Intervensi Keperawatan :

NANDA NIC NOC (NNN)

Based on NIC and NOC book

Dewi Baririet Baroroh Proses Dokumentasi Keperawatan (semester 2) PSIK FIKES UMM April 2011

Taxonomy Nomenclature :

NANDA NIC NOC (NNN)

13 domain 7 domain 7 domain 47 kelas 31 kelas 31 kelas 206 diagnosa 385 kriteria 542 intervensi

TRADISIONAL :

Tujuan jangka panjang dan jangka pendek Tujuan dan kriteria hasil Perencanaan

NANDA DIAGNOSE

Find a Diagnose :

1. 2. 3. 4. 5.

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 Diagnosis

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)

Dx Medis dan Dx Keperawatan

CLINICAL SITUATIONS
SYSTEMIC ARTERIAL HYPOTENSION HYPOVOLEMIA PAIN METABOLIC ACIDOSIS WOUND DRAINAGE SYSTEMIC ARTERIAL HYPERTENSION OLIGURIA POLYURIA HYPERTHERMIA

DIAGNOSTIC CONCEPT
Cardiac output Fluid balance Pain Tissue perfusion Skin integrity Tissue perfusion Urinary elimination Urinary elimination Body temperature

POSSIBLE NURSING DIAGNOSES Decreased cardiac output Deficient fluid volume Acute pain Tissue perfusion: cardiopulmonary, ineffective Impaired skin integrity Tissue perfusion: cardiopulmonary, ineffective Impaired urinary elimination Impaired urinary elimination 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)
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)

SEJARAH

Tidak ada kriteria pasien sembuh. Kematian, kesakitan dan gejala kesakitan ditentukan dg tradisional, dikira kira. Kriteria sembuh kinerja perawat dalam memberikan asuhan keperawatan. Beragam respon pasien dan beragam kemampuan perawat

SEJARAH

1973 : Hover dan Zimmer membagi kriteria sembuh dalam 5 domain ANA (american nurses association) : kriteria sembuh meningkatkan angka kesembuhan, menurunkan unit cost dan meningkatkan angka kesehatan negara 1982 : NANDA menyeragamkan kriteria sembuh dalam keperawatan NOC

Bekerjalah kalian, maka Allah dan RasulNya serta orang-orang mukmin akan melihat amal-amal kalian itu, dan kamu akan dikembalikan kepada Allah Yang Maha Mengetahui akan yang ghaib dan yang nyata, lalu diberitakanNya kepada kamu apa yang telah kamu kerjakan QS. At Taubah (9) : 105

SEJARAH

Cita-cita luhur keperawatan : Bermanfaat untuk manusia Jika tolak ukur kriteria sembuh hanya berasal dari profesi lain, rasa dari asuhan keperawatan tidak dapat diukur. Memacu perawat untuk memberikan asuhan keperawatan yang benar dan tepat.

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/Kalimat Outcomes :

Konsisten Memberikan pengertian yang sama terhadap sebuah istilah Bukan menjelaskan kegiatan perawat Bukan diagnosa keperawatan Dapat diukur Dapat dimengerti Spesifik

Outcomes Vs Intervention :
Intervensi keperawatan harus :

Menghasilkan O positif Mengarah pada O positif Berdasarkan O positif Meningkatkan O positif Mempertahankan O positif Mencegah perburukan O Dilakukan sebelum evaluasi O Diganti bila O negatif

Kapan Outcome diUKUR:

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 patients 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 thru 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

Features of NOC
Fluid Balance 0601
Balance of water in the intracellular and extracellular compartments of the body Extremely Substantially Moderately Mildly Compromised Compromised Compromised Compromised 1 2 3 4 Indicators: BP IER 1 2 3 4 Mean arterial pressure IER 1 2 3 4 Pulmonary wedge pressure IER 1 2 3 4 Peripheral pulses palpable 1 2 3 4 Ascites not present 1 2 3 4 Neck vein distention not present 1 2 3 4 Peripheral edema not present 1 2 3 4 Sunken eyes not present 1 2 3 4 Confusion not present 1 2 3 4

Not Comprised 5
5 5 5 5

5
5 5

5
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 2. Masukkan domain 3. Masukkan kelas 4. Pilih kriteria 5. pilih indikator 6. Tentukan skala

1. Tentukan diagnosa 2. Pilih kriteria 3. Pilih indikator 4. 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 Kolaborasi/(LIMPAHAN) tindakan medis

NIC component

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 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 (NIC, 2008)

Features of NIC
ELECTROLYTE MANAGEMENT 2000
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) - 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 lowcarbohydrate 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

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

PENULISAN NNN

Sample Care Plan using Case Study

NANDA Nursing Diagnoses Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter), chronic disease (ALL) and developmental level. NOC Outcomes and Indicators 0702Immune Status Definition: Natural and acquired appropriately targeted resistance to internal and external antigens. 1=severely compromised thru 5= not compromised Absolute WBC values WNL(within normal limits) 1 2 3 4 5 Differential WBC values WNL(within normal limits) 1 2 3 4 5 Skin integrity 1 2 3 4 5 Mucosa integrity 1 2 3 4 5 Body temperature IER( in expected range) 1 2 3 4 5 Gastrointestinal function 1 2 3 4 5 Respiratory Function 1 2 3 4 5 Genitourinary Function 1 2 3 4 5 1= severe thru 5= None Recurrent Infections 1 2 3 4 5 Weight Loss 1 2 3 4 5 Tumors (Immature WBCs) 1 2 3 4 5 (NOC, 2008 p.399) NIC Intervention Label and select nursing activities 6550 infection protection Definition: Prevention and early detection of infection in a patient at risk Activities: Monitor for systemic and localized signs & symptoms of infection (central line site check every 4 hours.) Monitor WBC, and differential results (qod) Follow neutropenic precautions Provide a private room Limit number of visitors 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) Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade) Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM) Monitor for change in energy level/malaise Instruct patient to take anti-infective as prescribed (Bactrim po BID; Nystatin 5cc,swish & swallow, TID) Teach Family about s & symptoms of infection and when to report them to HCP -Teach patient and family how to avoid infections (NIC, 2008)

Sample Blank Careplan

Nanda Nursing Diagnosis Complete NANDA Nursing Dx Statement including related or risk factors and defining characteristic NOC Outcome Rationale for NOC NIC Intervention Rationale for Label(s) and chosen label(s) and NIC Chosen indicators and indictor score nursing activities NOC label and Describe your NIC label and Describe your appropriate rationale for appropriate rationale for indicators and choosing this NOC activities with choosing this rating on scale label and the individualized NIC label with date (s) indicator ratings that information you chose for this added. patient.

Jazakumullah khoiron katsir..