NANDA, NIC And NOC Overview

Bahasa Baku dalam KeperawatanNANDA, NIC, & NOC1Mengapa harus mempelajari bahasa baku dalam keperawatan?Menciptakan suatu kesadaran mengenai bahasa baku dalam keperawatanMendukung pembelajaran proses keperawatanKonsisten antara praktikum dengan teoriMengembangkan kemampuan berpikir kritisMemperbaiki komunikasi (intra+interprofesi)Berbasis riset

2*This is the time when student are learning the nursing process and planning and implementing nursing care are central components of any undergraduate nursing practicum course (Schoenfelder, NOC, 2004,p.814) It also decrease the students confusion concerning the difference between an outcome and an intervention.**Standardized language improves consistency through out the undergraduate program, leading to less confusion for the student.*The use of standardized language should be implemented before the students learn other ways of developing plans of care. Therefore, old ways do not need to be un-taught.*Use of Standardized Language when developing plans of care can develop critical thinking skills (Van De Castle, 2003) Student swill need to prioritize their nursing Diagnosis and identify relevant nursing activities and outcome indicators. Students will also need to consider the needs of the patient and family when individualizing care.*The use of standardize language improves communication among nursing and other healthcare disciplines. It also assist faculty in understanding the students perception of the patients problem(s).*The use of NANDA, NIC & NOC frameworks are desirable because they are research based, therefore faculty will be utilizing evidence based practice.

PERLUNYA BAHASA BAKU DALAM KEPERAWATANMENGETAHUI DAMPAK ASUHAN KEPERAWATAN TERHADAP PENCAPAIAN PASIENDI KLINIKPENGELOLAAN STAF DAN VARIABEL ADMINISTRATIF LAINNYAMENYEDIAKAN STRUKTUR UNTUK PENGKAJIAN KLINIS YANG BERFOKUS PADA PASIEN MEREKAM AKTIVITAS SURVEILANS YANG DIGUNAKAN UNTUK MENCEGAH KOMPLIKASIMENGAJARKAN KEPADA MAMHASISWA KEPERAWATAN BAHASA PELAYANAN KLINIK DAN KEPERAWATANDISIPLIN ILMU YANG SPESIFIKKOLABORASI MULTIDISIPLINNILAI NILAI YANG TERDAPAT DALAM BAHASA BAKU YANG TERSTRUKTURLANDASAN UNTUK MENDAPATKAN:INTEGRASI PENGETAHUAN YANG DIARAHKAN OLEH FAKTA-FAKTADOKUMENTASI YANG FLEKSIBELKOORDINASI ASUHANMENGUKUR KUALITASKEJELASAN KEPERAWATANPENEMUAN PENGETAHUANTaxonomy dalam KeperawatanTaxonomi: suatu klasifikasi khususnya dalam pengelompokan hewan dan tanaman sesuai dengan hubungan alamiahnyaTaxonomi diaplikasikan untuk sistem pemberian nama (nomenklatur) yang formalInti dari taxonomi adalah pemberian nama untuk sekelompok karakter yang memiliki kesamaan/hubungan secara alamiahLanjutanPengelompokan nama dalam bahasa baku keperawatan: domain, kelas, dan diagnosis/outcome/intervensiDomain: pengelompokan pengetahuan, pengaruh atau pengamatanKelas: sekelompok, satu set, atau sesuatu yang memiliki ciri yang umumLanjutan.Bahasa baku untuk diagnosis keperawatan memiliki 7 unsur (axis)Fokus (nyeri, nutrisi, dll)Subjek diagnosis (individu, keluarga, kelompok, komunitas)Penilaian (kerusakan, tidak efektif, defisiensi, gangguan, dll)Lokasi (bladder, auditory, dll)Kelompok umur (bayi, anak-anak, dewasa, lansia)Waktu (kronik, akut, hilang timbul, terus menerus)Status diagnosis (aktual, risiko, promosi kesehatan)Komponen-komponen bahasa baku dalam keperawatanNANDA-INIC: Nursing Interventions ClassificationNOC: Nursing Outcomes Classification

8NANDA: Diagnosis keperawatanDiagnosis Keperawatan suatu penilaian klinis tentang respons/proses hidup individu, keluarga atau komunitas terhadap masalah kesehatan potensial/proses hidup. Diagnosis keperawatan merupakan dasar dalam memilih intervensi keperawatan utuk mencapai hasil sesuai dengan tanggung gugat perawat.(NANDA, 2009)

9A Nursing Diagnosis is critical component in the nursing process. This is the first step in identifying how we should plan nursing care for our patients to improve patient outcomes for which nurses are held accountable. It also helps us to identify what are the priorities in caring for this patient.

