NAMA : AYUDA MAHARANI

NIM : 2010068P
KELAS : 3A
TUGAS : SIK ( STANDAR DIAGNOSIS KEPERAWATAN INDONESIA )
ABSEN NO 7 ( 0031-0036 )
PROGRAM STUDI S1 KEPERAWATAN

Risiko Berat Badan Lebih D.0031

Kategori : Fisiologis
Subkategori : Nutrisi dan Cairan

Definisi
Berisiko mengalami akumulasi lemak berlebih atau abnormal yang tidak sesuai dengan usia
dan jenis kelamin.

Faktor Risiko
1. Kurang aktivitas fisik harian
2. Kelebihan konsumsi gula
3. Gangguan kebiasaan makan
4. Gangguan persepsi makan
5. Kelebihan konsumsi alkohol
6. Penggunaan energi kurang dari asupan
7. Sering mengemil
8. Sering memakan makanan berminyak/berlemak
9. Faktor keturunan (mis. distribusi jaringan adiposa, pengeluaran energi, aktivitas lipase
lipoprotein, sintesis lipid, lipolisis)
10. Penggunaan makanan formula atau makanan campuran pada bayı
11. Asupan kalsium rendah pada anak-anak
12. Berat badan bertambah cepat (selama masa anak-anak, selama masa bayi, termasuk minggu
pertama, 4 bulan pertama, dan tahun pertama)
13. Makanan padat sebagai sumber makanan utama pada usia <5 bulan.

Kondisi Klinis Terkait

1. Gangguan genetik
2. Hipotiroid
3. Diabetes melitus gestasional
4. Pola hidup kurang aktivitas

Referensi
Acklay, B. J., Ladwig, G. B., &Makic, M. B. F. (2017). Nursing Diagnosis Handbook, An Evidence-
Based Guideto PlanningCare. 11th Ed. St. Louis: Elsevier,
Herdman, T. H., & Kamitsuru, S. (2014). Nursing Diagnosis Definitions and Classification 2015-
2017. 10th Ed. Oxford: Wiley Blackwell.
International Council of Nurses (2015). Internasional Classification of Nursing Practice, Nursing
Diagnosis andOutcomesStatement. Geneva. Switzeriand: International Council of Nurses.
LeBlanc, E., O'Connor, E., Whitlock, E. P., et al. (2011). Screening for and Management of obesity
and overweight in adults. Evidence Report No. 89. AHRO Publication No. 11-05159-EF-1.
Rockville, MD: Agency for Healthcare Research and Quality.
Newijeld, S. A., Hinz, M. D Tiley, D. S., Sridaromont, K. L., Maramba, P. J. (2012). Cox’s Clinical
Applications of Nursing Diagnosis Adut, Chlid, Women's Mantal Health, Gerontic, and Home
Healh Considerations. 6th Ed. Philadelphia: F.A. Davis Companny.
Risiko Defisit Nutrisi D.0032
Kategori : Fisiologis
Subkategori : Nutrisi dan Cairan

Definisi
Berisiko mengalami asupan nutrisi tidak cukup untuk memenuhi kebutuhan metabolisme.

Faktor Risiko
1. Ketidakmampuan menelan makanan
2. Ketidakmampuan mencerna makanan
3. Ketidakmampuan mengabsorbsinutrien
4. Peningkatan kebutuhan metabolisme
5. Faktor ekonomi (mis. finansial tidak mencukupi)
6. Faktor psikologis (mis. stres, keengganan untuk makan)

Kondisi Klinis Terkait

1. Stroke
2. Parkinson
3. Mobius syndrome
4. Cerebral palsy
5. Cleft lip
6. Cleft palate
7. Amyotropic lateral sclerosis
8. Kerusakan neuromuskular
9. Luka bakar
10. Kanker
11. Infeksi
12. AIDS
13. Penyakit Crohn's
14. Enterokolitis
15. Fibrosis kistik

