ASUHAN

KEPERAWATAN
ANESTESIOLOGI
(ASKAN)
Mengapa Perawat Menggunakan Diagnosis Keperawatan

• Menggambarkan masalah klien secara terperinci untuk memberikan

perawatan berkelanjutan bagi klien dengan kebutuhan khusus
• Menyiapkan sistem klasifikasi standar untuk mengajarkan ilmu
keperawatan dan mengkomunikasikan masalah klien kepada
perawat dan disiplin ilmu lain
• Menggambarkan semua respons klien yang didiagnosis dan
diberikan intervensi keperawatan
Student Care Plans
• Membantu mahasiswa dalam pemecahan masalah
• Memberikan pedoman bagi mahasiswa dalam pemberian intervensi
tertentu sesuai dengan masalah klien
• Memprioritaskan intervensi keperawatan
• Menjelaskan standar perawatan untuk masalah atau situasi klien
Domain
Keahlian:
Praktisi
Perawat vs
Dokter
 Peran Perawat Profesional

• Memahami patofisiologi penyakit, komplikasi serta intervensi

keperawatan yang terkait
• Memonitor respons pasien
• Mendeteksi perubahan awal dalam status fisiologis
• Melakukan intervensi keperawatan dan / atau pendidikan kesehatan
yang relevan
• Secara aktif membantu klien dan keluarga untuk:
• Mengurangi atau menghilangkan masalah kesehatan pasien
• Mengurangi faktor risiko
• Mencegah masalah sekunder
• Meningkatkan gaya hidup sehat
Apakah Penata Anestesi memerlukan Diagnosis Keperawatan
dalam menjalankan tugasnya?
 PENGEMBANGAN
ASUHAN KEPERAWATAN
ANESTESI (ASKAN)
Nursing Diagnosis (NANDA, 1990)
 Diagnosis keperawatan adalah penilaian klinis tentang respon
individu, keluarga, atau masyarakat terhadap masalah kesehatan
actual, potensial atau proses kehidupan.
 Diagnosis keperawatan merupakan labelling masalah keperawatan
sesuai dengan tanggung jawab dan kewenangan perawat.
 “Perawat bertanggung jawab (the nurse is accountable)” direvisi
menjadi “perawat memiliki akuntabilitas (the nurse has
accountability)”  NANDA International di Miami (November, 2008)
 Respons dalam diagnosis keperawatan dapat berupa masalah
kesehatan atau tahap perkembangan dalam kehidupan (misal: pola
asuh, pengasuhan lanjut usia)
NANDA International
 1973 - Konferensi pertama tentang diagnosis keperawatan diselenggarakan untuk
membangun ilmu pengetahuan keperawatan dan untuk membangun sistem klasifikasi yang
sesuai untuk komputerisasi  National Group for the Classification of Nursing Diagnosis
mewakili semua elemen profesi: praktisi, pendidikan, dan penelitian (Amerika Serikat dan
Kanada)
 1982 - North American Diagnosis Association (NANDA)
didirikan.
 2002 – Penamaan diubah menjadi NANDA International
(NANDA-I)
 Jurnal NANDA-I yang bernama Nursing Diagnosis
dipublikasikan pertama kali pada Maret 1990.
 Jurnal saat ini diberi bernama International Journal of
Nursing Terminologies and Classifications  bertujuan
untuk mengembangkan, memperbaiki, dan menerapkan
diagnosis keperawatan dan memberikan ruang untuk
diskusi mengenai masalah yang berkaitan dengan
pengembangan dan klasifikasi pengetahuan keperawatan
NANDA-I Taxonomy?
 A taxonomy is a type of classification, the theoretical study of
systematic classifications including their bases, principles,
procedures, and rules
 NANDA-I taxonomic committee produced the beginnings of a
conceptual framework for the diagnostic classification system
 It was named NANDAI Nursing Diagnosis Taxonomy I 
comprised of nine patterns of human response
 2000 ~ NANDA-I approved a new Taxonomy II  13 domains,
106 classes, and 155 diagnoses (NANDA-I, 2001).
 “Does nursing really need a
classification system?”

