Saya pakai DOENGOES, Dia pakai CARPENITO Mereka pakai NANDA, NOC dan NIC (NNN) apakah bedanya? Intansari Nurjannah, SKp, MNSc

‘Saya pakai DOENGOES’, ‘Dia pakai CARPENITO’ Mereka pakai NANDA, NOC dan NIC (NNN) apakah bedanya? Intansari Nurjannah, SKp, MNSc., PhD

Adakah bedanya antara DOENGOES, CARPENITO dan NNN? DOENGOES

CARPENITO

NNN

Nama Orang

Nama Orang

Nama Standar Bahasa Keperawatan

Pengarang buku: Nursing Care Plan Guidelines for Individualizing Client Care Across the Life Span

Pengarang Buku: Nursing Diagnosis Application to Clinical Practice

Pengarang: Marilyn E. DOENGOS Mary Frances Moorhouse Alice C. Murr

Pengarang: Lynda Jual Carpenito Moyet

N-NANDA N-NOC N-NIC

Apa Isi Buku DOENGOES, CARPENITO DAN NNN? Doengoes

Carpenito

NANDA

NOC

NIC

Rancangan asuhan keperawatan: 1. Cardiovascular 2. Respiratory 3. Neurolological/Sensory disorders 4. Gastrointestinal disorders 5. Metabolic and Endocrine Disorders 6. Disease/Blood/Blood – Forming Organs 7. Renal and Urinary Tract 8. Womens’s Resproductive 9. Ortophedic 10. Integumentary 11. Systemic Infections and Immunological Disorders 12. General

rancangan asuhan keperawatan:

SNL – Diagnosis

SNL – Outcome Domain 1. Functional Health 2. Physiologic health 3. Psychosocial health 4. Health Knowledge & Behavior 5. Perceived Health 6. Family Health 7. Community Health

SNL – Intervensi Domain 1. Basic physiologica l 2. Complex physiologica l 3. Behavior 4. Safety 5. Family 6. Health System 7. Community

RANCANGAN ASKEP MENGGUNAKAN PENDEKATAN ‘DISORDERS’ -- Menggunakan NNN

1.

2.

3.

4.

Diagnosis keperawatan individual Diagonosis keperawatan keluarga/di rumah Diagnosis keperawatan promosi kesehatan Diagnosis kolaboratif

RANCANGAN ASKEP MENGGUNAKAN PENDEKATAN LABEL DIAGNOSIS -- Menggunakan NNN -- Non-NANDAApproved Diagnoses

Label diagnosis Domain: 1: Health Promotion 2: Nutrition 3: Elimination and Exchange 4: Activity/Rest 5: Perception/Cognition 6: Self-Perception 7: Role relationships 8: Sexuality 9: Coping/Stress Tolerance 10: Life Principles 11: Safety/Protection 12: Comfort 13: Growth/Development

Diagnostic reasoning Doenges

Halaman 11 (42) -nursing process Diagnostic reasoning – 11 (42) Halaman 12 (43) – Diagnostic reasoning

Carpenito

NANDA

Chapter 5:

Chapter 1 and 2 Assessment can be a from a nursing theory (page 24-54) Gordon’s FHP - recommended Diagnoses: Clinical reasoning -Distinguish normal from abnormal data -Clustered related data -Recognize missing data - Identify inconsistency in data -Make inferences (Alfaro,Lelebre, 2004, cited from page 25 (55))

Assessment -Initial, Baseline or Screening Assessment (53)

-Gordon’s Functional Health status (page 54) File click here

STEPS (page 32)

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Assessment

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NURSE

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Assessment

Figure 2.1 Diagram of the nursing process. The steps of the nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic.

TABLE 2.1 Nursing Diagnoses Accepted for Use and Research Through 2009 Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Airway Clearance, ineffective Allergy Response, latex Allergy Response, risk for latex Anxiety [specify level] Anxiety, death Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, risk-prone health Bleeding, risk for Body Image, disturbed Body Temperature, risk for imbalanced Bowel Incontinence Breastfeeding, effective Breastfeeding, ineffective Breastfeeding, interrupted Breathing Pattern, ineffective Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Childbearing Process, readiness for enhanced Comfort, impaired Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Conflict, decisional (specify) Conflict, parental role Confusion, acute Confusion, risk for acute Confusion, chronic Constipation Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, compromised family

8

Coping, defensive Coping, disabled family Coping, ineffective Coping, ineffective community Coping, readiness for enhanced Coping, readiness for enhanced community Coping, readiness for enhanced family Death Syndrome, risk for sudden infant Decision Making, readiness for enhanced Denial, ineffective Dentition, impaired Development, risk for delayed Diarrhea Dignity, risk for compromised human Distress, moral Disuse Syndrome, risk for Diversional Activity, deficient Electrolyte Imbalance, risk for Energy Field, disturbed Environmental Interpretation Syndrome, impaired Failure to Thrive, adult Falls, risk for Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear [specify focus] Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hypertonic/hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced

Gas Exchange, impaired Glucose Level, risk for unstable blood Grieving Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed Health Maintenance, ineffective Health Management, ineffective self Health Management, readiness for enhanced self Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Hyperthermia Hypothermia Identity, disturbed personal Immunization Status, readiness for enhanced Infant Behavior, disorganized Infant Behavior, risk for disorganized Infant Behavior, readiness for enhanced organized Infection, risk for Injury, risk for Injury, risk for perioperative positioning Insomnia Intracranial Adaptive Capacity, decreased Jaundice, neonatal Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Lifestyle, sedentary Liver Function, risk for impaired Loneliness, risk for

In this book, nursing priorities are listed in a certain order to facilitate the linking and ranking of selected associated nursing diagnoses that appear in the plan of care guidelines. In any given client situation, nursing priorities are based on the client’s specific needs and can vary from minute to minute. A nursing diagnosis that is a priority today may be less of a priority tomorrow, depending on the fluctuating physical and psychosocial condition of the client or the client’s changing responses to the existing condition. An example of nursing priorities for a client diagnosed with severe hypertension would include the following: 1. Maintain and enhance cardiovascular functioning. 2. Prevent complications. 3. Provide information about disease process, prognosis, and treatment regimen. 4. Support active client control or management of the condition.

Discharge Goals Once the nursing priorities are determined, the next step is to establish goals of treatment. In this book, each medical condition has established discharge goals, which are broadly stated and reflect the desired general status of the client on discharge or transfer to another care setting. Discharge goals for a client with severe hypertension would include the following: 1. Blood pressure within acceptable limits for individual 2. Cardiovascular and systemic complications prevented or minimized 3. Disease process and prognosis and therapeutic regimen understood 4. Necessary lifestyle and behavioral changes initiated

Nursing Diagnosis (Problem and Need Identification) Nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. Nursing diagnosis labels (see Table 2.1) provide a format for expressing the problem-identification portion of the nursing process. In 1989, NANDA developed a taxonomy or classification scheme to categorize and classify nursing diagnostic labels. (This was replaced by a new taxonomy in 2000.) The NANDA definition of nursing diagnosis approved in 1990 further clarified the second step of the nursing process (i.e., diagnosis or problem and need identification). The definition of nursing diagnosis developed by NANDA is presented in Box 2.1.

A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

There are several steps involved in the process of problem and need identification. Integrating these steps provides a systematic approach to accurately identifying nursing diagnoses using the process of critical thinking. 1. Collect a client database (nursing interview, physical assessment, and diagnostic studies) combined with information collected by other healthcare providers. 2. Review and analyze the client data. 3. Synthesize the gathered client data as a whole and then label the clinical judgment about the client’s responses to these actual or high-risk problems and life processes. 4. Compare and contrast the relationships of clinical judgments with related factors and define characteristics for the selected nursing diagnosis. This step is crucial to choosing and validating the appropriate nursing diagnosis label that will be used to create a specific client diagnostic statement. 5. Combine the nursing diagnosis with the related factors and define characteristics to create the client diagnostic statement. For example, the diagnostic statement for a paraplegic client with a decubitus ulcer could read as follows: impaired Skin Integrity related to pressure, circulatory impairment, and decreased sensation evidenced by draining wound, sacral area. The nursing diagnosis is as correct as the present information allows because it is supported by the immediate data collected. It documents the client’s situation at the present time and should reflect changes as they occur in the client’s condition. Accurate need identification and diagnostic labeling provide the basis for selecting nursing interventions. The nursing diagnosis may be a physical or a psychosocial response. Physical nursing diagnoses include those that pertain to physical processes, such as circulation (ineffective renal Tissue Perfusion), ventilation (impaired Gas Exchange), and elimination (Constipation). Psychosocial nursing diagnoses include those that pertain to the mind (acute Confusion), emotions (Fear), or lifestyle and relationships (ineffective Role Performance). Unlike medical diagnoses, nursing diagnoses change as the client progresses through various stages of illness and/or maladaptation to resolution of the problem or to the conclusion of the condition. Each decision the nurse makes is time dependent, and with additional information gathered at a later time, decisions may change. For example, the initial problems and needs for a client undergoing cardiac surgery may be acute Pain, decreased Cardiac Output, ineffective Airway Clearance, and risk for 11

THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES

Nursing Priorities

Box 2.1 NANDA-I Definition of Nursing Diagnosis

CHAPTER 2

results that require reporting to the physician and/or initiation of specific nursing interventions. In many cases, the relationship of the test to the pathological physiology is clear, but in other cases it is not. This is the result of the interrelationship between various organs and body systems.

Infection. As the client progresses, problems and needs are likely to shift to Activity Intolerance, deficient Knowledge, and ineffective Role Performance. Diagnostic reasoning is used to ensure the accuracy of the client diagnostic statement. The defining characteristics and related factors associated with the chosen nursing diagnosis are reviewed and compared with the client data. If the diagnosis is not consistent with a majority of the cues or is not supported by relevant cues, additional data may be required or another nursing diagnosis considered.

Desired Client Outcomes The nurse identifies outcomes for a plan of care individualized for a specific client (ANA, 2004). A desired client outcome is defined as the result of achievable nursing interventions and client responses that is desired by the client or caregiver and attainable within a defined time period, given the current situation and resources. These desired outcomes are the measurable steps toward achieving the previously established discharge goals and are used to evaluate the client’s response to nursing interventions. (The fifth step of the nursing process, evaluation, is addressed in the sample client situation provided in Chapter 3.) Useful desired client outcomes must have the following characteristics: 1. Be specific 2. Be realistic or achievable 3. Be measurable 4. Indicate a definite time frame for achievement 5. Consider client’s desires and resources Desired client outcomes are created by listing items and behaviors that can be observed or heard. They are monitored to determine whether an acceptable outcome has been achieved within a specified time frame. Action verbs and time frames are used, for example, “client will ambulate, using cane, within 48 hours of surgery.” The action verbs describe the client’s behavior to be evaluated. Time frames are dependent on the client’s projected or anticipated length of stay, often determined by diagnosis-related group (DRG) classification and considering the presence of complications or extenuating circumstances, such as age, debilitating disease process, and so on. The ongoing work of NOC in identifying 385 outcomes now also addresses client groups or aggregates. Although the NOC outcomes are listed in general terms such as Ambulation, 16 indicators are included for this outcome that can be measured by a five-point Likert-type scale, ranging from “severely compromised” to “not compromised.” This facilitates tracking clients across care settings and can demonstrate client progress even when outcomes are not met. When outcomes are properly written, they provide direction for planning and validating the selected nursing interventions. Consider the two following client outcomes: “Client will identify individual nutritional needs within 36 hours” and “. . . formulate a dietary plan based on identified nutritional needs within 12

72 hours.” Based on the clarity of these outcomes, the nurse can select nursing interventions to ensure that the client’s dietary knowledge is assessed, individual needs identified, and nutritional education presented. Often, the client outcomes identified are not unique to nursing because we provide care in a team approach with other disciplines. However, the NOC indicators for outcomes are generally more sensitive to nursing interventions. Other team members can use the majority of NOC labels and identify different indicators relative to their specialty focus to demonstrate their contribution to client improvement or to track deterioration. In this book, the identified outcomes in each plan of care are stated in more specific terms but are organized by using NOC labels (which are boxed to call attention to this language).

Planning (Goals and Actions/Interventions) Once outcomes are identified, the nurse develops strategies or interventions and alternatives to achieve the outcomes (ANA, 2004). Nursing interventions are prescriptions for specific behaviors expected from the client and actions to be carried out or facilitated by nurses. These actions and interventions are selected to assist the client in achieving the stated desired client outcomes and discharge goals. The expectation is that the prescribed behavior will benefit the client and family in a predictable way related to the identified problem, need, and chosen outcomes. These interventions have the intent of individualizing care by meeting a specific client need and should incorporate identified client strengths when possible. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity, for example, “Assist as needed with selfcare activities each morning”; “Record respiratory and pulse rates before, during, and after activity”; and “Instruct family in postdischarge care.” The NIC project has identified 542 interventions (both direct and indirect) that are stated in general terms, such as Respiratory Monitoring. Each label has a varied number of activities that may be chosen to accomplish the intervention. The interventions encompass a broad range of nursing practice, with some requiring specialized training or advanced certification. Others may be appropriate for delegation to other care providers, for example, licensed practical nurses (LPNs) or vocational nurses (LVNs), nursing assistants, and unlicensed personnel, but still require planning and evaluation by registered nurses. In this text, these NIC labels are boxed to help the user identify how they can be used. This book divides the nursing interventions and actions into independent (nurse initiated) and collaborative (initiated by and/or performed in conjunction with other care providers) under the appropriate NIC labels. Examples

5

PLANNING CARE WITH NURSING DIAGNOSIS Learning Objectives After reading the chapter, the student should be able to answer the following questions: • What are functional health patterns? • How are priority nursing diagnoses identified? • What is the difference between nursing and client goals? • How is evaluation different for nursing diagnoses and collaborative problems? • What are standardized care plans?

Because clients require nursing care 7 days a week and 24 hours a day, nurses must rely on one another and nonlicensed nursing personnel to help clients achieve outcomes of care. Obviously, some system of communication is necessary. For more than 30 years, this system consisted of handwritten care plans or verbal reports, neither of which was very useful. This chapter addresses the varied methods that nurses use today to communicate a client’s care to other caregivers.

Data Collection Formats___________________________________________________ Data collection usually consists of two formats: the nursing baseline or screening assessment and the focus or ongoing assessment. The nurse can use each alone or together. As discussed in Chapter 3, nurses encounter, diagnose, and treat two types of response: nursing diagnoses and collaborative problems. Each type requires a different assessment focus.

Initial, Baseline, or Screening Assessment An initial, baseline, or screening assessment involves collecting a predetermined set of data during initial contact with the client (e.g., on admission, first home visit). This assessment serves as a tool for “narrowing the universe of possibilities” (Gordon, 1994). During this assessment, the nurse interprets data as significant or insignificant. This process is explored later in this chapter. The nurse should organize the initial assessment to permit systematic, efficient data collection. Appendix B illustrates an assessment form with checking or circling options, which can help save time during documentation. The nurse always can elaborate with additional questions and comments. Open-ended questions are better for assessment of certain functional areas, such as fear or anxiety. Nurses should view printed assessment forms as guides, not mandates. Before requesting information from a client, nurses should ask themselves, “What am I going to do with the data?” If certain information is useless or irrelevant for a particular client, then its collection is unnecessary and potentially distressing. For example, asking a terminally ill client how much he or she smokes is unnecessary unless the nurse has a specific goal. If a client will be NPO, collecting data about eating habits is probably unnecessary. Such assessment will be indicated if the client resumes eating. If a client is extremely stressed, the nurse should collect only necessary data and defer the assessment of functional patterns to another time. A stressed client is not the best source of data, because stress may cloud the memory.

Functional Health Patterns As discussed earlier, nursing assessment focuses on collecting data that validate nursing diagnoses. Gordon’s system of functional health patterns provides an excellent, relevant format for nursing data collection to determine an individual’s or group’s health status and functioning (1994). After data collection is complete, the nurse and client can determine positive functioning, altered functioning, or at-risk for altered functioning. Altered functioning is defined as functioning that the client (individual or group) perceives as negative or undesirable. Refer to Box 5.1 for functional health patterns. Refer to Appendix B for a sample initial assessment organized according to functional health patterns. It is designed to assist the nurse in gathering subjective and objective data. Should questions arise

31

32 The Focus of Nursing Care

BOX 5.1 FUNCTIONAL HEALTH PATTERNS 1.

Health Perception–Health Management Pattern • Perceived pattern of health, well-being • Knowledge of lifestyle and relationship to health • Knowledge of preventive health practices • Adherence to medical, nursing prescriptions

7.

Self-Perception–Self-Concept Pattern • Attitudes about self, sense of worth • Perception of abilities • Emotional patterns • Body image, identity

2.

Nutritional–Metabolic Pattern • Usual pattern of food and fluid intake • Types of food and fluid intake • Actual weight, weight loss or gain • Appetite, preferences

8.

Role–Relationship Patterns • Patterns of relationships • Role responsibilities • Satisfaction with relationships and responsibilities

3.

Elimination Pattern • Bowel elimination pattern, changes • Bladder elimination pattern, changes • Control problems • Use of assistive devices • Use of medications

9.

Sexuality–Reproductive Pattern • Menstrual, reproductive history • Satisfaction with sexual relationships, sexual identity • Premenopausal or postmenopausal problems • Accuracy of sex education

10.

Coping–Stress Tolerance Patterns • Ability to manage stress • Knowledge of stress tolerance • Sources of support • Number of stressful life events in last year

11.

Value–Belief Pattern • Values, goals, beliefs • Spiritual practices • Perceived conflicts in values

4. Activity–Exercise Pattern • Pattern of exercise, activity, leisure, recreation • Ability to perform activities of daily living (selfcare, home maintenance, work, eating, shopping, cooking) 5. Sleep–Rest Pattern • Patterns of sleep, rest • Perception of quality, quantity 6.

