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Intervensi Keperawatan : NANDA – NIC – NOC (NNN) Dewi Baririet Baroroh Proses Dokumentasi Keperawatan (semester 2) PSIK FIKES UMM April 2011 Based on NIC and NOC book

Intervensi Keperawatan Nanda Nic Noc

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Page 1: Intervensi Keperawatan Nanda Nic Noc

Intervensi Keperawatan :

NANDA – NIC – NOC (NNN)

Dewi Baririet Baroroh

Proses Dokumentasi Keperawatan (semester 2)

PSIK FIKES UMM

April 2011

Based on NIC and NOC book

Page 2: Intervensi Keperawatan Nanda Nic Noc
Page 3: Intervensi Keperawatan Nanda Nic Noc

Taxonomy – Nomenclature :

NANDA – NIC – NOC (NNN)

13 domain 47 kelas 206 diagnosa

7 domain 31 kelas 385 kriteria

7 domain 31 kelas 542 intervensi

Page 4: Intervensi Keperawatan Nanda Nic Noc

TRADISIONAL :

Tujuan jangka panjang dan jangka pendek

Tujuan dan kriteria hasil

Perencanaan

Page 5: Intervensi Keperawatan Nanda Nic Noc

NANDA DIAGNOSE

Page 6: Intervensi Keperawatan Nanda Nic Noc

Find a Diagnose :

1. Identifikasi keluhan

2. Masukkan domain

3. Masukkan kelas

4. Lihat definisi

5. Lihat batasan karakteristik

Page 7: Intervensi Keperawatan Nanda Nic Noc

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

Page 8: Intervensi Keperawatan Nanda Nic Noc

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

Page 9: Intervensi Keperawatan Nanda Nic Noc

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

Page 10: Intervensi Keperawatan Nanda Nic Noc

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)

Page 11: Intervensi Keperawatan Nanda Nic Noc

Dx Medis dan Dx Keperawatan

CLINICAL SITUATIONS DIAGNOSTIC CONCEPT POSSIBLE NURSING

DIAGNOSES

SYSTEMIC ARTERIAL HYPOTENSION

Cardiac output Decreased cardiac output

HYPOVOLEMIA Fluid balance Deficient fluid volume

PAIN Pain Acute pain

METABOLIC ACIDOSIS Tissue perfusion Tissue perfusion:

cardiopulmonary, ineffective

WOUND DRAINAGE Skin integrity Impaired skin integrity

SYSTEMIC ARTERIAL HYPERTENSION

Tissue perfusion Tissue perfusion:

cardiopulmonary, ineffective

OLIGURIA Urinary elimination Impaired urinary elimination

POLYURIA Urinary elimination Impaired urinary elimination

HYPERTHERMIA Body temperature Hyperthermia

HYPOCALCEMIA Cardiac output Decreased cardiac output

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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

Page 13: Intervensi Keperawatan Nanda Nic Noc

NOC (Nursing Outcomes Classification)

Kriteria hasil (dan indikator)

Page 14: Intervensi Keperawatan Nanda Nic Noc

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)

Page 15: Intervensi Keperawatan Nanda Nic Noc

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

Page 16: Intervensi Keperawatan Nanda Nic Noc

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

Page 17: Intervensi Keperawatan Nanda Nic 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

Page 18: Intervensi Keperawatan Nanda Nic Noc

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.

Page 19: Intervensi Keperawatan Nanda Nic Noc

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

Page 20: Intervensi Keperawatan Nanda Nic Noc

Pernyataan/Kalimat Outcomes :

Konsisten

Memberikan pengertian yang sama terhadap sebuah istilah

Bukan menjelaskan kegiatan perawat

Bukan diagnosa keperawatan

Dapat diukur

Dapat dimengerti

Spesifik

Page 21: Intervensi Keperawatan Nanda Nic Noc

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

Page 22: Intervensi Keperawatan Nanda Nic Noc

Kapan Outcome diUKUR:

Saat mengkaji pasien

Saat akan dilakukan intervensi

Saat dilakukan intervensi

Saat setelah dilakukan intervensi

Saat “jatuh tempo”

Page 23: Intervensi Keperawatan Nanda Nic Noc

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 patient‘s status for each of the indicators