“How can such a system be

developed in a scientifically sound
manner?”
TYPES AND COMPONENTS
OF NURSING DIAGNOSES
 Types and Components of Nursing Diagnoses
Project analysis slide 3

ACTUAL RISK AND POSSIBLE HEALTH- SYNDROME

nursing HIGH-RISK nursing PROMOTION nursing
diagnoses nursing diagnoses
nursing diagnoses diagnoses
diagnoses
DIAGNOSIS KEPERAWATAN
 Merupakan “clinical judjment” yang berfokus pada
respons manusia terhadap kondisi kesehatan atau proses
kehidupan atau kerentanan terhadap respons dari
individu, keluarga, kelompok atau komunitas
 Label diagnosis keperawatan
 Diagnosis AKTUAL
 Diagnosis RISIKO dan RISIKO TINGGI
 Diagnosis yang MEMUNGKINKAN
 Diagnosis PROMOSI KESEHATAN
 Diagnosis SINDROMA
Diagnosis keperawatan : AKTUAL
 Menggambarkan respons yang tidak diinginkan klien terhadap
kondisi kesehatan atau proses kehidupan baik individu, keluarga
maupun komunitas
 It is supported by defining characteristics (manifestations, signs,
and symptoms) that cluster in patterns of related cues or
inferences - (NANDA-I, 2009).
 This type of nursing diagnosis has four components: label,
definition, defining characteristics, and related factors.
ACTUAL nursing diagnoses
 Label = clear and concise terms that convey the meaning of the
diagnosis
 Definition = add clarity to the diagnostic label
 Defining characteristics = signs and symptoms that, when seen
together, represent the nursing diagnosis.
 Major. For nonresearched diagnoses  at least one must be present for
validation of the diagnosis. For researched diagnoses  at least one must
be present under the 80% to 100% grouping.
 Minor. These characteristics provide supporting evidence but may not be
present
 Related Factors = related factors are contributing factors that have
influenced the change in health status
ACTUAL nursing diagnoses
Related Factors :
1. Pathophysiologic, Biologic, or Psychological. e.g. compromised oxygen
transport, and compromised circulation. Inadequate circulation can cause
Impaired Skin Integrity.
2. Treatment-Related. e.g. medications, therapies, surgery, and diagnostic
study. Specifically, medications can cause nausea. Radiation can cause
fatigue. Scheduled surgery can cause Anxiety.
3. Situational. e.g. environmental, home, community, institution, personal, life
experiences, and roles. Specifically, a flood in a community can contribute
to Risk for Infection; divorce can cause Grieving; obesity can contribute to
Activity Intolerance.
4. Maturational. e.g. age-related influences, such as in children and the
elderly. Specifically, the elderly are a risk for Social Isolation; infants are at
Risk for Injury; adolescents are at Risk for Infection.
RISK AND HIGH-RISK nursing diagnoses
 human responses to health conditions/life processes that may
develop in a vulnerable individual, family, or community.
 It is supported by risk factors that contribute to increased vulnerability
(NANDA-I, 2009).
 The concept of “at risk” is useful clinically. Nurses routinely prevent
problems in people experiencing similar situations such as surgery or
childbirth who are not at high risk. e.g.
 all postoperative clients are at risk for infection
 All women postdelivery are at risk for hemorrhage. Thus, there are expected
or predictive
 Diagnoses for all clients who have undergone surgery while on
chemotherapy or with a fractured hip.
 RISK AND HIGH-RISK nursing diagnoses
 Label = In a risk nursing diagnosis, the term Risk for precedes the
nursing diagnosis label or High Risk for if this concept is used.
 Definition = As in an actual nursing diagnosis, the definition in a
risk nursing diagnosis expresses a clear, precise meaning of the
diagnosis.
 Risk Factors = Risk factors for risk and high-risk nursing diagnoses
represent those situations that increase the vulnerability of the
client or group.
ACTUAL DIAGNOSIS HIGH-RISK DIAGNOSIS
validation signs and symptoms risk factors
e.g. Impaired Skin Integrity related to immobility High Risk for Impaired Skin Integrity related to
secondary to pain as evidenced by 2-cm immobility secondary to pain
erythematous sacral lesion
POSSIBLE nursing diagnoses
 Suspected problem requiring additional data. It is unfortunate that
many nurses have been socialized to avoid appearing tentative
 In scientific decision making, a tentative approach is not a sign of
weakness or indecision, but an essential part of the process
 The nurse should delay a final diagnosis until he or she has gathered
and analyzed all necessary information to arrive at a sound scientific
conclusion.
 Physicians demonstrate tentativeness with the statement rule out (R/O).
 Nurses also should adopt a tentative position until they have completed
data collection and evaluation and can confirm or R/O.
HEALTH-PROMOTION nursing diagnoses
 a clinical judgment of a person’s, family’s, or community’s
motivation and desire to increase well-being and actualize human
health potential as expressed in the readiness to enhance specific
health behaviors, such as nutrition and exercise” (NANDA-I, 2009)
 NANDA-I previously defined wellness diagnoses as a separate
type of diagnosis, but this category has been eliminated and the
diagnoses have been reclassified as health-promotion diagnoses
in the NANDA-I taxonomy (NANDA-I, 2012).
SYNDROME nursing diagnoses
 Interesting development in nursing diagnosis. They comprise a
cluster of predicted actual or high-risk nursing diagnoses related
to a certain event or situation. For example,
 Carlson-Catalino (1998) used an exploratory qualitative study of
post–acute-phase battered women to identify
 24 nursing diagnoses in all the subjects. This research supports a
diagnosis of Battered Woman Syndrome. In medicine, syndromes
cluster signs and symptoms, not diagnoses. In nursing, a cluster of
signs and symptoms represents a single nursing diagnosis, not a
syndrome nursing diagnosis.
SYNDROME nursing diagnoses
Diagnostic Statements
Avoiding Errors in Diagnostic Statements
Nursing diagnostic statements should not be written in terms of:
 Cues (e.g., crying, hemoglobin level)
 Inferences (e.g., dyspnea)
 Goals (e.g., should perform own colostomy care)
 Client needs (e.g., needs to walk every shift; needs to express fears)
 Nursing needs (e.g., change dressing, check blood pressure)