Variasi Diagnosis Keperawatan

1. Diagnosis Aktual: menjelaskan kondisi kesehatan yang ada dan didukung oleh batasan karakteristik (P + E +S)2. Diagnosis Risiko: menjelaskan penyakit atau kondisi lain yang dapat berkembang dan didukung oleh faktor risiko (P + E) 3. Diagnosis sehat/sejahtera: menjelaskan tingkat kesehatan dan potensi untuk meningkatkan ke tingkat fungsi yang lebih tinggi (NANDA, 2009) and (Denehy & Poulton, 1999)

10Komponen Diagnosis Keperawatan1.Label atau nama dan definisi2. faktor yang berhubungan atau fakor risiko (Related factor)3. batasan karakteristik (defining characteritics)..tanda dan gejala111. A label or name and definition: the label is selected base upon a) matching the related factors or defining characteristics and the definition of the label validates your decision.2. Related factor(s) which describe conditions antecedent to or associated with the diagnosis ORRisk factor(s) which describe the environmental factors and physiologic ,genetic or chemical elements that increase the vulnerability of a (client) to an unhealthful event ( NANDA, 2009)3. Defining characteristics, which are observable signs and symptoms that are manifestations of the diagnosis (Denehy & Poulton. 1999)

a definition does not need to be written in the care plan. It is there to help you decide if this Nursing Diagnosis is appropriate for this patient.Related factors are elements that have an effect on the person, family or community, either internal or external, that contribute to the problemDefining Characteristics are subjective or objective s&s indicating the presence of a conditionRisk for Nursing Diagnosis do not need to include defining characteristics, because at this time there is no evidence that the condition exists. There is only a possibility the condition could exist.

Taxonomi Diagnosis Keperawatan (NANDA-I)DomainClass1Health Promotion2Nutritions3Elimination/Exchange4Activity/Rest5Perception/Cognition6Self Perceptions1Health awarenessIngestion Urinary FunctionSleep/RestattentionSelf-Concept2Health managementDigestionGastrointestinal FunctionActivity/ExerciseOrientationSelf-Esteem3Absorption Integumentary FunctionEnergy BalanceSensation/PerceptionBody Image4Metabolism Respiratory FunctionCardiovascular/Pulmonary ResponsesCognition5hydrationSelf-CareCommunication6DomainClass7Role Relationship8Sexuality 9Coping/stress Tolerance10Life Principles11Safety/Protection12Comfort13Growth Development1Caregiving RolesSexual IdentityPost-Trauma ResponseValuesInfectionPhysical ComfortGrowth2Family RrelationshipSexual FunctionCoping ResponseBeliefsPhysical InjuryEnvironmental ComportDevelopment3Role PerformanceReproductionNeuro-Behavioural StressValue/Beliefs/Action CongruenceViolenceSocial Comfort4Environmental Hazards5Defensive Processes6ThermoregulationDomain, class, Nsg. Dx. yang sering digunakan di klinik untuk memenuhi kebutuhan dasarDomain 2: Nutritionclass1class2class3class4class5Ingestion DigestionAbsorptionMetabolismHydrationInsufisiensi menyusui

Tidak efektif pola makan bayi

Ketidakseimbangan nutrisi: kurang dari yang dibutuhkan tubuhKetidakseimbangan nutrisi: lebih dari yang dibutuhkan tubuh

Saat ini belum adaSaat ini belum adaRisiko ketidakstabilan kadar glukose

Kuning pada neonatal

Risiko kuning pada neonatal

Risiko kerusakan fungsi liver

Risiko ketidakseimbangan elektrolit

Kesiapan untuk meningkatkan keseimbangan cairan

Defisiensi volume cairan

Kelebihan volume cairan

Risiko kekurangan cairan

Aaaarisiko ketidakseimbangan volume cairanDomain 3: Elimination and ExchangeClass1: urinary functionClass2: Gastrointestinal FunctionClass3: Integumentary FunctionClass4: Respiratory functionInkontinensia urin fungsional

