INTERVENSI KEPERAWATAN

NANDA-NIC-NOC (NNN)

ERLINA SUCI ASTUTI

TAXONOMY NNN

13 domain 47 kelas 206 diagnosa

7 domain 31 kelas 385 kriteria

7 domain 31 kelas 542 intervensi

 TRADISIONAL :
• Tujuan jangka panjang dan jangka
pendek
• Tujuan dan kriteria hasil
• Perencanaan
NANDA DIAGNOSE
-----------------------
 FIND a NANDA DIAGNOSE
• Identifikasi keluhan
• Masukkan domain
• Masukkan kelas
• Lihat definisi
• 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 Diagnose
1. Label or Name and definition
(Axis 1 – 2 – 3)
2. Related Factors OR Risk Factors
3. Defining Characteristics

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 : Resiko Infeksi 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)
Proritas 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 Clasification)
-------------------------------
kriteria hasil dan indikator
 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)
 Tujuan Penyeragaman Outcomes
• Memudahkan pengaturan sistem informasi
keperawatan
• Memberikan definisi sama pada setiap
intepretasi data
• Mengukur kualitas asuhan keperawatan
• Mengukur efektifitas asuhan keperawatan
• Meningkatkan inovasi keperawatan
 Pernyataan Outcomes
• Konsisten
• Memberikan pengertian yang sama terhadap
sebuah istilah
• Bukan menjelaskan kegiatan perawat
• Bukan diagnosa keperawatan
• Dapat diukur
• Dapat dimengerti
• Spesifik
 Outcomes diukur kapan?

• Saat mengkaji pasien

• Saat akan dilakukan intervensi
• Saat dilakukan intervensi
• Saat setelah dilakukan intervensi
• Saat “jatuh tempo”
 NOC Component
• 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 patient‘s status
for each of the indicators
 Label : Immune Status (0702)
• Definition: Natural and acquired appropriately targeted
resistance to internal and external antigens.
• Skala : 1=severely compromised thrue
5= not compromised
• Indikator :
• •Absolute WBC values WNL
• •Differential WBC values WNL
• •Skin integrity
• •Mucosa integrity
• •Body temperature IER
• •Gastrointestinal function
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
 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
• Tentukan diagnosa
• Pilih kriteria
• Pilih indikator
• 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)
 Tujuan Standar 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
• Kolaborasi/(LIMPAHAN) tindakan medis
 NIC Component
• Name or label
• A definition
• A set of activities the nurse does to carry out
the intervention
 Ex: Diagnose : Risk for infection
NOC yang di pilih :
–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 prot………..(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

(NIC, 2008)
 ELECTROLYTE MANAGEMENT
• Definition: Promotion of electrolyte balance and prevention of
complications resulting from abnormal or undesired serum electrolyte
levels
• Activities:
 Monitor for manifestations of electrolyte imbalance
 Maintain patent IV access Administer fluids, as prescribed, if appropriate
 Maintain intravenous solution containing electrolyte(s) at constant flow rate,
as appropriate
 Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if
appropriate
 Consult physician on administration of electrolyte-sparing medications (e.g.,
spiranolactone), as appropriate
 Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as
prescribed, if appropriate
 Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g.,
ABG, urine, and serum levels
ELECTROLIT MANAGEMENT CONT……..
 Monitor for loss of electrolyte-rich fluids (e.g.,
nasogastric suction, ileostomy drainage, diarrhea,
wound drainage, and diaphoresis)
 Irrigate nasogastric tubes with normal saline
 Provide diet appropriate for patient's electrolyte
imbalance (e.g., potassium-rich, low-sodium, and
low-carbohydrate foods)
 Teach patient and family about the type, cause, and
treatments for electrolyte imbalance, as appropriate -
Consult physician if signs and symptoms of fluid
and/or electrolyte imbalance persist or worsen
 Monitor patient's response to prescribed electrolyte
therapy - Place on cardiac monitor, as appropriate
 PENULISAN NNN
NANDA Nursing NOC Outcomes and Indicators NIC Intervention Label and
Diagnoses select nursing activities

Risk for infection Definition: Natural and acquired 6550 infection protection
related to appropriately targeted resistance Definition: Prevention and
immunosuppression to internal and external antigens. early detection of infection
secondary to 1=severely compromised thru 5= in a patient at risk
chemotherapy, not compromised Activities:
inadequate primary Absolute WBC values •Monitor for systemic and
defenses (central WNL(within normal limits) localized signs & symptoms
venous catheter), 12345 of infection (central line
chronic disease (ALL) Differential WBC values site check every 4 hours.)
and developmental WNL(within normal limits) •Monitor WBC, and
level. 12345 differential results (qod)
Skin integrity •Follow neutropenic
12345 precautions
Thank You