis
■ Low caloric intake
■ Low fiber diet
■ Multiple sclerosis
■ Myotonic dystrophy
■ Panhypopituitarism
■ Paraplegia
■ Parkinson’s disease
■ Pelvic floor dysfunction
■ Perineal damage
■ Pharmaceutical agent
■ Polypharmacy
■ Porphyria
■ Postinflammatory stenosis
■ Pregnancy
■ Proctitis
■ Scleroderma
■ Sedentary lifestyle
■ Slow colon transit time
■ Spinal cord injury
■ Surgical stenosis
 Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00236
Risk for chronic functional constipation
(2013; LOE 2.2)

3.
Eli Definition
mi Vulnerable to infrequent or difficult evacuation of feces, which has
na been present nearly 3 of the prior 12 months, which may compromise
tio health.
n
an
d
Ex Risk Factors
ch ■ Aluminum-containing antacids ■ Failure to thrive
an
ge ■ Anti-epileptics ■ Habitual ignoring of urge
■ Antihypertensives to defecate
■ Anti-Parkinsonian agents ■ Impaired mobility
(anticholinergic or ■ Low-fiber diet
dopaminergic) ■ Insufficient fluid intake
■ Calcium-channel antagonists ■ Inactive lifestyle
■ Chronic intestinal ■ Iron preparations
pseudo- obstruction ■ Low caloric intake
■ Decreased food intake ■ Non-steroidal
■ Dehydration anti-inflammatories (NSAIDs)
■ Depression ■ Opioids
■ Diet proportionally high in ■ Polypharmacy
protein and fat ■ Slow colon transit time
■ Diuretics ■ Tricyclic antidepressants

Original literature support available at www.nanda.org

Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00012

3. Elimination and Exchange

Perceived constipation
(1988)

Definition
Self-diagnosis of constipation combined with abuse of laxatives, ene-
mas, and/or suppositories to ensure a daily bowel movement.

Defining Characteristics
■ Enema abuse ■ Laxative abuse
■ Expects daily bowel movement ■ Suppository abuse
■ Expects daily bowel movement
at same time every day

Related Factors
■ Cultural health ■ Impaired thought process
beliefs
■ Family health beliefs
 Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00013
Diarrhea
(1975, 1998)

3. Definition
Eli
Passage of loose, unformed stools.
mi
na
tio
n
an
d
Defining Characteristics
Ex ■ Abdominal pain ■ Hyperactive bowel sounds
ch ■ Bowel urgency ■ Loose liquid stools > 3 in
an ■ Cramping 24 hours
ge

Related Factors
Physiological ■ Malabsorption
■ Gastrointestinal inflammation ■ Parasite
■ Gastrointestinal irritation
■ Infection

Psychological
■ Anxiety ■ Increase in stress level
Situational ■ Substance abuse
■ Enteral feedings ■ Travel
■ Exposure to contaminant ■ Treatment regimen
■ Exposure to toxin
■ Laxative abuse
Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00196

3. Elimination and Exchange

Dysfunctional gastrointestinal motility
(2008; LOE 2.1)

Definition
Increased, decreased, ineffective, or lack of peristaltic activity within the
gastrointestinal system.

Defining Characteristics

■ Abdominal cramping ■ Diarrhea

■ Abdominal distention ■ Difficulty with defecation
■ Abdominal pain ■ Hard, formed stool
■ Absence of flatus ■ Increase in gastric residual
■ Acceleration of gastric ■ Nausea
emptying ■ Regurgitation
■ Bile-colored gastric residual ■ Vomiting
■ Change in bowel sounds

Related Factors
■ Ingestion of contaminated
■ Aging material (e.g., radioactive,
■ Anxiety food, water)
■ Enteral feedings ■ Malnutrition
■ Food intolerance ■ Prematurity
■ Immobility ■ Sedentary lifestyle
■ Treatment regimen

Original literature support available at www.nanda.org

 Domain 3. Elimination and Exchange Class 2. Gastrointestinal
Function
00197
Risk for dysfunctional gastrointestinal motility
(2008, 2013; LOE 2.1)

3.
Eli Definition
mi Vulnerable to a decrease in normal frequency of defecation accompa-
na nied by difficult or incomplete passage of stool, which may compromise
tio health.
n
an
d
Ex Risk Factors
ch
■ Aging ■ Gastroesophageal reflux
an
ge ■ Anxiety disease
■ Change in water source ■ Immobility
■ Decrease in gastrointestinal ■ Infection
circulation ■ Pharmaceutical agent
■ Diabetes mellitus ■ Prematurity
■ Eating habit change (e.g., ■ Sedentary lifestyle
foods, eating times) ■ Stressors
■ Food intolerance ■ Unsanitary food preparation

Original literature support available at www.nanda.org

Domain 3. Elimination and Exchange Class 2. Gastrointestinal
00014
Bowel incontinence
(1975, 1998)
Definition
Change in normal bowel habits characterized by involuntary passage
of stool.
Defining Characteristics
■ Bowel urgency
■ Constant passage of soft stool
■ Does not recognize urge to
defecate
■ Fecal odor
■ Fecal staining of bedding
■ Fecal staining of clothing
■ Inability to delay defecation
Related Factors
■ Abnormal increase
in abdominal
pressure
■ Abnormal increase in
intestinal pressure
■ Alteration in cognitive
functioning
■ Chronic diarrhea
■ Colorectal lesion
■ Deficient dietary habits
■ Difficulty with toileting self-care
■ Dysfunctional rectal sphincter
■ Environmental factor (e.g.,
inaccessible bathroom)
Function
3. Elimination and Exchange
■ Inability to expel formed stool
despite recognition of rectal
fullness
■ Inability to recognize rectal
fullness
■ Inattentive to urge to defecate
■ Reddened perianal skin
■ Generalized decline in muscle
tone
■ Immobility
■ Impaction
■ Impaired reservoir capacity
■ Incomplete emptying
of bowel
■ Laxative abuse
■ Lower motor nerve damage
■ Pharmaceutical agent
■ Rectal sphincter abnormality
■ Stressors
■ Upper motor nerve damage
 Domain 3. Elimination and Exchange Class 4. Respiratory
Function
00030
Impaired gas exchange
(1980, 1996, 1998)

3.
Eli Definition
mi Excess or deficit in oxygenation and/or carbon dioxide elimination at the
na alveolar-capillary membrane.
tio
n
an
d Defining Characteristics
Ex
ch ■ Abnormal arterial blood gases ■ Dyspnea
an ■ Abnormal arterial pH ■ Headache upon awakening
ge ■ Abnormal breathing pattern ■ Hypercapnia
(e.g., rate, rhythm, depth) ■ Hypoxemia
■ Abnormal skin color (e.g., pale, ■ Hypoxia
dusky, cyanosis) ■ Irritability
■ Confusion ■ Nasal flaring
■ Cyanosis ■ Restlessness
■ Decrease in carbon dioxide ■ Somnolence
(CO2) level ■ Tachycardia
■ Diaphoresis ■ Visual disturbance

Related Factors
■ Alveolar-capillary membrane ■ Ventilation-perfusion
changes imbalance