Diagnosa Keperawatan Kriteria Nanda Dan Nic

Diagnosa Keperawatan Kriteria Nanda dan Nic-Noc DIAGNOSA KEPERAWATAN (KRITERIA NANDA, NOC, NIC) 1. DIAGNOSA I a. KEKURANGAN VOLUME CAIRAN 1) Nanda (Deficien !"#id V$"#%e&1',1''*) D$%ain + &N#-ii C"a + /&0id-ai Dian$i + K#-an 2$"#%e cai-an Pene-ian + Pen#-#nan cai-an in-a2ac#"a-, ine-iia" ine-iia",, dan aa# in-ae"#"e-, %ena-a3 4ada de3id-ai, 5e3i"anan cai-an an4a 4e-#6a3an $di#%.

8 8 8 8 8 8 8 8 8 8 8 8

7aaan Ka-a5e-i Ka-a5e-ii5 i5 + Ke"e%a3an 0a# Pen#-#nan #-$- 5#"i9"ida3 Me%6-an %#5$a95#"i 5e-in Penin5aan den:# nadi, 4en#-#nan e5anan da-a3, 4en#-#nan 2$"#%e9e5anan nadi Peniian 2ena %en#-#n Pe-#6a3an a# %ena" Pen#-#nan $#4# #-ine K$nen-ai #-ine %enin5a Te%4e-a#Te %4e-a#- #6#3 %enin5a 0e%a$5-i %enini Ke3i"anan 6e-a 6adan e5ei5a (5ec#a"i 4ada 3i-d 4acin)

) NOC + !LUID 7ALANCE (;*;1) D$%ain + P3:i$"$ic 3ea"3 (II) C"a + !"#id < E"ec-$":e (G) Sca"e + E=-e%e": c$%4-$%ied $ n$ c$%4-$%ied (a) Indi5ai + ;*;1;1 7"$$d 4-e#-e >IER ;*;1;1 Te Te5anan 5anan a-e-i -aa&-aa >IER ;*;1;/ Pa"4ai nadi 4e-ife;*;1; Keei%6anan %a#5an dan 5e"#a-an ? @a% ;*;1;' 7e-a 6adan a6i" ;*;11; Tida5 ada aie ;*;11 Tida5 ada ede%a 4e-ife-  ;*;11? Tida5 ada 5$nf#i ;*;11/ 3id-ai 5#"i

;*;11 ;*;11'

e"e5-$"i e-#%>WNL 3e%a$5-i >WNL

) NIC + AIRWAB MANAGEMENT  A5i2ia + 8 D#5#nan e%4$-e- da-i i-5#"ai %e"a"#i 4en#naan a"a&a"a %e5ani aa# 4$%4a 8 Ka@i $"e-ani a5i2iaa 4aien denan %e%4e-3ai5an aa" nafa 4ende5, n:e-i, 4a"4iai, aa# 4#in 8 E2a"#ai -e4$n 4aien e-3ada4 e-a4i $5ien 8 e"a5an #@#an 4e%6e-ian $5ien 4e- naa" 5an#"a aa# %a5e-. . DIAGNOSA II a. PER!USI ARINGAN TIDAK E!EKTI! (SPESI!IK + RENAL, CERE7RAL, KARDIOPULMONAL, GASTROINTESTINAL, PERI!ER) 1) Nanda (Ineffeci2e i#e 4e-f#i$n (4ecif: :4e  -ena", ce-e6-a", ca-di$4#"%$na-:, a-$ineina", 43e-i43e-a")). D$%ain + ?&A5i2ia9Tid#-  C"a + ?&Re4$n 5a-di$2a5#"e-9P#"%$na" Dian$i + Pe-f#i @a-inan ida5 efe5if (4eifi5 + -ena", ce-e6-a", 5a-di$4#"%$na", a-$ineina", 4e-ife-)) 4ene-ian + Pen#-#nan 5ada- $5ien e6ai a5i6a da-i 5eaa"an da"a% %e%e"i3a-a @a-inan di in5a 5a4i"e7aaan Ka-a5e-ii5+ Rena" 8 Pe-#6a3an e5anan da-a3 di "#a- 6aa 4a-a%ee-  8 0e%a#-ia 8 O"i#-i9an#-ia 8 E"e2ai94en#-#nan 7UN9-ai$ 5-eainin Ga-$ Ineina" 8 S#a-a ## 3i4$a5if aa# ida5 ada 8 Na#ea 8 Dieni a6d$%en 8 N:e-i a6d$%en aa# ida5 e-aa "#na5 (ende-ne) Pe-i43e-a" 8 Ede%a 8 Tanda 0$%an 4$iif  8 Pe-#6a3an 5a-a5e-ii5 5#"i (-a%6#, 5#5#, ai-95e"e%6a6an) 8 Den:# nadi "e%a3 aa# ida5 ada 8 Di5$"$-iai 5#"i 8 Pe-#6a3an #3# 5#"i