Cognitive–Perceptual Pattern • Vision, learning, taste, touch, smell • Language adequacy • Memory • Decision-making ability, patterns • Complaints of discomforts

concerning a pattern, the nurse would gather more data about the diagnosis by using the focus assessment under the diagnosis. When collecting data according to the functional health patterns, the nurse questions, observes, and evaluates the client or family. For example, under the Cognitive–Perceptual Pattern, the nurse asks the client if he or she has difficulty hearing, observes if the client is wearing a hearing aid, and evaluates if the client understands English.

Physical Assessment In addition to functional health pattern assessment, the nurse also collects data related to body system functioning. Physical assessment, the collection of objective data concerning the client’s physical status, incorporates head-to-toe examination, with a focus on the body systems. The techniques used include inspection, palpation, percussion, and auscultation. Appendix B lists those areas of physical assessment in which nurse generalists should be proficient. Physical assessment by nurses should be clearly “nursing” in focus. By examining their philosophy and definition of nursing, nurses should seek to develop expertise in those areas that will enhance nursing practice. Keep in mind that separation of functional health patterns from physical assessment is done for organizational purposes only. No useful nursing assessment framework can restrict actual data collection in such a manner. Because humans are open systems, a problem in one functional health pattern invariably influences body system functioning or functioning in another functional health pattern. Anxiety can effect appetite; Sleep problems can increase coping difficulties

health promotion opportunities. All of these steps require knowledge of underlying concepts of nursing science before patterns can be identified in clinical data or accurate diagnoses can be made.

Understanding Nursing Concepts Knowledge of key concepts, or nursing diagnostic foci, is necessary before beginning an assessment. Examples of critical concepts important to nursing practice include breathing, elimination, thermoregulation, physical comfort, self-care, and skin integrity. Understanding such concepts allows the nurse to identify patterns in the data and diagnose accurately. Key areas to understand with the concept of pain, for example, include manifestations of pain, theories of pain, populations at risk, related pathophysiological concepts (e.g., fatigue, depression), and management of pain. Full understanding of key concepts is needed as well to differentiate diagnoses. For example, in order to understand hypothermia or hyperthermia, a nurse must first understand the core concepts of thermal stability and thermoregulation. In looking at problems that can occur with thermoregulation, the nurse will be faced with the diagnoses of hypothermia (00006) (or risk for), hyperthermia (00007) (or risk for), but also risk for imbalanced body temperature (00005) and ineffective thermoregulation (00008). The nurse may collect a significant amount of data, but without a sufficient understanding of the core concepts of thermal stability and thermoregulation, the data needed for accurate diagnosis may have been omitted and patterns in the assessment data go unrecognized.

Assessment Assessment involves the collection of subjective and objective information (e.g., vital signs, patient/family interview, physical exam) and review of historical information in the patient chart. Nurses also collect information on strengths (to identify health promotion opportunities) and risks (areas that nurses can prevent or potential problems they can postpone). Assessments can be based on a particular nursing theory such as one developed by Sister Callista Roy, Wanda Horta, or Dorothea Orem, or on a standardized assessment framework such as Marjory Gordon’s Functional Health Patterns. These frameworks provide a way of categorizing large amounts of data into a manageable number of related patterns or categories of data. The foundation of nursing diagnosis is clinical reasoning. Clinical reasoning is required to distinguish normal from abnormal data, cluster related data, recognize missing data, identify inconsistencies in 24 Nursing Diagnoses 2015–2017

Outcome Doengoes

Carpenito

NOC

Characteristic of Outcome: 1. Be specific 2. Be realistic or achievable 3. Be measurable 4. Indicate a definite time frame for achievement 5. Consider client’s desires and resources

Goal for Collaborative Problems (halaman 59) Goal for Nursing Diagnosis (halamam 60)

Pertimbangan ketika memilih NOC (hal. 28 -) 1. Tipe masalah kesehatan 2. Diagnosis Keperawatan atau Diagnosis medis 3. Karakteristik pasien 4. Sumber daya yang tersedia 5. Pilihan pasien 6. Potensi pengobatan

File Click here

Planning Care with Nursing Diagnosis 37

Certain situations may call for involvement from several disciplines. For example, for a client experiencing extreme anxiety, the physician may prescribe an antianxiety medication, an occupational therapist may provide diversional activities, and a nurse may institute nonpharmacologic anxiety-reducing measures, such as relaxation exercises. According to Gordon (1994), “Saying a nursing diagnosis is a health problem a nurse can treat does not mean that non-nursing consultants cannot be used. The critical element is whether the nurse-prescribed interventions can achieve the outcome established with the client.”

INTERACTIVE EXERCISE

5.3

Examine the following goals: The client will • Demonstrate stable vital signs • Have electrolytes within normal range • Have cardiac rhythm and rate within normal limits • Have blood loss within acceptable limits after surgery While you are caring for this client, his cardiac rhythm becomes abnormal and his surgical wound begins to bleed. What would you do? • Change the nursing interventions. • Revise the goal. • Change the diagnosis. • Call the doctor for physician-prescribed interventions. (Answer at end of chapter)

Revaluating the Goal If a client goal is not achieved or progress toward achievement is not evident, the nurse must reevaluate the attainability of the goal or review the nursing care plan, asking the following questions (Carpenito, 1999): • Is the diagnosis correct? • Has the goal been set mutually? Is the client participating? • Is more time needed for the plan to work? • Does the goal need to be revised? • Does the plan need to be revised? • Are physician-prescribed interventions needed?

Goals for Collaborative Problems As discussed earlier, identifying client goals for collaborative problems is inappropriate and can imply erroneous accountability for nurses. Rather, collaborative problems involve nursing goals that reflect nursing accountability in situations requiring physician-prescribed and nurse-prescribed interventions. This accountability includes (1) monitoring for physiologic instability, (2) consulting standing orders and protocols or a physician to obtain orders for appropriate interventions, (3) performing specific actions to manage and to reduce the severity of an event or situation, and (4) evaluating client responses. Nursing goals for collaborative problems can be written as “The nurse will manage and minimize the problem.” The following are examples of goals for collaborative problems: Collaborative Problem

Nursing Goal

Risk for Complications of Bleeding

The nurse will monitor to detect early signs/symptoms of bleeding and collaboratively intervene to stabilize the client. Indicators Calm, alert, oriented Urine output 5 ml/kg/hr Pulse 60-100 breaths/min


Goals for Nursing Diagnoses Client goals can represent predicted resolution of a problem, evidence of progress toward resolution of a problem, progress toward improved health status, or continued maintenance of good health or function. Nurses and clients use these goals to direct interventions to achieve desired changes or maintenance and to measure the effectiveness and validity of interventions. Nurses can formulate goals (outcome criteria) to direct and measure positive results or to prevent complications. Goals (outcome criteria) seek to direct interventions to provide the client with: • Improved health status by increasing comfort (physiologic, psychological, social, spiritual) and coping abilities (e.g., The client will discuss relationship between activity and carbohydrate requirements and walk unassisted to end of hall four times a day.) • Maintenance of present optimal level of health (e.g., The client will continue to share fears.) • Optimal levels of coping with significant others (e.g., The client will relate an intent to discuss with her husband her concern about returning to work.) • Optimal adaptation to deterioration of health status (e.g., The client will visually scan the environment to prevent injury while walking.) • Optimal adaptation to terminal illness (e.g., The client will compensate for periods of anorexia and nausea.) • Collaboration and satisfaction with health care providers (e.g., The client will ask questions concerning the care of his colostomy.) Alternatively, goals (outcome criteria) seek to direct interventions to prevent negative alterations in the client, such as: • Complications (e.g., The client will not experience the complications of imposed bed rest as evidenced by continued intact skin; full range of motion, no calf tenderness, and clear lung fields.) • Disabilities (e.g., The client will elevate left arm on pillow and exercise fingers on sponge ball to reduce edema.) • Unwarranted death (e.g., The infant will be attached to an apnea monitor at night.)

Components of Goals The essential characteristics of goals are as follows: • Long-term or short-term • Measurable behavior • Specific in content and time • Attainable Long and Short Term Goals A long-term goal is an objective that the client is expected to achieve over weeks or months. A short-term goal is an objective that the client is expected to achieve in a few days or as a stepping stone toward a longterm goal. Long-term goals are appropriate for all clients in long-term care facilities and for some clients in rehabilitation units, mental health units, community nursing settings, and ambulatory services. For a client with a nursing diagnosis of Risk for Suicide (Varcarolis, 2007): Long-term Goal Short-term Goals

Client will state that she wants to live. Client will discuss painful feelings. Client will make no-suicide contract with nurse by end of first session.

Measurable behavior is expressed by use of measurable verbs, or verbs that describe the exact action that the nurse expects the client to display when he or she has met the goal. The action or behavior must be such that the nurse can validate it through seeing or hearing. (The nurse may occasionally use touch, taste, and smell to measure goal achievement.) If the verb does not describe a result that can be seen or heard (e.g., The client will experience less anxiety), the nurse can change it to a behaviorally measurable one (e.g., The client will report less anxiety).

Intervensi Doenges

Carpenito

NANDA

Under appropriate NIC label:

NIC Halaman 62-63

Pertimbangan pemilihan NIC (hal 16) 1. Hasil yang diinginkan pasien 2. Karakteristik diagnosis keperawatan 3. Dasar penelitian untuk intervensi 4. Kelayakan untuk melakukan intervensi 5. Penerimaan bagi pasien 6. Kemampuan perawat

1. Nurse Initiated 2. Collaborative

40 The Focus of Nursing Care Possible nursing diagnoses do not have goals until they are confirmed. How can the nurse write a client goal for a diagnosis that has not been confirmed or ruled out yet?

Prescribing Nursing Interventions As previously discussed (see Chapter 4), the two types of nursing interventions are nurse prescribed and physician prescribed (delegated). Nurse-prescribed interventions are those that nurses formulate for themselves or other nursing staff to implement. Physician-prescribed (delegated) interventions are prescriptions for clients that physicians formulate for nursing staff to implement. Physicians’ orders are not orders for nurses; rather, they are orders for clients that nurses implement if indicated. Both types of interventions require independent nursing judgment, because legally the nurse must determine whether it is appropriate to initiate the action, regardless of whether it is independent or delegated. Box 5.2 shows a sample nursing care plan with both types of interventions. Note that nurses can and should consult with other disciplines, such as social workers, nutritionists, and physical therapists, as appropriate. Nevertheless, doing so is consultative only; if interventions for nursing diagnoses result from such consultation, the nurse writes these orders on the nursing care plan for other nursing staff to implement. (A discussion of other disciplines and their role in nursing care plans is included later in this chapter.)

BOX 5.2 NURSE-PRESCRIBED AND DELEGATED INTERVENTIONS Standard of Care Risk for Complications of Increased Intracranial Pressure NP

1.

Monitor for signs and symptoms of increased intracranial pressure. • Pulse changes: slowing rate to 60 or below; increasing rate to 100 or above • Respiratory irregularities: slowing rate with lengthening periods of apnea • Rising blood pressure or widening pulse pressure with moderately elevated temperature • Temperature rising • Level of responsiveness: variable change from baseline (alert, lethargic, comatose) • Pupillary changes (size, equality, reaction to light, movements) • Eye movements (doll’s eyes, nystagmus) • Vomiting • Headache: constant, increasing in intensity; aggravated by movement/standing • Subtle changes: restlessness, forced breathing, purposeless movements, and mental cloudiness • Paresthesia, paralysis NP 2. Avoid: • Carotid massage • Prone position • Neck flexion • Extreme neck rotation • Valsalva maneuver • Isometric exercises • Digital stimulation (anal) NP 3. Maintain a position with slight head elevation. NP 4. Avoid rapidly changing positions. NP 5. Maintain a quiet, calm environment (soft lighting). NP 6. Plan activities to reduce interruptions. NP 7. Intake and output; use infusion pump to ensure accuracy. NP 8. Consult for stool softeners. Del 9. Maintain fluid restrictions as ordered (may be restricted to 1000 mL/day for a few days). Del 10. Administer fluids at an even rate as prescribed. Del 11. Administer medications (osmotic diuretics [e.g., mannitol] and corticosteroids [e.g., dexamethasone, methylprednisolone if administered]). (Del = Delegated; NP = Nurse-prescribed)

Planning Care with Nursing Diagnosis 41

Bulechek and McCloskey (1989) define nursing interventions as “any direct care treatment that a nurse performs on behalf of a client. These treatments include nurse-initiated treatments resulting from nursing diagnoses, physician-initiated treatments resulting from medical diagnoses, and performance of essential daily functions for the client who cannot do these.” Their definition links all nursing interventions with nursing diagnoses. This author links all nursing interventions with nursing diagnoses and collaborative problems. Figure 5.1 lists the six basic types of nursing interventions identified by Bulechek and McCloskey (1989), with this author’s changes.

Focus of Nursing Interventions As discussed in Chapter 4, the major focus of interventions differs for actual, risk, and possible nursing diagnoses and collaborative problems. For actual nursing diagnoses, interventions seek to: • Reduce or eliminate contributing factors or the diagnosis • Promote higher-level wellness • Monitor and evaluate status For risk nursing diagnoses, interventions seek to: • Reduce or eliminate risk factors • Prevent the problem • Monitor and evaluate status For possible nursing diagnoses, interventions seek to: • Collect additional data to rule out or confirm the diagnosis For collaborative problems, interventions seek to: • Monitor for changes in status • Manage changes in status with nurse-prescribed and physician-prescribed interventions • Evaluate response

Nursing Orders The specific directions for nursing—nursing orders—consist of the following: • Date • Directive verb • What, when, how often, how long, where • Signature

Nursing Diagnosis

1. Assessment activities to make nursing diagnoses [and collaborative problems] 2. [Monitoring] activities to [evaluate status] 3. Nurse-initiated treatments 4. Physician-initiated treatments, in response to medical diagnoses 5. Daily essential function activities that may not relate to either medical or nursing diagnoses but are done by the nurse for clients who cannot do these for themselves 6. Activities to evaluate the effects of nursing and medical treatments. These are also assessment activities but they are done for purposes of evaluation, not diagnosis

Collaborative Problems

FIGURE 5.1 Relationship of nursing interventions to nursing diagnosis and collaborative problems. (Bulechek, G., & McCloskey, J. (1989). Nursing interventions: Treatments for potential nursing diagnoses. In CarrollJohnson, R.M. [Ed.]. Classification of nursing diagnoses: Proceedings of the eighth national conference. Philadelphia: J.B. Lippincott. Brackets indicate changes made by author.)

Nursing Process Doengoes

Carpenito

NOC

Format Pengkajian

Pengkajian (theory) Format pengkajian

NOC NIC -Lihat bagian 4 – hal 584 -Lihat bagian 6 – hal 495

Care Plan (Planning) halaman 56-67

Impaired skin integrity (p. 617)

Contoh NCP: Impaired skin integrity Risk for Unstable Blood Glucose Acute Pain Ineffective peripheral tissue perfusion

Risiko Kadar Glukosa darah tidak stabil (p. 682)

Diagnosis berdasarkan Divisi diagnosis (Diagnosis Division) – halaman 51-53 Kasus NCP

NIC

Impaired skin integrity (p. 525) Risiko Kadar Glukosa darah tidak stabil (p. 530) Acute Pain (559-560)

Acute Pain (645) Ineffective Periph eral Tissue Pefussion (653)

Ineffective Peripheral Tissue Pefussion (570)

Activity/Rest Subjective (Reports) Occupation: _____________________________________________ Able to participate in usual activities/hobbies:______________ Ambulatory: _____ Gait (describe): _______________ Activity level (sedentary to very active): ___________________ Daily exercise/type: ______________________________________ Muscle mass/tone/strength (e.g., normal, increased, decreased): _________________________________ History of problems/limitations imposed by condition (e.g., immobility, can’t transfer, weakness, breathlessness): _______________________________________ Feelings (e.g., exhaustion, restlessness, can’t concentrate, dissatisfaction): _______________________________________ Developmental factors (e.g., delayed/age): _________________ Sleep: Hours: ______ Naps: _______________________________ Insomnia: _____ Related to: ____________________________ Difficulty falling asleep: ________________________________ Difficulty staying asleep: _______________________________ Rested on awakening: _________________________________ Excessive grogginess: _________________________________ Bedtime rituals: _________________________________________ Relaxation techniques: ___________________________________ Sleeps on more than one pillow: _________________________ Oxygen use (type): _______When used: ___________________ Medications or herbals for/affecting sleep: _________________ ______________________________________________________

Objective (Exhibits) Observed response to activity: Heart rate: ____________________ Rhythm (reg/irreg): _______________________________________ Blood pressure: __________________________________________ Respiration rate: _________________________________________ Pulse oximetry: __________________________________________ Mental status (i.e., cognitive impairment, withdrawn/lethargic): _____________________________________ Muscle mass/tone: _________________________________________ Posture (e.g., normal, stooped, curved spine): ______________ Tremors: ________________________________________________ (location): _____________________________________________ ROM: ____________________________________________________ Strength: ________________________________________________ Deformity: _______________________________________________ Uses mobility aid (list): _____________________________________

Circulation Subjective (Reports)

Objective (Exhibits)

History of/treatment for (date): High blood pressure: _______ Brain injury: _________ Stroke: _________ Heart problems/surgery: _________ Palpitations: _________ Syncope: _____ Cough/hemoptysis: _____ Blood clots: ____ Bleeding tendencies/episodes: __________ Pain in legs w/activity __________ Extremities: Numbness: _______ (location): _______ Tingling: _______ (location): _______ Slow healing (describe): __________ Change in frequency/amount of urine:_____________________ History of spinal cord injury/dysreflexia episodes: _________ Medications/herbals: _____________________________________

