Intervensi Keperawatan : NANDA NIC NOC (NNN) - UMM
Intervensi Keperawatan :NANDA – NIC – NOC (NNN)Based on NIC and NOC bookDewi Baririet BarorohProses Dokumentasi Keperawatan (semester 2)PSIK FIKES UMMApril 2011
Taxonomy – Nomenclature :NANDA – NIC – NOC (NNN)13 domain47 kelas206 diagnosa7 domain31 kelas385 kriteria7 domain31 kelas542 intervensi
TRADISIONAL : Tujuan jangka panjang dan jangka pendekTujuan dan kriteria hasilPerencanaan
NANDA DIAGNOSE
Find a Diagnose : 1.2.3.4.5.Identifikasi keluhanMasukkan domainMasukkan kelasLihat definisiLihat batasan karakteristik
Contoh : 1. Identifikasi keluhan : sering terbangunjika tidur tidak tahu penyebabnya2. Masukkan domain : 43. Masukkan kelas : 14. Lihat definisi : insomnia5. Lihat batasan karakteristik : insomnia
Components ofa Nursing Diagnosis 1. Label or Name and definition(Axis 1 – 2 – 3)2. Related Factors OR Risk Factors3. Defining Characteristics Axis 1 – 7Penulisan 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 ditandaidengan wheezing, sianosis, dispnea2. Aktual : Ketidakefektifan (axis 3) bersihan jalan nafas(axis 1) individu (axis 2, jika individu tdk ditulis) b.dmukus dalam jumlah berlebih ditandai dengan wheezing,sianosis, dispnea3. Aktual : Ketidakefektifan bersihan jalan nafas b.d mukusdalam jumlah berlebih
Contoh 4. Resiko : Resiko Infeksi b.d penyakitkronis (kanker paru) 5. Promosi : Kesiapan meningkatkan(axis 3) rasa nyaman (axis 1) keluarga(axis 2) 6. Kesejahteraan : Diare b.d keracunanmakanan (petis)
Dx Medis dan Dx KeperawatanCLINICAL SITUATIONSDIAGNOSTIC CONCEPTPOSSIBLE NURSINGDIAGNOSESSYSTEMIC ARTERIALHYPOTENSIONCardiac outputDecreased cardiac outputHYPOVOLEMIAPAINFluid balancePainMETABOLIC ACIDOSISTissue perfusionDeficient fluid volumeAcute painTissue perfusion:cardiopulmonary,ineffectiveWOUND DRAINAGESkin integrityImpaired skin integrityTissue perfusion:cardiopulmonary,ineffectiveSYSTEMIC ARTERIALHYPERTENSIONTissue perfusionOLIGURIAUrinary eliminationImpaired urinary eliminationPOLYURIAUrinary eliminationImpaired urinary eliminationHYPERTHERMIABody temperatureHyperthermiaHYPOCALCEMIACardiac outputDecreased cardiac output
Prioritas diagnosa Standar asuhan keperawatan : (1) mengancam kehidupan,(2) mengancam kesehatan, (3) mempengaruhi perilakumanusiaDEPKES RI ; (1) aktual, (2) potensial/resikoMaslow : (1) fisiologis, (2) aman&nyaman, (3) cinta&kasihsayang, (4) harga diri, (5) aktualisai diriPer sistem : B1, B2, B3, B4, B5, B6
NOC(Nursing Outcomes Classification)Kriteria hasil (dan indikator)
NOC The nursing outcomes classification (NOC) is aclassification of nurse sensitive outcomesNOC outcomes and indicators “allow formeasurement of the patient, family, orcommunity outcome at any point on a continuumfrom most negative to most positive and atdifferent points in time.” ( Iowa Outcome Project,2008)
SEJARAH Tidak ada kriteria pasien sembuh. Kematian,kesakitan dan gejala kesakitan ditentukan dgtradisional, dikira kira.Kriteria sembuh kinerja perawat dalammemberikan asuhan keperawatan.Beragam respon pasien dan beragamkemampuan perawat
SEJARAH 1973 : Hover dan Zimmer membagi kriteriasembuh dalam 5 domainANA (american nurses association) : kriteriasembuh meningkatkan angka kesembuhan,menurunkan unit cost dan meningkatkan angkakesehatan negara1982 : NANDA menyeragamkan kriteriasembuh dalam keperawatan NOC
“Bekerjalah kalian, maka Allah dan RasulNya sertaorang-orang mukmin akan melihat amal-amalkalian itu, dan kamu akan dikembalikan kepadaAllah Yang Maha Mengetahui akan yang ghaib danyang nyata, lalu diberitakanNya kepada kamu apayang telah kamu kerjakan”QS. At Taubah (9) : 105
SEJARAH Cita-cita luhur keperawatan : Bermanfaatuntuk manusia Jika tolak ukur kriteria sembuh hanya berasaldari profesi lain, “rasa” dari asuhankeperawatan tidak dapat diukur.Memacu perawat untuk memberikan asuhankeperawatan yang benar dan tepat.