Incontinensia urin overflow

Inkontinensia urin stress

Risk for urge urinary incontinence

Kerusakan eliminasi urinKesiapan untuk meningkatkan eliminasi urin

Retensi urinKonstipasi

Konstipasi yang dipersepsikan

Risiko konstipasi

Diare

Disfungsi motilitas gastrointestinal

Risiko Disfungsi motilitas gastrointestinal

Bowel incontinenceSaat ini belum adaKerusakan pertukaran gasDomain 4: Activity/RestClass1: Sleep/RestClass2: Activity/ExerciceClass3: energy balanceClass4: Cardiovascular/Pulmonary Response Class5: self-careInsomnia

Sleep deprivasion

Readiness for enhance sleep

Gaangguan pola tidurRisk for dysuse syndrome

Kerusakan mobilitas di tempat tidur

Kerusakan mobilitas fisik

Kerusakan mobilitas kursi roda

Kerusakan kemampuan berpindah tempat

Kerusakan berjalanDisturbed energy field

Kelelahan

WanderingIntoleransi aktivitasRisiko Intoleransi aktivitasTidak efektif pola napasPenurunan curah jantungRisiko tidak efektif perfusi gastrointestinalRisiko tidak efektif perfusi ginjalKerusakan ventilasi spontanTidak efektif perfusi jaringan periferRisiko penurunan perfusi jaringan cardiacRisiko tidak efektif perfusi jaringan serebralRisiko tidak efektif perfusi jaringan periferDisfungsi respons penyapihan ventilatorKerusakan pemeliharaan rumah

Kesiapan untuk meningkatkan perawatan diri

Defisit perrawatan diri mandi

Defisit perrawatan diri berpakaian

Defisit perrawatan diri makan

Defisit perrawatan diri toileting

Melalaikan diri sendiri

Domain 11: Safety/ProtectionClass1: InfectionClass2:Physical InjuryClass6: ThermoregulationRisiko infeksiTidak efektif bersihan jalan napas

Risiko aspirasi

Risiko perdarahan

Kerusakan gigi

Risiko mata kering

Risiko jatuh

Risiko perlukaan

Kerusakan membran mukosa mulut

Risiko perlukaan posisi perioperatif

Risiko disfungsi neurovaskular

Risiko syokKerusakan integritas kulit

Risiko sindrom kematian mendadak pada bayi

Risiko tersedak

Pemulihan pembedahan tertunda

Risiko perlukaan panas

Kerusakan integritas kulit

Risiko trauma

Risiko trauma vaskular

Risiko ketidakseimbangan suhu tubuh

Hipertermi

Hipotermi

Tidak efektif pengaturan panasDomain 12: ComfortClass1: Physical comfortClass2: Environmental comfortClass3: Social ComfortKerusakan kenyamanan

Kesiapan untuk meningkatkan kenyamanan

Mual

Nyeri akut

Nyeri kronisKerusakan kenyamanan

Kesiapan untuk meningkatkan kenyamanan

Kerusakan kenyamanan

Kesiapan untuk meningkatkan kenyamanan

Isolasi Sosial

Cara-cara menemukan diagnosis keperawatanIdentifikasi tanda dan gejala yang menonjol pada klienIdentifikasi pola yang tergangguNANDA-I penulisannya disusun berdasarkan pola (domain) bukan huruf awal diagnosisCari kelas (class)Perhatikan pengklasifikasian berdasarkan pengetahuan mengenai respons sistem tubuh manusiaBuat kata kunci untuk memudahkan menghubungkan dengan NANDAMual, nyeri, berhubungan dengan kenyamanan (sesuatu sensasi yang dirasakan secara subjektif)Contoh:Ketidakseimbangan nutrisi: kurang dari yang diperlukan tubuh (00002)Domain 2: NutrisiKelas 1: ingestionDefinisi: asupan nutrien kurang untuk memenuhi kebutuhan metabolik

Contoh Domain2: NutrisiClass1: IngestionNsg Dx.:Insufficient breast milk (00216)Ineffective Infant Feeding Pattern (00107)Imbalance Nutrition: less than body requirements (00002) Imbalance Nutrition: more than body requirements (00001)Readiness for enhance nutritions(00163)Risk for imbalance nutrition: more than body requirement (00003)