Color (e.g., pale, cyanotic, jaundiced, mottled, ruddy): Skin: ______ Mucous membranes: _________ Lips: __________ Nail beds:__________ Conjunctiva: _________ Sclera: ________ Skin moisture (e.g., dry, diaphoretic): ________________________ BP: Lying: R________ L________ Sitting: R________ L________ Standing: R________ L________ Pulse pressure: ____________ Auscultatory gap: _____________ Pulses (palpated 1–4 strength): Carotid: _____ Temporal: ______ Jugular: _____ Radial: _____ Femoral: _____ Popliteal: ______ Post-tibial: _____________Dorsalis pedis: ___________________ Cardiac (palpation): Thrill: _________ Heaves: _________ Heart sounds (auscultation): Rate: _________ Rhythm: _________ Quality: _________ Friction rub: _________ Murmur (describe location/sounds): _______________________ Vascular bruit (location): ______ Jugular vein distention: _______ Breath sounds (location/describe): ___________________________ Extremities: Temperature: ___________ Color: _________________ Capillary refill (1–3 sec): _________ Homans’ sign: __________ Varicosities (location): ____________________________________ Edema (location/severity +1– +4): ____________________________ Distribution/quality of hair: _______________________________ Trophic skin changes: ________ Nail abnormalities: ________

15

CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE

Name: _________________________________________________________________________________________________________________ Age: _____________ DOB: ___________ Gender: ____________ Race: __________________________ Admission Date: ___________________ Time:_______________From: _________________________ Reason for this visit (primary concern): __________________________________________________________________________________ Cultural concerns (relating to healthcare decisions, religious concerns, pain, childbirth, family involvement, communication, etc.): _______________________________________________________________________________________________________________________ Source of information: _________________________ Reliability (1–4 with 4 = very reliable):_____________________________________

CHAPTER 3

ADULT MEDICAL/SURGICAL ASSESSMENT TOOL General Information

Ego Integrity Subjective (Reports) Relationship status: _____________________________________ Expression of concerns (e.g., financial, lifestyle or role changes): ______________________________________ Stress factors: __________________________________________ Usual ways of handling stress: ___________________________ Expression of feelings: Anger: _________ Anxiety: __________ Fear: ________ Grief: __________ Helplessness: ___________ Hopelessness: __________ Powerlessness: ______________ Cultural factors/ethnic ties: _______________________________ Religious affiliation: _________ Active/practicing: ___________ Practices prayer/meditation: ___________________________ Religious/spiritual concerns: ___________________________ Desires clergy visit: ___________________________________ Expression of sense of connectedness/harmony with self and others: __________________________________ Medications/herbals: ____________________________________

Objective (Exhibits) Emotional status (check those that apply): Calm: __________________Anxious: ________________________ Angry: _________________Withdrawn: _____________________ Fearful: _________________Irritable: ________________________ Restive: ________________Euphoric: _______________________ Observed body language: ___________________________________ Observed physiological responses (e.g., palpitations, crying, change in voice quality/volume): __________________________ Changes in energy field: Temperature: ____________________________________________ Color: ___________________________________________________ Distribution: _____________________________________________ Movement: ______________________________________________ Sounds: _________________________________________________

Elimination Subjective (Reports)


Usual bowel elimination pattern: _________________________ Character of stool (e.g., hard, soft, liquid): ______________ Stool color (e.g., brown, black, yellow, clay colored, tarry): ___________________________________ Date of last BM and character of stool: ____________________ History of bleeding: ________ Hemorrhoids/fistula: _________ Constipation: acute: ___________ or chronic: _______________ Diarrhea: acute: _____________ or chronic: _______________ Bowel incontinence: ___________________________________ Laxative: _________ (how often): __________________________ Enema/suppository: _________ (how often): ______________ Usual voiding pattern and character of urine: ______________ Difficulty voiding: _________Urgency: _____________________ Frequency: _____________Retention: ____________________ Bladder spasms: ________Burning: _____________________ Urinary incontinence (type/time of day usually occurs): _____ ______________________________________________________ History of kidney/bladder disease: ________________________ Diuretic use: ________ Herbals: ____________________________

Abdomen (auscultation): Bowel sounds (location/type): _______ Abdomen (palpation): Soft/firm: _____________________________ Tenderness/pain (quadrant location): ______________________ Distention: __________ Palpable mass/location: ____________ Size/girth: ___________ CVA tenderness: __________________ Bladder palpable: _______ Overflow voiding: _________________ Rectal sphincter tone (describe): _____________________________ Hemorrhoids/fistulas: _________ Stool in rectum: _____________ Impaction: __________ Occult blood (+ or –): ________________ Presence/use of catheter or continence devices: ______________ Ostomy appliances (describe appliance and location): ________ _________________________________________________________

Food/Fluid Subjective (Reports)


Usual diet (type): ________________________________________ Calorie, carbohydrate, protein, fat intake (g/day): ________ # of meals daily: ____ Snacks (number/time consumed): ____ Dietary pattern/content: B _____________________________________________________ L:_____________________________________________________ D: ____________________________________________________ Snacks: _______________________________________________ Last meal consumed/content: ____________________________ Food preferences: _______________________________________ Food allergies/intolerances: ______________________________ Cultural or religious food preparation concerns/prohibitions: _________________________________ Usual appetite: ________ Change in appetite: ______________ Usual weight: ________ Unexpected/undesired weight loss or gain: _____________ Nausea/vomiting: ____ (related to): _______________________ Heartburn/indigestion: ________________________________ (related to): ________ (relieved by): ______________________ Chewing/swallowing problems: ___________________________ Gag/swallow reflex present: ____________________________

Current weight: _____ Height: _______________________________ Body build: ________ Body fat %: __________________________ Skin turgor (e.g., firm, supple, dehydrated): __________________ Mucous membranes (moist/dry): ____________________________ Edema: Generalized: _______________________________________ Dependent: ______________________________________________ Feet/ankles: ______________________________________________ Periorbital: ______________________________________________ Abdominal/ascites: _______________________________________ Jugular vein distention: _____________________________________ Breath sounds (auscultate)/location: _________________________ Faint/distant: ________ Crackles: ________ Wheezes: _________ Condition of teeth/gums: _______ Appearance of tongue: ______ Mucous membranes: _____________________________________ Abdomen: Bowel sounds (quadrant location/type): ___________ Hernia/masses: ____________________________________________ Urine S/A or Chemstix: _____________________________________ Blood glucose (Glucometer): ______________________________

16

CHAPTER 3

Food/Fluid (continued) Subjective (Reports)


Facial injury/surgery: ____________________________________ Stroke/other neurological deficit: _______________________ Teeth: Normal: ____ Dentures (full/partial): _________________ Loose/absent teeth/poor dental care: ___________________ Sore mouth/gums:_____________________________________ Diabetes: ______ Controlled with diet/pills/insulin: __________ Vitamin/food supplements: _______________________________ Medications/herbals: _____________________________________

Hygiene Subjective (Reports)


Ability to carry out activities of daily living: ________________ General appearance: Manner of dress: ____________________ Independent/dependent (level 1 = no assistance needed Grooming/personal habits: ____________________________ to level 4 = completely dependent): _____________________ Condition of hair/scalp: ________________________________ Mobility: ___ Assistance needed (describe): _______________ Body odor: ___________________________________________ Assistance provided by: _______________________________ Presence of vermin (e.g., lice, scabies): ___________________ Equipment/prosthetic devices required: _________________ Feeding: ___ Help with food preparation: __________________ Help with eating utensils: ______________________________ Hygiene: ____ Get supplies: ____ Wash body/body parts: ___ Regulate bath water temperature: ___ Get in/out alone: ___ Preferred time of personal care/bath: ___________________ Dressing: ___ Can select clothing: ____ Can dress self: ______ Needs assistance with(describe): _______________________ Toileting: ___ Can get to toilet/commode alone: ___________ Needs assistance with (describe): _______________________

Neurosensory Subjective (Reports)


History of brain injury, trauma, stroke (residual effects): ____ Fainting spells/dizziness: _________________________________ Headaches (location/type/frequency): _____________________ Tingling/numbness/weakness (location): __________________ Seizures: ____ History or new onset seizures: ______________ Type (e.g., grandmal, partial): ______ Frequency: ________ Aura: _______ Postictal state: ______ How controlled: ____ Vision: Loss/changes in vision: ________ Date last exam: ____ Glaucoma: ____ Cataract: ____ Eye surgery (type/date): ___ Hearing loss: ____ Sudden or gradual: ____________________ Date last exam:________________________________________ Sense of smell (changes): ________________________________ Sense of taste (changes): ___________ Epistaxis: ____________ Other: __________________________________________________

Mental status (note duration of change):______________________ Oriented/disoriented: Time: ____________ Place:_____________ Person: __________________________________________________ Situation: ________________________________________________ Check all that apply: Alert: _____ Drowsy: _____ Lethargic: _____ Stupor: __ Comatose: __ Cooperative: __ Agitated/Restless: __ Combative: _____ Follows commands: _____________________ Delusions (describe): _______ Hallucinations (describe): ________ Affect (describe): ___________ Speech Pattern: ________________ Memory: Recent: ___________ Remote: _______________________ Pupil shape: _______________ Size/reaction: R/L: _______________ Facial droop: ______________ Swallowing: ____________________ Hand grasp/release: R: _______________ L: ____________________ Coordination: ________ Balance: ________ Walking: ____________ Deep tendon reflexes (present/absent/location): ______________ Tremors: ________ Paralysis (R/L): ________ Posturing: _________ Wears glasses: _______ Contacts: _______ Hearing aids: ________

Pain/Discomfort Subjective (Reports)


Primary focus: ____________________ Location: _____________ Facial grimacing: _______ Guarding affected area: _____________ Intensity (use pain scale or pictures): ______________________ Emotional response (e.g., crying, withdrawal, anger): _______ Quality (e.g., stabbing, aching, burning): ________________ Narrowed focus: _________________________________________ Radiation: ________ Duration: ________ Frequency: _______ Vitals sign changes (acute pain): Precipitating factors: _____________________________________ BP: ______________________________________________________ Relieving factors (including nonpharmaceuticals/therapies): Pulse:____________________________________________________ ______________________________________________________ Respirations: ____________________________________________ Associated symptoms (e.g., nausea, sleep problems, crying): ______________________________________________________ Effect on daily activities: _______________________________ Relationships: ________________ Job:____________________ Enjoyment of life:______________________________________ Additional pain focus (describe): __________________________ Medications: _________________Herbals: ___________________

17

Respiration Subjective (Reports)


Dyspnea/related to: ______________________________________ Precipitating factors: _________ Relieving factors: _________ Airway clearance (e.g., spontaneous/device): ______________ Cough (e.g., hard, persistent, croupy): ____________________ Produces sputum (describe color/character): ____________ Requires suctioning: __________________________________ History of (year): Bronchitis: _________ Asthma: ___________ Emphysema: _____________ Tuberculosis: _______________ Recurrent pneumonia: _________________________________ Exposure to noxious fumes/allergens, infectious agents/ diseases, poisons/pesticides: __________________________ Smoker: ______ packs/day: _________ # of years: ___________ Use of respiratory aids: ____ Oxygen (type/frequency): _____ Medications/herbals: _____________________________________

Respirations (spontaneous/assisted): ________ Rate: ___________ Depth: _______ Chest excursion (e.g., equal/unequal): _______ Use of accessory muscles: ________________________________ Nasal flaring: ________________ Fremitus:___________________ Breath sounds (presence/absence; crackle, wheezes): _________ Egophony: ______________________________________________ Skin/mucous membrane color (e.g., pale, cyanotic): ___________ Clubbing of fingers: ________________________________________ Sputum characteristics: _____________________________________ Mentation (e.g., calm, anxious, restless): _____________________ Pulse oximetry: ____________________________________________

Safety Subjective (Reports)


Allergies/sensitivity (medications, foods, environment, latex): ______________________________________________________ Type of reaction: _______________________________________ Blood transfusion/number: ____ Date: _____________________ Reaction (describe): ___________________________________ Exposure to infectious diseases (e.g., measles, influenza, pink eye): _____________________________________________ Exposure to pollution, toxins, poisons/pesticides, radiation: ______________________________________________________ (describe reactions): ___________________________________ Geographic areas lived in/visited: ________________________ Immunization history: Tetanus:____ MMR: ____ Polio: ______ Influenza: ____ Pneumonia: ____ Hepatitis: ____ HPV: _____ Altered/suppressed immune system (list cause): ___________ History of sexually transmitted disease (date/type): ________ Testing: ______________________________________________ High risk behaviors: ______________________________________ Uses seat belt regularly: __________ Bike helmets: __________ Other safety devices: __________________________________ Workplace safety/health issues (describe): _________________ Currently working: ____________________________________ Rate working conditions (e.g., safety, noise, heating, water, ventilation):_____________________________________ History of accidental injuries: _____________________________ Fractures/dislocations: ___________________________________ Arthritis/unstable joints: ________ Back problems: __________ Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes) describe: ______________________________ Delayed healing (describe): _______________________________ Cognitive limitations (e.g., disoriented, confusion): ________ Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell, touch): __________________________ Prostheses: __________ Ambulatory devices: _______________ Violence (episodes or tendencies): _______________________

Body temperature/method: (e.g., oral, rectal, tympanic): _______ Skin integrity (mark location on diagram): Scars: ______________ Bruises:__________ Rashes:_________ Abrasions: ____________ Lacerations:_______Ulcerations: ________ Blisters: __________ Drainage: _____________ Burns [degree/%]: _________________

Musculoskeletal: General strength: ______ Muscle tone: _______ Gait: ________ ROM: ________ Paresthesia/paralysis: __________ Results of testing (e.g., cultures, immune function, TB, hepatitis): _________________________________________________________

Sexuality [Component of Social Interaction] Subjective (Reports) Sexually active: _________ Birth control method: ___________ Use of condoms: ______________________________________ Sexual concerns/difficulties (e.g., pain, relationship, role): _________________________________________________________ Recent change in frequency/interest: _________________________

Male: Subjective (Reports) Circumcised: ____ Vasectomy (date): ______________________ Prostate disorder: _______________________________________ Practice self-exam: Breast: __________ Testicles: ___________ Last proctoscopic/prostate exam: _____ Last PSA/date: _____ Medications/herbals: ____________________________________

18

Objective (Exhibits) Genitalia: Penis: Circumcised: _______ Warts/lesions: __________ Bleeding/discharge: ______Testicles (e.g., lumps): ___________ Vasectomy: ______________________________________________ Breasts examination: _______________________________________ Test results: PSA: ________________ STD: _____________________

Female: Subjective (Reports)

Objective (Exhibits) Breasts examination: _______________________________________ Genitalia: Warts/lesions: ____________________________________ Vaginal bleeding/discharge: ______________________________ Test results: PAP: __________________________________________ Mammogram: ___________________________________________ STD: ____________________________________________________

Social Interactions Subjective (Reports) Relationship status (check): Single: ______ Married: ________ Living with partner: ____ Divorced: _____ Widowed: ______ Years in relationship: ____ Perception of relationship: ____ Concerns/stresses: ____________________________________ Role within family structure: _____________________________ Number/age of children: ________________________________ Perception of relationship with family members: __________ Extended family: ________________________________________ Other support person(s): ______________________________ Ethnic/cultural affiliations: _______________________________ Strength of ethnic identity: ____________________________ Lives in ethnic community: ____________________________ Feelings of (describe): Mistrust: ________ Rejection: ________ Unhappiness: __________ Loneliness/isolation: ___________ Problems related to illness/condition: _____________________ Problems with communication (e.g., speech, another language, brain injury): ________________________________ Use of speech/communication aids (list): _______________ Interpreter needed: ____ Primary language:______________ Genogram: Diagram on separate page

Objective (Exhibits) Communication/speech: Clear: ______________________________ Slurred:__________________________________________________ Unintelligible: ___________________________________________ Aphasic: _________________________________________________ Unusual speech pattern/impairment: ______________________ Laryngectomy present: ___________________________________ Verbal/nonverbal communication with family/SO(s): __________ _________________________________________________________ Family interaction (behavioral) pattern: ____________________

Teaching/Learning Subjective (Reports) Communication: Dominant language (specify): ____________ Second language: ______ Literate (reading/writing): ______ Education level: _______________________________________ Learning disabilities (specify): __________________________ Cognitive limitations: __________________________________ Culture/ethnicity: Where born: ___________________________ If immigrant, how long in this country: __________________ Health and illness beliefs/practices/customs: _______________ Which family member makes healthcare decisions/is spokesperson for client:________________________________ Presence of Advance Directives: ______ Code status: _______ Durable Medical Power of Attorney: ____________________ Designee: _____________________________________________ Health goals: ____________________________________________ Current health problem: __________________________________ Client understanding of problem: _________________________ Special healthcare concerns (e.g., impact of religious/cultural practices): ____________________________

Prescribed medications: Drug: ________________ Dose:_________ Times (circle last dose): ______Take regularly: ______________ Purpose: ________ Side effects/problems:___________________ Nonprescription drugs/frequency: OTC drugs: ________________ Vitamins: ______________________ Herbals: _________________ Street drugs: ________ Alcohol (amount/frequency): ___________ Tobacco: _____________ Smokeless tobacco: ________________ Admitting diagnosis per provider: ___________________________ Reason for hospitalization/visit per client: ____________________ History of current problem: _________________________________ Expectations of this hospitalization/visit: _____________________ Will admission cause any lifestyle changes (describe): _________ _________________________________________________________ Previous illnesses and/or hospitalizations/surgeries: __________ _________________________________________________________ Evidence of failure to improve: ______________________________ Last complete physical exam: _______________________________

19


Menstruation: Age at menarche: ____ Length of cycle: ______ Duration: _____ Number of pads/tampons used/day: _____ Last menstrual period: ________________________________ Bleeding between periods: ____________________________ Reproductive: Infertility concerns: ________________________ Type of therapy: ____________ Pregnant now: ____________ Para: _________ Gravida: _________ Due date: ____________ Menopause: ____ Last period: ____________________________ Hysterectomy (type/date): _____________________________ Problem with: Hot flashes: _________ Night sweats: ______ Vaginal lubrication: ____ Vaginal discharge: _____________ Hormonal therapies: _____________________________________ Osteoporosis medications: ____________________________ Breasts: Practices breast self-exam: _______________________ Last mammogram: ____________________________________ Last PAP smear: _________________________________________

CHAPTER 3

Sexuality [Component of Social Interaction] (continued)

Teaching/Learning (continued) Subjective (Reports) Familial risk factors (indicate relationship): Diabetes: ________ Thyroid (specify): ___________________ Tuberculosis: ______Heart disease: ________ Stroke: ______ Hypertension: _____Epilepsy/seizures:___________________ Kidney disease: ________ Cancer: _______________________ Mental illness/depression: ________ Other: ______________

Discharge Plan Considerations Projected length of stay (days or hours): ___________________ Anticipated date of discharge: ____________________________ Date information obtained: ______________________________ Resources available: Persons: ____________________________ Financial: _____________________________________________ Community supports: ___________________________________ Groups: ______________________________________________ Areas that may require alteration/assistance Food preparation: ____ Shopping:_____Transportation: __ Ambulation: ____Medication/IV therapy: ________________ Treatments: ________________________ Wound care: _____ Supplies: __________________Self-care (specify): _________ Homemaker/maintenance (specify): ____Socialization:____ Physical layout of home (specify): ______________________

Anticipated changes in living situation after discharge: ________ Living facility other than home (specify): ___________________ Referrals (date/source/services): Social Services: _____________ Rehab services: _______ Dietary: ______ Home care: _________ Resp/O2: ______ Equipment: _______________________________ Supplies: ____________________ Other: _____________________

Figure 3.1 Adult medical-surgical assessment tool. This is a suggested guide and tool for creating a database reflecting a nursing focus. Although the diagnostic divisions are alphabetized here for ease of presentation, they can be prioritized or rearranged in any manner to meet individual needs. In addition, this assessment tool can be adapted to meet the needs of specific client populations.

Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions After data are collected and areas of concern or need identified, the nurse is directed to the Diagnostic Divisions to review the list of nursing diagnoses that fall within the individual categories. This will assist the nurse in choosing the specific diagnostic label to accurately describe the data. Then, with the addition of etiology or related/risk factors (when known), and signs and symptoms, or cues (defining characteristics), the client diagnostic statement emerges. Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest

• Activity Intolerance • Activity Intolerance, risk for • Activity Planning, ineffective • Disuse Syndrome, risk for • Diversional Activity, deficient • Fatigue • Insomnia • Lifestyle, sedentary • Mobility, impaired bed • Mobility, impaired wheelchair • Sleep, readiness for enhanced • Sleep Deprivation • Sleep Pattern, disturbed • Transfer Ability, impaired • Walking, impaired

20

Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs

• Autonomic Dysreflexia • Autonomic Dysreflexia, risk for • Bleeding, risk for • Cardiac Output, decreased • Intracranial Adaptive Capacity, decreased • Perfusion, ineffective peripheral tissue • Perfusion, risk for decreased cardiac tissue • Perfusion, risk for ineffective cerebral tissue • Perfusion, risk for ineffective gastrointestinal • Perfusion, risk for ineffective renal • Shock, risk for Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences

• Anxiety [specify level] • Anxiety, death • Behavior, risk-prone health • Body Image, disturbed • Conflict, decisional (specify) • Coping, defensive • Coping, ineffective • Coping, readiness for enhanced • Decision Making, readiness for enhanced • Denial, ineffective

CHAPTER 3

Client Situation: Diabetes Mellitus


Mr. R.S., a client with type 2 diabetes (non–insulin-dependent) for 8 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done in the doctor’s office revealed blood glucose (BG) of 356/fingerstick and urine Chemstix of 2%. Because of distance from medical provider and lack of local community services, he is admitted to the hospital.

Admitting Physician’s Orders Culture/sensitivity and Gram’s stain of foot ulcer Random blood glucose on admission and fingerstick BG qid CBC, electrolytes, serum lipid profile, glycosylated Hb in AM Chest x-ray and ECG in AM DiaBeta 10 mg, PO BID Glucophage 500 mg, PO daily to start—will increase gradually Humulin N 10 U SC q AM and HS. Begin insulin instruction for post-discharge self-care if necessary Dicloxacillin 500 mg PO q6h, start after culture obtained Darvocet-N 100 mg PO q4h prn pain Diet—2400 calories, 3 meals with 2 snacks Up in chair ad lib with feet elevated Foot cradle for bed Irrigate lesion L foot with NS tid, then cover with wet to dry sterile dressing Vital signs qid

Client Assessment Database Name: R.S. Gender: M

Informant: Client Reliability (Scale 1–4): 3 Age: 72 Adm. date: 6/28/2007 Time: 7 PM From: Home

DOB: 5/3/36

Race: Caucasion

ACTIVITY/REST Subjective (Reports):

Occupation: Farmer Usual activities/hobbies: reading, playing cards. “Don’t have time to do much. Anyway, I’m too tired most of the time to do anything after the chores.” Limitations imposed by illness: “Have to watch what I order if I eat out.” Sleep: Hours: 6 to 8 hr/night Naps: No Aids: No Insomnia: “Not unless I drink coffee after supper.” Usually feels rested when awakens at 4:30 AM

Objective (Exhibits):

Observed response to activity: Limps, favors L foot when walking Mental status: Alert/active Neuro/muscular assessment: Muscle mass/tone: Bilaterally equal/firm Posture: Erect ROM: Full Strength: Equal 4 extremities/(favors L foot currently)

CIRCULATION Subjective (Reports):

History of slow healing: Lesion L foot, 3 weeks’ duration Extremities: Numbness/tingling: “My feet feel cold and tingly like sharp pins poking the bottom of my feet when I walk the quarter mile to the mailbox.” Cough/character of sputum: Occ./white Change in frequency/amount of urine: Yes/voiding more lately


Peripheral pulses: Radials 3+; popliteal, dorsalis, post-tibial/pedal, all 1+ BP: R: Lying: 146/90 Sitting: 140/86 Standing: 138/90 L: Lying: 142/88 Sitting: 138/88 Standing: 138/84 Pulse: Apical: 86 Radial: 86 Quality: Strong Rhythm: Regular Chest auscultation: Few wheezes clear with cough, no murmurs/rubs Jugular vein distention: 0 Extremities: Temperature: Feet cool bilaterally/legs warm Color: Skin: Legs pale Capillary refill: Slow both feet (approx. 4 seconds) Homans’ sign: 0 Varicosities: Few enlarged superficial veins both calves Nails: Toenails thickened, yellow, brittle Distribution and quality of hair: Coarse hair to midcalf, none on ankles/toes Color: General: Ruddy face/arms Mucous membranes/lips: Pink Nailbeds: Blanch well Conjunctiva and sclera: White 23

EGO INTEGRITY Subjective (Reports):

Report of stress factors: “Normal farmer’s problems: weather, pests, bankers, etc.” Ways of handling stress: “I get busy with the chores and talk things over with my livestock. They listen pretty good.” Financial concerns: No insurance; needs to hire someone to do chores while here Relationship status: Married Cultural factors: Rural/agrarian, eastern European descent, “American,” no ethnic ties Religion: Protestant/practicing Lifestyle: Middle class/self-sufficient farmer Recent changes: No Feelings: “I’m in control of most things, except the weather and this diabetes now.” Concerned re possible therapy change “from pills to shots.”


Emotional status: Generally calm, appears frustrated at times Observed physiological response(s): Occasionally sighs deeply/frowns, fidgeting with coin, shoulders tense/shrugs shoulders, throws up hands

ELIMINATION Subjective (Reports):

Usual bowel pattern: almost every PM Last BM: Last night Character of stool: Firm/brown Bleeding: 0 Hemorrhoids: 0 Constipation: occ. Laxative used: Hot prune juice on occ. Urinary: No problems Character of urine: Pale yellow


Abdomen tender: No Soft/firm: Soft Palpable mass: 0 Bowel sounds: Active all 4 quads

FOOD/FLUID Subjective (Reports):

Usual diet (type): 2400 calorie (occ. “cheats” with dessert; “My wife watches it pretty closely.”) No. of meals daily: 3/1 snack Dietary pattern: B: Fruit juice/toast/ham/decaf coffee L: Meat/potatoes/veg/fruit/milk D: ½ meat sandwich/soup/fruit/decaf coffee Snack: Milk/crackers at HS. Usual beverage: Skim milk, 2 to 3 cups decaf coffee, drinks “lots of water”— several quarts Last meal/intake: Dinner: Roast beef sandwich, vegetable soup, pear with cheese, decaf coffee Loss of appetite: “Never, but lately I don’t feel as hungry as usual.” Nausea/vomiting: 0 Food allergies: None Heartburn/food intolerance: Cabbage causes gas, coffee after supper causes heartburn Mastication/swallowing problems: 0 Dentures: Partial upper plate—fits well Usual weight: 175 lb Recent changes: Has lost about 6 lb this month Diuretic therapy: No


Wt: 171 lb Ht: 5 ft 10 in Build: Stocky Skin turgor: Good/leathery Mucous membranes: Moist Condition of teeth/gums: Good, no irritation/bleeding noted Appearance of tongue: Midline, pink Mucous membranes: Pink, intact Breath sounds: Few wheezes cleared with cough Bowel sounds: Active all 4 quads Urine Chemstix: 2% Fingerstick: 356 (Dr. office) 450 random BG on adm

HYGIENE

24

Subjective (Reports):

Activities of daily living: Independent in all areas Preferred time of bath: PM


General appearance: Clean, shaven, short-cut hair; hands rough and dry; skin on feet dry, cracked, and scaly Scalp and eyebrows: Scaly white patches No body odor

CHAPTER 3

NEUROSENSORY Headache: “Occasionally behind my eyes when I worry too much.” Tingling/numbness: Feet, 4 or 5 times/week (as noted) Eyes: Vision loss, farsighted, “Seems a little blurry now.” Examination: 2 yr ago Ears: Hearing loss R: “Some” L: No (has not been tested) Nose: Epistaxis: 0 Sense of smell: “No problem.”


Mental status: Alert, oriented to time, place, person, situation Affect: Concerned Memory: Remote/recent: Clear and intact Speech: Clear/coherent, appropriate Pupil reaction: PERRLA/small Glasses: Reading Hearing aid: No Handgrip/release: Strong/equal



PAIN/DISCOMFORT Subjective (Reports):

Primary focus: L foot Location: Medial aspect, L heel Intensity (0–10): 4 to 5 Quality: Dull ache with occ. sharp stabbing sensation Frequency/duration: “Seems like all the time.” Radiation: No Precipitating factors: Shoes, walking How relieved: ASA, not helping Other complaints: Sometimes has back pain following chores/heavy lifting, relieved by ASA/liniment rubdown


Facial grimacing: When lesion border palpated Guarding affected area: Pulls foot away Narrowed focus: No Emotional response: Tense, irritated

RESPIRATION Subjective (Reports):

Dyspnea: 0 Cough: Occ. morning cough, white sputum Emphysema: 0 Bronchitis: 0 Asthma: 0 Tuberculosis: 0 Smoker: Filters pk/day: 1/2 No. yrs: 25+ Use of respiratory aids: 0


Respiratory rate: 22 Depth: Good Symmetry: Equal, bilateral Auscultation: Few wheezes, clear with cough Cyanosis: 0 Clubbing of fingers: 0 Sputum characteristics: None to observe Mentation/restlessness: Alert/oriented/relaxed

SAFETY Subjective (Reports):

Allergies: 0 Blood transfusions: 0 Sexually transmitted disease: 0 Wears seat belt Fractures/dislocations: L clavicle, 1960s, fell getting off tractor Arthritis/unstable joints: “Some in my knees.” Back problems: Occ. lower back pain Vision impaired: Requires glasses for reading Hearing impaired: Slightly (R), compensates by turning “good ear” toward speaker Immunizations: Current flu/pneumonia 3 yrs ago/tetanus maybe 8 yrs ago


Temperature: 99.4°F (37.4°C) tympanic Skin integrity: Impaired L foot Scars: R inguinal, surgical Rashes: 0 Bruises: 0 Lacerations: 0 Blisters: 0 Ulcerations: Medial aspect L heel, 2.5-cm diameter, approx. 3 mm deep, wound edges inflamed, draining small amount cream-color/pink-tinged matter, slight musty odor noted Strength (general): Equal all extremities Muscle tone: firm ROM: Good Gait: Favors L foot Paresthesia/paralysis: Tingling, prickly sensation in feet after walking ¼ mile

SEXUALITY: MALE Subjective (Reports):

Sexually active: Yes Use of condoms: No (monogamous) Recent changes in frequency/interest: “I’ve been too tired lately.” Penile discharge: 0 Prostate disorder: 0 Vasectomy: 0 25

SEXUALITY: MALE (continued) Subjective (Reports):

Last proctoscopic examination: 2 yr ago Prostate examination: 1 yr ago Practice self-examination: Breast/testicles: No Problems/complaints: “I don’t have any problems, but you’d have to ask my wife if there are any complaints.”


Examination: Breast: No masses

Testicles: Deferred Prostate: Deferred

SOCIAL INTERACTIONS Subjective (Reports):

Marital status: Married 45 yr Living with: Wife Report of problems: None Extended family: 1 daughter lives in town (30 miles away); 1 daughter married/grandson, living out of state Other: Several couples, he and wife play cards/socialize with 2 to 3 times/mo Role: Works farm alone; husband/father/grandfather Report of problems related to illness/condition: None until now Coping behaviors: “My wife and I have always talked things out. You know the 11th commandment is ‘Thou shalt not go to bed angry.’”


Speech: Clear, intelligible Verbal/nonverbal communication with family/SO(s): Speaks quietly with wife, looking her in the eye; relaxed posture Family interaction patterns: Wife sitting at bedside, relaxed, both reading paper, making occasional comments to each other

TEACHING/LEARNING Subjective (Reports):

Dominant language: English Second language: 0 Literate: Yes Education level: 2-yr college Health and illness/beliefs/practices/customs: “I take care of the minor problems and see the doctor only when something’s broken.” Presence of Advance Directives: Yes—wife to bring in Durable Medical Power of Attorney: Wife Familial risk factors/relationship: Diabetes: Maternal uncle Tuberculosis: Brother died, age 27 Heart disease: Father died, age 78, heart attack Strokes: Mother died, age 81 High BP: Mother Prescribed medications: Drug: Diabeta Dose: 10 mg bid Schedule: 8 AM/6 PM, last dose 6 PM today Purpose: Control diabetes Takes medications regularly? Yes Home urine/glucose monitoring: “Only using TesTape, stopped some months ago when I ran out. It was always negative, anyway.” Nonprescription (OTC) drugs: Occ. ASA Use of alcohol (amount/frequency): Socially, occ. beer Tobacco: 1/2 pk/day Admitting diagnosis (physician): Hyperglycemia with nonhealing lesion L foot Reason for hospitalization (client): “Sore on foot and the doctor is concerned about my blood sugar, and says I’m supposed to learn this fingerstick test now.” History of current complaint: “Three weeks ago I got a blister on my foot from breaking in my new boots. It got sore so I lanced it but it isn’t getting any better.” Client’s expectations of this hospitalization: “Clear up this infection and control my diabetes.” Other relevant illness and/or previous hospitalizations/surgeries: 1960s, R inguinal hernia repair Evidence of failure to improve: Lesion L foot, 3 wk Last physical examination: Complete 1 yr ago, office follow-up 5 mo ago

DISCHARGE CONSIDERATIONS (AS OF 6/28) Anticipated discharge: 7/1/07 (3 days) Resources: Self, wife 26

CHAPTER 3

DISCHARGE CONSIDERATIONS (AS OF 6/28) (continued)


Financial: “If this doesn’t take too long to heal, we got some savings to cover things.” Community supports: Diabetic support group (has not participated) Anticipated lifestyle changes: Become more involved in management of condition Assistance needed: May require farm help for several days Teaching: Learn new medication regimen and wound care; review diet; encourage smoking cessation Referral: Supplies: Downtown Pharmacy or AARP Equipment: Glucometer-AARP Follow-up: Primary care provider 1 wk after discharge to evaluate wound healing and potential need for additional changes in diabetic regimen Figure 3.2 Client situation: Diabetes Mellitus.

ND: deficient Knowledge of self-care - review disease process - BS monitoring - insulin administration - s/s hyper/hypoglycemia - dietary needs - foot care

leads to

demonstrates Blood sugar 450 thirst/wt loss

complication

RS

Perform Self-admin Understand RFS DM and insulin treatment

ND: unstable blood Glucose - fingerstick 4x day - 2,400 cal diet 3 meals/2 snack - Humulin N - Glucophage

impairs healing

FBS < 120

DM Type 2

ND: impaired Skin Integrity - wound care - dressing change - infection precautions - Dicloxacillin

pulses numbness & tingling due to ND: impaired peripheral Tissue Perfusion - feet when in chair - increase fluids/l&O - safety precautions - foot inspection

Wound clean/pink

increases risk for

causes

No drainage/ erythemia

ND: Acute Pain - foot cradle - Darvocet N

Pressure ulcer Maintain hydration

Understand relationship of DM to circulatory changes

Pain free

Full wt. bearing

Figure 3.3 Mind map for Mr. R.S.

27

CHAPTER 3

Client Situation: Diabetes Mellitus


Mr. R.S., a client with type 2 diabetes (non–insulin-dependent) for 8 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done in the doctor’s office revealed blood glucose (BG) of 356/fingerstick and urine Chemstix of 2%. Because of distance from medical provider and lack of local community services, he is admitted to the hospital.

