1 How to Use Nanda Nic Noc 23 Feb

7/25/2019 1 How to Use Nanda Nic Noc 23 Feb

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How To Use

NANDA NIC NOCDisampaikan oleh:

Agung Waluyo, SKp, MS, !hD


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Nu"sing Ou#omes Classi$ia#ion

%NOC&

The nursing outcomes classification

(NOC) is a classification of nurse

sensitive outcomes

NOC outcomes and indicators allowfor measurement of the patient,

family, or community outcome at any

point on a continuum from mostnegative to most positive and at

different points in time. (!owa

Outcome "ro#ect, $%%&)


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NOC

'efore providing an intervention,nurses use NOC to understand the

patients current prolems and nursing

diagnoses and rate the chosenoutcome to otain a aseline rating.

*fter providing an intervention, NOCis used to measure the outcome and

determine a change score.


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NANDA'NOC (inkage

+ach nursing iagnosis is followedy a list of suggested outcomes to

measure whether the chosen

interventions are helping theidentified prolem

+ach outcome can e individuali-edto the patient or family y choosing

the appropriate indicators or adding

additional indicators as necessary


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NANDA NIC NOC %NNN& (inkages

The first step in the process to lin NNN

is for nurses to determine a nursing

diagnosis using N*N*/! diagnoses.

*fter determining the nursing diagnosis,nurses consider which NOC outcomes

are appropriate for the patient situation,

and then Choose N!C interventions that are most

liely to achieve the desired outcome

(0ohnson, $%%1).


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Ta)onomy NOC

2evel 34 omain

5 Contoh4 6unctional 7ealth 2evel $4 Classes

5 Contoh4 +nergy 8aintenance

2evel 94 Outcomes5 Contoh4 6atigue, isruptive +ffects

5 !ndiator4

8alaise 2ethargy

8enurunnya +nergi

:angguan *2 , etc


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!mmune ;tatus (%ternalantigens.

3?severely compromised thru @? not

compromised *solute A'C values Aithin Normal 2imit

(AN2) ifferential A'C values AN2

;in integrity 8ucosa integrity 'ody temperature !+B

:astrointestinal function


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!mmune ;tatus (Continued)

3? severe thru @? None

Becurrent !nfections Aeight 2oss

Tumors (!mmature A'Cs)

(NOC, $%39 p.$


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;cale

+>tremely compromised 3

;ustantially compromised $ 8oderately compromised 9 8ildly compromised Not compromised @

DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD ;evere 3 ;ustantial $

8oderate 9 8ild None @


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Nu"sing In#e"*en#ions Classi$ia#ion

%NIC&

The nursing interventions

classification (N!C) is a

comprehensive, standardi-edlanguage descriing treatments that

nurses perform in all settings and in

all specialties. (!owa !ntervention"ro#ect, $%%&)


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!nterventions

efinition4 any treatment ased

upon clinical #udgment and

nowledge, that a nurse performsto enhance patientEclient

outcomes. (!owa !ntervention

"ro#ect, $%%%,p.9)


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INT+-+NTION


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Nursing Intervention Classification

(NIC)

Nsg intervention standardcomprehensive ased on research.

N!C4 Nsg intervention direct,indirect, independent, collaorative @3 interventions (@$ interventions)

N!C "ro#ect of Fniversity of !OA*


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NIC TA.ONOM/


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2+G+2 $ C2*;;+;


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*giDCollections 16

2+G+2 $ C2*;;+;


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;tudi Hasus

Tn aii @ th di rawatdengan 8 type !!

irawat se#a 3 minggu yglalu setelah ainya luayang dia tida sadariseelumnya, yangemudian disertai demam

9IC 2euosit 3&.%%% Furan lua $J&J3 :ula darah 9&% mgEd2


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Nu"sing Diagnosis 0:

Bis for infection

(%%%%) related tochronic disease4 8,

inade=uate primarydefenses4 roen sin.


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Was ou" hoie o""e#1

De$ini#ion o$ #he la2el:*t increasedris for eing invaded y pathogenicorganisms

isk 3a#o"s:5 !nsufficient nowledge to avoid e>posure

to pathogens (developmental level)

5 !nade=uate secondary defenses (8)5 !nade=uate primary defenses (roensin from wound)

(N*N*,$%%I)


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Nursing iagnosis $4

!mpaired sin integrity(%%%1) related to

impaired metaolicstate


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NOC :angguan !ntegritas Hulit

temperatur jaringan dalam rentang yangdiharapkan

elastisitas dalam rentang yang diharapkan

hidrasi dalam rentang yang diharapkan

pigmentasi dalam rentang yang diharapkan

warna dalam rentang yang diharapkan

tektur dalam rentang yang diharapkan

bebas dari lesi

kulit utuh


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N!C 8ana#emen 2ua

:anti alutan lama dengan alutan yang aru

Cuur ramut diseitar lua #ia diperluan

Ha#i ondisi lua (pus, warna, uuran dan au) Fur wound ed

'ersihan dengan NaCl steril atau larutan

pemersih stK


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Nursing iagnosis 94

Bis for deficient fluid volume

(%%%$&) related to4

5+>cessive loss through normal routes(polyuria)

