KASUS

Riwayat masuk RS
n Klien Ny. SM ( 43 th) , masuk RS dengan keluhan sulit defekasi dan feses berdarah dan bau
busuk, perut terasa penuh dan mual.
n Dx. Medis: Ca Rectosigmoid Kondisi klien saat ini
n Post laparotomi dan colostomi hari 2
n Luka operasi kering, pus (-)
n Produk stoma lunak,warna kecoklatan, bau khas , perdarahan (-)
n Mengeluh nyeri pd daerah operasi dan tidak tahu cara merawat stoma
n Posisi stoma 2,5 cm dari luka laparotomi
Tanda-tanda vital:
n TD: 120/70 mmHg
n N : 84 x/mnt
n S : 37,2 C
n P : 20 x/mnt Terapi analgetik 3 x 100 mg (IM) antibiotika 2 x 1 gr ( IV )
n Lab: Hb: 9,8 ; Alb: 2,9
n Klien tampak lemah, pucat dan bibir kering
n Terpasang infus D5% : 20 tetes/mntn Skema infus: D5% : RL = 2 : 2
n Klien mengeluh tidak nafsu makan dan hanya menghabiskan 3 sdk makan bubur & sayur
n BB sebelum sakit: 62 kg
n BB saat ini : 50 kg Setelah dilakukan pengkajian keperawatan pada Ny.SM maka dapat ditetapkan
Fuctional Health Patterns yang sesuai dg Ny.SM adalah:
n Nutrition - Metabolic
n Cognitive - Perceptual
n Coping /stress/tolerance
n Elimination
n Self Perception/ Self - Concept
n Health Perception Health Management Berdasarkan data yang diperoleh, ditetapkan berbagai
masalah keperawatan yang sesuai dengan kondisi klien.

Masalah Keperawatan NANDA yg sesuai dg Ny.SM adalah:
n Deficient Knowledge : Ostomy Care
n Acute Pain
n Disturbed Body image
n Risk for infection
n Imbalance Nutrition : less than body requirements
n Fatigue
n dll
Penentuan Masalah keperawatan dapat mengalami kesulitan/hambatan dan keragu-raguan perawat
terutama jika data yang diperoleh sangat minimal dan memiliki karakteristik yang sama dengan
diagnosis keperawatan lain, maka Domain pada NANDA dapat digunakan sebagai alat bantu dalam
penentuan Diagnosis Keperawatan.

Diagnosis Keperawatan NANDA, NOC dan NIC pd Ny.SM
Knowledge defisit : Ostomy Care(Kurang pengetahuan tentang perawatan kolostomi )
definisi: mengungkapkan secara verbal masalah yg dihadapi dan menunjukkan ekspresi
ambivalenEtiologi /faktor yg berhubungan:lack of exposure( belum pernah mengalami kolostomi) dan
tidak terbiasa dgn sumber informasi Perawat menentukan NOC yang sesuai dengan kondisi klien ,
dari beberapa NOC yang ada pada diagnosis keperawatan Knowledge defisit : Ostomy Care.
Ditetapkan ada 2 NOC yang sesuai dengan klien yaitu:

NOC :
Knowledge: Treatment Procedure (Colostomy Care)(Pengetahuan : Prosedur perawatan
kolostomi
Pengetahuan : Penanganan penyakit (Knowledge:treatment Regimen)
Dalam penulisan NOC pada rekam asuhan keperawatan hendaknya dituliskan secara lengkap dengan
mencantumkan Subyek, Predikat, dan obyek ,keterangan waktu dan skala indikator.
NOC 1: Pasien mampu mengetahui Prosedur perawatan kolostomi (Treatment Procedure) dalam 3
hari perawatan
Indikator :
pasien mampu :
Menjelaskan langkah2 prosedur perawatan kolostomi
Menjelaskan alat2 yg dibutuhkan
Menjelaskan berbagai tindakan yg dilakukan utk mencegah/mengatasi komplikasi
Mampu melakukan perawatan kolostomiSkala indikator dapat dilihat pada panduan NOC dan
penentuan skala dapat disesuaikan dengan target waktu dan kondisi klien atau berdasarkan
evidence /hasil penelitian
NOC 2:
Pengetahuan : Penanganan penyakit (treatment Regimen)Indikator:
Menjelaskan diet yg dianjurkan
- Memilih makanan yg sesuai dgn anjuran diet
- Menjelaskan aktifitas yg dianjurkan
- Mampu mengontrol/monitor diri sendiri
- Menjelaskan cara merawat diri sendiri pd kondisi darurat

Penentuan NIC berdasarkan masing-masing NOC
NIC yang tersedia harus dipilih dan disesuaikan dengan kebutuhan klien dalam mencapai
tujuan/mengatasi masalah. Beberapa sumber menyebutkan bahwa tindakan-tindakan yang ada pada
NIC minimal 5 tindakan (aktivitas) yang dapat digunakan untuk mengatasi masalah keperawatan klien
Untuk mencapai NOC 1:
Pengetahuan : Prosedur perawatan kolostomiDiperlukan NIC :
n Perawatan Kolostomi
n Pemantauan kulit NIC Ostomy CareActivities (NIC3 pg. 483)
Mark the skin for stoma placement
Instruct patient/significant other in the use of ileostomy/colostomy equipment
Assist patient in providing ostomy /ileostomy self-care
Have patient/significant other demonstrate use of equipment
Apply appropriately-fitting ostomy appliance, as needed
Monitor for incision/stoma healing