Admitting Physician’s Orders Culture/sensitivity and Gram’s stain of foot ulcer Random blood glucose on admission and fingerstick BG qid CBC, electrolytes, serum lipid profile, glycosylated Hb in AM Chest x-ray and ECG in AM DiaBeta 10 mg, PO BID Glucophage 500 mg, PO daily to start—will increase gradually Humulin N 10 U SC q AM and HS. Begin insulin instruction for post-discharge self-care if necessary Dicloxacillin 500 mg PO q6h, start after culture obtained Darvocet-N 100 mg PO q4h prn pain Diet—2400 calories, 3 meals with 2 snacks Up in chair ad lib with feet elevated Foot cradle for bed Irrigate lesion L foot with NS tid, then cover with wet to dry sterile dressing Vital signs qid

Client Assessment Database Name: R.S. Gender: M

Informant: Client Reliability (Scale 1–4): 3 Age: 72 Adm. date: 6/28/2007 Time: 7 PM From: Home

DOB: 5/3/36

Race: Caucasion

ACTIVITY/REST Subjective (Reports):

Occupation: Farmer Usual activities/hobbies: reading, playing cards. “Don’t have time to do much. Anyway, I’m too tired most of the time to do anything after the chores.” Limitations imposed by illness: “Have to watch what I order if I eat out.” Sleep: Hours: 6 to 8 hr/night Naps: No Aids: No Insomnia: “Not unless I drink coffee after supper.” Usually feels rested when awakens at 4:30 AM


Observed response to activity: Limps, favors L foot when walking Mental status: Alert/active Neuro/muscular assessment: Muscle mass/tone: Bilaterally equal/firm Posture: Erect ROM: Full Strength: Equal 4 extremities/(favors L foot currently)

CIRCULATION Subjective (Reports):

History of slow healing: Lesion L foot, 3 weeks’ duration Extremities: Numbness/tingling: “My feet feel cold and tingly like sharp pins poking the bottom of my feet when I walk the quarter mile to the mailbox.” Cough/character of sputum: Occ./white Change in frequency/amount of urine: Yes/voiding more lately


Peripheral pulses: Radials 3+; popliteal, dorsalis, post-tibial/pedal, all 1+ BP: R: Lying: 146/90 Sitting: 140/86 Standing: 138/90 L: Lying: 142/88 Sitting: 138/88 Standing: 138/84 Pulse: Apical: 86 Radial: 86 Quality: Strong Rhythm: Regular Chest auscultation: Few wheezes clear with cough, no murmurs/rubs Jugular vein distention: 0 Extremities: Temperature: Feet cool bilaterally/legs warm Color: Skin: Legs pale Capillary refill: Slow both feet (approx. 4 seconds) Homans’ sign: 0 Varicosities: Few enlarged superficial veins both calves Nails: Toenails thickened, yellow, brittle Distribution and quality of hair: Coarse hair to midcalf, none on ankles/toes Color: General: Ruddy face/arms Mucous membranes/lips: Pink Nailbeds: Blanch well Conjunctiva and sclera: White 23

EGO INTEGRITY Subjective (Reports):

Report of stress factors: “Normal farmer’s problems: weather, pests, bankers, etc.” Ways of handling stress: “I get busy with the chores and talk things over with my livestock. They listen pretty good.” Financial concerns: No insurance; needs to hire someone to do chores while here Relationship status: Married Cultural factors: Rural/agrarian, eastern European descent, “American,” no ethnic ties Religion: Protestant/practicing Lifestyle: Middle class/self-sufficient farmer Recent changes: No Feelings: “I’m in control of most things, except the weather and this diabetes now.” Concerned re possible therapy change “from pills to shots.”


Emotional status: Generally calm, appears frustrated at times Observed physiological response(s): Occasionally sighs deeply/frowns, fidgeting with coin, shoulders tense/shrugs shoulders, throws up hands

ELIMINATION Subjective (Reports):

Usual bowel pattern: almost every PM Last BM: Last night Character of stool: Firm/brown Bleeding: 0 Hemorrhoids: 0 Constipation: occ. Laxative used: Hot prune juice on occ. Urinary: No problems Character of urine: Pale yellow


Abdomen tender: No Soft/firm: Soft Palpable mass: 0 Bowel sounds: Active all 4 quads

FOOD/FLUID Subjective (Reports):

Usual diet (type): 2400 calorie (occ. “cheats” with dessert; “My wife watches it pretty closely.”) No. of meals daily: 3/1 snack Dietary pattern: B: Fruit juice/toast/ham/decaf coffee L: Meat/potatoes/veg/fruit/milk D: ½ meat sandwich/soup/fruit/decaf coffee Snack: Milk/crackers at HS. Usual beverage: Skim milk, 2 to 3 cups decaf coffee, drinks “lots of water”— several quarts Last meal/intake: Dinner: Roast beef sandwich, vegetable soup, pear with cheese, decaf coffee Loss of appetite: “Never, but lately I don’t feel as hungry as usual.” Nausea/vomiting: 0 Food allergies: None Heartburn/food intolerance: Cabbage causes gas, coffee after supper causes heartburn Mastication/swallowing problems: 0 Dentures: Partial upper plate—fits well Usual weight: 175 lb Recent changes: Has lost about 6 lb this month Diuretic therapy: No


Wt: 171 lb Ht: 5 ft 10 in Build: Stocky Skin turgor: Good/leathery Mucous membranes: Moist Condition of teeth/gums: Good, no irritation/bleeding noted Appearance of tongue: Midline, pink Mucous membranes: Pink, intact Breath sounds: Few wheezes cleared with cough Bowel sounds: Active all 4 quads Urine Chemstix: 2% Fingerstick: 356 (Dr. office) 450 random BG on adm

HYGIENE

24


Activities of daily living: Independent in all areas Preferred time of bath: PM


General appearance: Clean, shaven, short-cut hair; hands rough and dry; skin on feet dry, cracked, and scaly Scalp and eyebrows: Scaly white patches No body odor

CHAPTER 3

NEUROSENSORY Headache: “Occasionally behind my eyes when I worry too much.” Tingling/numbness: Feet, 4 or 5 times/week (as noted) Eyes: Vision loss, farsighted, “Seems a little blurry now.” Examination: 2 yr ago Ears: Hearing loss R: “Some” L: No (has not been tested) Nose: Epistaxis: 0 Sense of smell: “No problem.”


Mental status: Alert, oriented to time, place, person, situation Affect: Concerned Memory: Remote/recent: Clear and intact Speech: Clear/coherent, appropriate Pupil reaction: PERRLA/small Glasses: Reading Hearing aid: No Handgrip/release: Strong/equal



PAIN/DISCOMFORT Subjective (Reports):

Primary focus: L foot Location: Medial aspect, L heel Intensity (0–10): 4 to 5 Quality: Dull ache with occ. sharp stabbing sensation Frequency/duration: “Seems like all the time.” Radiation: No Precipitating factors: Shoes, walking How relieved: ASA, not helping Other complaints: Sometimes has back pain following chores/heavy lifting, relieved by ASA/liniment rubdown


Facial grimacing: When lesion border palpated Guarding affected area: Pulls foot away Narrowed focus: No Emotional response: Tense, irritated

RESPIRATION Subjective (Reports):

Dyspnea: 0 Cough: Occ. morning cough, white sputum Emphysema: 0 Bronchitis: 0 Asthma: 0 Tuberculosis: 0 Smoker: Filters pk/day: 1/2 No. yrs: 25+ Use of respiratory aids: 0


Respiratory rate: 22 Depth: Good Symmetry: Equal, bilateral Auscultation: Few wheezes, clear with cough Cyanosis: 0 Clubbing of fingers: 0 Sputum characteristics: None to observe Mentation/restlessness: Alert/oriented/relaxed

SAFETY Subjective (Reports):

Allergies: 0 Blood transfusions: 0 Sexually transmitted disease: 0 Wears seat belt Fractures/dislocations: L clavicle, 1960s, fell getting off tractor Arthritis/unstable joints: “Some in my knees.” Back problems: Occ. lower back pain Vision impaired: Requires glasses for reading Hearing impaired: Slightly (R), compensates by turning “good ear” toward speaker Immunizations: Current flu/pneumonia 3 yrs ago/tetanus maybe 8 yrs ago


Temperature: 99.4°F (37.4°C) tympanic Skin integrity: Impaired L foot Scars: R inguinal, surgical Rashes: 0 Bruises: 0 Lacerations: 0 Blisters: 0 Ulcerations: Medial aspect L heel, 2.5-cm diameter, approx. 3 mm deep, wound edges inflamed, draining small amount cream-color/pink-tinged matter, slight musty odor noted Strength (general): Equal all extremities Muscle tone: firm ROM: Good Gait: Favors L foot Paresthesia/paralysis: Tingling, prickly sensation in feet after walking ¼ mile

SEXUALITY: MALE Subjective (Reports):

Sexually active: Yes Use of condoms: No (monogamous) Recent changes in frequency/interest: “I’ve been too tired lately.” Penile discharge: 0 Prostate disorder: 0 Vasectomy: 0 25

SEXUALITY: MALE (continued) Subjective (Reports):

Last proctoscopic examination: 2 yr ago Prostate examination: 1 yr ago Practice self-examination: Breast/testicles: No Problems/complaints: “I don’t have any problems, but you’d have to ask my wife if there are any complaints.”


Examination: Breast: No masses

Testicles: Deferred Prostate: Deferred

SOCIAL INTERACTIONS Subjective (Reports):

Marital status: Married 45 yr Living with: Wife Report of problems: None Extended family: 1 daughter lives in town (30 miles away); 1 daughter married/grandson, living out of state Other: Several couples, he and wife play cards/socialize with 2 to 3 times/mo Role: Works farm alone; husband/father/grandfather Report of problems related to illness/condition: None until now Coping behaviors: “My wife and I have always talked things out. You know the 11th commandment is ‘Thou shalt not go to bed angry.’”


Speech: Clear, intelligible Verbal/nonverbal communication with family/SO(s): Speaks quietly with wife, looking her in the eye; relaxed posture Family interaction patterns: Wife sitting at bedside, relaxed, both reading paper, making occasional comments to each other

TEACHING/LEARNING Subjective (Reports):

Dominant language: English Second language: 0 Literate: Yes Education level: 2-yr college Health and illness/beliefs/practices/customs: “I take care of the minor problems and see the doctor only when something’s broken.” Presence of Advance Directives: Yes—wife to bring in Durable Medical Power of Attorney: Wife Familial risk factors/relationship: Diabetes: Maternal uncle Tuberculosis: Brother died, age 27 Heart disease: Father died, age 78, heart attack Strokes: Mother died, age 81 High BP: Mother Prescribed medications: Drug: Diabeta Dose: 10 mg bid Schedule: 8 AM/6 PM, last dose 6 PM today Purpose: Control diabetes Takes medications regularly? Yes Home urine/glucose monitoring: “Only using TesTape, stopped some months ago when I ran out. It was always negative, anyway.” Nonprescription (OTC) drugs: Occ. ASA Use of alcohol (amount/frequency): Socially, occ. beer Tobacco: 1/2 pk/day Admitting diagnosis (physician): Hyperglycemia with nonhealing lesion L foot Reason for hospitalization (client): “Sore on foot and the doctor is concerned about my blood sugar, and says I’m supposed to learn this fingerstick test now.” History of current complaint: “Three weeks ago I got a blister on my foot from breaking in my new boots. It got sore so I lanced it but it isn’t getting any better.” Client’s expectations of this hospitalization: “Clear up this infection and control my diabetes.” Other relevant illness and/or previous hospitalizations/surgeries: 1960s, R inguinal hernia repair Evidence of failure to improve: Lesion L foot, 3 wk Last physical examination: Complete 1 yr ago, office follow-up 5 mo ago

DISCHARGE CONSIDERATIONS (AS OF 6/28) Anticipated discharge: 7/1/07 (3 days) Resources: Self, wife 26

CHAPTER 3

DISCHARGE CONSIDERATIONS (AS OF 6/28) (continued)


Financial: “If this doesn’t take too long to heal, we got some savings to cover things.” Community supports: Diabetic support group (has not participated) Anticipated lifestyle changes: Become more involved in management of condition Assistance needed: May require farm help for several days Teaching: Learn new medication regimen and wound care; review diet; encourage smoking cessation Referral: Supplies: Downtown Pharmacy or AARP Equipment: Glucometer-AARP Follow-up: Primary care provider 1 wk after discharge to evaluate wound healing and potential need for additional changes in diabetic regimen Figure 3.2 Client situation: Diabetes Mellitus.

ND: deficient Knowledge of self-care - review disease process - BS monitoring - insulin administration - s/s hyper/hypoglycemia - dietary needs - foot care

leads to

demonstrates Blood sugar 450 thirst/wt loss

complication

RS

Perform Self-admin Understand RFS DM and insulin treatment

ND: unstable blood Glucose - fingerstick 4x day - 2,400 cal diet 3 meals/2 snack - Humulin N - Glucophage

impairs healing

FBS < 120

DM Type 2

ND: impaired Skin Integrity - wound care - dressing change - infection precautions - Dicloxacillin

pulses numbness & tingling due to ND: impaired peripheral Tissue Perfusion - feet when in chair - increase fluids/l&O - safety precautions - foot inspection

Wound clean/pink

increases risk for

causes

No drainage/ erythemia

ND: Acute Pain - foot cradle - Darvocet N

Pressure ulcer Maintain hydration

Understand relationship of DM to circulatory changes

Pain free

Full wt. bearing

Figure 3.3 Mind map for Mr. R.S.

27

5

PLANNING CARE WITH NURSING DIAGNOSIS Learning Objectives After reading the chapter, the student should be able to answer the following questions: • What are functional health patterns? • How are priority nursing diagnoses identified? • What is the difference between nursing and client goals? • How is evaluation different for nursing diagnoses and collaborative problems? • What are standardized care plans?

Because clients require nursing care 7 days a week and 24 hours a day, nurses must rely on one another and nonlicensed nursing personnel to help clients achieve outcomes of care. Obviously, some system of communication is necessary. For more than 30 years, this system consisted of handwritten care plans or verbal reports, neither of which was very useful. This chapter addresses the varied methods that nurses use today to communicate a client’s care to other caregivers.

Data Collection Formats___________________________________________________ Data collection usually consists of two formats: the nursing baseline or screening assessment and the focus or ongoing assessment. The nurse can use each alone or together. As discussed in Chapter 3, nurses encounter, diagnose, and treat two types of response: nursing diagnoses and collaborative problems. Each type requires a different assessment focus.

Initial, Baseline, or Screening Assessment An initial, baseline, or screening assessment involves collecting a predetermined set of data during initial contact with the client (e.g., on admission, first home visit). This assessment serves as a tool for “narrowing the universe of possibilities” (Gordon, 1994). During this assessment, the nurse interprets data as significant or insignificant. This process is explored later in this chapter. The nurse should organize the initial assessment to permit systematic, efficient data collection. Appendix B illustrates an assessment form with checking or circling options, which can help save time during documentation. The nurse always can elaborate with additional questions and comments. Open-ended questions are better for assessment of certain functional areas, such as fear or anxiety. Nurses should view printed assessment forms as guides, not mandates. Before requesting information from a client, nurses should ask themselves, “What am I going to do with the data?” If certain information is useless or irrelevant for a particular client, then its collection is unnecessary and potentially distressing. For example, asking a terminally ill client how much he or she smokes is unnecessary unless the nurse has a specific goal. If a client will be NPO, collecting data about eating habits is probably unnecessary. Such assessment will be indicated if the client resumes eating. If a client is extremely stressed, the nurse should collect only necessary data and defer the assessment of functional patterns to another time. A stressed client is not the best source of data, because stress may cloud the memory.

Functional Health Patterns As discussed earlier, nursing assessment focuses on collecting data that validate nursing diagnoses. Gordon’s system of functional health patterns provides an excellent, relevant format for nursing data collection to determine an individual’s or group’s health status and functioning (1994). After data collection is complete, the nurse and client can determine positive functioning, altered functioning, or at-risk for altered functioning. Altered functioning is defined as functioning that the client (individual or group) perceives as negative or undesirable. Refer to Box 5.1 for functional health patterns. Refer to Appendix B for a sample initial assessment organized according to functional health patterns. It is designed to assist the nurse in gathering subjective and objective data. Should questions arise

31


BOX 5.1 FUNCTIONAL HEALTH PATTERNS 1.

Health Perception–Health Management Pattern • Perceived pattern of health, well-being • Knowledge of lifestyle and relationship to health • Knowledge of preventive health practices • Adherence to medical, nursing prescriptions

7.

Self-Perception–Self-Concept Pattern • Attitudes about self, sense of worth • Perception of abilities • Emotional patterns • Body image, identity

2.

Nutritional–Metabolic Pattern • Usual pattern of food and fluid intake • Types of food and fluid intake • Actual weight, weight loss or gain • Appetite, preferences

8.

Role–Relationship Patterns • Patterns of relationships • Role responsibilities • Satisfaction with relationships and responsibilities

3.

Elimination Pattern • Bowel elimination pattern, changes • Bladder elimination pattern, changes • Control problems • Use of assistive devices • Use of medications

9.

Sexuality–Reproductive Pattern • Menstrual, reproductive history • Satisfaction with sexual relationships, sexual identity • Premenopausal or postmenopausal problems • Accuracy of sex education

10.

Coping–Stress Tolerance Patterns • Ability to manage stress • Knowledge of stress tolerance • Sources of support • Number of stressful life events in last year

11.

Value–Belief Pattern • Values, goals, beliefs • Spiritual practices • Perceived conflicts in values

4. Activity–Exercise Pattern • Pattern of exercise, activity, leisure, recreation • Ability to perform activities of daily living (selfcare, home maintenance, work, eating, shopping, cooking) 5. Sleep–Rest Pattern • Patterns of sleep, rest • Perception of quality, quantity 6.

Cognitive–Perceptual Pattern • Vision, learning, taste, touch, smell • Language adequacy • Memory • Decision-making ability, patterns • Complaints of discomforts

concerning a pattern, the nurse would gather more data about the diagnosis by using the focus assessment under the diagnosis. When collecting data according to the functional health patterns, the nurse questions, observes, and evaluates the client or family. For example, under the Cognitive–Perceptual Pattern, the nurse asks the client if he or she has difficulty hearing, observes if the client is wearing a hearing aid, and evaluates if the client understands English.