5eficient nowledge (8

management)

57yper metaolic state


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D) 4:

!neffective ;elf/7ealth 8anagement (%%%ity of therapeutic regimen4 !nade=uate

lood sugar monitoring

5 ;ocial support deficit

efinition4 pattern of regulating into daily living

a therapeutic regimen for the treatment that isunsatisfactory for meeting specific health

goals


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N*N*EN!C 2inage

+ach N*N* diagnosis is followed y alist of suggested interventions forresolving the identified prolem

!nterventions and activities should echosen to meet the individual clientsneeds

*ctivities can e further individuali-ed

y adding client specific information *dditional activities may e added if

appropriate


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N!C +>amples4 2ined with

Bis for !nfection

1@@% infection protection

911% wound care

33%% nutrition management

9@I% sin surveillance 11@% surveillance


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NOC +>amples4 2ined with Bis for

!nfection !mmune status (%


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NOC: Immune status (0702)0702 Immune StatusDefinition: Natural and acquired appropriately targeted resistance to internal and external antigens.1=severely compromised thru 5= not compromisedAbsolute WBC values WNL(it!in nor"al li"its#$ % & ' Differential WBC values WNL(it!in nor"al li"its#$ % & ' )*in integrity$ % & ' +ucosa integrity$ % & '

Body te"perature ,-( in expected range#$ % & ' /astrointestinal function$ % & ' espiratory 0unction$ % & ' /enitourinary 0unction

$ % & ' 1= severe thru 5= Noneecurrent ,nfections$ % & ' Weig!t Loss$ % & ' 1u"ors (,""ature WBC2s#$ % & ' (N3C4 %556 p.&77#


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NOC: Wound Healing (1102)

1=none thru 5= extensiveWound approxi"ation$ % & ' Wound edge approxi"ation$ % & ' /ranulation8scar for"ation

$ % & ' 1= extensive thru 5= None)urrounding s*in eryt!e"a$ % & ' Wound ede"a$ % & '

,ncreased s*in te"perature$ % & ' Wound odor$ % & ' (N3C4 %556 p.9&5#


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N!C4 !nfection "rotection 1@@%

De$ini#ion: !"e*en#ion an5 ea"ly 5e#e#ion

o$ in$e#ion in a pa#ien# a# "isk

A#i*i#ies:

5 Moni#o" $o" sys#emi an5 loali6e5 sign 7

symp#oms o$ in$e#ion %woun5 si#e hek

e*e"y 4 hou"s8&

5 Moni#o" W9C, an5 5i$$e"en#ial "esul#s %5 o"

o5&5 3ollow neu#"openi p"eau#ions

5 !"o*i5e a p"i*a#e "oom

5 (imi# num2e" o$ *isi#o"s


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N!C4 !nfection "rotection 1@@% (Cont.)

A#i*i#ies %Con#8&5 S"een all *isi#o"s $o" ommunia2le 5isease

5 Main#ain asepsis

5 Inspe# skin an5 muous mem2"anes $o""e5ness, e)#"eme wa"m#h o" 5"ainage %4 hou"s&

5 Inspe# on5i#ion o$ su"gial inision % en#"alline inse"#ion si#e 4 hou"s&

5 O2#ain ul#u"es, as nee5e5 %9loo5 ul#u"es p"nT;4 hou"s&

5 !"omo#e Nu#"i#ional in#ake %0?@@ kal pe" 5ay, !#8likes e"eal&


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NIC: In$e#ion !"o#e#ion ??@ %on#8&

A#i*i#ies %on#8&5 +nou"age $lui5 in#ake %B >?@@ pe" 5ay, !#

likes ua*a uie&

5 +nou"age "es# %naps e*e"y a$#e"noon $"om 0E

< !M, 2e5#ime a# >@@@=&


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N!C4 Aound Care 911%

efinition4 "revention of woundcomplications and promotion of wound

healing

*ctivities45 Bemove dressing L adhesive tape

5 8onitor characteristics of the wound

5 8easure the si-e of the wound5 Cleanse with normal saline

5*pply a dressing

5 8aintain sterile techni=ue


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N!C4 Aound Care 911%

*ctivities45 Change dressing according to amount of e>udate

5 Begularly compare and record any change in the

wound5 "osition to avoid placing tension on the wound

5 Beposition patient at least every $ hours

5 +ncourage fluids, as appropriate5*ssist patient and family to otain supplies

5 !nstruct patient or family memer(s) wound care

procedure

S l C Pl i C


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Sample Care Plan using CaseStudy

NANDA NursingDiagnoses

N! utcomes and Indicators NI! Intervention "a#el and select nursingactivities

$is% &or in&ectionrelated to c!ronicdisease: D+4inadequate pri"arydefenses: bro*ens*in.

