E-Learning Keperawatan: DIAGNOSA NANDA (2005)

Friday, January 09, 2009

DIAGNOSA NANDA (2005)

DIAGNOSA NANDA (2005)

Taxonomy II : Domains, Kelas dan Diagnosis

A. Domain I : Promosi Kesehatan

Kelas 1 : Kesadaran akan Kesehatan : Rekognisi dari fungsi normal dan kesehatan

Kelas 2 : Managemen kesehatan : identifikasi, controlling, performing dan aktifitas yang terintegrasi untuk memelihara sehat dan kesehatan

Diagnosa yang berhubungan
1. Manajemen regimen terapi efektif
2. Manajemen regimen terapi tak efektif
3. Manajemen regimen terapi keluarga tak efektif
4. Manajemen regimen terapi komuniti tak efektif
5. Perilaku mencari bantuan kesehatan
6. Pemeliharan kesehatan tak efektif
7. kerusakan pemeliharaan rumah
8. Kesiapan untuk meningkatkan Manajemen regimen terapi
9. Kesiapan untuk meningkatkan nutrisi

B. Domain 2 : Nutrisi
Aktifitas untuk mengambil, asimilasi dan menggunakan nutrient untuk keseimbangan jaringan, perbaikan jaringan dan memproduksi energi

Kelas 1 : Ingesti : mengambil makanan atau nutrient kedalam tubuh
Diagnosa yang berhubungan
1. Pola makan infant tak efektif
2. Kerusakan menelan
3. Ketidakseimbangan nutrisi : kurang dari kebutuhan tubuh
4. Ketidakseimbangan nutrisi : lebih dari kebutuhan tubuh
5. Risiko terhadap ketidakseimbangan nutrisi : lebih dari kebutuhan tubuh
Kelas 2 : Digesti : aktifitas fisik dan kimia yang mengubah bahan makanan menjadi substansi yang memungkinkan diabsorpsi dan dicerna

Kelas 3 : Absorpsi: kegiatan mengambil nutrisi menuju jaringan tubuh

Kelas 4 : Metabolisme :

Kelas 5 : Hidrasi : pengambilan dan absorpsi cairan dan elektrolit
Diagnosa yang berhubungan
1. Kurang volume cairan
2. Risiko untuk kurang volume cairan
3. Kelebihan volume cairan
4. Risiko untuk ketidakseimbangan volume cairan
5. Kesiapan untuk meningkatkan keseimbangan cairan

C. Domain 3: Eliminasi
Sekresi dan ekskresi terhadap produk akhir dari tubuh

Kelas 1 : Fungsi Urinari
Diagnosa yang berhubungan
1. Kerusakan eliminasi urine
2. Retensi urine
3. Inkontinesia urine total
4. Inkontinensia urine fungsional
5. Inkontinensia urine stress
6. Inkontinensia urine tak tertahankan
7. Inkontinensia refleks urine
8. Risiko Inkontinensia urine tak tertahankan
9. Kesiapan meningkatkan eliminasi urine

Kelas 2 : Fungsi Gastrointestinal
Diagnosa yang berhubungan
1. Inkontinensia usus
2. Diare
3. Konstipasi
4. Risiko untuk konstipasi
5. Konstipasi dirasakan

Kelas 3: Fungsi Integumen/Kulit

Kelas 4 : Fungsi Respirasi : proses pertukaran gas dan pengeluaran produk akhir metabolisme

Diagnosa yang berhubungan
1. Kerusakan pertukaran gas

D. Domain 4 : Aktifitas dan Istirahat
Kelas 1 : Tidur/istirahat
Diagnosa yang berhubungan
1. Gangguan pola tidur
2. Kesulitan tidur
3. Kesiapan untuk meningkatkan tidur

Kelas 2 : Aktifitas/Kegiatan : pergerakan bagian dari tubuh (mobilitas), bekerja atau menunjukkan suatu kegiatan melawan tahanan
Diagnosa yang berhubungan
1. Risiko untuk Sindrom disuse
2. Kerusakan mobilitas fisik
3. Kerusakan mobilitas di tempat tidur
4. Kerusakan mobilitas di kursi roda
5. Kerusakan kemampuan berpindah
6. Kerusakan berjalan
7. Kurang aktifitas diversional (Hiburan)
8. Kelambatan penyembuhan pembedahan
9. Perilaku tak berubah

Kelas 3 : Keseimbangan Energi : keadaan dinamis antara pemasukan dan kebutuhan
Diagnosa yang berhubungan
1. Gangguan bidang energi
2. Kelemahan