Nurses should avoid legally inadvisable or judgmental statements, such as

 Fear related to frequent beatings by husband
 Ineffective Family Coping related to mother-in-law’s continual harassment of
daughter-in-law
 Risk for Impaired Parenting related to low IQ of mother
COLLABORATIVE
DIAGNOSES
Collaboration With Other Disciplines
The practice of nursing requires 3 different types of nursing
responsibilities:
1. Validating nursing diagnoses, providing interventions to treat, and
evaluating progress
2. Monitoring for physiologic instability and collaborating with
physicians and nurse practitioners, who determine medical
treatment
3. Consulting with other disciplines (physical therapy, occupational
therapy, social service, respiratory therapy, pharmacology) to
increase the nurse’s expertise in providing care to a particular
client
 Bifocal Clinical Practice Model

primary prescriber

collaboration with medicine

Domains
of expertise of
professional
nurses and
physicians.
Comparison of type of knowledge by
discipline
Nursing prescribes for and treats client and group responses to
situations. These situations can be organized into five categories:
 Pathophysiologic (e.g., myocardial infarction, borderline
personality, burns)
 Treatment-related (e.g., anticoagulant therapy, dialysis,
arteriography)
 Personal (e.g., dying, divorce, relocation)
 Environmental (e.g., overcrowded school, no handrails on steps,
rodents)
 Maturational (e.g., peer pressure, parenthood, aging)
nursing diagnoses and collaborative problems represent the range of
conditions that necessitate nursing care. The major assumptions in
the bifocal clinical practice model are as follows
1. Client*
 Has the power for self-healing
 Continually interrelates with the environment
 Makes decisions according to individual priorities
 Is a unified whole, seeking balance
 Has individual worth and dignity
 Is an expert on own health
2. Health
 Is a dynamic, ever-changing state
 Is defined by the client
 Is an expression of optimum well-being
 Is the responsibility of the client