8 Pe-#6a3an enai 8 Ke6i-#&6i-#an 8 Pe-#6a3an e5anan da-a3 di e5-e%ia 8 7-#i 8 Te-"a%6a e%6#3 8 P#"ai a-e-ia" 6e-5#-an 8 Wa-na 5#"i 4#ca 4ada e"e2ai, a-na ida5 5e%6a"i 4ada 4en#-#nan 5a5i Ce-e6-a" 8 A6n$-%a"ia 6ica-a 8 Ke"e%a3an e5-e%ia aa# 4a-a"ii 8 Pe-#6a3an a# %ena" 8 Pe-#6a3an 4ada -e4$n %$$-i5 8 Pe-#6a3an 5e6iaaan 8 Pe-#6a3an -ea5i 4#4i" 8 Ke#"ian #n#5 %ene"an Ka-di$4#"%$na-  8 Pe-#6a3an f-e5#eni -e4i-ai di "#a- 6aa 4a-a%ee-  8 Pen#naan $$ 4e-nafaan a%6a3an 8 7a"i55an 5a4i"e- F  dei5 (Ca4i""a-: -efi"") 8 A6n$-%a" a da-a3 a-e-i 8 Pe-aaan I%4endin D$$%H (Ta5di- e-anca%) 8 7-$n5$4a%e 8 A-i%ia 8 Re-a5i dada 8 D:4nea 8 0id#n 5e%e-a3an 8 N:e-i dada ) NOC + URINARB ELIMINATION (;/;) D$%ain + P3:i$"$ica" 3ea"3 (II C"a + E"i%inai$n (!) Sca"e + E=e%e": c$%4-$%ied $ n$ c$%4-$%ied (a) Indi5ai + ;/;;1 ;/;; ;/;; ;/;;? ;/;;/ ;/;;* ;/;; ;/;1/

P$"a e"i%inai >IER 7a# #-in >IER #%"a3 #-in >IER Wa-na #-in U-in 6e6a 4a-i5e" U-in :an @e"a Keei%6anan ? @a% %a#5an dan 5e"#a-an 7UN (ni-a$en #-ea da-a3)

;/;1 ;/;1'

P-$ein da-a3 G#"a #-in

) NIC + !LUID MANAGEMENT (?1;)  A5i2ia + 8 Kecende-#nan %e%$ni$- 6e-a 4e-3a-i 8 Ma#55an 5aee- #-ina-:, @i5a di4e-"#5an 8 Pana# a# 3id-ai (%i + 5e5#aan nadi, aa# e5anan $-$aic da-a3) 8 Pana# a# 3e%$dina%i5 :ai# CVP, MAP, PCWP, @i5a di4e-"#5an 8 Pana# anda&anda 2ia" 8 Pana# #n#5 indi5ai 4ene"#a-an95e"#a-an cai-an (%i + aie, ede%a, d"") 8 Pana# a# 3ai" "a6$-a$-i#% #n#5 -eeni cai-an (%i + 5e"#a-an 3e%a$5-i dan %a#5an in5a $%$"a"ia #-in) 8 Pana# a# n#-ii 8 7e-i5an cai-an, @i5a di4e-"#5an

. DIAGNOSA III a. KERUSAKAN PERTUKARAN GAS 1) Nanda (I%4ai-ed a e=c3ane&1';, 1''*, 1'') D$%ain + &E"i%inai dan 4e"e4aan C"a + ?&!#ni -e4i-a$-i5 Dian$i + Ke-#a5an 4e-#5a-an a Pene-ian + Le6i3 aa# 5#-an da"a% e"i%inai $5ieniai dan aa# 5a-6$ndi$5ida di %e%6-an 5a4i"e-&   a"2e$"a-. 7aaan 5a-a5e-ii5 + 8 Gan#an 4en"i3aan 8 Pen#-#nan CO 8 Ta53i5a-di 8 0i4e-5a4nia 8 Ke"ei3an 8 Sa%n$"en 8 I-ia6i"ia 8 0:4$=ia 8 Ke6in#nan 8 D:4n$e 8 A-e-i a da-a3 a6n$-%a" (AGD) 8 C:an$i (3an:a 4ada ne$na#) 8 Wa-na 5#"i a6n$-%a" (4#ca, 5e3ia%&3ia%an) 8 0:4$5e%ia

