Intervensi Keperawatan :

NANDA – NIC – NOC (NNN)Muhammad Muslih

Based on NIC and NOC book

Taxonomy – Nomenclature :NANDA – NIC – NOC (NNN)

13 domain 47 kelas 206 diagnosa

7 domain 31 kelas 385 kriteria

7 domain 31 kelas 542 intervensi

NANDA DIAGNOSE

Find a Diagnose :

• 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

• Label or Name and definition (Axis 1 – 2 – 3)• Related Factors OR Risk Factors• 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 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 KeperawatanCLINICAL SITUATIONS DIAGNOSTIC CONCEPT POSSIBLE NURSING

DIAGNOSESSYSTEMIC ARTERIAL

HYPOTENSION Cardiac output Decreased cardiac output

HYPOVOLEMIA Fluid balance Deficient fluid volumePAIN Pain Acute pain

METABOLIC ACIDOSIS Tissue perfusionTissue perfusion:

cardiopulmonary,ineffective

WOUND DRAINAGE Skin integrity Impaired skin integrity

SYSTEMIC ARTERIALHYPERTENSION Tissue perfusion

Tissue perfusion:cardiopulmonary,

ineffectiveOLIGURIA Urinary elimination Impaired urinary eliminationPOLYURIA Urinary elimination Impaired urinary elimination

HYPERTHERMIA Body temperature HyperthermiaHYPOCALCEMIA Cardiac output 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)

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)

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

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

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.

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

Pernyataan/Kalimat Outcomes :

• Konsisten• Memberikan pengertian yang sama terhadap

sebuah istilah• Bukan menjelaskan kegiatan perawat• Bukan diagnosa keperawatan• Dapat diukur• Dapat dimengerti• Spesifik

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

Kapan Outcome diUKUR:

• Saat mengkaji pasien• Saat akan dilakukan intervensi• Saat dilakukan intervensi• Saat setelah dilakukan intervensi• Saat “jatuh tempo”

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

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

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

Features of NOCFluid Balance 0601Balance 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

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 NNN•1. Tentukan diagnosa•2. Masukkan domain•3. Masukkan kelas•4. Pilih kriteria•5. pilih indikator•6. Tentukan skala

Dengan NNN1. Tentukan diagnosa2. Pilih kriteria3. Pilih indikator4. Tentukan skala

NIC (Nursing Intervention 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)

FENOMENA

• Apa yang dilakukan perawat ?• Apakah kegiatan perawat mempengaruhi tingkat

kesembuhan ?• Efektifkah kegiatan perawat dalam pengurangan biaya ?

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

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 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)

Features of NIC

ELECTROLYTE MANAGEMENT 2000Definition: 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

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 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 (Immature WBC’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 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)

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

TRADISIONAL :

• Tujuan jangka panjang dan jangka pendek• Tujuan dan kriteria hasil• Perencanaan

Terimakasih