Kelas 4 : Respon Kardiovaskuler/Pulmoner
Diagnosa yang berhubungan
1. Penurunan Curah Jantung
2. Kerusakan Ventilasi Spontan
3. Pola Nafas Takefektif
4. Aktifitas intoleran
5. Rsiko terhadap aktifitas intoleran
6. Disfungsi respon penyapihan ventilator
7. Perfusi jaringan takefektif (Spesifik : renal, cerebral, kardiopulmoner, gastrointestinal, perifer)

Kelas 5 : Perawatan Diri
Diagnosa yang berhubungan
1. Kurang perawatan diri : Berpakaian/berhias
2. Kurang perawatan diri : Mandi/hygiene
3. Kurang perawatan diri : Makan
4. Kurang perawatan diri : Toileting

E. Domain 5 : Persepsi/Kognisi
Kelas 1 : Perhatian
Diagnosa yang berhubungan
1. Pengabaian unilateral

Kelas 2 : Orientasi
Diagnosa yang berhubungan
1. Sindrom kerusakan interpretasi lingkungan
2. Wandering

Kelas 3 : Sensasi/Persepsi
Diagnosa yang berhubungan
1. Gangguan sensori persepsi (spesifikkan : visual, auditory, kinestetik, gustatori, taktil)

Kelas 4 : Kognisi
Diagnosa yang berhubungan
1. Kurang pengetahuan (spesifikkan)
2. Kesiapan untuk meningkatkan pengetahuan (spesifikkan)
3. Kebingungan akut
4. Kebingungan kronik
5. Kerusakan memori
6. Gangguan proses fikir

Kelas 5 : Komunikasi
Diagnosa yang berhubungan
1. Kerusakan komunikasi verbal
2. Kesiapan untuk meningkatkan komunikasi

F. Domain 6 : Persepsi – Diri : kesadaran akan diri
Kelas 1 : Konsep Diri
Diagnosa yang berhubungan
1. Gangguan identitas diri
2. Kelemahan
3. Risiko terhadap ketidakberdayaan
4. Ketidakberdayaan
5. Risiko terhadap kesepian
6. Kesiapan untuk meningkatkan konsep diri

Kelas 2 : Harga – Diri
Diagnosa yang berhubungan
1. Harga diri rendah kronik
2. Harga diri rendah situasional
3. Risiko terhadap harga diri rendah situasional

Kelas 3 : Citra Tubuh : pencitraan diri sendiri secara mental
Diagnosa yang berhubungan
1. Gangguan citra tubuh

G. Domain 7 : Hubungan Peran : hubungan positif dan negatif antara individu dan kelompok

Kelas 1: Peran Pemberi Asuhan
Diagnosa yang berhubungan :
1. Ketegangan pemberi asuhan
2. Risiko terhadap ketegangan pemberi asuhan
3. Kerusakan peran orang tua
4. Risiko Kerusakan peran sebagai orang tua
5. Kesiapan untuk meningkatkan peran sebagai orang tua

Kelas 2 : Hubungan Keluarga
Diagnosa yang berhubungan
1. Hambatan proses keluarga
2. Kesiapan meningkatkan proses keluarga
3. Disfungsi proses keluarga : alkoholisme
4. Risiko terhadap kerusakan kedekatan orang tua/anak

Kelas 3 : Penampilan Peran
Diagnosa yang berhubungan
1. Menyusui efektif
2. Menyusui tak efektif
3. Menyusui terganggu
4. Penampilan peran tak efektif
5. Konflik peran orang tua
6. Kerusakan interaksi sosial

H. Domain 8 : Seksualitas
Kelas 1 : Identitas Seksual

Kelas 2 : Fungsi Seksual
Diagnosa yang berhubungan
1. Disfungsi seksual
2. Pola seksualitas tak efektif

Kelas 3 : Reproduksi

I. Domain 9 : Koping/Toleransi Terhadap Stress
Kelas 1 : Respon Post-trauma
Diagnosa yang berhubungan
1. Sindrom stres relokasi
2. Risiko terhadap Sindrom stres relokasi
3. Sindrom trauma perkosaan
4. Sindrom trauma perkosaan : Reaksi diam
5. Sindrom trauma perkosaan : Reaksi gabungan
6. Sindrom post-trauma
7. Risiko Sindrom post-trauma

Kelas 2 : Respon Koping
Diagnosa yang berhubungan
1. Ketakutan
2. Kecemasan
3. Kecemasan akan kematian
4. Berduka kronik
5. Mengingkari tak efektif
6. Berduka antisipasi
7. Disfungsi berduka
8. Kerusakan penilaian
9. Koping tak efektif
10. Ketidakmampuan koping keluarga
11. Koping keluarga kompromi
12. Koping defensif
13. Koping komunitas tak efektif
14. Kesiapan untuk meningkatkan koping (individual)
15. Kesiapan untuk meningkatkan koping keluarga
16. Kesiapan untuk meningkatkan koping komuniti
17. Risiko terhadap disfungsi berduka