8 8 8 8

0:4e-5a-6ia Sa5i 5e4a"a 5ei5a 6an#n La@# dan -i%e e-a 5eda"a%an 4e-nafaan a6n$-%a" Naa" f"a-in

) NOC + RESPIRATORB STATUS + VENTILATION (;?;) D$%ain + P3:i$"$ic 3ea"3 (II) C"a + Ca-di$4#"%$na-: (E) Sca"e + E=-e%e": c$%4-$%ied $ n$ c$%4-$%ied (a) Indi5ai + ;?;;1 ;?;; ;?;; ;?;;/ ;?;;* ;?;; ;?;;' ;?;1 ;?;1/

#%"a3 4e-nafaan Ri%e 4e-nafaan Pe-nafaan da"a% Ii-a3a c#5#4 Pe-e-a5an 4##% 5e"#a- da-i @a"an #da-a Ke5#aan 2$5a" A5e$-ie $n# $$ ida5 ada Di4n#e ida5 ada O-3$4nea ida5 ada

) NIC + ACID&7ASE MANAGEMENT (1'1;)  A5i2ia + 8 Pe-a3an5an 5e4aenan @a"an %a#5 IV 8 Pe-a3an5an @a"an nafa 8 Pana# A7C (acid&6ae %anae%en) dan in5a e"e5-$"i, @i5a dida4a5an 8 Pana# a# 3e%$dina%i5 :ai# CVP, MAP, PCWP, @i5a di4e-"#5an 8 Pana# #n#5 5e5#-anan cai-an (%i + %#na3, dia-e, di#-ei) @i5a di4e-"#5an 8 P$ii #n#5 fai"iai 5e5#aan 2eni"ai (%i + 6#5a @a"an nafa dan %enan5a 5e4a"a da-i e%4a id#-) 8 Pana# a# 4e-nafaan 8 7e-i5an e-a4i $5ien, @i5a di4e-"#5an

?. DIAGNOSA IV a. KELE7I0AN VOLUME CAIRAN 1) Nanda (e=ce f"#id 2$"#%e) D$%ain + &n#-ii C"a + /&3id-ai

Dian$i + 5e"e6i3an 2$"#%e cai-an Pene-ian + 4enin5aan -eeni cai-an i$$nic 7aaan Ka-a5e-ii5+ 8 7e-a 6adan %enin5a 4ada a5# :an in5a 8 A#4an 6e-"e6i3an di6andin $#4# 8 Te5anan da-a3 6e-#6a3, e5anan a-e-i 4#"%$na"i 6e-#6a3, 4enin5aan CVP 8 Ede%a, 5e%#n5inan 6e-5e%6an 5e anaa-ca 8 Dieni 2ena @##"a-i 8 Pe-#6a3an 4ada 4$"a nafa, d:4n$e9ea5 nafa, $-3$4n$e, #a-a nafa a6n$-%a" (Ra"e aa# c-a5"e), 5$nei95e%acean 4a-#, 4"e#-a" eff#i$n 8 06 dan 3e%a$5-i %en#-#n, 4e-#6a3an e"e5-$"i, 53##n:a 4e-#6a3an 6e-a @eni 8 S#a-a @an#n S III 8 Ref"e5 3e4a$@##"a- 4$iif  8 O"i#-ia, a$e%ia 8 Pe-#6a3an a# %ena", 5ee"ia3an, 5ece%aan ) NOC + !LUID 7ALANCE (;*;1) D$%ain + P3:i$"$ic 3ea"3 (II) C"a + !"#id < E"ec-$":e (G) Sca"e + E=-e%e": c$%4-$%ied $ n$ c$%4-$%ied (a) Indi5ai + ;*;1;1 7"$$d 4-e#-e >IER ;*;1;1 Te5anan a-e-i -aa&-aa >IER ;*;1;/ Pa"4ai nadi 4e-ife;*;1; Keei%6anan %a#5an dan 5e"#a-an ? @a% ;*;1;' 7e-a 6adan a6i" ;*;11; Tida5 ada aie ;*;11 Tida5 ada ede%a 4e-ife-  ;*;11? Tida5 ada 5$nf#i ;*;11/ 0id-ai 5#"i ;*;11 E"e5-$"i e-#%>WNL ;*;11' 0e%a$5-i >WNL

) NIC + AIRWAB MANAGEMENT  A5i2ia + 8 D#5#nan e%4$-e- da-i i-5#"ai %e"a"#i 4en#naan a"a&a"a %e5ani aa# 4$%4a 8 Ka@i $"e-ani a5i2iaa 4aien denan %e%4e-3ai5an aa" nafa 4ende5, n:e-i, 4a"4iai, aa# 4#in 8 E2a"#ai -e4$n 4aien e-3ada4 e-a4i $5ien 8 e"a5an #@#an 4e%6e-ian $5ien 4e- naa" 5an#"a aa# %a5e-.