TujuAn Penyeragaman Outcomes Memudahkan pengaturan sistem informasikeperawatanMemberikan definisi sama pada setiapintepretasi dataMengukur kualitas asuhan keperawatanMengukur efektifitas asuhan keperawatanMeningkatkan inovasi keperawatan
Pernyataan/Kalimat Outcomes : KonsistenMemberikan pengertian yang sama terhadapsebuah istilahBukan menjelaskan kegiatan perawatBukan diagnosa keperawatanDapat diukurDapat dimengertiSpesifik
Outcomes Vs Intervention :Intervensi keperawatan harus : Menghasilkan O positifMengarah pada O positifBerdasarkan O positifMeningkatkan O positifMempertahankan O positifMencegah perburukan ODilakukan sebelum evaluasi ODiganti bila O negatif
Kapan Outcome diUKUR: Saat mengkaji pasienSaat akan dilakukan intervensiSaat dilakukan intervensiSaat setelah dilakukan intervensiSaat “jatuh tempo”
NOC componentA neutral label or name used tocharacterize the behavior or patient status A list of indicators that describe clientbehavior or patient status. A five point scale to rate the patient‘s statusfor each of the indicators
Label : Immune Status (0702)Definition: Natural and acquired appropriatelytargeted resistance to internal and externalantigens.Skala : 1 severely compromised thru 5 notcompromisedIndikator : Absolute WBC values WNL Differential WBC values WNL Skin integrity Mucosa integrity Body temperature IER Gastrointestinal function
ScaleExtremely compromised1 Substantially compromised2 Moderately compromised3 Mildly compromised4 Not compromised5 Severe1 Substantial2 Moderate3 Mild4 None5
Features of NOCFluid Balance 0601Balance of water in the intracellular and extracellular compartments of the :BP IER1234Mean arterial pressure IER1234Pulmonary wedge pressure IER1234Peripheral pulses palpable1234Ascites not present1234Neck vein distention not present1234Peripheral edema not present1234Sunken eyes not present1234Confusion not present1234NotComprised5555555555
NANDA/NOC LinkageEach nursing Diagnosis is followed by a listof suggested outcomes to measure whetherthe chosen interventions are helping theidentified problem Each outcome can be individualized to thepatient or family by choosing theappropriate indicators or adding additionalindicators as necessary
Membuat NOCTanpa NNN 1. Tentukan diagnosa2. Masukkan domain3. Masukkan kelas4. Pilih kriteria5. pilih indikator6. Tentukan skalaDengan NNN 1. Tentukan diagnosa2. Pilih kriteria3. Pilih indikator4. Tentukan skalaNIC NOC Judith MWilkinson
NIC(Nursing Intervention Classification)Intervensi
NIC “The nursing interventions classification(NIC) is a comprehensive, standardizedlanguage describing treatments that nursesperform in all settings and in allspecialties.” (Iowa Intervention Project,2008)
FENOMENAApa yang dilakukan perawat ? Apakah kegiatan perawat mempengaruhitingkat kesembuhan ? Efektifkah kegiatan perawat dalampengurangan biaya ?
Tujuan Penyeragaman NIC : Standarkan intervensiMemberikan definisi yang sama tentang diagnosaMempermudah sistem informasi keperawatanMemudahkan pengajaranMengukur biaya keperawatanMemudahkan perencanaan administrasi/unit costMeminimalkan 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 labelA definitionA set of activities the nurse does to carry outthe 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 ofinfection in a patient at riskActivities: Monitor for systemic and localized s & sx ofinfection (central line site check every 4 hours.)Monitor WBC, and differential results (qd or qod)Follow neutropenic precautionsProvide a private roomLimit number of visitors
Infection Protection (Cont.) Activities (Cont.) Screen all visitors for communicable diseaseMaintain asepsisInspect skin and mucous membranes for redness,extreme warmth or drainage (q4 hours)Inspect condition of surgical incision ( central lineinsertion site q 4 hours)Obtain cultures, as needed (Blood cultures prnT 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 orangeGatorade) Encourage rest (naps every afternoon from 1-3 PM, bedtimeat 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 reportthem to HCP(NIC, 2008)
Features of NICELECTROLYTE MANAGEMENT 2000Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormalor undesired serum electrolyte levelsActivities:- 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, wounddrainage, 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 LinkageEach NANDA diagnosis is followed by a listof suggested interventions for resolving theidentified problem Interventions and activities should bechosen to meet the individual clients needs Activities can be further individualized byadding client specific information Additional activities may be added ifappropriate
