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Proses Keperawatan

sebagai Metode
Problem Solving
By
Endang Sri P Ningsih

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Dasar Hukum
KepmenKes RI No
660/Menkes/SK/IX/1987
Surat Edaran Dirjen YanMed No
105/Yan.med/Raw/1988
SK Dirjen YanMed No YM00.0326.7637
tgl 18 Agustus 1999 ttg berlakunya standar
akep di RS
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Fakta
Pelaksanaan belum optimal
Dokumentasi asuhan belum terlihat
lengkap

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Penyebab
Kemampuan Perawat dalam Penerapan
Proses Keperawatan ?
Beban Kerja ?
Metode Pendokumentasian ? (paper based)
Bahasa belum terstandar
Reward ?

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Implikasi/ Dampak
Layanan berkualitas Peningkatan
profesional
Hubungan terapeutik perawat-pasien
Kepuasan bekerja
Pengembangan kreativitas
Mencegah kejenuhan.rutinitas (task
approach)
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PENDAHULUAN
Proses Keperawatan Sebagai Kerangka
Kerja (Framework) dari asuhan
keperawatan
Metode sistematik dan logis dalam
pemecahan masalah klien
Terdiri : koleksi informasi; identifikasi
problem; pembuatan tujuan /out come;
perencanaan tindakan ; evaluasi

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Karakteristik Proses
Keperawatan
sistematis
Dinamis
Interpersonal
Goal-oriented
Universally applicable /

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Tahapan Proses Keperawatan

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Pengkajian
Sumber data Tehnik Pengumpulan
Primer data
Sekundet Observasi
Tipe data Interview
Objektif Pemeriksaan Fisik
Subjektif
Writing Nursing Diagnoses
NANDA
1. The clients problem (Masalah)
2. Etiology (r/t) (Penyebab/b.d)
3. Defining characteristics (a.m.b.)/Ditandai
dengan
Actual diagnosis ( Diagnosis aktual)
Risk nursing diagnoses ( Diagnosis
Resiko)
Syndrome diagnosis (diagnosis sindrome)
Wellness diagnosis (diagnosis sejahtera)
Prioritas Masalah
1. Threat to well-being or life
2. Non-life threatening
3. Not related to current illness

Maslow
Steps of the Nursing Process
Planning/Perencanaan
Tulis Goals/ Tujuan
Kembangkan strategi evaluasi (Kriteria
Hasil)
Tulis nursing care plan / NCP
Menulis tujuan
Subject Pasien/ klien
Verb indikasi yang dapat diobeservasi
diperiksa, di demonstrasikan , dll.
Kriteria (SMART/Spesifik, measurable,
Achievable, Realistik,Timing)
Writing nursing orders
Describe the action
Answer
Who
What
Where
When
How
Independent
Dependent (we include collaborative here)
Implementing
Reassessment
Obtaining help
Implementing the orders
Delegating and supervising
Documenting
Evaluating
Based on the clients response
Terminate the plan
Modify or revise the plan
Continue the plan
Care Plan forms and examples
Care Plan Guidelines
Care Plan Form
Patient Profile
APLIKASI NANDA NIC NOC

Endang Sri P Ningsih


Beberapa istilah
NANDA: Nursing Diagnosis: Definitions
and Classification
NIC: Nursing Interventions Classification
NOC: Nursing Outcomes Classification
Jenis Diagnosa :
1. Actual diagnosis: describes health
conditions that exist and supported by
defining characteristics
2. Risk diagnosis: those which describe
disease or other conditions that may develop
and are supported by risk factors
3. Wellness diagnosis: describe levels of
wellness and potential for enhancement to a
higher level of functioning
(NANDA, 2009) and (Denehy & Poulton, 1999)
Komponen
1. Label or Name and definition
2. Related Factors OR Risk Factors
3. Defining Characteristics
Case Study
4 year old boy with
ALL
Admitted one week
after chemo with a fever
of 102.5F
WBC is 0.3,absolute
neutrophil count is zero
New central line placed
10 days ago
C/O nausea & vomiting
Cries and hides behind
mother when approach
by nursing staff
Examples
1. Risk for infection related to
immunosuppression secondary to
chemotherapy, inadequate primary
defenses (central venous catheter),chronic
disease (ALL)and developmental level.
Was our choice correct?
Definition of the label: At increased risk for
being invaded by pathogenic organisms
Risk Factors:
Insufficient knowledge to avoid exposure to
pathogens (developmental level)
Inadequate secondary defenses (leukopenia)
Inadequate primary defenses (broken skin from
newly placed central line)
Pharmaceutical Agents (immunosuppressant, i.e.
chemotherapy)
(NANDA,2009)
Examples
2. Nausea related to chemotherapy as
evidenced by vomiting, patient c/o tummy
ache and aversion toward food.
Examples
3. Fear related to unfamiliarity with
environmental experiences as evidenced by
avoidance behaviors (hides behind mother)
and crying.
NOC
The nursing outcomes classification (NOC)
is a classification of nurse sensitive
outcomes
NOC outcomes and indicators allow for
measurement of the patient, family, or
community outcome at any point on a
continuum from most negative to most
positive and at different points in time. (
Iowa Outcome Project, 2008)
Components
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
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
NOC examples: Linked with Risk for
Infection
Immune Status (0702)
Infection Severity (0703)
Knowledge: Infection Control (1807)
Nutritional Status (1004)
Tissue Integrity: Skin & Mucous
membranes (1101)
Wound Healing: Primary Intention (1102)
Location of wound (#4, Front of Neck)
Immune Status (0702)
Definition: Natural and acquired appropriately
targeted resistance to internal and external
antigens.
1=severely compromised thru 5= not compromised
Absolute WBC values WNL
Differential WBC values WNL
Skin integrity
Mucosa integrity
Body temperature IER
Gastrointestinal function
Immune Status (Continued)
1= severe thru 5= None
Recurrent Infections
Weight Loss
Tumors (Immature WBCs)
(NOC, 2004 p.322)
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
NIC
The nursing interventions classification
(NIC) is a comprehensive, standardized
language describing treatments that nurses
perform in all settings and in all
specialties. (Iowa Intervention Project,
2008)
Interventions
Definition: any treatment based upon
clinical judgment and knowledge, that a
nurse performs to enhance patient/client
outcomes. (Iowa Intervention Project,
2000,p.3)
Components
Name or label
A definition
A set of activities the nurse does to carry
out the intervention
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
NIC Examples: Linked with Risk for
Infection
6550 infection protection
1100 nutrition management
3590 skin surveillance
6650 surveillance
3660 wound care
Infection Protection 6550
Definition: Prevention and early detection of
infection in a patient at risk
Activities:
Monitor for systemic and localized s & sx of
infection (central line site check every 4 hours.)
Monitor WBC, and differential results (qd or qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors
Infection Protection (Cont.)
Activities (Cont.)
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for redness,
extreme warmth or drainage (q4 hours)
Inspect condition of surgical incision ( central line
insertion site q 4 hours)
Obtain cultures, as needed (Blood cultures prn
T>38.3 C q 24 hours) (Drainage @ Central line
site)
Promote Nutritional intake (1500 kcal per day, Pt.
likes cereal)
Infection Protection (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
Sample Care Plan using Case
Study
NANDA Nursing Diagnoses NOC Outcomes and Indicators NIC Intervention Label and select nursing activities