Referensi
Ackley, B. J., Ladwig, G. B., &Makic, M. B. F. (2017). Nursing Diagnosis Handbook, An Evidence-
Based Guide to Planning Care. 11th Ed. St. Louis: Elsevier.
Carpernito-Moyet, L. J. (2013). Nursing Diagnosis Application to Clinical Practice. 14th Ed.
Philadelphia: Lippincott Williams &Wilkins,
Doenges, M. E., Moorhouse, M. F., &Murr, A. C. (2013). Nursing Diagnosis Manual Planning,
Individualizing and Documenting Client Care. 4th Ed Philadelphia: F. A. Davis Company.
Herdman, T. H., &Kamitsuru, S. (2014). Nursing Diagnosis Definitionsand Classification 2015-2017.
10th Ed. Oxford: Wiley Blackwell.
Internasional Council of Nurses (2015). Internasional Classification of Nursing Practice, Nursing
Diagnosisi and Outcomes Statement. Geneva Switzerland: Iternatonal Council of Nurses.
Newfield, S .A., Hinz , M. D.,Tiley, D. S., Sridaromonet’ K. L ., Maramba , P. J (2012). Cox s
Clinical Applicatones of Nursig Diagnosis Adult, Chaild, Women’ S Mental Health,Gerotic ,
and Home Health Considerations. 6 th Ed. Philadelphia: F. A Davis Company.
Teixeira, I . X., Lompes, M.O., Martins , L. G., Dinez , C. M., de Menezes , A. P., & Alves ,N.P.,
(2016) . Validation of Clinical Indicators of Imbalancad Nutrition: Less Than Body
Requirements I Early Childhood. Journal Of Pediatric Nursing , 31(2), 1799-186, doi:
10.1016/j.pedn.2015.02.011.
Resiko Disfungsi Motilitas Gestrointestinal D.0033
Kategori : Fungsional
Subkategori : Nutrisi/Cairan

Definisi
Resiko peningkatan , penurunan atau tidak efektifnya aktivitas peristaltik pada sistem
gestrointestinal.

Faktor Resiko
1. Pembedahan Abdomen
2. Penurunan Sirkulasi Gestrointestinal
3. Intoleransi Makanan
4. Refluks Gestrointestinal
5. Hiperglikemia
6. Imobelitas
7. Proses Penuaan
8. Infeksi Gestrointestinal
9. Efek Agen Formokologis ( Mis. Antibiotik , Laksatif , Narkotika/Opiat )
10. Prematuritas
11. Kecemasan
12. Stres
13. Kurangnya Sanitas Pada Persiapan Makanan

Kondisi klinis terkait

1. Pembedahan Abdomen Atau Usus
2. Malnutrisi
3. Anemia
4. Kecemasan
5. Kangker Empedu
6. Kolesistektomi
1. 7.Infeksi Pencernan
7. Gastroesophageal Reflux Disease ( GERD)
8. Dialisis Peritoneal
9. Terapi Radiasi
10. Multiple organ dysfuncation syndrome

Referensi
Ackley, B.J., Ladwig ,G. B., & Makic , M, B, F (2017) Nursing Diagnosisi Handbook ,An Evidence-
Based Guide To Planning Care. 11 th Ed . St , Louls: Elsevier .
Aderinto-adike, A.O., & Quigley, E. M ( 2014). Gestrointestinal motility problems in critical care : a
clinica perspective. Chinese Journal of Digestive Diseases , 15(7), 335-344.
Ambartsumyan, L, & Rodriguez, L (2014) gestrointestinal motility children. Gastroenterologia Y
Hepatologia , 10(1), 16-26.
Carpernito-Moyet, L, J. (2013) Nursing Diagnosis Application to Clinical Practice , 14 th Ed.
Philadelphia : Lippincott Wilitiames & Wilkins .
Doenges, M. E., Moorhouse ,M. F., & murr, A. C. (2013) Nursing Diagnosis Manual Planning
Individualizing And Documenting Client Care . 4 th Ed philadelephia: F.A. Davis Company .
Herdman, T. H., & kamitsuru, S. (2014). Nursing Diagnosis Definintions And Classification 2015-
2017. 10 th Ed. Oxford; Wiley Blackwell.
Risiko Hipovolemia D.0034
Kategori : Fisiologis
Subkategori : Nutrisi dan Cairan

Definisi
Berisiko mengalamai peurunan volume cairan intravaskular, interstisial dan/atau intraseluler.

Faktor Risiko
1. Kehilanagan Cairan Secara Aktif
2. Ganguan Absorbsi Cairan
3. Usia Lanjut
4. Kelebihan Berat Badan
5. Status Hipermetabolik
6. Kegagalan Mekanisme Regulasi
7. Evaporasi
8. Kekurangan Intake Cairan
9. Efek Agen Farmokologis

Kondisi Klinis Terkait

1. Penyakit Addison
2. Trauma/ Predarahan
3. Luka Bakar
4. AIDS
5. Penyakit Crohn
6. Muntah
7. Diare
8. Kolitis ulseratif