Kelas 3 : Neurhobehavioural Stress : respon perilaku yang melibatkan fungsi saraf dan otak
1. Disrefleksi otonom
2. Risiko untuk Disrefleksi otonom
3. Perilaku bayi takteratur
4. Risiko untuk Perilaku bayi takteratur
5. Kesiapan untuk meningkatkan Keteraturan perilaku bayi
6. Penurunan kapasitas adaptif intrakranial

J. Domain 10 : Prinsip Hidup
Kelas 1 : Nilai

Kelas 2 : Kepercayaan
Diagnosa yang berhubungan
1. Kesiapan untuk meningkatkan kesehatan spiritual

Kelas 3 : Nilai/Kepercayaan/Kesesuaian Tindakan
Diagnosa yang berhubungan
1. Distress spiritual
2. Risiko untuk distress spiritual
3. Konflik memutuskan (Spesifikkan)
4. Tidak terpenuhinya (Spesifikkan)
5. Risiko untuk kerusakan beragama
6. Kerusakan Beragama
7. Kesiapan untuk meningkatkan beragama

K. Domain 11 : Keamanan/Proteksi : terbebas dari bahaya, kecelakaan fisik atau kerusakan sistem imun.
Kelas 1 : Infeksi
Diagnosa yang berhubungan
1. Risiko terhadap infeksi

Kelas 2 : Cedera Fisik
Diagnosa yang berhubungan
1. Kerusakan membran mukosa oral
2. Risiko terhadap cedera
3. Risiko terhadap cedera posisi perioperasi
4. Risiko terjatuh
5. Risiko terhadap trauma
6. Kerusakan integritas kulit
7. Risiko terhadap kerusakan integritas kulit
8. Kerusakan integritas jaringan
9. Kerusakan pertumbuhan gigi
10. Risiko kekurangan nafas
11. Risiko aspirasi
12. Bersihan jalan nafas tak efektif
13. Risiko terhadap disfungsi neurovaskular perifer
14. Proteksi tak efektif
15. Risiko terhadap sindrom kematian bayi

Kelas 3 : Kekerasan
Diagnosa yang berhubungan
1. Risiko untuk mutilasi diri
2. Mutilasi diri
3. Risiko untuk mencederai orang lain
4. Risiko untuk mencederai diri sendiri
5. Risiko bunuh diri

Kelas 4 : Bahaya Lingkungan
Diagnosa yang berhubungan
1. Risiko keracunan

Kelas 5 : Proses Defensif
Diagnosa yang berhubungan
1. Respon alergi getah
2. Risiko terhadap alergi getah

Kelas 6 : Thermoregulasi
Diagnosa yang berhubungan :
1. Risiko terhadap ketidakseimbangan suhu tubuh
2. Termoregulasi tak efektif
3. Hipotermi
4. Hipertermi

L. Domain 12 : Kenyamanan
Kelas 1 : Kenyamanan Fisik
Diagnosa yang berhubungan
1. Nyeri akut
2. Nyeri kronik
3. Mual

Kelas 2 : Kenyamanan Lingkungan

Kelas 3 : Kenyamanan Sosial
Diagnosa yang berhubungan
1. Isolasi Sosial

M. Domain 13 : Pertumbuhan/Perkembangan
Kelas 1 : Pertumbuhan
Diagnosa yang berhubungan
1. Pertumbuhan dan perkembangan terhambat
2. Risiko terhadap pertumbuhan tidak proporsional
3. Kegagalan pertumbuhan dewasa

Kelas 2 : Perkembangan
Diagnosa yang berhubungan
1. Pertumbuhan dan perkembangan terhambat
2. Risiko untuk perkembangan terhambat

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Blog Contents

Florence Nightingales’s Environmental Theory

by Sudiryo NPM 220111080041

Florence Nightingales’s Environmental Theory

Defined Nursing: “The act of utilizing the environment of the patient to assist him in his recovery.”
Focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.
Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and light/direct sunlight.
Considered a clean, well-ventilated, quiet environment essential for recovery.
Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself.

Virginia Henderson’s Definition of the Unique Function of Nursing

By Sudiryo NPM 220111080041

Virginia Henderson’s Definition of the Unique Function of Nursing

Defined Nursing: “Assisting the individual, sick or well, in the performance of those activities contributing to health or it’s recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”.
Identified 14 basic needs :
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range
8. Keeping the body clean and well-groomed
9. Avoiding dangers in the environment
10. Communicating with others
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing/participating in various forms of recreation
14. Learning, discovering or satisfying the curiosity that leads to normal development and health and using available health facilities.