Physical Assessment In addition to functional health pattern assessment, the nurse also collects data related to body system functioning. Physical assessment, the collection of objective data concerning the client’s physical status, incorporates head-to-toe examination, with a focus on the body systems. The techniques used include inspection, palpation, percussion, and auscultation. Appendix B lists those areas of physical assessment in which nurse generalists should be proficient. Physical assessment by nurses should be clearly “nursing” in focus. By examining their philosophy and definition of nursing, nurses should seek to develop expertise in those areas that will enhance nursing practice. Keep in mind that separation of functional health patterns from physical assessment is done for organizational purposes only. No useful nursing assessment framework can restrict actual data collection in such a manner. Because humans are open systems, a problem in one functional health pattern invariably influences body system functioning or functioning in another functional health pattern. Anxiety can effect appetite; Sleep problems can increase coping difficulties

B

APPENDIX

Nursing Admission Data Base

961

962 Appendix B

Appendix B 963

964 Appendix B

Bibliography Citations listed under the general category are used throughout the book

General References Abdellah, F. G., & Levine, E. (1965). Better patient care through nursing research. New York: Macmillan. Alfaro-LeFevre, R. (1998). Applying nursing process: A step-by-step guide (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Allender, J., & Spradley, B. (2006). Community health nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins. American Nurses Association. (1980). ANA social policy statement. Washington, DC: Author. American Psychiatric Association. (2004). DSM IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Andrews, M., & Boyle, J. (2008). Transcultural concepts in nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Archangelo, V. P., & Peterson, A. (2006) Pharmacotherapeutics for advanced practice (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Aspinall, M. J., & Tanner, C. (1981). Decision-making in patient care. New York: Appleton-Century-Crofts. Bickley, B. (2003). A guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Block, G. J., & Nolan, J. W. (1986). Health assessment for professional nursing: A developmental approach (2nd ed.). New York: Appleton-Century-Crofts. Boyd, M. A. (2005). Psychiatric nursing: Contemporary practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Bulechek, G. M., Butcher, G. M., & Dochterman, J. M. (Eds.). (2008). Nursing interventions: Treatments for nursing diagnoses (5th ed.). Philadelphia: W. B. Saunders. Bulechek, G., & McCloskey, J. (1985). Nursing interventions: Treatments for potential nursing diagnoses. In R. M. Carroll-Johnson (Ed.), Classification of nursing diagnoses: Proceedings of the eighth national conference. Philadelphia: J. B. Lippincott. Carpenito-Moyet, L. J. (2009). Nursing care plans and documentation: Nursing diagnoses and collaborative problems (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Carpenito-Moyet, L. J. (2007). Understanding the nursing process: Concept mappping and care planning for students. Philadelphia: Lippincott Williams & Wilkins. Carpenito, L. J. (1995). Nurse practitioner and physician discipline specific expertise in primary care. Unpublished manuscript. Clemen-Stone, E., Eigasti, D. G., & McGuire, S. L. (2001). Comprehensive family and community health nursing (6th ed.). St. Louis: Mosby– Year Book. Curtin, L., & Flaherty, M. J. (1982). Nursing ethics. Bowie, MD: Brady Communications. Dudek, S. (2006). Nutrition handbook for nursing practice (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Edelman, C. H., & Mandle, C. (2006). Health promotion throughout the life span (6th ed.). St. Louis: Mosby–Year Book. Giger, J., & Davidhizar, R. (2009). Transcultural nursing: Assessment and intervention (6th ed.). St. Louis: Mosby–Year Book. Gordon, M. (1994). Nursing diagnosis: Process and application. St. Louis: Mosby–Year Book. Gordon, M. (1982). Historical perspective: The National Group for Classification of Nursing Diagnoses. In M. J. Kim & D. A. Moritz (Eds.), Classification of nursing diagnoses: Proceedings of the fourth national conference. New York: McGraw-Hill. Grondin, L., Lussier, R., Phaneuf, M., & Riopelle, L. (2005). Planification des soins infirmiers. Montreal: Les Editions de la Cheneliere.

Henderson, U., & Nite, G. (1960). Principles and practice of nursing (5th ed.). New York: Macmillan. Hickey, J. (2006). The clinical practice of neurological and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Hockenberry, M. J., Wilson, D., & Winkelstein, M.L. (2008) Wong’s nursing care of infants and children (7th ed.). Elsevier. Hockenberry, M. J., & Wilson, D. (2009). Essentials of pediatric nursing. Elsevier. Luis, M. T. (2008). Diagnostico de enfermeria (2nd ed.). Barcelona: Doyma. Matteson, M. A., & McConnell, E. S. (1988). Gerontological nursing: Concepts and practices. Philadelphia: W. B. Saunders. May, K. A., & Mahlmeister, L. R. (1994). Maternal and neonatal nursing: Family-centered care (3rd ed.). Philadelphia: J. B. Lippincott. McCourt, A. (1991). Syndromes in nursing. In R. M. Carroll-Johnson (Ed.), Classification of nursing diagnoses: Proceedings of the ninth NANDA national conference. Philadelphia: J. B. Lippincott. Miller, C. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia. Lippincott Williams & Wilkins. Mitchell, G. J. (1991). Nursing Diagnosis: An Ethical Analysis. Image: The Journal of Nursing Scholarship. 23, 99-103. Mohr, W. K. (2007). Psychiatric–mental health nursing: Adaptation and growth (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing outcomes classification (NOC). St. Louis: Mosby. Morton, P., Fontaine, D., Hudak, C., & Gallo, B. (2005). Critical care nursing (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Murray, R. B., Zentner, J. P., & Yakimo, R. (2009). Health promotion strategies through the life span (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Norris, J., & Kunes-Connell, M. (1987). Self-esteem disturbance: A clinical validation study. In A. McLane (Ed.), Classification of nursing diagnoses: Proceedings of the seventh NANDA national conference. St. Louis: C. V. Mosby. North American Nursing Diagnosis Association. (2002). Nursing diagnosis: Definitions and classification 2001–2002. Philadelphia: Author. North American Nursing Diagnosis Association. (1992). Taxonomy of nursing diagnoses. Philadelphia: Author. North American Nursing Diagnosis Association. (2009). Nursing diagnoses: Definitions and Classifications 2009-2010. Ames, IA: Wiley–Blackwell. Pillitteri, A. (2009). Maternal and child health nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Popkess-Vawter, S. (1984). Strength-oriented nursing diagnoses. In M. J. Kim, G. McFarland, & A. McLane (Eds.), Classification of nursing diagnoses. St. Louis: C. V. Mosby. Porth, C. (2007). Pathophysiology (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth’s textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Stuart, G. W., & Sundeen, S. (2002). Principles and practice of psychiatric nursing (6th ed.). St. Louis: Mosby–Year Book. Varcarolis, E., Carson, V. B., & Shoemaker, N. C. (2006). Foundations of psychiatric mental health nursing (4th ed.). Philadelphia: W. B. Saunders. Varcarolis, E. M. (2007) Manual of psychiatric nursing care plans (3rd ed.). St. Louis: Saunders. Weber, J., & Kelley, J. (2003). Health assessment in nursing. Philadelphia: Lippincott Williams & Wilkins. Wong, D. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby-Year Book.

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474 Impaired Skin Integrity

Sensory Deficit Inspect the client’s skin daily because he or she will not experience discomfort. Teach the client or family to inspect the skin with a mirror. R: A pressure-reducing surface must not be able to be fully compressed by the body. To be effective, a support surface must be capable of first being deformed and then redistributing the weight of the body across the surface. Comfort is not a valid criterion for determining adequate pressure reduction. A hand check should be performed to determine if the product is effectively reducing pressure. The palm is placed under the pressure-reducing mattress; if the client can feel the hand or the caregiver can feel the client, the pressure is not adequate (AHCPR, 1992; Bergstrom et al., 1994).

Initiate Health Teaching, as Indicated Instruct the client and family in specific techniques to use at home to prevent pressure ulcers. Consider the use of long-term pressure-relieving devices for permanent disabilities. R: Pressure reduction is the one consistent intervention that must be included in all pressure ulcer treatment plans.

IMPAIRED SKIN INTEGRITY wR elated to the Effects of Pressure, Friction, Shear, and Maceration

NOC See Impaired Skin Integrity

➤ Goal_______________________________________________________ The client will demonstrate progressive healing of dermal ulcer.

Indicators: • Identify causative factors for pressure ulcers. • Identify rationale for prevention and treatment. • Participate in the prescribed treatment plan to promote wound healing.

NIC See Impaired Skin Integrity

➤ General Interventions_ ______________________________________ Identify the Stage of Pressure Ulcer Development (AHCPR, 1992) Stage I: Nonblanchable erythema of intact skin Stage II: Ulceration of epidermis and/or dermis Stage III: Ulceration involving subcutaneous fat Stage IV: Extensive ulceration penetrating muscle, bone, or supporting structure

Reduce or Eliminate Factors that Contribute to the Extension of Pressure Ulcers Refer to Risk for Impaired Skin Integrity Related to Immobility Prevent Deterioration of the Ulcer Wash reddened area gently with mild soap, rinse area thoroughly to remove soap, and pat dry. Avoid massage of bony prominence to stimulate circulation. Protect the healthy skin surface with one or a combination of the following:

Impaired Skin Integrity 475

• Apply a thin coat of liquid copolymer skin sealant. • Cover the area with moisture-permeable film dressing. • Cover the area with a hydrocolloid wafer barrier and secure with strips of 1-inch tape; leave in place for 2 to 3 days. • Wound healing occurs most efficiently with the following extrinsic factors (Maklebust & Sieggreen, 2000): • Humidity affects the rate of epithelialization and the amount of scar formation. A moist environment provides optimal conditions for rapid healing. • When wounds are left uncovered, epidermal cells must migrate under the scab and over the fibrous tissue below. When wounds are semi-occluded and the surface of the wound remains moist, epidermal cells migrate more rapidly over the surface. • Appropriate use of dressings may promote a moist wound. Use of semi-occlusive film dressings or hydrocolloid barrier wafers mechanically protect and properly humidify wounds that are epidermal or dermal. These dressings bathe the wound in serous exudate and do not adhere to the wound surface when they are removed. A physician’s order may be required. Increase dietary intake to promote wound healing: • Initiate calorie count. Consult a dietitian. • Increase protein and carbohydrate intake to maintain a positive nitrogen balance. Weigh daily and determine serum albumin level weekly to monitor status. • Ascertain that client maintains daily intake of vitamins and minerals through diet or supplements (see Key Concepts for recommended amounts). • See Imbalanced Nutrition: Less Than Body Requirements for additional interventions. R: Wound healing occurs most efficiently with the following extrinsic factors (Maklebust & Sieggreen, 2006): • Humidity affects the rate of epithelialization and the amount of scar formation. A moist environment provides optimal conditions for rapid healing. • When wounds are left uncovered, epidermal cells must migrate under the scab and over the fibrous tissue below. When wounds are semi-occluded and the surface of the wound remains moist, epidermal cells migrate more rapidly over the surface. • Appropriate use of dressings may promote a moist wound. Use of semi-occlusive film dressings or hydrocolloid barrier wafers mechanically protect and properly humidify wounds that are epidermal or dermal. These dressings bathe the wound in serous exudate and do not adhere to the wound surface when they are removed. A physician’s order may be required. R: Wound healing requires increased protein–carbohydrates intake to prevent weight loss and increased intake of vitamins and minerals (Dudek, 2006).

Devise a Plan for Pressure Ulcer Management Using Principles of Moist Wound Healing (Maklebust & Sieggreen, 2006) Assess the status of pressure ulcer (Bates-Jensen, 1999).* Assess the size—measure the longest and widest wound surface. Assess depth: • No break in skin • Abrasion or shallow crater • Deep crater • Necrosis • Involved tendon, joint capsule • Assess edges. • Attached • Not attached • Fibrotic

*Areas with little soft tissue over a bony prominence are at greatest risk.

476 Impaired Skin Integrity Assess undermining: • Less than 2 cm • 2 to 4 cm • Greater than 4 cm • Tunneling Assess necrotic tissue type (color, consistency, adherence) and amount. Assess exudate type and amount. Assess surrounding skin color. Check for any peripheral edema and induration. Assess for granulation tissue. Assess for epithelialization. Débride necrotic tissue (collaborate with physician). Flush ulcer base with sterile saline solution. Avoid use of harsh antiseptic solutions. Protect granulating wound bed from trauma and bacteria. Insulate wound surface. Cover pressure ulcer with a sterile dressing that maintains a moist environment over the ulcer base (e.g., film dressing, hydrocolloid wafer dressing, moist gauze dressing). Do not occlude ulcers on immunocompromised patients. Avoid the use of drying agents (heat lamps, Maalox, Milk of Magnesia). Monitor for clinical signs of wound infection. Measure the pressure ulcer weekly to determine progress of wound healing. R: Rationales for topical treatment (Maklebust & Sieggreen, 2006) are as follows: • Remove necrotic tissue, which delays wound healing by prolonging the inflammatory phase. • Cleanse wound bed to decrease bacterial count. Bacterial counts above 105 may produce infection by overwhelming the host. • Obliterate dead space in the wound, which prevents premature closure and abscess formation. • Absorb excess exudate, which macerates surrounding skin and increases the risk of infection in the wound bed. • Maintain a moist wound surface, which promotes cellular migration. Dry wound surfaces delay epithelialization secondary to difficult cellular migration. • Insulate the wound surface; this enhances blood flow and increases epidermal migration. • Protect the healing wound from trauma and bacterial invasion. Open wounds are vulnerable to abrasion, contamination, drying, and shear mechanisms.

Consult With Nurse Specialist or Physician for Treatment of Necrotic, Infected, or Deep Pressure Ulcers R: Surgical debridement may be needed.

Initiate Health Teaching and Referrals, as Indicated Instruct the client and family on care of ulcers. Teach the client importance of good skin hygiene and optimal nutrition. Refer the client to a community nursing agency if additional assistance at home is needed. R: Wound healing occurs most efficiently with the following extrinsic factors (Maklebust & Sieggreen, 2006): • Humidity affects the rate of epithelialization and the amount of scar formation. A moist environment provides optimal conditions for rapid healing. • When wounds are left uncovered, epidermal cells must migrate under the scab and over the fibrous tissue below. When wounds are semi-occluded and the surface of the wound remains moist, epidermal cells migrate more rapidly over the surface. • Appropriate use of dressings may promote moist wound. Use of semi-occlusive film dressings or hydrocolloid barrier wafers mechanically protect and properly humidify wounds that are epidermal or dermal. These dressings bathe the wound in serous exudate and do not adhere to the wound surface when they are removed. A physician’s order may be required.

RISK FOR UNSTABLE BLOOD GLUCOSE w Risk for Complications of

Hypoglycemia/Hyperglycemia

Definition (NANDA)______________________________________________________ Risk for Variation of Blood Glucose/Sugar Levels from the Normal Range

Risk Factors (NANDA)____________________________________________________ Deficient knowledge of diabetes management (e.g., action plan) Developmental level Dietary intake Inadequate blood glucose monitoring Lack of acceptance of diagnosis Lack of adherence to diabetes management (e.g., action plan) Lack of diabetes management (e.g., action plan)

Medication management Physical activity level Physical health status Pregnancy Rapid growth periods Stress Weight gain Weight loss

AUTHOR’S NOTE This new nursing diagnosis represents a situation that requires collaborative intervention with medicine. This author recommends that the Collaborative Problem Hyper/Hyperglycemia be used instead. Students should consult with their faculty for advice to use Risk for Unstable Blood Glucose or Risk for Complications of Hypoglycemia/ Hyperglycemia. Refer to Section 3 for interventions for these diagnoses.

RISK FOR IMBALANCED BODY TEMPERATURE Hyperthermia Hypothermia Ineffective Thermoregulation Related to Newborn Transition to Extrauterine Environment

DEFINITION_ _____________________________________________________________ The state in which the individual is at risk for failing to maintain body temperature within normal range (36° to 37.5° C or 98° to 99.5° F) (Smeltzer & Bare, 2008)

RISK FACTORS____________________________________________________________ Presence of risk factors (see Related Factors).

88

INEFFECTIVE TISSUE PERFUSION Ineffective Tissue Perfusion Risk for Decreased Cardiac Tissue Perfusion Risk for Ineffective Cerebral Tissue Perfusion Risk for Ineffective Gastrointestinal Tissue Perfusion Peripheral Tissue Perfusion, Ineffective Renal Perfusion, Risk for Ineffective

Definition (NANDA)______________________________________________________ Decrease in oxygen resulting in failure to nourish tissues at capillary level

AUTHOR’S NOTE The use of any Ineffective Tissue Perfusion diagnosis other than Peripheral merely provides new labels for medical diagnoses, labels that do not describe the nursing focus or accountability. NANDA approved the diagnosis Ineffective Tissue Perfusion in 1980. It does not conform to the NANDA definition approved in 1990 (refer to Chapter 2). When using these diagnoses, nurses cannot be accountable for prescribing the interventions for outcome achievement. Instead of using Ineffective Tissue Perfusion, the nurse should focus on the nursing diagnoses and collaborative problems applicable because of altered renal, cardiac, cerebral, pulmonary, or gastrointestinal (GI) tissue perfusion. Refer to Section 3 for specific collaborative problems for example: RC of Increased Intracranial Pressure, RC of GI Bleeding Ineffective Peripheral Tissue Perfusion can be a clinically useful nursing diagnosis if used to describe chronic arterial or venous insufficiency or potential thrombophlebitis. (In contrast, acute embolism and thrombophlebitis represent collaborative problems.) A nurse focusing on preventing thrombophlebitis in a postoperative client would write the diagnosis Risk for Ineffective Peripheral Tissue Perfusion related to postoperative immobility and dehydration.