Referensi
Carpernito-Moyet, L. J. (2013). Nursing Diagnosisi Application to Clinical Practice. 14th
Ed. Philadelphia: Lippincott Williams & Wilkins.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nursing Diagnosis Manual
Planning, Individualizing and Documenting Client Care. 4th Ed. Philadelphia: F. A.
Davis Company.
Herdman, T. H., & Kamitsuru, S. (2014). Nursing Diagnosis Definitions amd Classification
2015-2017. 10 th Ed. Oxford: Wiley Blackwell.
International Council Of Nurses ( 2015). Internasional Classification Of Nursing Practice,
Nursing Diagnosis Adn Outcomes Statement. Geneve, Switzerland ; International
Council of Nurses,
Newfield, S. A., Hinz, M. D., Tiley, D. S., Sridaromont, K. L., Maramba , P. J, (2012). Cox’s
Clinical Application Of Nursing Diagnosis Adult , Child , Women S, Mental Health,
Gerontic , And Home Health Considerations. 6 Th Ed. Philadelphia: F.A Davis
Companny.
Risiko Ikterik Neonatus D.0035
Kategori : Fisiologis
Subkategori : Nutrisi/Cairan

Definisi
Berisiko mengalami kulit membran mukosa neonatus menguning setelah 24 jam kelahiran
akibat bilirubin tak terkonjugasi masuk dalam sirkulasi.

Faktor Risiko
1. Penurunan Berat Badan Abnormal > 7-8% Pada Bayi Baru Lahir Yang Menyusu ASI, >
15% Pada Bayi Cukup Bulan)
2. Pola Makan Tidak Ditetapkan Dengan Baik
3. 3 Kesulitan Transisi Kehidupan Ekstra Uterin
4. Usia Kurang Dari 7 Hari
5. Keterlambatan Pengeluaran Feses (Mekonium )
6. 6 Prematuritas ( <37 Minggu )

Kondisi Klinis Terkait

1. Neonatus
2. Bayi Prematur

Referensi
Ackley, B. J., Ladwig, G. B., & Makic , M. B. F. ( 2017). Nursing Diagnosis Handbook, An
Evidence- Based Guide To Planning Care. 11 th Ed. St. Louis; Elsevier.
Carpernito-moyet, L. J. (2013). Nursing Diagnosis Application to Clinical Practice. 14th Ed.
Philadelphia : Lippincott Wiliames & Wilkins
Doenges, M. E., Moorhouse, M. F., & Murr , A. C. (2013). Nursing Diagnosis Manual
Planning Individualizing And Documenting Client Care. 4 th Philadelphia : F. A.
Davis Company.
Herdman, T. H., & Kamitsuru , S. (2014). Nursing Diagnosis Definitions And Classifikation
2015-2017. 10 th Ed. Oxford : Wiley Blackwell.
Maisels, M. J., et al. ( 2009). hyperbilirubinemia in the newborn infant > 35 weeks gestation:
an update with clarifications. Pediatrices, 124(4), 1193-1198,
Perry, S.E., at al. (2014). Maternal child nursing care. 5 th Ed. St louis : Elsevier/Mosby.
Risiko Ketidakseimbangan Cairan D.0036
Kategori : Fisiologis
Subkategori : Nutrisi/Cairan

Definisi
Berisiko mengalami penurunan, peningkatan atau percepatan perpindahan cairan dari
intravaskula, interstisial atau intraselular.

Faktor Risiko
1. Proseduer Pembedahan Moyar
2. Trauma/ Perdarahan
3. Luka Bakar
4. Aferesisi
5. Asites
6. Obstruksi Intestinal
7. Pradangan Pankreas
8. Penyakit Ginjal Dan Kelenjar
9. Disfungsi Intestinal

Kondisi Klinis Terkait

1. Prosedur Pembedahan Mayor
2. Penyakit Ginjal Dan Kelenjar
3. Perdarahan
4. Luka Bakar

Referensi
Ackley, B. J.,Ladwig , G.B., & Makic ,M,B,F. (2017). Nursing Diagaonis Handbook, An
Evidenc- Based Guide To Plainning Care . 11 th Ed St Louis ; Elsevier .
Carpernlto-moyet , L. J. ( 2013). Nursing Diagonisis Application to Clinical Practice. 14 th
Ed philadelphia: lippincott williams 7 wilikins.
Doenges, M. E., Moorhouse, M. F., & Murr , A. C. ( 2013). Nursing Diagnosis Manual
Planning Individualizing And Documenting Client Care. 4 th Ed. Philadelphia : F. A.
Davis company.
Herdman , T. H., & Kamitsuru, S. (2014). Nursing Diagonsis Definitions and Classification
2015-2017.10 Th Ed Oxford : Wiley Blackwell,
Newfield, S. A., Hinz , M. D., Tiley , D. S., Sridaromonet, K. L., Maramba ,P. J. ( 2012).
Cox’s Clincial Applications of Nursing Diagonsis Adult, Chlid , Women S Mental
Health , Gerontic, And Home Health Considerations. 6 Th Ed. Philadelphia : F.A.
Davis Company
Sparks & taylor ( 2011). Nursiang Diagonsis Pocket Gulde. Philadelphia: Lippnicott Willian
& Wilikins.