0702Immune StatusDefinition: Natural and acquiredappropriately targeted resistance tointernal and external antigens.1=severely compromised thru 5=not compromised

Absolute WBC values WNL(it!innor"al li"its#$ % & ' Differential WBC valuesWNL(it!in nor"al li"its#$ % & ' )*in integrity$ % & ' +ucosa integrity$ % & '

'550 in&ection protectionDefinition: revention and early detection ofinfection in a patient at ris*Activities(+onitor for syste"ic and locali;ed signs 38.3 C q 24 hours) ro"ote Nutritional inta*e (1!! kcal per day" #tlikes cereal) -ncourage fluid inta*e (122 cc per day" #t likes

oran$e %atorade) -ncourage rest (naps daily 1&3 #'" edtie t 8*3!#') +onitor for c!ange in energy level8"alaise ,nstruct patient to ta*e anti=infective as prescribed

(Bactri po B+,- ystatin cc"s/ish 0 s/allo/"T+,)

1eac! 0a"ily about s < sy"pto"s of infection and!en to report t!e" to >C=1eac! patient and fa"ily !o to avoid infections(N,C4 %556#

Sample Care Plan using Case Study


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Impaired s%inintegrity(555'?# relatedto i"paired"etabolic state

1=none thru 5= extensiveWound approxi"ation$ % & ' Wound edge approxi"ation$ % & ' /ranulation8scar for"ation$ % & '

1= extensive thru 5= None)urrounding s*in eryt!e"a$ % & ' Wound ede"a$ % & ' ,ncreased s*in te"perature$ % & '

Wound odor$ % & ' (N3C4 %556 p.9&5#

Definition: revention of oundco"plications and pro"otion of ound!ealing

Activities:e"ove dressing < ad!esive tape

+onitor c!aracteristics of t!e ound+easure t!e si;e of t!e oundCleanse it! nor"al salineApply a dressing+aintain sterile tec!nique

S l C Pl i C St d


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Impaired s%inintegrity(555'?# relatedto i"paired"etabolic state

1=none thru 5= extensiveWound approxi"ation$ % & ' Wound edge approxi"ation$ % & ' /ranulation8scar for"ation$ % & ' 1= extensive thru 5= None)urrounding s*in eryt!e"a$ % & ' Wound ede"a$ % & ' ,ncreased s*in te"perature$ % & ' Wound odor$ % & ' (N3C4 %556 p.9&5#

Activities:C!ange dressing according to a"ount ofexudateegularly co"pare and record any c!angein t!e ound

osition to avoid placing tension on t!eoundeposition patient at least every % !ours-ncourage fluids4 as appropriateAssist patient and fa"ily to obtainsupplies

,nstruct patient or fa"ily "e"ber(s#ound care procedure


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Sample lan! Care Plan

Nanda NursingDiagnosis

N! utcome"a#el)s* andindicators

$ationale &or N!chosenand indictor score

NI! Intervention la#el)s*and nursing activities

$ationale &or NI! !hosen

Coplete ,ursin$ ,tateentincludin$ relatedor risk actors and

deinin$characteristics

5C lael andappropriateindicators andratin$ on scale/ith date (s)

,escrie yourrationale orchoosin$ this 5Clael and theindicator ratin$s that

you chose or thispatient.

+C lael and appropriateactivities /ithindividuali6ed inorationadded.

,escrie your rationale orchoosin$ this +C lael

Nursing Diagnosis and Interventions( C!oose t!e !ig!est priority Nursing Diagnosis as indicated on t!e clinical reasoningeb. ,ncludeprole stateent(NANDA#4 related toor risk actors(etiology#4 and defining c!aracteristics (asevidenced yor 7B# as

appropriate. List all of t!e appropriate N3C 3utco"e labels and indicators and N,C intervention labels and nursing activities !ic! ill best!elp your client ac!ieve t!ose outco"es. List t!e rationale for eac! and deter"ine !ere your client falls on t!e outco"e indicator scale ($=#

at t!e specified ti"e intervals. ,n t!e final colu"n su""ari;e !y you gave your client t!e indicator scores t!at ere given and any c!anges

in your care plan t!at s!ould be "ade.

+rie&ly descri#e ho, the plan o& care is helping the patient meet the desired outcomes and any changes that need to #e made(


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Hesimpulan

= erlu proses pengenalan berta!ap= erlu bi"bingan senior atau "ere*a yang

tela! "endapat*an progra" pendidi*an

yang "engguna*an NANDA4 N,C4 N3C("is. )$4 atau )%#

= )edi*it lebi! "e"butu!*an proses

analisa < sintesa per"asala!an pasien= Diguna*an untu* "e"per"uda!

penge"bangan riset *eperaatan


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1 How to Use Nanda Nic Noc 23 Feb

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