ERRORS IN DIAGNOSTIC STATEMENTS 1. Ineffective GI Tissue Perfusion related to esophageal bleeding varices Because this diagnosis actually represents a situation that nurses monitor and manage with nursing and medical interventions, the diagnosis should be rewritten as the collaborative problem RC of Esophageal bleeding varices. 2. Ineffective Cerebral Tissue Perfusion related to cerebral edema secondary to intracranial infections This diagnosis represents merely a new label for encephalitis, meningitis, or abscess. Instead, the nurse should specify collaborative problems to clearly describe and designate the nursing accountability: RC of Increased intracranial pressure and RC of Septicemia. In addition, certain nursing diagnoses may be indicated (e.g., Risk for Infection Transmission, Impaired Comfort). 3. Ineffective Peripheral Tissue Perfusion related to deep vein thrombosis Deep vein thrombosis is a medical diagnosis that evokes responses for which nurses are accountable: monitoring for and managing, with physician- and nurse-prescribed interventions, physiologic complications (e.g., embolism, venous ulcers). This situation would be represented by collaborative problems such as RC of Embolism. In addition, the nurse would intervene independently to prevent complications of immobility and teach how to prevent recurrence, applying nursing diagnoses such as Disuse Syndrome and Risk for Ineffective Health Maintenance related to insufficient knowledge of risk factors.

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Bagian Empat | Tautan NOC: Pola Kesehatan dan NANDA International

Integritas Jaringan, Kerusakan Definisi: Kerusakan jaringan membran mukosa, kornea, integumen, atau subkutan Outcome Untuk Mengukur Penyelesaian dari Diagnosis

Integritas Jaringan: Kulit & Membran Mukosa Outcome Tambahan untuk Mengukur Batasan Karakteristik

Kesehatan Mulut Penyembuhan Luka: Primer Penyembuhan Luka: Sekunder

Respon Alergi: Lokal Penyembuhan Luka Bakar Pemulihan Luka Bakar Keparahan Mata Kering

Outcome yang Berkaitan dengan Faktor yang Berhubungan atau Outcome Menengah

Posisi Tubuh: Berinisiatif Sendiri Status Sirkulasi Keparahan Cairan Berlebihan Hidrasi Konsekuensi Imobilitas: Fisiologi Keparahan Infeksi Keparahan Infeksi: Bayi Baru Lahir Pengetahuan: Manajemen Infeksi Pengetahuan: Manajemen Penyakit Arteri Perifer Pengetahuan: Regimen Perawatan

Pergerakan Status Nutrisi Status Nutrisi: Asupan Nutrisi Perawatan Ostomi Sendiri Kontrol Risiko: Mata Kering Kontrol Risiko: Proses Infeksi Manajemen Diri: Penyakit Arteri Perifer Fungsi Sensori: Taktil Perfusi Jaringan: Perifer

Integritas Kulit, Kerusakan Definisi: Perubahan/gangguan epidermis dan/atau dermis Outcome Untuk Mengukur Penyelesaian dari Diagnosis

Integritas Jaringan: Kulit & Membran Mukosa Outcome Tambahan untuk Mengukur Batasan Karakteristik

Respon Alergi: Lokal Penyembuhan Luka Bakar Akses Hemodialisis

Penyembuhan Luka: Primer Penyembuhan Luka: Sekunder


Posisi Tubuh: Berinisiatif Sendiri Pemulihan Luka Bakar Status Sirkulasi Keseimbangan Cairan Keparahan Cairan Berlebihan Konsekuensi Imobilitas: Fisiologi Respon Pengobatan Status Neurologi: Perifer Status Nutrisi Perawatan Ostomi Sendiri Penuaan Fisik Kontrol Risiko: Hipertermia

Kontrol Risiko: Hipotermi Kontrol Risiko: Terpapar Matahari Perawatan Diri: Mandi Perawatan Diri: Kebersihan Fungsi Sensori: Taktil Termoregulasi Termoregulasi: Bayi Baru Lahir Perfusi Jaringan Perfusi Jaringan: Seluler Perfusi Jaringan: Perifer Berat Badan: Massa Tubuh

617

682 Nursing Outcomes Classification (NOC)

Risiko Intoleransi terhadap Aktifitas Definisi: Berisiko kekurangan energi fisik atau psikologis untuk menanggung atau menyeselesaikan aktifitas sehari-hari yang dibutuhkan atau diinginkan Outcome untuk Menilai dan Mengukur Kejadian Aktual dari Diagnosis

Toleransi terhadap Aktifitas

Energi Psikomotor

Outcome yang Berhubungan dengan Faktor Risiko

Adaptasi terhadap Disabilitas Fisik Penampilan Mekanik Tubuh Keefektifan Pompa Jantung Status Jantung Paru Status Sirkulasi Koordinasi Pergerakan Daya Tahan Konservasi Energi Tingkat Kelelahan Perilaku Promosi Kesehatan Pengetahuan: Mekanik Tubuh Pengetahuan: Konservasi Enegi Pengetahuan: Aktifitas yang Disarankan

Status Nutrisi: Energi Kebugaran Fisik Status Pernafasan Status Pernafasan: Pertukaran Gas Status Pernafasan: Ventilasi Kontrol Risiko Kontrol Risiko: Penyakit Kardiovaskular Deteksi Risiko Manajemen Diri: Asma Manajemen Diri: Penyakit Jantung Manajemen Diri: Multiple Sclerosis Manajemen Diri: Osteoporosis Perilaku Berhenti Merokok

Risiko Kadar Glukosa Darah Tidak Stabil Definisi: Berisiko variasi tingkat glukosa/gula darah berada di luar kisaran normal yang dapat mengganggu kesehatan Outcome untuk Menilai dan Mengukur Kejadian Aktual dari Diagnosis

Kadar Glukosa Darah Keparahan Hiperglikemia

Keparahan Hipoglikemia

Outcome yang Berhubungan dengan Faktor Risiko

Penerimaan: Status Kesehatan Perilaku Patuh: Aktifitas yang Disarankan Perilaku Patuh: Diet yang Disarankan Perilaku Patuh: Pengobatan yang Disarankan Koping Tingkat Depresi Daya Tahan Partisipasi dalam Latihan Pengetahuan: Manajemen Diabetes Pengetahuan: Pengobatan Pengetahuan: Aktifitas yang Disarankan Pengetahuan: Diet yang Disarankan Pengetahuan: Rejimen Penanganan Pengetahuan: Manajemen Berat Badan Status Maternal: Antepartum Status Maternal: Intrapartum Status Maternal: Postpartum

Respon Pengobatan Keseimbangan Alam Perasaan Status Nutrisi Status Nutrisi: Pengukuran Biokimia Status Nutrisi: Asupan Makanan & Cairan Status Nutrisi: Asupan Nutrisi Status Kesehatan Pribadi Kebugaran Fisik Perilaku Kesehatan Prenatal Kontrol Risiko Deteksi Risiko Manajemen Diri: Diabetes Tingkat Stres Perilaku Menambah Berat Badan Perilaku Mengurangi Berat Badan Perilaku Menjaga Berat Badan

Bagian Empat | Tautan NOC: Pola Kesehatan dan NANDA International 645

Nyeri, Akut Definisi: Pengalaman sensori dan emosional yang tidak menyenangkan yang muncul akibat kerusakan jaringan yang aktual atau potensial atau digambarkan dalam hal kerusakan sedemikian rupa (International Association for the Study of Pain); awitan yang tiba-tiba atau lambat dari intensitas ringan hingga berat dengan akhir yang dapat diantisipasi atau diprediksi dan berlangsung <6 bulan Outcome Untuk Mengukur Penyelesaian dari Diagnosis

Kontrol Nyeri

Tingkat Nyeri

Outcome Tambahan untuk Mengukur Batasan Karakteristik

Keparahan Mual & Muntah Nyeri: Respon Psikologis Tambahan Nyeri: Efek yang Mengganggu Tidur Kontrol Gejala Keparahan Gejala Tanda-Tanda Vital

Tingkat Kecemasan Nafsu Makan Kepuasan Klien: Manajemen Nyeri Kepuasan Klien: Kontrol Gejala Status Kenyamanan Status Kenyamanan: Fisik Tingkat Ketidaknyamanan Pergerakan


Pemulihan Luka Bakar Fungsi Gastrointestinal Fungsi Ginjal Pengetahuan: Manajemen Penyakit Akut Pengetahuan: Manajemen Penyakit Peradangan Usus Pengetahuan: Manajemen Nyeri Respon Pengobatan Status Neurologi Keparahan Cedera Fisik Manajemen Diri: Penyakit Akut Tingkat Stres

Pemulihan Pembedahan: Penyembuhan Pemulihan Pembedahan: Segera Setelah Operasi Integritas Jaringan: Kulit & Membran Mukosa Perfusi Jaringan Perfusi Jaringan: Organ Abdominal Perfusi Jaringan: Kardiak Perfusi Jaringan: Seluler Perfusi Jaringan: Perifer Penyembuhan Luka: Primer Penyembuhan Luka: Sekunder

Nyeri, Kronis Definisi: Pengalaman sensori dan emosional yang tidak menyenangkan dan muncul akibat kerusakan jaringan yang aktual atau potensial atau digambarkan dalam hal kerusakan sedemikian rupa (International Association for the Study of Pain); awitan yang tiba tiba atau lambat dari intensitas ringan hingga berat dengan akhir yang dapat diantisipasi atau diprediksi dan berlangsung >6 bulan Outcome Untuk Mengukur Penyelesaian dari Diagnosis

Nyeri: Respon Psikologis Tambahan Kontrol Nyeri

Nyeri: Efek yang Mengganggu Tingkat Nyeri

Outcome Tambahan untuk Mengukur Batasan Karakteristik

Tingkat Agitasi Tingkat Kecemasan Nafsu Makan Kepuasan Klien: Manajemen Nyeri Kepuasan Klien: Kontrol Gejala

Status Kenyamanan Status Kenyamanan: Fisik Tingkat Depresi Kontrol Diri terhadap Depresi Tingkat Kelelahan

Bagian Empat | Tautan NOC: Pola Kesehatan dan NANDA International

Kinerja Pengasuhan: Anak Usia Pertengahan Kinerja Pengasuhan: Usia Pra Sekolah Kinerja Pengasuhan: Keamanan Psikososial Kinerja Pengasuhan: Toddler Kerentanan Personal

Manajemen Waktu Sendiri Pengaturan Psikososial: Perubahan Kehidupan Ketrampilan Interaksi Sosial Keterlibatan Sosial


Penghentian Terhadap Kekerasan Adaptasi terhadap Disabilitas Fisik Tingkat Agitasi Citra Tubuh Adaptasi Caregiver Terhadap Hospitalisasi Pasien Persiapan Perawatan di Rumah bagi Caregiver Kontrol Diri Terhadap Depresi Risiko Kecenderungan Perilaku Melarikan Diri Fungsi Keluarga Tingkat Kelelahan

Memproses Informasi Memori Tingkat Nyeri Energi Psikomotor Adaptasi Relokasi Harga Diri Tingkat Kecemasan Sosial Dukungan Sosial Tingkat Stress Konsekuensi Ketagihan Zat

Perfusi Jaringan Perifer, Ketidakefektifan Definisi: Penurunan sirkulasi darah ke perifer yang dapat mengganggu kesehatan Outcome Untuk Mengukur Penyelesaian dari Diagnosis

Perfusi Jaringan: Perifer Outcome Tambahan untuk Mengukur Batasan Karakteristik

Ambulasi Status Sirkulasi Koordinasi Pergerakan Keparahan Cairan Berlebihan Tingkat Nyeri Keparahan Penyakit Arteri Perifer Fungsi Sensori: Taktil

Integritas Jaringan: Kulit & Membran Mukosa Perfusi Jaringan Perfusi Jaringan: Seluler Tanda-Tanda Vital Penyembuhan Luka: Primer Penyembuhan Luka: Sekunder


Koagulasi Darah Keefektifan Pompa Jantung Partisipasi Latihan Keparahan Hipertensi Pengetahuan: Manajemen Penyakit Kronik Pengetahuan: Manajemen Diabetes Pengetahuan: Proses Penyakit Pengetahuan: Promosi Kesehatan Pengetahuan: Diet Sehat Pengetahuan: Manajemen Hipertensi

Pengetahuan: Manajemen Gangguan Lipid Pengetahuan: Manajemen Penyakit Arteri Perifer Pergerakan Keparahan Cedera Fisik Manajemen Diri: Diabetes Manajemen Diri: Hipertensi Manajemen Diri: Kelainan Lipid Manajemen Diri: Penyakit Arteri Perifer Perilaku Berhenti Merokok Berat Badan: Massa Tubuh

653

Bagian Enam | Intervensi-Intervensi NIC Dikaitkan dengan Diagnosis Nanda-I 525 Pengecekan Kulit Pembidaian Menjahit Luka Perawatan Traksi/Imobilisasi Perawatan Inkontinensia Urin Perawatan Luka Perawatan Luka: Luka Bakar Perawatan Luka: Tidak Sembuh Irigasi Luka Pilihan Intervensi Tambahan: Memandikan Kontrol Infeksi

Terapi Lintah Monitor Ekstremitas Bawah Pemijatan Pemberian Obat Manajemen Pengobatan Perawatan Ostomi Manajemen Tekanan Pengajaran: Perawatan Kaki Perawatan Selang: Perkemihan Monitor Tanda Tanda Vital

Integritas Kulit, Kerusakan Definisi: Perubahan/gangguan epidermis dan/atau dermis Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Perawatan Amputasi Memandikan Pengurangan Perdarahan Pengurangan Perdarahan: Luka Perawatan Gips: Pemeliharaan Perawatan Gips: Basah Perawatan Sirkumsisi Monitor Elektrolit Peningkatan Latihan Manajemen Elektrolit/Cairan Perawatan Kaki Perawatan Area Sayatan Perlindungan terhadap Latex Monitor Ekstremitas Bawah Pemberian Obat: Kulit Manajemen Pengobatan Perawatan Ostomi Perawatan Perineum Pengaturan Posisi Manajemen Tekanan Perawatan Luka Tekan Pencegahan Luka Tekan Manajemen Pruritus Perawatan Kulit: Area Donor Perawatan Kulit: Area Cangkok Perawatan Kulit: Pengobatan Topikal

Pengecekan Kulit Pembidaian Menjahit Luka Pengajaran: Perawatan Kaki Perawatan Traksi/Imobilisasi Perawatan Luka Perawatan Luka: Luka Bakar Perawatan Luka: Drainase Tertutup Perawatan Luka: Tidak Sembuh Irigasi Luka Pilihan Intervensi Tambahan: Perawatan Tirah Baring Stimulasi Kutaneus Peningkatan Latihan: Peregangan Terapi Latihan: Ambulasi Terapi Latihan: Keseimbangan Terapi Latihan: Pergerakan Sendi Terapi Latihan: Kontrol Otot Kontrol Infeksi Perlindungan Infeksi Terapi Lintah Manajemen Nutrisi Terapi Nutrisi Perawatan Penyisipan Kateter Sentral Perifer Surveilans Pemberian Nutrisi Total Parenteral (TPN) Stimulasi Listrik Syaraf Transkutaneus (TENS) Monitor Tanda Tanda Vital

Integritas Kulit, Risiko Kerusakan Definisi: Berada pada risiko terjadinya perubahan epidermis dan/atau dermis Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Perawatan Amputasi Memandikan Perawatan Tirah Baring Perawatan Inkontinensia Saluran Cerna

Perawatan Gips: Pemeliharaan Perawatan Gips: Basah Perawatan Sirkulasi: Insufisiensi Arteri Perawatan Sirkulasi: Insufisiensi Vena Perawatan Sirkumsisi Manajemen Gangguan Makan

530 Nursing Interventions Classification (NIC)

Kadar Glukosa Darah, Risiko Ketidakstabilan Definisi: Risiko terhadap variasi kadar glukosa/gula darah dari rentang normal Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Manajemen Hiperglikemi Manajemen Hipoglikemi Manajemen Pengobatan Peningkatan Efikasi Diri Pengajaran: Proses Penyakit Pengajaran: Peresepan Diet Pengajaran: Peresepan Latihan Pengajaran: Peresepan Obat Obatan Pengajaran: Prosedur / Perawatan Pilihan Intervensi Tambahan: Modifikasi Perilaku

Peningkatan Keterlibatan Keluarga Pendidikan Kesehatan Peningkatan Kesadaran Kesehatan Perawatan Kehamilan Risiko Tinggi Peningkatan Kesiapan Pembelajaran Konseling Nutrisi Monitor Nutrisi Identifikasi Risiko Fasilitasi Tanggung Jawab Diri Surveilans Manajemen Teknologi Manajemen Berat Badan

Kealpaan Tubuh Unilateral Definisi: Gangguan respons sensorik dan motorik, representasi, mental dan perhatian spasial terhadap tubuh dan lingkungan sekitar, yang ditandai dengan tidak perhatian salah satu sisi dan perhatian berlebihan terhadap satu sisi lain. Kealpaan tubuh sisi kiri lebih berat dan lebih persisten dibanding kealpaan tubuh sisi kanan Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Peningkatan Citra Tubuh Peningkatan Komunikasi: Kurang Penglihatan Peningkatan Koping Manajemen Lingkungan: Keselamatan Pencegahan Jatuh Monitor Neurologi Pengaturan Posisi Bantuan Perawatan Diri Sentuhan Manajemen Pengabaian Unilateral Pilihan Intervensi Tambahan:

Perawatan Amputasi Dukungan Pengasuhan [Caregiver Support] Peningkatan Perfusi Serebral Peningkatan Latihan Peningkatan Latihan: Peregangan Terapi Latihan: Ambulasi Terapi Latihan: Keseimbangan Terapi Latihan: Pergerakan Sendi Terapi Latihan: Kontrol Otot Monitor Ekstremitas Bawah Pengaturan Tujuan Saling Menguntungkan Peningkatan Sistem Dukungan Pengajaran: Individu