/. DIAGNOSA V a. PENURUNAN CURA0 ANTUNG 1) Nanda (dec-eaed ca-diac $#4#&1'/, 1''*, ;;;) D$%ain + ?&a5i2ia9ii-a3a C"a + ?&-e4$n 5a-di2a5#"e-94#"%$na" Dian$i + Pen#-#nan c#-a3 @an#n Pene-ian + 5eida5%a%4#an @an#n da"a% %e%$%4a da-a3 eca-a ade5#a #n#5 %e%n#3i 5e6##3an %ea6$"i%e #6#3. 7aaan Ka-a5e-ii5+ 8 Pe-#6a3an den:# @an#n9i-a%a @an#n 8 A-i%ia (a5i5a-di,6-adi5a-di) Pe-#6a3an P-e"$ad 8 Dieni 2ena @##"a-i 8 Ede%a 8 Penin5aan94en#-#nan CVP (Cen-a" 2en$# P-e#-e) 8 Penin5aan94en#-#nan PAWP (P#"%$na-: a-e-: Wede P-e#-e) 8 Pena%6a3an 6e-a 8 Ke"e"a3an 8 M#-%#-  Pe-#6a3an afe-"$ad 8 K#"i dinin9"e%6a6 8 Ca4i""a-: Refi"" ana "a%6a 8 Pen#-#nan nadi 4e-ife-  8 Pe-#6a3an a-na 5#"i 8 Penin5aan94en#-#nan SVR (S:e%ic 2ac#"a- -eiance) 8 0ai" 4en#5#-an e5anan da-a3 6e-2a-iai 8 Nafa 4ende59d:4nea 8 O"i#-i Pen#-#nan 5$n-a5i"ia 8 C-ac5"e 8 O-3$4nea94a-$=:%a" n$c#-na" d:4nea 8 Ca-diac O#4# J ? L9%eni 8 Ca-diac Inde= J ./ L9%eni 8 Pen#-#nan f-a5i e@e5i, -$5e 2$"#%e inde= (SVI), Lef Ven-ic#"a- S-$5e W$-5 Inde= (LVSWI) 8 S#a-a S aa# S? 8 7a#5 Pe-i"a5#9e%$i 8 Kece%aan 8 Kee"ia3an

) NOC + NEUROLOGICAL STATUS (;';') D$%ain + 43:c$"$ica" a# (II) C"a + ne#-$c$nii2e () Sca"e + e=-e%e": $ n$ c$%4-$%ied (a) Indi5ai + ;';1 f#ni 4e-a-afan + 5eada-an ;'; f#ni 4e-a-afan + c$n-$" a-af 4#a ;'; f#ni 4e-a-afan + en$- 5-ania"9f#ni %$$-i5 ;';? f#ni 4e-a-afan + en$- 4ina"9f#ni %$$-i5 ;';* e5anan in-a5-ania" ;'; 5$%#ni5ai ;'; #5#-an 4#4i" ;';' -ea5i 4#4i" ;'1; 4e-e-a5an %aa ;'11 4$"a id#-  ;'1 anda&anda 2ia" ) NIC + CARDIAC CARE (?;?;)  A5i2ia + 8 E2a"#ai "$5ai n:e-i (%i + inenia, -adiai, d#-ai, "$5ai) 8 Caa anda dan e@a"a da-i 5e"#a-an c#-a3 @an#n 8 Pana# a# dan f-e5#eni anda 2ia" 8 Pana# a# i-a%a @an#n 8 Pana# 5eei%6anan cai-an (%i+ %a#5an95e"#a-an dan 6e-a 4e-3a-i) 8 Pana# f#ni 4ace%a5e-, @i5a di4e-"#5an 8 Pana# den:# nadi 4e-ife-, a5# 4eniian 5a4i"e- dan #3# e-a a-na e5-e%ia. 8 Pana# a#4an93a"#a-an #-ine dan 6e-a 6adan 4aien denan e4a. 8 Pana# -eieni ie%i5 dan 2a5#"a- 4a-# denan e4a. 8 A#5#"ai 6#n:i 4a-# #n#5 %enea3#i adan:a -$n5i 6aa3 5aa- aa# 6#n:i a%6a3an "ainn:a. 8 Pana# dan d$5#%enai5an den:# @an#n, i-a%a dan nadi.