Risk for infection related to 0702Immune Status 6550 infection protection


immunosuppression secondary to Definition: Natural and acquired appropriately targeted resistance Definition: Prevention and early detection of infection in a patient at risk
chemotherapy, inadequate primary to internal and external antigens. Activities:
defenses (central venous catheter), 1=severely compromised thru 5= not compromised Monitor for systemic and localized signs & symptoms of infection (central line site check
chronic disease (ALL) and Absolute WBC values WNL(within normal limits) every 4 hours.)
developmental level. 1 2 3 4 5 Monitor WBC, and differential results (qod)
Differential WBC values WNL(within normal limits) Follow neutropenic precautions
1 2 3 4 5 Provide a private room
Skin integrity Limit number of visitors
1 2 3 4 5 Screen all visitors for communicable disease
Mucosa integrity Maintain asepsis
1 2 3 4 5 Inspect skin and mucous membranes for redness, extreme warmth or drainage (q4 hours)
Body temperature IER( in expected range) Inspect condition of surgical incision
1 2 3 4 5 (central line insertion site q 4 hours)
Gastrointestinal function Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage @
1 2 3 4 5 Central line site)
Respiratory Function Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
1 2 3 4 5 Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
Genitourinary Function Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
1 2 3 4 5 Monitor for change in energy level/malaise
1= severe thru 5= None Instruct patient to take anti-infective as prescribed
Recurrent Infections (Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
1 2 3 4 5 Teach Family about s & symptoms of infection and when to report them to HCP
Weight Loss -Teach patient and family how to avoid infections
1 2 3 4 5 (NIC, 2008)
Tumors (Immature
WBCs)
1 2 3 4 5
(NOC, 2008 p.399)
Sample Blank Careplan
Nursing Diagnosis and Interventions: Choose the highest priority Nursing Diagnosis as indicated on the clinical reasoning web.
Include problem statement (NANDA), related to or risk factors (etiology), and defining characteristics (as evidenced by or AEB) as appropriate.
List all of the appropriate NOC Outcome labels and indicators and NIC intervention labels and nursing activities which will best help your client achieve those outcomes.
List the rationale for each and determine where your client falls on the outcome indicator scale (1-5) at the specified time intervals.
In the final column summarize why you gave your client the indicator scores that were given and any changes in your care plan that should be made.
Briefly describe how the plan of care is helping the patient meet the desired outcomes and any changes that need to be made:

Nanda Nursing Diagnosis NOC Outcome Label(s) Rationale for NOC chosen NIC Intervention label(s) and Rationale for NIC Chosen
and indicators and indictor score nursing activities

Complete NANDA Nursing NOC label and Describe your rationale for NIC label and appropriate activities Describe your rationale for choosing this
Dx Statement including appropriate indicators choosing this NOC label and with individualized information added. NIC label
related or risk factors and and rating on scale with the indicator ratings that you
defining characteristics date (s) chose for this patient.
References
Denehy,J. & Poulton,S. (1999) Journal of School
Nursing, 15 (1), 38-45.
Iowa Intervention Project (2008). Nursing
interventions and Classification (NIC). (4th ed.) St.
Louis: Mosby, Inc.
Iowa Outcomes Project (2008). Nursing outcomes
classification (NOC). (3rd ed.) St. Louis: Mosby, Inc.
NANDA Nursing Diagnosis: Definitions and
Classifications 2009-2011. (2009). Indianapolis, IN:
Wiley-Blackwell.
References (cont.)
Pesut, D. & Herman, J. (1999) Clinical Reasoning: The
Art & Science of Critical and Creative Thinking.
Albany, NY: Delmar Publishers.
Schoenfelder, Deborah (2004). Nursing outcomes
classification (NOC). Appendix F. (2004) St. Louis:
Mosby, Inc.
Van De Castle, B. (2003) Comparisons of
Nanda/NIC/NOC linkages between experts and nursing
students. International Journal of Terminologies and
Classifications 14(4)

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