Encourage patient/significantother to express feelings and concerns about changes in body
image
Encourage visitation to client by persons from such support groups as ileostomy/colostomy
clubs
Irrigate colostomy, as appropriate
Assist patient in obtaining ostomy/ileostomy equipment
Instruct patient on mechanisms to reduce odor
Instruct patient/significant other in appropriate diet and expected changes in elimination
function
Provide and assistance, while client develops skill in caring for stoma/surrounding tissue
Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment
Change/empty ostomy bag, as appropriate
Encourage participation in ostomy support groups after hospital discharge
NIC Skin Surveillance Activities (NIC 3 pg. 601)
Inspect condition of surgical incision, as appropriate
Observe extremities for color, warmth, swelling, pulses, texture, edema, and ulcerations
Inspect skin and mucous membranes for redness, extreme warmth, or drainage
Monitor skin for areas of redness and breakdown
Monitor for sources of pressure and friction
Monitor for infection, especially of edematous areas
Monitor skin for rashes and abrasions
Monitor skin for excessive dryness and moistness
Inspect clothing for tightness
Monitor skin color Monitor skin temperature Note skin or mucous membrane changes
Institute measures to prevent further deterioration, as needed
Instruct family member/caregiver about signs f skin breakdown, as appropriate
NOC 2:
Pengetahuan : Penanganan penyakiT(treatment Regimen)
NIC:
n Teaching Prescribed Diet
n Teaching Prescribed Activity /exercise NIC Teaching: Prescribed Diet (NIC3 pg., 649)

Appraise the patients current level of knowledge about prescribed diet
Determine the patients/significant others feelings/attitude toward prescribed diet and
expected degree of dietary compliance
Instruct the patient on the proper name of the prescribed diet
Explain the purpose of the diet Inform the patient about how long the diet should be followed
Instruct the patient about how to keep a food diary, as appropriate
Instruct the patient on allowed and prohibited foods
Inform the patient of possible drug/food interactions, as appropriate
Assist the patient to accommodate food preferences into theprescribed diet
Assist the patient in substituting ingredients to conform favorite recipes to the prescribed
diet
Instruct the patient about how to read labels and select appropriate foods
Observe the patients selection of foods appropriate to prescribed diet
Instruct the patient about how to plan appropriate meals
Provide written meal plans, as appropriate
Recommend a cookbook that includes recipes consistent with the diet, as appropriate
Reinforce information provided by other health care team members, as appropriate
Refer patient to dietitian/nutritionist, as appropriate Include the family/significant others, as
appropriate
NIC Teaching: Prescribed Activity/Exercise(NIC 3, pg.648)
Appraise the patients current level of exercise and knowledge ofprescribed activity/exercise
Inform the patient of the purpose for, and the benefits of, the prescribed activity/exercise
Instruct the patient how to perform the prescribed activity/exercise
Instruct the patient how to monitor tolerance of the activity/exercise
Instruct the patient how to keep an exercise diary, as appropriate
Inform the patient what activities are appropriate based on physical condition

Instruct the patient how to safely progress activity/exercise
Caution the patient on the dangers of overestimating capabilities, as appropriate
Warn the patient of the effects of extreme heat and cold, as appropriate
Instruct the patient on methods to conserve energy, as appropriate
Instruct the patient how to warm up and cool down before and after activity/exercise and the
importance of doing so, as appropriate
Instruct the patient on good posture and body mechanics, as appropriate
Observe the patient perform the prescribed activity/exercise
Provide information on available assistive devices that may be used to facilitate performance
of required skill, as appropriate
Instruct the patient on the assembly, use, and maintenance of assistive devices , as
appropriate
Assist the patient to incorporate activity/exercise regimen into daily routine/life style
Assist the patient to properly alternate periods of rest and activity
Refer the patient to physical therapist/occupational therapist/exercise physiologist, as
appropriate
Reinforce information provided by other health care team members, as appropriate
Include the family/significant others, as appropriate

Provide information on available community resources/support groups to increase the
patients compliance with activity/exercise, as appropriate
Refer the patient to a rehabilitation center, as appropriate
DAFTAR PUSTAKA
1. Black. J.M.; Jacob, E.M. (1993). Luckman & Sorensens : Medical Surgical Nursing: a
Psychophysiologic approach. 3
rd
ed. Philadelphia W.B. Saunder Company
2. Earnest, Vicki Vine. (1993). Clinical skills in Nursing Practice. (2 nd). Philadelphia. J.B. Lippincott
Company.
3.Flue, Jenice R., Nowlis, Elizabeth A., Bentz, Patricia M.(1996). Moduls for basic Nursing Skills.
6
th
ed.Philadelphia: Llppincott.
4. Hampton, Beverly G. and Ruth A. Bryant . (1992). Ostomies and Divertions. Nursing
Management. Philadelphia. Mosby - Year Book, Inc.
5. NANDA International.(2005). Nursing Diagnoses: Definitions and Classification 2005
2006.Philadelphia: NANDA International.
6. Nettina, Sandra M. (1996). The Lippincott Manual of Nursing Practice.6
th
ed. Philadelphia:
Lippincott.
7. Potter. PA; Perry,A.G. (1993). Fundamental of Nursing : Concepts, Process and Practical. 3
rd
ed. St.
Louis: Mosby Year Book
8. Smeltzer, Suzanne C. and Brenda G. Bare.(1996)Brunner and Suddarths Textbook of Medical
Surgical Nursing. Lippincot Raven Publishers,Philadelphia.