Intervensi

:
NANDKeperawatan
NI NOC

(NNN)
Based on NIC and NOC
book

Disampaikan oleh:
Achmad Syukkur, S.Kep.,Ners
Akademi Keperawatan
Panti Waluya Malang
2016

Taxonomy
Nomenclature
NANDA

(NNN
NOC )

NIC
13
domain
7 domain
kriteria
7
domain

47
kelas

206
diagnosa

31 kelas
31
kelas

385

542
intervensi

TRADISIONAL
:

Tujuan jangka
dan jangka
panjang
Tujuan dan kriteria pendek
hasil
Perencanaan

NAND
A

DIAGNOS
E

Find a
Diagnose :

1.

2.

3.

4.

5.

Identifikasi keluhan
Masukkan
domain
Masukkan
kelas
Lihat definisi
Lihat batasan
karakteristik

Contoh
: Identifikasi keluhan : sering
1.

2.

3.

4.

5.

terbangun
jika tidur tidak tahu
penyebabnya
Masukkan domain : 4
Masukkan kelas : 1
Lihat definisi : insomnia
Lihat batasan karakteristik :
insomnia

Components of
a Nursing
Label or Name and
Diagnosis
1. definition
(Axis 1 2 3)

2. Related Factors OR Risk

Factors
3. Defining Characteristics

1
Penulisan axis lengkap, mempermudah
Axis 7
NOC NIC

Conto
h1. 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

Conto
h
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

Dx
dan Dx
CLINICAL
SITUATIONS Keperawatan
DIAGNOSTIC CONCEPT
Medis
DIAGNOSES
POSSIBLE NURSING

SYSTEMIC ARTERIAL
HYPOTENSION
HYPOVOLEMIA

Cardiac output

Decreased cardiac output

Fluid balance

Deficient fluid volume

PAIN

Pain

METABOLIC ACIDOSIS

Tissue perfusion

WOUND DRAINAGE

Skin integrity

Acute pain
Tissue perfusion:
cardiopulmonary,
ineffective
Impaired skin integrity
Tissue perfusion:
cardiopulmonary,
ineffective

SYSTEMIC ARTERIAL
HYPERTENSION

Tissue perfusion

OLIGURIA

Urinary elimination

Impaired urinary elimination

POLYURIA

Urinary elimination

Impaired urinary elimination

HYPERTHERMIA
HYPOCALCEMIA

Body temperature
Cardiac output

Hyperthermia
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)

NO
C
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 diferent points in time. (
Iowa Outcome Project,
2008)

SEJARA
H

Tidak ada kriteria pasien sembuh.

Kematian,
d
kesakitan dan gejala kesakitan
g
ditentukan
tradisional, dikira kira.
Kriteria sembuh kinerja perawat
dalam
memberikan asuhan keperawatan.
Beragam respon pasien dan
beragam kemampuan perawat

SEJARA
H

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 amalamal 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

SEJARA
H

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

Pernyataan/Kalim Outcom :
at
es
Konsisten
Memberikan pengertian yang sama
terhadap sebuah istilah
Bukan menjelaskan kegiatan perawat
Bukan diagnosa keperawatan
Dapat diukur
Dapat dimengerti
Spesifik

Outcom V Interventio :
es
s n
Intervensi
keperawatan

haru :
s

Menghasilkan O positif
Mengarah pada O
positif
Berdasarkan O positif
Meningkatkan O positif

Mempertahankan
Dilakukan sebelumO
O
positif
evaluasi

Mencegah
Diganti bilaperburukan
O negatif
O

Kapan Outcome
diUKUR:

Saat

Saat

Saat

Saat

Saat

mengkaji pasien
akan dilakukan
intervensi
dilakukan intervensi
setelah dilakukan
intervensi
jatuh tempo

NOC
component
A neutral label or name

characterize
the behavior or patient
used
to
status
or patientthat
status.
A list of indicators
describe
behavior
client
A fve point scale to rate the
for eachstatus
of the
patients
indicators

Label : Immune Status

(0702)
Definition: Natural and acquired
appropriately
targeted resistance to internal and
thr 5 no
external
Skala : 1=severely
u
=
t
antigens.
compromised

Absolute WBC values

compromised
WNL
Indikator
:
Diferential
WBC values
WNL
Skin integrity
Mucosa integrity

Scal
Extremely
e

compromised
Substantially
compromised
Moderately
compromised Mildly
compromised
Severe
Substanti
Not compromised
al
Moderate
Mild
None

1
2
3
4
5
1
2
3
4
5

Features of
Fluid Balance
NOC
0601

Balance of water in the intracellular and extracellular compartments

Extremel
Substantial
Moderatel
Mildly
of the
body
Compromis
Compromis
Compromis
Compromis
y
ly
y
2
3
ed 1
ed
ed
ed 4
Indicator
BP
s:
1
2
3
4
IER
Mean arterial pressure
1
2
3
4
IER
Pulmonary wedge pressure
1
2
3
4
IER
Peripheral pulses
1
2
3
4
palpable
Ascites not
2
3
4
present1
Neck vein distention not
2
3
4
present1
Peripheral edema not
2
3
4
present1
Sunken eyes not
2
3
4
present1
Confusion not
2
3
4
present1

Not
Comprise
d5
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
Tentukan
NNN

1.

2.

3.

4.

5.

6.

diagnosa
Masukkan
domain
Masukkan kelas
Pilih kriteria
pilih indikator
Tentukan skala

Dengan

1 Tentukan
NNN

. diagnosa
2 Pilih kriteria
. Pilih
3 indikator
.
Tentukan
NIC
NOC Judith
4
M skala
.
Wilkinson

NIC
(Nursing Intervention
Classification)
Interven
si

NI
C
The nursing interventions
classification
(NIC) is a comprehensive,
standardized language describing
specialtie
Intervention
treatments(Iowa
that nurses
perform in
s.
all settings Project,
and in all
2008)

FENOMEN
A
Apa yang dilakukan perawat ?
Apakah kegiatan perawat
mempengaruhi tingkat
kesembuhan ?
Efektifkah kegiatan perawat
dalam pengurangan biaya ?

Tujuan Penyeragaman
NIC
:
Standarkan
intervensi
Memberikan defnisi 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
the out
intervention

Example : Diagnose :
Risk for
NOC yang di
pilih
: infection

6550 protection

nutrition
1100 management

skin surveillance
3590
surveillance

6650 wound care

Infection

Infection Protection
6550
Definition: Prevention and early

o
f

detection
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 diferential results
(qd or qod)
Follow neutropenic precautions
Provide a private room

Infection Protection
(Cont.)
Activities
Screen all visitors for communicable
(Cont.)

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 @

Infection Protection
Activities (cont.)
(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

Features of
NIC
ELECTROLYTE
MANAGEMENT
Definition:
2000

Promotion of electrolyte balance and prevention of complications

or undesired serum electrolyte
resulting
from abnormal
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, lowsodium, and low-

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

PENULISA NN
N
N

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
Defnition: 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
Diferential 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

NIC Intervention Label and select nursing

activities
6550 infection protection
Defnition: 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 diferential 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

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
activities with
choosing this
indicators and choosing this NOC
individualized
NIC label
rating on scale
label and the
information
with date (s) indicator ratings that
added.
you chose for this
patient.

Jazakumullah khoiron
katsir..