PENULISAN NNN
Sample Care Plan using Case StudyNANDA Nursing DiagnosesNOC Outcomes and IndicatorsNIC Intervention Label and select nursing activitiesRisk for infection related toimmunosuppressionsecondary to chemotherapy,inadequate primary defenses(central venous catheter),chronic disease (ALL) anddevelopmental level.0702Immune StatusDefinition: Natural and acquired appropriatelytargeted resistance to internal and external antigens.1 severely compromised thru 5 not compromisedAbsolute WBC values WNL(within normal limits)1 2 3 4 5Differential WBC values WNL(within normal limits)1 2 3 4 5Skin integrity1 2 3 4 5Mucosa integrity1 2 3 4 5Body temperature IER( in expected range)1 2 3 4 5Gastrointestinal function1 2 3 4 5Respiratory Function1 2 3 4 5Genitourinary Function1 2 3 4 51 severe thru 5 NoneRecurrent Infections1 2 3 4 5Weight Loss1 2 3 4 5Tumors (ImmatureWBC’s)1 2 3 4 5(NOC, 2008 p.399)6550 infection protectionDefinition: Prevention and early detection of infection in a patient at riskActivities:Monitor for systemic and localized signs & symptoms of infection (central linesite check every 4 hours.)Monitor WBC, and differential results (qod)Follow neutropenic precautionsProvide a private roomLimit number of visitorsScreen all visitors for communicable diseaseMaintain asepsisInspect skin and mucous membranes for redness, extreme warmth ordrainage (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/malaiseInstruct 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 toHCP-Teach patient and family how to avoid infections(NIC, 2008)
Sample Blank CareplanNandaNursingDiagnosisCompleteNANDANursing DxStatementincludingrelated orrisk factorsand definingcharacteristicNOC Outcome Rationale for NOC NIC Intervention Rationale forLabel(s) andchosenlabel(s) andNIC Chosenindicatorsand indictor score nursing activitiesNOC label andDescribe yourNIC label andDescribe yourappropriaterationale forappropriaterationale forindicators and choosing this NOCactivities withchoosing thisrating on scalelabel and theindividualizedNIC labelwith date (s) indicator ratings thatinformationyou chose for thisadded.patient.
Jazakumullah khoiron katsir.
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)
clasificaciones nanda, noc, nic 2018-2020 clasificaciones nanda, noc, nic 2018-2020 autorÍa: carlos valdespina aguilar salusplay editorial estartetxe 5, oficina 306. 48940 leioa, bizkaia, pais vasco tel.: 34 946522986 fecha y lugar de publicaciÓn: leioa
3. NANDA, NOC, NIC El módulo de taxonomías permite consultar cómodamente las etiquetas comprendidas en cada una de ellas. Así mismo, las etiquetas NANDA, NOC, NIC han sido relac ionadas para agilizar la búsqueda y selección en los trabajos relacionados con las taxonomías. Podemos seleccionar la taxonomía que deseemos consultar bien desde el
keperawatan sesuai NANDA NIC-NOC sebagian besar rencana tindakan keperawatan dapat dilaksanakan pada implementasi keperawatan dan evaluasi keperawatan terhadap diagnosa keperawatan yang ditemukan dapat teratasi. Diharapkan bagi perawat ruangan agar dapat lebih giat lagi dalam melakukan implementasi dan pendokumentasian untuk lebih meningkatkan .
Nursing Outcomes Classification (NOC) outcomes were explicitly stated in 22%, and implied in 72%. Interventions matched appropriate Nursing Interventions Classification (NIC) activities in 61%. CONCLUSIONS. NANDA, NIC, and NOC (NNN) language was used inconsistent
sification (NIC), of nursing outcomes classification (NOC) and their correlation NANDA-NIC-NOC linkage (NNN linkage) in order to define a standardized language for all nursing staff. This is a retro-spective study involving a sample of 168 patients discharged from CR. The NANDA-I, the NIC, the NOC and the most frequently
North American Nursing Diagnosis Association (NANDA) NANDA didirikan sebagai badan formal untuk meningkatkan, mengkaji kembali dengan mengesahkan daftar terbaru dari diagnosis keperawatan yang digunakan oleh perawat praktisi. NANDA mengidentifikasi masalah atau k
instalasi rumah sakit dapat melakukan asuhan keperawatan mengacu kepada NANDA, NIC-NOC, agar asuhan keperawatan yang dilakukan kepada pasien terarah dan terlaksana secara optimal. Kata Kunci : Asuhan Keperawatan, NANDA
The hallmark of the ISO 14001 standard that differentiates it from other environmental standards is the integration of managerial decision-making with environmental protection efforts (Raines, 2002). This is a more effective approach that divorces environmental protection efforts from other management activities. Despite its merits, several criticisms have been leveled against the ISO 14001 .