Calixta Roy’s Adaptation Theory

By Sudiryo NPM 220111080041

Calixta Roy’s Adaptation Theory

Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who cope with their environment through Biopsychosocial adaptation mechanisms.
Focuses on the ability of Individuals., families, groups, communities, or societies to adapt to change.
The degree of internal or external environmental change and the person’s ability to cope with that change is likely to determine the person’s health status.
Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptation.

Jean Watson’s The Philosophy and Science of Caring

By Sudiryo NPM 220111080041

Jean Watson’s The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health.
Nursing is a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human care transactions
She defined caring as a nurturant way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in a caring environment
Carative Factors:

1. The promotion of a humanistic-altruistic system of values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development and acceptance of the expression of positive and negative feelings.
5. The systemic use of the scientific problem-solving method for decision making
6. The promotion of interpersonal teaching-learning
7. The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritual environment
8. Assistance with the gratification of human needs
9. The allowance for existential phenomenological forces

Dorothea Orem’s Self-Care Theory

By Sudiryo, NPM 220111080041

Dorothea Orem’s Self-Care Theory

Defined Nursing: “The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness.”
Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being.
Has a strong health promotion and maintenance focus.
Identified 3 related concepts:
1. Self-care - activities an Individual performs independently throughout life to promote and maintain personal well-being.
2. Self-care deficit - results when self-care agency (Individual’s ability) is not adequate to meet the known self-care needs.
3. Nursing System - nursing interventions needed when Individual is unable to perform the necessary self-care activities:
  1. Wholly compensatory - nurse provides entire self-care for the client.
    - Example: care of a new born, care of client recovering from surgery in a post-anesthesia care unit
  2. Partial compensatory - nurse and client perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently.
    - Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who can feed himself
  3. Supportive-educative - nurse’s actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement.
- - - Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychiatric client on more adaptive coping strategies.

Madeleine Leininger’s Transcultural Care Theory and Ethno-nursing

Madeleine Leininger’s Transcultural Care Theory and Ethnonursing

Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death.
Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care services to people according to their cultural values and health-illness context.
Focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors.
Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Hildegard Peplau’s Interpersonal Relations Theory

Hildegard Peplau’s Interpersonal Relations Theory

Defined Nursing: “An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.
Nursing is a “maturing force and an educative instrument”
Identified 4 phases of the Nurse - Patient relationship:
1. Orientation - individual/family has a “felt need” and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase.
2. Identification - where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance.
3. Exploitation - the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services.
4. Resolution - where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Faye Glenn Abdellah’s Concept of Twenty One Nursing Problems

by Sudiryo, NPM : 220111080041

Faye Glenn Abdellah’s Concept of Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.
Nursing is a comprehensive service that is based on the art and science and aims to help people, sick or well, cope with their health needs.

21 Nursing Problems

To maintain good hygiene.
To promote optimal activity; exercise, rest and sleep.
To promote safety.
To maintain good body mechanics
To facilitate the maintenance of a supply of oxygen
To facilitate maintenance of nutrition
To facilitate maintenance of elimination
To facilitate the maintenance of fluid and electrolyte balance
To recognize the physiologic response of the body to disease conditions
To facilitate the maintenance of regulatory mechanisms and functions
To facilitate the maintenance of sensory functions
To identify and accept positive and negative expressions, feelings and reactions
To identify and accept the interrelatedness of emotions and illness.
To facilitate the maintenance of effective verbal and non-verbal communication
To promote the development of productive interpersonal relationship
To facilitate progress toward achievement of personal spiritual goals
To create and maintain a therapeutic environment
To facilitate awareness of self as an individual with varying needs.
To accept the optimum possible goals
To use community resources as an aid in resolving problems arising from illness.
To understand the role of social problems as influencing factors

Rosemarie Rizzo Parse’s Theory of Human Becoming

Martha Roger’s Concept of Science of Unitary Human Beings, and Principles of Homeodynamics

By Sudiryo NPM 220111080041

Martha Roger’s Concept of Science of Unitary Human Beings, and Principles of Homeodynamics

Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development. The goal of nurses is to participate in the process of change..
Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to achieve maximum health.
5 basic assumptions:

1. The human being is a unified whole, possessing individual integrity and manifesting characteristics that are more than and different from the sum of parts.
2. The individual and the environment are continuously exchanging matter and energy with each other
3. The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum
4. Patterns identify human being and reflect their innovative wholeness
5. The individual is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion