MODEL DOKUMENTASI

NANDA
Oleh
Nunung Siti Sukaesih
Definition
• NANDA (North American Nursing Diagnosis Association)
• Nursing diagnosis is a clinical judgement conserning a
human response to health conditions/life process, or
vulnerability for that response.
• The use of standized nursing language began in 1970s
with the development of NANDA’s diagnostic
classification.
Definition cont..
• Each health profession has way to describe “what” the
profession knows and “how” it acts on what it knows.
• Physicians treat disease ang use the International
Classification of Disease taxonomy (ICD-10)
• Psycologists, psychiatrists and other mental health
professionals use the Diagnostic and Satistical Manual of
Mental Disorder (DSM-V)
• Nurses treat human responses to health problem use
NANDA International (NANDA-I)
What happens during assessment

Screening test Potential In depth Nursing

diagnosis assessment diagnosis

• Data • Consider all • Focussed • Determining

collection possible data priority
• Data diagnosis collection nursing
analysis that match • Data diagnosis
• Clustering information analysis
of available • Confirming
information or refuting
potenstial
dignosis
NANDA I Taxonomy II Domains and
7. Role relationship
Classes
1. Healt promotion 8. Sexuality

2. Nutrition 9. Coping/stress tolerance

3. Elimination/exchange 10. Life principles

4. Activity/Rest 11. Safety

5. Perception/cognition 12. Comfort

6. Self -perception 13. Growth and development

Classes
Domain 1 Health promotion (12) Domain 3 elimination and
exchange (19)
1. Health awarness (2)
2. Health management (10) 1. Urinary function (9)
2. Gastrointestinal function (9)
3. Integumentary function (0)
Domain 2 Nutrition (21) 4. Respiratory function (1)
1. Ingestion (11) Domain 4 Activity and rest (35)
2. Digestion (0)
3. Absorption (0) 1. Sleep and rest (4)
4. Metabolism (4) 2. Activity and exercise (8)
5. Hydration (6) 3. Energy balance (2)
4. Cardiovascular/pulmonary
responses (14)
5. Self care (7)
Classes
Domain 5 Perception/cognition (11) Domain 7 Role relationship (15)
1. Attention (1) 1. Caregiving roles (5)
2. Orientation (0) 2. Family relationship (4)
3. Sensation/perception (0) 3. Role performance (6)
4. Cognition (8)
5. Communication (2)

Domain 6 Self perception (11) Domain 8 Sexuality (6)

1. Self concept (6) 1. Sexual identity (0)
2. Self esteem (4) 2. Sexual function (2)
3. Body image (1) 3. Reproduction (4)
Classes
Domain 9 Coping/stress tolerance Domain 12 Comfort (13)
(37) 1. Physical comfort (7)
1. Post trauma response (5) 2. Environmental (2)
2. Coping response (26) 3. Social comfort (4)
3. Neurobehavioral stress (6)
Domain 10 life principles (12) Domain 13 Growth and
development (2)
1. Values (0)
2. Beliefs (1) 1. Growth (1)
3. Value, belief action congruence 2. Development (1)
(11)
Domain 11 safety and protection
(45) Total 239 nursing
1. Infection (1)
2. Physical injury (26) diagnosis, 47 classes
3. Violence (5) and 13 domain
4. Environmental hazard (3)
5. Defensive processes (4)
6. Thermoregulation (6)
Example NANDA-1 Taxonomy II
Activity/Rest Domain
Sleep and rest Activity/exercise Energy balance CP response Self care

• Insomnia • Risk for disuse • Fatigue • Activity • Impaired home

• Sleep syndrome • Wandering intolerance maintenance
deprivation • Impaired bed • Risk for • Bathing self
• Readiness for mobility activity care deficit
enhance sleep • Impaired intolerance • Dressing self
• Disturbed physical • Ineffective care deficit
sleep pattern mobility breathing • Feeding self
• Impaired pattern care deficit
wheelchair • Decreased • Toileting
mobility cardiac output selfcare deficit
• Impaired • Risk for • Readiness for
sitting decreased enhanced self
• Impaired cardiac output care
standing • Risk for • Self necglect
• Impaired impaired
transfer ability cardiovascular
• Impaired function
walking • ect
A nursing diagnosis
‘Can be problem focused or a state of health promotion or
potential risk ( Herdman, 2012)’
1. Problem focused diagnosis
2. Risk diagnosis
3. Health promotion diagnosis
How does a nurse diagnose?
• The modified nursing process

Theory/
Continual re-
nursing
evaluation
science

Assessment
implementation (patient
hystory)

Planning
NANDA, NOC,
NIC
Part of nursing diagnosis label
Modifier Diagnosis focus

Ineffective Airway clearence

Risk for Overweigh

Readiness for enhanced Knowledge

Impaired Memory
Key terms at a glance
Term Brief description
Nursing diagnosis Problem, strength, or risk
identified for a client, family,
group or community
Defining characteristic Sign or symptom (objective
or subjective cue)
Related factor Cause or contributing factor
(etiological factor)
Risk factor Determinant (increase risk)
For example
• _________(nursing dx)related to______(cause/related
factor)______as evidence
by_____________(symptoms/defining characteristic
For example
• Ineffective airway clearance related to exessive mucus
and asthma as evidence by decreased breathe sound
bilaterally, crackles over left lobe and persisntent
ineffective coughing.