Page 24: Intervensi Keperawatan Nanda Nic Noc

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

Page 25: Intervensi Keperawatan Nanda Nic Noc

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

Page 26: Intervensi Keperawatan Nanda Nic Noc

Features of NOC Fluid Balance 0601 Balance of water in the intracellular and extracellular compartments of the body Extremely Substantially Moderately Mildly Not Compromised Compromised Compromised Compromised Comprised 1 2 3 4 5 Indicators: BP IER 1 2 3 4 5 Mean arterial pressure IER 1 2 3 4 5 Pulmonary wedge pressure IER 1 2 3 4 5 Peripheral pulses palpable 1 2 3 4 5 Ascites not present 1 2 3 4 5 Neck vein distention not present 1 2 3 4 5 Peripheral edema not present 1 2 3 4 5 Sunken eyes not present 1 2 3 4 5 Confusion not present 1 2 3 4 5

Page 27: Intervensi Keperawatan Nanda Nic Noc

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

Page 28: Intervensi Keperawatan Nanda Nic Noc

Membuat NOC

Tanpa NNN 1. Tentukan diagnosa

2. Masukkan domain

3. Masukkan kelas

4. Pilih kriteria

5. pilih indikator

6. Tentukan skala

Dengan NNN 1. Tentukan diagnosa

2. Pilih kriteria

3. Pilih indikator

4. Tentukan skala

NIC NOC Judith M Wilkinson

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Page 30: Intervensi Keperawatan Nanda Nic Noc

NIC (Nursing Intervention Classification)

Intervensi

Page 31: Intervensi Keperawatan Nanda Nic Noc

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)

Page 32: Intervensi Keperawatan Nanda Nic Noc

FENOMENA

Apa yang dilakukan perawat ?

Apakah kegiatan perawat mempengaruhi tingkat kesembuhan ?

Efektifkah kegiatan perawat dalam pengurangan biaya ?

Page 33: Intervensi Keperawatan Nanda Nic Noc

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

Page 34: Intervensi Keperawatan Nanda Nic Noc

Komponen intervensi :

Pengkajian/Diagnostik/Observasi

Tindakan Mandiri perawat/terapeutik

Pendidikan kesehatan/health education

Kolaborasi/(LIMPAHAN) tindakan medis

Page 35: Intervensi Keperawatan Nanda Nic Noc

NIC component

Name or label

A definition

A set of activities the nurse does to carry out the intervention

Page 36: Intervensi Keperawatan Nanda Nic Noc

Example : Diagnose : “Risk for Infection”

NOC yang di pilih :

6550 infection protection

1100 nutrition management

3590 skin surveillance

6650 surveillance

3660 wound care

Page 37: Intervensi Keperawatan Nanda Nic Noc

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

Page 38: Intervensi Keperawatan Nanda Nic Noc

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)

Page 39: Intervensi Keperawatan Nanda Nic Noc

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)

Page 40: Intervensi Keperawatan Nanda Nic Noc

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

Page 41: Intervensi Keperawatan Nanda Nic Noc

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

Page 42: Intervensi Keperawatan Nanda Nic Noc

PENULISAN NNN

Page 43: Intervensi Keperawatan Nanda Nic Noc

Sample Care Plan using Case Study NANDA Nursing Diagnoses NOC Outcomes and Indicators NIC Intervention Label and select nursing activities

Risk for infection related to

immunosuppression

secondary to chemotherapy,

inadequate primary defenses

(central venous catheter),

chronic disease (ALL) and

developmental level.

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

WBC’s)

1 2 3 4 5

(NOC, 2008 p.399)

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)

Page 44: Intervensi Keperawatan Nanda Nic Noc

Sample Blank Careplan

Nanda

Nursing

Diagnosis

NOC Outcome

Label(s) and

indicators

Rationale for NOC

chosen

and indictor score

NIC Intervention

label(s) and

nursing activities

Rationale for

NIC Chosen

Complete

NANDA

Nursing Dx

Statement

including

related or

risk factors

and defining

characteristic

NOC label and

appropriate

indicators and

rating on scale

with date (s)

Describe your

rationale for

choosing this NOC

label and the

indicator ratings that

you chose for this

patient.

NIC label and

appropriate

activities with

individualized

information

added.

Describe your

rationale for

choosing this

NIC label

Page 45: Intervensi Keperawatan Nanda Nic Noc

Jazakumullah khoiron katsir..