3. Environment
 Represents external factors, situations, and people who influence or are
influenced by the client
 Includes physical and ecologic environments, life events, and treatment
modalities
4. Nursing
 Is accessed by the client when he or she needs assistance to
improve, restore, or maintain health or to achieve a peaceful death
(Henderson & Nite, 1960)
 Ensures the client has the needed information for an informed
consent
 Supports the right of the client to refuse recommendations
 Engages the client to assume responsibility in self-healing decisions
and practices
 Reduces or eliminates environmental factors that can or do cause
compromised functioning
Bifocal clinical
nursing model
© 1985 by
Lynda Juall Carpenito
Understanding Collaborative Problems
 Certain physiologic complications that nurses monitor to detect
onset or changes in status. Nurses manage collaborative problems
using physician-prescribed and nursing-prescribed interventions
to minimize the complications of the events (Carpenito, 1999)
 The designation certain clarifies that all physiologic complications
are not collaborative problems
 If the nurse can prevent the onset of the complication or provide
the primary treatment for it, then the diagnosis
is a nursing diagnosis.
 Collaborative Problems presents 54 specific collaborative problems
grouped under 9 generic collaborative problem categor
 Discussions of the 54 specific collaborative problems cover the following
information:
 Definition
 High-Risk Populations
 Nursing Goals: A statement specifying the nursing accountability for the
collaborative problem. Indicators have been added to evaluate specific
physiologic status.
 General Interventions and Rationales: These specifically direct the nurse to:
 Monitor for onset or early changes in status.
 Initiate physician- or advanced practice nurse-prescribed interventions as indicated.
 Initiate nurse-prescribed interventions as indicated.
 Evaluate the effectiveness of these interventions.
#01 ~ RISK FOR COMPLICATIONS (RC) of CARDIAC/VASCULAR
DYSFUNCTION

1. RC of Bleeding
2. RC of Decreased Cardiac Output
3. RC of Dysrhythmias
4. RC of Pulmonary Edema
5. RC of Deep Vein Thrombosis
6. RC of Hypovolemia
7. RC of Compartment Syndrome
8. RC of Pulmonary Embolism
#02 ~ RISK FOR COMPLICATIONS of RESPIRATORY DYSFUNCTION

1. RC of Hypoxemia
2. RC of Atelectasis, Pneumonia
3. RC of Tracheobronchial Constriction
4. RC of Pneumothorax
#03 ~ RISK FOR COMPLICATIONS of
METABOLIC/HEMATOPOIETIC DYSFUNCTION
1. RC of Hypo/Hyperglycemia
2. RC of Negative Nitrogen Balance
3. RC of Electrolyte Imbalances
4. RC of Sepsis
5. RC of Acidosis (Metabolic, Respiratory)
6. RC of Alkalosis (Metabolic, Respiratory)
7. RC of Allergic Reaction
8. RC of Thrombocytopenia
9. RC of Opportunistic Infections
10. RC of Sickling Crisis
#04 ~ RISK FOR COMPLICATIONS of RENAL/URINARY DYSFUNCTION

1. RC of Acute Urinary Retention

2. RC of Renal Insufficiency
3. RC of Renal Calculi
#05 ~ RISK FOR COMPLICATIONS of NEUROLOGIC/SENSORY DYSFUNCTION

1. RC of Increased Intracranial Pressure

2. RC of Seizures
3. RC of Increased Intraocular Pressure
4. RC of Neuroleptic Malignant Syndrome (NMS)
5. RC of Alcohol Withdrawal
#06 ~ RISK FOR COMPLICATIONS of
GASTROINTESTINAL/HEPATIC/BILIARY
DYSFUNCTION
1. RC of Paralytic Ileus
2. RC of GI Bleeding
3. RC of Hepatic Dysfunction
4. RC of Hyperbilirubinemia
#07 ~ RISK FOR COMPLICATIONS of
MUSCULAR/SKELETAL DYSFUNCTION

1. RC of Pathologic Fractures
2. RC of Joint Dislocation
#08 ~ RISK FOR COMPLICATIONS of
REPRODUCTIVE DYSFUNCTION
1. RC of Prenatal Bleeding
2. RC of Preterm Labor
3. RC of Pregnancy-Associated Hypertension
4. RC of Nonreassuring Fetal Status
5. RC of Postpartum Hemorrhage
#09 ~ RISK FOR COMPLICATIONS of MEDICATION THERAPY ADVERSE
EFFECTS

1. RC of Anticoagulant Therapy Adverse Effects

2. RC of Antianxiety Therapy Adverse Effects
3. RC of Adrenocorticosteroid Therapy Adverse Effects
4. RC of Antineoplastic Therapy Adverse Effects
5. RC of Anticonvulsant Therapy Adverse Effects
6. RC of Antidepressant Therapy Adverse Effects
7. RC of Antiarrhythmic Therapy Adverse Effects
8. RC of Antipsychotic Therapy Adverse Effects
9. RC of Antihypertensive Therapy Adverse Effects
10. RC of ß-Adrenergic Blocker Therapy Adverse Effects
11. RC of Calcium Channel Blocker Therapy Adverse Effects
12. RC of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker
Therapy Adverse Effects
13. RC of Diuretic Therapy Adverse Effects
Matur Nuwun