Batasan karakteristik:Kram perutNyeri perutTidak ada nafsu makanBerat badan dibawah 20% atau lebih rendah dari BB rata-rataKapiler rapuhDiareRambut rontok berlebihan ..Faktor yang berhubungan Biologis Ketidakmampuan menyerap nutrienKetidakmampuan mencerna makananKetidakmampuan memasukkan makananKekurangan finansialFaktor psikologisContoh kasus4 year old boy with ALLAdmitted one week after chemo with a fever of 102.5FWBC is 0.3,absolute neutrophil count is zeroNew central line placed 10 days agoC/O nausea & vomitingCries and hides behind mother when approach by nursing staff

Nursing diagnoses are chosen by using this subjective and objective data.24Examples 1. Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter),chronic disease (ALL)and developmental level.25Definition of the label: At increase risk for being invaded by pathogenic organisms ( NANDA,2009)Was our choice correct?Definition of the label: At increased risk for being invaded by pathogenic organisms Risk Factors: Insufficient knowledge to avoid exposure to pathogens (developmental level)Inadequate secondary defenses (leukopenia)Inadequate primary defenses (broken skin from newly placed central line)Pharmaceutical Agents (immunosuppressant, i.e. chemotherapy)(NANDA,2009)

26There are no defining characteristics for this diagnosis since it is a Risk for Nursing Diagnosis. More on that later.Examples 2. Nausea related to chemotherapy as evidenced by vomiting, patient c/o tummy ache and aversion toward food.

27Other pertinent Nursing DiagnosisExamples 3.Fear related to unfamiliarity with environmental experiences as evidenced by avoidance behaviors (hides behind mother) and crying.28A pertinent Growth and Development NDNote defining characteristics.NOCThe nursing outcomes classification (NOC) is a classification of nurse sensitive outcomesNOC 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)

29The use of NOC outcomes provides a quantitative measure of the [patient's] progress that is easy for all health care providers to understand and use. (Denehy and Poulton)ComponentsA neutral label or name used to characterize the behavior or patient statusA list of indicators that describe client behavior or patient status.A five point scale to rate the patients status for each of the indicators30The NOC outcome label indicates the behavior or status to be monitored.When using NOC Outcomes, You must use the label and definition as written, but the outcome can be individualized by selecting only the appropriate indicators or adding additional indicators if needed (Denehy and Poulton)NOC Domains in the Taxonomy

Functional Health Physiological Health Psychological Health Health Knowledge Behavior Perceived Health Family Health Community Health

Taxonomi NOCDomain(level 1)1Functional Health2Physiologic Health3Psychosocial Health4Health Knowledge and Behavior5Perceived Health6Family Health7Community HealthLevel 2AEnergy MaintenanceECardiopulmonaryMPsychological Well-BeingQHealth BehaviorUHealth & Life QualityWFamily Caregiver PerformancebCommunity Well-Being BGrowth & DevelopmentFEliminationNPsychosocial AdaptationRHaelth BeliefsVSymptom StatusZFamily Member Health StatuscCommunity Health ProtectionCMobilityGFluid & electrolytesOSelf-ControlSHealth KnowledgeeSatisfaction with CareXFamily Well-BeingD Self-CareHImmune ResponsePSocial InteractionTRisk Control & SafetydParentingIMetabolic RegulationJNeurocgnitiveKDigestion & NutritioneTherapeutic ResponseLTissue IntegrityYSensory Function32A five-point Likert type scale that quantifies a patient outcome or indicator status on a continuum from least to most desirable and provides a rating at a point in time 1 = Least Desirable State 5 = Most Desirable State Very weak to Very strong Never to Consistently Demonstrated Severe to None Poor to Excellent Not at all to Completely Satisfied No Knowledge to Extensive Knowledge Severely to Not Compromised Severe to No Deviation from Normal Range Not Adequate to Totally Adequate 10 and over to None None to Extensive Never Positive to Consistently Positive Select Outcome

Problem/Diagnoses Patient Preferences Patient Characteristics Nursing Treatment

Rate Patient Status

Select indicators Evaluate patient on selected indicators Determine overall outcome rating Set target rating- goal Determine focus of each discipline involved in care

