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Intervensi Keperawatan : NANDA – NIC – NOC (NNN) Based on NIC and NOC book Dewi Baririet Baroroh Proses Dokumentasi Keperawatan (semester 2) PSIK FIKES UMM April 2011 Taxonomy – Nomenclature : NANDA – NIC – NOC (NNN) 13 domain 47 kelas 206 diagnosa 7 domain 31 kelas 385 kriteria 7 domain 31 kelas 542 intervensi TRADISIONAL : Tujuan jangka panjang dan jangka pendek Tujuan dan kriteria hasil Perencanaan NANDA DIAGNOSE Find a Diagnose : 1. 2. 3. 4. 5. Identifikasi keluhan Masukkan domain Masukkan kelas Lihat definisi 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 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 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 Keperawatan CLINICAL SITUATIONS DIAGNOSTIC CONCEPT POSSIBLE NURSING DIAGNOSES SYSTEMIC ARTERIAL HYPOTENSION Cardiac output Decreased cardiac output HYPOVOLEMIA PAIN Fluid balance Pain METABOLIC ACIDOSIS Tissue perfusion Deficient fluid volume Acute pain Tissue perfusion: cardiopulmonary, ineffective WOUND DRAINAGE Skin integrity Impaired skin integrity Tissue perfusion: cardiopulmonary, ineffective SYSTEMIC ARTERIAL HYPERTENSION Tissue perfusion OLIGURIA Urinary elimination Impaired urinary elimination POLYURIA Urinary elimination Impaired urinary elimination HYPERTHERMIA Body temperature Hyperthermia HYPOCALCEMIA 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 “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 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 NOC Fluid Balance 0601 Balance of water in the intracellular and extracellular compartments of the body Extremely Substantially Moderately Mildly Compromised Compromised Compromised Compromised 1 2 3 4 Indicators: BP IER 1 2 3 4 Mean arterial pressure IER 1 2 3 4 Pulmonary wedge pressure IER 1 2 3 4 Peripheral pulses palpable 1 2 3 4 Ascites not present 1 2 3 4 Neck vein distention not present 1 2 3 4 Peripheral edema not present 1 2 3 4 Sunken eyes not present 1 2 3 4 Confusion not present 1 2 3 4 Not Comprised 5 5 5 5 5 5 5 5 5 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 NNN 1. Tentukan diagnosa 2. Pilih kriteria 3. Pilih indikator 4. Tentukan skala NIC NOC Judith M Wilkinson 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 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 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 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 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 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 PENULISAN NNN 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) Sample Blank Careplan Nanda Nursing Diagnosis Complete NANDA Nursing Dx Statement including related or risk factors and defining characteristic NOC Outcome Rationale for NOC NIC Intervention Rationale for Label(s) and chosen label(s) and NIC Chosen indicators and indictor score nursing activities NOC label and Describe your NIC label and Describe your appropriate rationale for appropriate rationale for indicators and choosing this NOC activities with choosing this rating on scale label and the individualized NIC label with date (s) indicator ratings that information you chose for this added. patient. 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