*.

DIAGNOSA VI

a. MANAEMEN REGIMEN TERAPEUTIK TIDAK E!EKTI! 1) Nanda (Ineffeci2e 3e-a4e#ic -ei%en %anae%en&1'') D$%ain + 1&Penin5aan 5ee3aan C"a + &Mana@e%en 5ee3aan Dian$i + Mana@e%en -ei%en e-a4e#i5 ida5 efe5if. Pene-ian + P$"a da"a% %ena#- dan %enine-ai5an 4-$-a% e-a4i 4en:e%6#3an 5e da"a% 5e3id#4an :an ida5 %e%#a5an dan ida5 %enc#5#4i e#ai denan #@#an 4e%#"i3an 5ee3aan :an inin dica4ai. 7aaan Ka-a5e-ii5+ 8 Pe%i"i3an a5i2ia 3a-ian :an ida5 efe5if #n#5 %ene%#5an #@#an da-i "ai3an aa# 4-$-a% 4encea3an 8 Seca-a 2e-6a" %en#n5a45an ida5 %e"a5#5an inda5an #n#5 %en#-ani fa5$- -ei5$ 6ai 5e%a@#an a5i dan a5i6an:a 8 Keininan eca-a 2e-6a" #n#5 %ena#- "ai3an 6ai a5in:a dan 4encea3an a5i6a "an@#ann:a 8 Seca-a 2e-6a" %en:aa5an 5e#"ian denan 4ena#-an aa# ine-ai da-i a# aa# "e6i3 4e-ina3 -ei%en #n#5 %encea3 5$%4"i5ai dan "ai3an aa# a5i aa# a5i6an:a 8 Seca-a 2e-6a" %en:aa5an ida5 %e"a5#5an inda5an #n#5 %eni5#i -ei%en "ai3an da"a% -#inia 3a-ian ) NOC + KNOWLEDGE  TREATMENT REGIMEN (11) D$%ain + 0ea"3 5n$"ede 6e3a2i$#- (IV) C"a + 0ea"3 5n$"ede (S) Sca"e + N$ne $ e=eni2e (i) Indi5ai + 11;1 De5-i4i5an9a%6a-5an 4e-aaan :an 6ena-  11; De5-i4i5an9a%6a-5an #n#5 i#ai da-#-a. 11;/ De5-i4i5an9a%6a-5an 11;* De5-i4i5an9a%6a-5an 11; De5-i4i5an9a%6a-5an 11; De5-i4i5an9a%6a-5an

eca-a -ai$na" #n#5 -e4$n 4e-aaan di-i #n#5 4enen#an $6a #n#5 4en$6aan #n#5 a5i2ia #n#5 "ai3an

) NIC + 0EALT0 EDUCATION (//1;)  A5i2ia + 8 Ka@i 4enea3#an 4aien da"a% %enin5a5an 5ee3aan 4encea3an 4en:a5i. 8 Idenifi5ai %e$de 5$4in dan 4e%eca3an %aa"a3 :an 6iaa di"a5#5an $"e3 4aien. 8 e"a5an ie% 4e-aaan 5ee3aan ee-a, 3a" i# 6e5e-@a dan a4a :an da4a di3a-a45an $"e3 4aien95e"#a-a.

8 Inf$-%ai5an 4aien enan a5-ediai dan 4e-:a-aan da-i ae 3ea"3 de4a-%en #n#5 %eni"ai 5#a"ia fai"ia. 8 7e-i5an in-#5i e-#"i #n#5 #@#an dan 4ene%4aan a5i2ia 4e-aaan 5eea3an, @i5a di4e-"#5an. 8 Inf$-%ai5an 4aien 6aai%ana %ena5e "a:anan 5eda-#-aan %e"a"#i e"4$n dan 5enda-aan, 6i"a %e%#n5in5an. 8 Menidenifi5ai dan %e%fai"iai 5$%#ni5ai diana-a 4e%6e-i "a:anan 5ee3aan dan 4aien95e"#a-a 6i"a %e%#n5in5an.