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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$e %atorade) -ncourage rest (naps daily 1&3 #'" edtie t 8*3!#') +onitor for c!ange in energy level8"alaise ,nstruct patient to ta*e anti=infective as prescribed
(Bactri po B+,- ystatin cc"s/ish 0 s/allo/"T+,)
1eac! 0a"ily about s < sy"pto"s of infection and!en to report t!e" to >C=1eac! patient and fa"ily !o to avoid infections(N,C4 %556#
Sample Care Plan using Case Study
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Sample Care Plan using Case Study
NANDA NursingDiagnoses
N! utcomes and Indicators NI! Intervention "a#el and select nursingactivities
Impaired s%inintegrity(555'?# relatedto i"paired"etabolic state
1=none thru 5= extensiveWound approxi"ation$ % & ' 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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Sample Care Plan using Case Study
NANDA NursingDiagnoses
N! utcomes and Indicators NI! Intervention "a#el and select nursingactivities
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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T+IMA KASIH
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