Intervensi Keperawatan Nanda Nic Noc
Intervensi Keperawatan Nanda Nic Noc
1. Identifikasi keluhan
2. Masukkan domain
3. Masukkan kelas
4. Lihat definisi
5. Lihat batasan karakteristik
Contoh :
1. Identifikasi keluhan : sering terbangun
jika tidur tidak tahu penyebabnya
2. Masukkan domain : 4
3. Masukkan kelas : 1
4. Lihat definisi : insomnia
5. Lihat batasan karakteristik : insomnia
Components of
a Nursing Diagnosis
Axis 1 7
Penulisan axis lengkap, mempermudah NOC NIC
Contoh
1. Aktual : Ketidakefektifan (axis 3) bersihan jalan nafas
(axis 1), individu (axis 2, jika individu tdk ditulis),
kardiopulmonal (axis 4), dewasa (axis 5), kronis (axis 6),
aktual (axis 7) b.d mukus dalam jumlah berlebih ditandai
dengan wheezing, sianosis, dispnea
2. Aktual : Ketidakefektifan (axis 3) bersihan jalan nafas
(axis 1) individu (axis 2, jika individu tdk ditulis) b.d
mukus dalam jumlah berlebih ditandai dengan wheezing,
sianosis, dispnea
3. Aktual : Ketidakefektifan bersihan jalan nafas b.d mukus
dalam jumlah berlebih
Contoh
4. Resiko : ResikoInfeksi b.d penyakit
kronis (kanker paru)
5. Promosi : Kesiapan meningkatkan
(axis 3) rasa nyaman (axis 1) keluarga
(axis 2)
6. Kesejahteraan : Diare b.d keracunan
makanan (petis)
Dx Medis dan Dx Keperawatan
CLINICAL SITUATIONS DIAGNOSTIC CONCEPT POSSIBLE NURSING
DIAGNOSES
SYSTEMIC ARTERIAL
Cardiac output Decreased cardiac output
HYPOTENSION
HYPOVOLEMIA Fluid balance Deficient fluid volume
PAIN Pain Acute pain
Tissue perfusion:
METABOLIC ACIDOSIS Tissue perfusion cardiopulmonary,
ineffective
WOUND DRAINAGE Skin integrity Impaired skin integrity
Tissue perfusion:
SYSTEMIC ARTERIAL Tissue perfusion cardiopulmonary,
HYPERTENSION ineffective
OLIGURIA Urinary elimination Impaired urinary elimination
POLYURIA Urinary elimination Impaired urinary elimination
HYPERTHERMIA Body temperature Hyperthermia
HYPOCALCEMIA Cardiac output Decreased cardiac output
Prioritas diagnosa
Standar asuhan keperawatan : (1) mengancam kehidupan,
(2) mengancam kesehatan, (3) mempengaruhi perilaku
manusia
DEPKES RI ; (1) aktual, (2) potensial/resiko
Maslow : (1) fisiologis, (2) aman&nyaman, (3) cinta&kasih
sayang, (4) harga diri, (5) aktualisai diri
Per sistem : B1, B2, B3, B4, B5, B6
NOC
(Nursing Outcomes Classification)
Severe 1
Substantial 2
Moderate 3
Mild 4
None 5
Features of NOC
Fluid Balance 0601
Balance of water in the intracellular and extracellular compartments of the body
Extremely Substantially Moderately Mildly Not
Compromised Compromised Compromised Compromised Comprised
1 2 3 4 5
Indicators:
BP IER
1 2 3 4 5
Mean arterial pressure IER
1 2 3 4 5
Pulmonary wedge pressure IER
1 2 3 4 5
Peripheral pulses palpable
1 2 3 4 5
Ascites not present
1 2 3 4 5
Neck vein distention not present
1 2 3 4 5
Peripheral edema not present
1 2 3 4 5
Sunken eyes not present
1 2 3 4 5
Confusion not present
1 2 3 4 5
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
Membuat NOC
Tanpa NNN Dengan NNN
1. Tentukan diagnosa 1. Tentukan diagnosa
2. Masukkan domain 2. Pilih kriteria
3. Masukkan kelas 3. Pilih indikator
4. Pilih kriteria 4. Tentukan skala
5. pilih indikator
6. Tentukan skala NIC NOC Judith M
Wilkinson
NIC
(Nursing Intervention Classification)
Intervensi
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)
FENOMENA
Apa yang dilakukan perawat ?
Apakah kegiatan perawat mempengaruhi
tingkat kesembuhan ?
Efektifkah kegiatan perawat dalam
pengurangan biaya ?
Tujuan Penyeragaman NIC :
Standarkan intervensi
Memberikan definisi yang sama tentang diagnosa
Mempermudah sistem informasi keperawatan
Memudahkan pengajaran
Mengukur biaya keperawatan
Memudahkan perencanaan administrasi/unit cost
Meminimalkan kesalah fahaman antar perawat
Komponen intervensi :
Pengkajian/Diagnostik/Observasi
Tindakan Mandiri perawat/terapeutik
Pendidikan kesehatan/health education
Name or label
A definition
A set of activities the nurse does to carry out
the intervention
Example : Diagnose : Risk for Infection
NOC yang di pilih :
6550 infection protection
1100 nutrition management
3590 skin surveillance
6650 surveillance
0702Immune Status
Risk for infection related to 6550 infection protection
immunosuppression Definition: Natural and acquired appropriately Definition: Prevention and early detection of infection in a patient at risk
secondary to chemotherapy, targeted resistance to internal and external antigens. Activities:
inadequate primary defenses 1=severely compromised thru 5= not compromised Monitor for systemic and localized signs & symptoms of infection (central line
(central venous catheter), Absolute WBC values WNL(within normal limits) site check every 4 hours.)
chronic disease (ALL) and 1 2 3 4 5 Monitor WBC, and differential results (qod)
developmental level. 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
Body temperature IER( in expected range) drainage (q4 hours)
1 2 3 4 5 Inspect condition of surgical incision
Gastrointestinal function (central line insertion site q 4 hours)
1 2 3 4 5 Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage
Respiratory Function @ Central line site)
1 2 3 4 5 Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Genitourinary Function
Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
1 2 3 4 5
1= severe thru 5= None Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
Recurrent Infections Monitor for change in energy level/malaise Instruct
1 2 3 4 5 patient to take anti-infective as prescribed (Bactrim
Weight Loss 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
Tumors (Immature HCP
WBCs) -Teach patient and family how to avoid infections
1 2 3 4 5 (NIC, 2008)
(NOC, 2008 p.399)
Sample Blank Careplan
Nanda NOC Outcome Rationale for NOC NIC Intervention Rationale for
Nursing Label(s) and chosen label(s) and NIC Chosen
Diagnosis indicators and indictor score nursing activities
Complete NOC label and Describe your NIC label and Describe your
NANDA appropriate rationale for appropriate rationale for
Nursing Dx indicators and choosing this NOC activities with choosing this
Statement rating on scale label and the individualized NIC label
including with date (s) indicator ratings that information
related or you chose for this added.
risk factors patient.
and defining
characteristic
Jazakumullah khoiron katsir..