Академический Документы
Профессиональный Документы
Культура Документы
1. Identifikasi keluhan
2. Masukkan domain
3. Masukkan kelas
4. Lihat definisi
5. 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
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
POSSIBLE NURSING
CLINICAL SITUATIONS DIAGNOSTIC CONCEPT
DIAGNOSES
SYSTEMIC ARTERIAL
Cardiac output Decreased cardiac output
HYPOTENSION
HYPOVOLEMIA Fluid balance Deficient fluid volume
PAIN Pain Acute pain
Tissue perfusion:
METABOLIC ACIDOSIS Tissue perfusion cardiopulmonary,
ineffective
WOUND DRAINAGE Skin integrity Impaired skin integrity
Tissue perfusion:
SYSTEMIC ARTERIAL
Tissue perfusion cardiopulmonary,
HYPERTENSION
ineffective
OLIGURIA Urinary elimination Impaired urinary elimination
POLYURIA Urinary elimination Impaired urinary elimination
HYPERTHERMIA Body temperature Hyperthermia
HYPOCALCEMIA Cardiac output Decreased cardiac output
NOC
(Nursing Outcomes 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)
NIC component
Name or label
A definition
A set of activities the nurse does to carry out
the intervention
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
NIC Examples: Linked with “Risk for
Infection”
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)
Format 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 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
Sample Care Plan using Case Study
NANDA Nursing Diagnoses NOC Outcomes and Indicators NIC Intervention Label and select nursing activities