Target Outcome Rating Allows for setting goal for patient related to a NOC outcome score using 2 options: Maintain at _____ Increase to _____ NANDA/NOC LinkageEach nursing Diagnosis is followed by a list of suggested outcomes to measure whether the chosen interventions are helping the identified problemEach outcome can be individualized to the patient or family by choosing the appropriate indicators or adding additional indicators as necessary39Menyambungkan NANDA-NOC ContohNICNOCDomain classLevel 1Level 22 nutrition1 ingestion2 Physiologic HealthK Nutrition2 metabolism2 Physiologic Healtha Therapeutic respons3 hydration2 Physiologic HealthG fluid electrolyte3 eliminasi exchange1 urinary2 Physiologic HealthF Elimination2 gastrointestinal2 Physiologic HealthF Elimination4 respiratory2 Physiologic HealthE Cardiopumonary4 activity rest1 sleep rest1 functional healthA Energy mantenance2 activity exercise1 functional healthC Mobility3 energy balance1 functional healthA Energy mantenance4 cardiopulmonary2 Physiologic HealthE Cardiopumonary5 self care1 functional healthD Self care11 safety protection1 infection2 Physiologic HealthH immune respons2 physical injury2 Physiologic HealthE Cardiopumonary6 thermoregulation2 Physiologic HealthI Metabolic regulation12 comfort1 phycical5 Perceived HealthV symptom status, U health life qualitty2 environmental3 socialNOC examples: Linked with Risk for InfectionImmune Status (0702)Infection Severity (0703)Knowledge: Infection Control (1807)Nutritional Status (1004)Tissue Integrity: Skin & Mucous membranes (1101)Wound Healing: Primary Intention (1102) Location of wound (#4, Front of Neck)

41Immune Status (0702)Definition: Natural and acquired appropriately targeted resistance to internal and external antigens.1=severely compromised thru 5= not compromisedAbsolute WBC values WNLDifferential WBC values WNLSkin integrityMucosa integrityBody temperature IERGastrointestinal function

42The scale applies to each outcome indicator in above exampleie. WBC count would be rated at a 1 since it is 38.3 C q 24 hours) (Drainage @ Central line site)Promote Nutritional intake (1500 kcal per day, Pt. likes cereal)

54Infection 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/malaiseInstruct 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)

55If there is something that the nurse feels needs to be added, then she should rely on her own clinical decision making skills and add additional activity(ies) as necessary.Sample Care Plan using Case StudyNANDA Nursing DiagnosesNOC Outcomes and IndicatorsNIC Intervention Label and select nursing activitiesRisk 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 WBCs)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)56Sample Blank CareplanNanda Nursing DiagnosisNOC Outcome Label(s) and indicatorsRationale for NOC chosenand indictor scoreNIC Intervention label(s) and nursing activitiesRationale for NIC ChosenComplete NANDA Nursing Dx Statement including related or risk factors and defining characteristics

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 labelNursing Diagnosis and Interventions: Choose the highest priority Nursing Diagnosis as indicated on the clinical reasoning web. Include problem statement (NANDA), related to or risk factors (etiology), and defining characteristics (as evidenced by or AEB) as appropriate. List all of the appropriate NOC Outcome labels and indicators and NIC intervention labels and nursing activities which will best help your client achieve those outcomes. List the rationale for each and determine where your client falls on the outcome indicator scale (1-5) at the specified time intervals. In the final column summarize why you gave your client the indicator scores that were given and any changes in your care plan that should be made.Briefly describe how the plan of care is helping the patient meet the desired outcomes and any changes that need to be made:

57ReferencesDenehy,J. & Poulton,S. (1999) Journal of School Nursing, 15 (1), 38-45.Iowa Intervention Project (2008). Nursing interventions and Classification (NIC). (4th ed.) St. Louis: Mosby, Inc.Iowa Outcomes Project (2008). Nursing outcomes classification (NOC). (3rd ed.) St. Louis: Mosby, Inc.NANDA Nursing Diagnosis: Definitions and Classifications 2009-2011. (2009). Indianapolis, IN: Wiley-Blackwell.

58References (cont.)Pesut, D. & Herman, J. (1999) Clinical Reasoning: The Art & Science of Critical and Creative Thinking. Albany, NY: Delmar Publishers.Schoenfelder, Deborah (2004). Nursing outcomes classification (NOC). Appendix F. (2004) St. Louis: Mosby, Inc.Van De Castle, B. (2003) Comparisons of Nanda/NIC/NOC linkages between experts and nursing students. International Journal of Terminologies and Classifications 14(4)59