Kekuatan, Kesiapan Meningkatkan Definisi: Suatu pola berpartisipasi melalui pengetahuan dalam suatu perubahan yang cukup untuk kesejahteraan dan dapat diperkuat Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Bimbingan Antisipasif Latihan Asertif Pujian Dukungan Pengambilan Keputusan Dukungan Emosional Pendidikan Kesehatan Panduan Sistem Pelayanan Kesehatan Fasilitasi Pembelajaran Pengaturan Tujuan Saling Menguntungkan Peningkatan Ketahanan Peningkatan Kesadaran Diri

Peningkatan Efikasi Diri Peningkatan Harga Diri Bantuan Modifikasi Diri Fasilitasi Tanggung Jawab Diri Klarifikasi Nilai Pilihan Intervensi Tambahan: Dukungan Perlindungan terhadap Kekerasan Pengurangan Kecemasan Mediasi Konflik Intervensi Krisis Manajemen Lingkungan Peningkatan Kecakapan Hidup Fasilitasi Meditasi

Bagian Enam | Intervensi-Intervensi NIC Dikaitkan dengan Diagnosis Nanda-I 559

Nutrisi: Ketidakseimbangan, Lebih dari Kebutuhan Tubuh Definisi: Asupan nutrien yang melebihi kebutuhan tubuh Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Modifikasi Perilaku Peningkatan Latihan Manajemen Cairan Manajemen Nutrisi Konseling Nutrisi Monitor Nutrisi Pengajaran: Peresepan Diet Manajemen Berat Badan Bantuan Penurunan Berat Badan Pilihan Intervensi Tambahan: Pengurangan Kecemasan Manajemen Perilaku Pemberian Makan dengan Botol Peningkatan Koping Pemberian Makan dengan Tabung Enteral

Terapi Latihan: Ambulasi Pemberian Makan Monitor Cairan Manajemen Hiperglikemi Manajemen Hipoglikemi Perawatan Bayi Pembatasan Setting Pengaturan Tujuan Saling Menguntungkan Terapi Nutrisi Bantuan Pasien untuk Mengontrol Pemberian Analgesik Rujukan Bantuan Modifikasi Diri Fasilitasi Tanggung Jawab Diri Pengecekan Kulit Dukungan Kelompok Pengajaran: Individu

Nutrisi: Ketidakseimbangan, Risiko Lebih dari Kebutuhan Tubuh Definisi: Berisiko pada asupan nutrien melebihi kebutuhan metabolik Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Pengurangan Kecemasan Modifikasi Perilaku Peningkatan Latihan Manajemen Nutrisi Terapi Nutrisi Konseling Nutrisi Monitor Nutrisi Identifikasi Risiko Bantuan Modifikasi Diri Pengajaran: Nutrisi Bayi 0-3 Bulan Pengajaran: Nutrisi Bayi 4-6 Bulan Pengajaran: Nutrisi Bayi 7-9 Bulan

Pengajaran: Nutrisi Bayi 10-12 Bulan Pengajaran: Nutrisi Balita 13-18 Bulan Pengajaran: Nutrisi Balita 19-24 Bulan Pengajaran: Nutrisi Balita 25-36 Bulan Manajemen Berat Badan Pilihan Intervensi Tambahan: Pemberian Makan dengan Botol Pemberian Makan dengan Tabung Enteral Perawatan Bayi Pengaturan Tujuan Saling Menguntungkan Pengajaran: Individu Pengajaran: Peresepan Diet Bantuan Penurunan Berat Badan

Nyeri, Akut Definisi: Pengalaman sensori dan emosional yang tidak menyenangkan yang muncul akibat kerusakan jaringan yang aktual atau potensial atau digambarkan dalam hal kerusakan sedemikian rupa (International Association for the Study of Pain); awitan yang tiba-tiba atau lambat dari intensitas ringan hingga berat dengan akhir yang dapat diantisipasi atau diprediksi dan berlangsung <6 Bulan Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Akupressur Pemberian Analgesik Pemberian Analgesik: Intraspinal Pemberian Anastesi Pengurangan Kecemasan

Stimulasi Kutaneus Manajemen Lingkungan: Kenyamanan Pengurangan Perut Kembung Aplikasi Panas/Dingin Pemberian Obat Pemberian Obat: Intramuskular (IM) Pemberian Obat: Intravena (IV)

560 Nursing Interventions Classification (NIC) Pemberian Obat: Oral Manajemen Pengobatan Peresepan Obat Manajemen Nyeri Bantuan Pasien untuk Mengontrol Pemberian Analgesik Manajemen Prolaps Rektum Manajemen Sedasi Stimulasi Listrik Syaraf Transkutaneus (TENS) Pilihan Intervensi Tambahan: Mendengar Aktif Terapi Bantuan Hewan Latihan Autogenik Memandikan Biofeedback Peningkatan Mekanika Tubuh Manajemen Saluran Cerna Peningkatan Koping Pengalihan Dukungan Emosional Manajemen Energi Manajemen Lingkungan Peningkatan Latihan Peningkatan Latihan: Peregangan Terapi Latihan: Ambulasi Terapi Latihan: Keseimbangan Terapi Latihan: Pergerakan Sendi

Terapi Latihan: Kontrol Otot Fasilitasi Proses Berduka Imajinasi Terbimbing Inspirasi Harapan Humor Hipnosis Perawatan Intrapartum: Risiko Tinggi Melahirkan Supresi Laktasi Pemijatan Fasilitasi Meditasi Terapi Musik Pemulihan Kesehatan Mulut Terapi Oksigen Pengaturan Posisi Perawatan Paska Anastesi Persiapan Informasi Sensorik Menghadirkan Diri Relaksasi Otot Progresif Terapi Relaksasi Peningkatan Keamanan Fasilitasi Hipnosis Diri Peningkatan Tidur Bermain Terapeutik Sentuhan Terapeutik Sentuhan Monitor Tanda Tanda Vital

Nyeri, Kronis Definisi: Pengalaman sensori dan emosional yang tidak menyenangkan dan muncul akibat kerusakan jaringan yang aktual atau potensial atau digambarkan dalam hal kerusakan sedemikian rupa (International Association for the Study of Pain); awitan yang tiba tiba atau lambat dari intensitas ringan hingga berat dengan akhir yang dapat diantisipasi atau diprediksi dan berlangsung > 6 Bulan Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Akupressur Pemberian Analgesik Pemberian Analgesik: Intraspinal Peningkatan Koping Stimulasi Kutaneus Imajinasi Terbimbing Aplikasi Panas/Dingin Pemijatan Pemberian Obat Manajemen Pengobatan Peresepan Obat Manajemen Alam Perasaan Manajemen Nyeri Bantuan Pasien untuk Mengontrol Pemberian Analgesik Relaksasi Otot Progresif Stimulasi Listrik Syaraf Transkutaneus (TENS) Pilihan Intervensi Tambahan: Mendengar Aktif Terapi Bantuan Hewan

Latihan Autogenik Biofeedback Pengalihan Manajemen Lingkungan: Kenyamanan Peningkatan Latihan: Peregangan Terapi Latihan: Ambulasi Terapi Latihan: Pergerakan Sendi Terapi Latihan: Kontrol Otot Sentuhan yang Menyembuhkan Humor Hipnosis Fasilitasi Meditasi Terapi Musik Pengaturan Posisi Reiki Terapi Relaksasi Fasilitasi Hipnosis Diri Peningkatan Tidur Sentuhan Terapeutik Sentuhan Monitor Tanda Tanda Vital


Perfusi Jaringan Perifer, Ketidakefektifan Definisi: Penurunan sirkulasi darah ke perifer yang dapat mengganggu kesehatan Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Manajemen Asam Basa Monitor Asam-Basa Tes Laboratorium di Samping Tempat Tidur Perawatan Sirkulasi: Insufisiensi Arteri Perawatan Sirkulasi: Alat Bantu Mekanik Perawatan Sirkulasi: Insufisiensi Vena Perawatan Sirkumsisi Perawatan Gawat Darurat Manajemen Elektrolit/Cairan Manajemen Cairan Monitor Cairan Perawatan Kaki Pengaturan Hemodinamik Manajemen Hipervolemia Manajemen Hipovolemi Monitor Hemodinamik Invasif Interpretasi Data Laboratorium Monitor Ekstremitas Bawah Monitor Neurologi Manajemen Nutrisi Terapi Oksigen Manajemen Sensasi Perifer Perlindungan terhadap Torniket Pneumatik Pengaturan Posisi Pencegahan Luka Tekan Resusitasi

Resusitasi: Neonatus Manajemen Syok Manajemen Syok: Jantung Manajemen Syok: Vasogenik Pengecekan Kulit Bantuan Penghentian Merokok Pengajaran: Proses Penyakit Monitor Tanda Tanda Vital Pilihan Intervensi Tambahan: Perawatan Emboli: Perifer Pencegahan Emboli Peningkatan Latihan Terapi Latihan: Ambulasi Terapi Latihan: Keseimbangan Terapi Latihan: Pergerakan Sendi Terapi Latihan: Kontrol Otot Pemasangan Infus Terapi Intravena (IV) Pemberian Obat Manajemen Pengobatan Manajemen Nyeri Perawatan Penyisipan Kateter Sentral Perifer Phlebotomi: Sampel Darah Arteri Phlebotomi: Pembuluh Darah yang Terkanulasi Phlebotomi: Sampel Darah Vena Surveilans Pengaturan Suhu Pemberian Nutrisi Total Parenteral (TPN)

Perfusi Jaringan Perifer, Risiko Ketidakefektifan Definisi: Berisiko mengalami penurunan sirkulasi darah ke perifer yang dapat mengganggu kesehatan Intervensi Keperawatan yang Disarankan untuk Menyelesaikan Masalah: Perawatan Sirkulasi: Insufisiensi Vena Perawatan Sirkumsisi Perawatan Emboli: Perifer Pencegahan Emboli Peningkatan Latihan Manajemen Hiperglikemi Manajemen Hipoglikemi Monitor Ekstremitas Bawah Pengecekan Kulit Bantuan Penghentian Merokok Pengajaran: Proses Penyakit Pengajaran: Perawatan Kaki

Pengajaran: Peresepan Diet Pengajaran: Peresepan Latihan Pengajaran: Peresepan Obat Obatan Bantuan Penurunan Berat Badan Pilihan Intervensi Tambahan: Perawatan Tirah Baring Interpretasi Data Laboratorium Pemberian Obat Manajemen Pengobatan Peresepan Obat Manajemen Sensasi Perifer Pengaturan Posisi Pembidaian Monitor Tanda Tanda Vital

Defining characteristic: Nursing diagnosis Impaired skin integrity Doengoes

Carpenito

NANDA

Draining wound of L Food (p. 32 (63) Disruption of skin surface (p.108 (139) Absence of viable tissue (p. 681 (712) Dst....

Major (Must be present): Disruption of epiderma and dermal tissue

Alteration in skin integrity Foreign matter piercing skin

Minor (May be present): Denuded skin Lesions (primary, secondary) Erythema Pruritus

Risk factors of Nursing Diagnosis: Risk for unstable blood glucose level Doengoes

Carpenito

NANDA

Unstable blood glucose

Risk for unstable blood glucose Deficient knowledge of diabetes management (e.g., action plan) Developmental level Dietary intake Inadequate blood glucose monitoring Lack of acceptance of diagnosis Lack of adherence to diabetes management (e.g., action plan) Lack of diabetes management (e.g., action plan) Medication management Physical activity level Physical health status Pregnancy Rapid growth periods Stress Weight gain Weight loss

Risk for unstable blood glucose level

Fingerstick 450/adm

NANDA halaman: 171 (201)

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Defining characteristic nursing diagnosis: Acute pain Doengoes

Carpenito

NANDA

Verbal report of pain and guarding behavior (p. 33 (64) P. 43 (74) p.68 (99) Dst

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Hal 440 (470) Click here

ACUTE PAIN Definition_ _____________________________________________________________ The state in which a person experiences and reports the presence of severe discomfort or an uncomfortable sensation, lasting from 1 s to less than 6 months

Defining Characteristics_ ______________________________________________ Self Report of Pain Quality and Intensity (Attempt to use with all patients)

For Patients Unable to Provide Self-Report (in order of preference): • Presence of pathological condition or procedure known to cause pain • Physical responses such as diaphoresis, changes in blood pressure or pulse, pupil dilation, change in respiratory rate, guarding, grimacing, moaning, crying, or restlessness • Surrogate reporting (family members, caregivers) • Response to an analgesic trial (Herr et al., 2006)

Related Factors_ _______________________________________________________ See Impaired Comfort.

AUTHOR’S NOTE Nursing management of pain presents specific challenges. Is acute pain a response that nurses treat as a nursing diagnosis or collaborative problem? Is acute pain the etiology of another response that better describes the condition that nurses treat? Does some cluster of nursing diagnoses represent a pain syndrome or chronic pain syndrome (e.g., Fear, Risk for Ineffective Family Coping, Impaired Physical Mobility, Social Isolation, Ineffective Sexuality Patterns, Risk for Colonic Constipation, Fatigue)? McCafferty and Beebe (1989) cite 18 nursing diagnoses that can apply to people experiencing pain. Viewing pain as a syndrome diagnosis can provide nurses with a comprehensive nursing diagnosis for people in pain to whom many related nursing diagnoses could apply.

ERRORS IN DIAGNOSTIC STATEMENTS 1. Pain related to surgical incision Viewing incisional pain as an etiology rather than a response may better relate to nursing’s focus. For a client who has undergone surgery, the nurse focuses on reducing pain to permit increased participation in activities and to reduce anxiety, as described by the nursing diagnosis Impaired Physical Mobility related to fear of pain and weakness secondary to anesthesia and insufficient fluids and nutrients. 2. Pain related to cardiac tissue ischemia The nurse has several responsibilities for a person experiencing chest pain: evaluating cardiac status, reducing activity, administering PRN medication, and reducing anxiety. Before discharge, the nurse teaches self- monitoring, self-medication, signs and symptoms of complications, follow-up care, and necessary lifestyle modifications. Management of chest pain involves nurse-prescribed and physician-prescribed interventions, so this situation should be described as the collaborative problem RC of Cardiac Dysfunction. This collaborative problem encompasses various cardiac complications (e.g., dysrhythmias, decreased cardiac output, angina). In addition, two nursing diagnoses would apply: Anxiety related to present situation, unknown future, and perceived effects on self and significant others, and Ineffective Health Maintenance related to insufficient knowledge of condition, signs and symptoms of complications, risk factors, activity restrictions, and follow-up care.

132

Domain 12. Comfort

Class 1. Physical Comfort

00132

Acute pain

(1996, 2013; LOE 2.2)

Definition

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

Defining Characteristics

12. Comfort

Appetite change Change in physiological parameter (e.g., blood pressure, heart rate, respiratory rate, oxygen saturation, and end-tidal CO2) ■■ Diaphoresis ■■ Distraction behavior ■■ Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally (e.g., Neonatal Infant Pain Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate) ■■ Expressive behavior (e.g., restlessness, crying, vigilance) ■■ Facial expression of pain (e.g., eyes lack luster, beaten look, fixed or scattered movement, grimace) ■■ Guarding behavior

Hopelessness Narrowed focus (e.g., time perception, thought processes, interaction with people and environment) ■■ Positioning to ease pain ■■ Protective behavior ■■ Proxy report of pain behavior/ activity changes (e.g., family member, caregiver) ■■ Pupil dilation ■■ Self-focused ■■ Self-report of intensity using standardized pain scale (e.g., Wong-Baker FACES scale, visual analogue scale, numeric rating scale) ■■ Self-report of pain characteristics using standardized pain instrument (e.g., McGill Pain Questionnaire, Brief Pain Inventory)

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440 Domain 12: Comfort

Defining characteristi of nursing diagnoses: Ineffective peripheral tissue perfusion Doengoes

Carpenito

NANDA

Tisssue edema, pain Diminished peripheral pulses, slow or diminished capillary refill Skin color changes – pallor, erythema (p. 114 (145)

Halaman 680

Halaman 237 (267)

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INEFFECTIVE PERIPHERAL TISSUE PERFUSION Definition_ _____________________________________________________________ State in which a person experiences or is at risk of experiencing a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary blood supply

Defining Characteristics_ ______________________________________________ Major (Must Be Present, One or More) Presence of one of the following types (see Key Concepts for definitions): Claudication (arterial) Aching pain (arterial or venous) Rest pain (arterial) Diminished or absent arterial pulses (arterial) Skin color changes Pallor (arterial) Reactive hyperemia (arterial) Cyanosis (venous) Skin temperature changes Cooler (arterial) Warmer (venous) Decreased blood pressure (arterial) Capillary refill longer than 3 s (arterial)

Minor (May Be Present) Edema (venous) Change in motor function (arterial) Hard, thick nails Loss of hair Nonhealing wound

Change in sensory function (arterial) Trophic tissue changes (arterial)

Related Factors_ _______________________________________________________ Pathophysiologic Related to compromised blood flow secondary to: Vascular disorders Arteriosclerosis Leriche’s syndrome Raynaud’s disease/syndrome Aneurysm Arterial thrombosis Buerger’s disease Sickle cell crisis Collagen vascular disease Rheumatoid arthritis Alcoholism Diabetes mellitus Hypotension Blood dyscrasias Renal failure Cancer/tumor

Venous hypertension Varicosities Deep vein thrombosis Cirrhosis

Treatment-Related Related to immobilization Related to presence of invasive lines Related to pressure sites/constriction (elastic compression bandages, stockings, restraints) Related to blood vessel trauma or compression

Situational (Personal, Environmental) Related to pressure of enlarging uterus on pelvic vessels

658

Domain 4. Activity/Rest

Class 4. Cardiovascular/Pulmonary Responses

00204

Ineffective peripheral tissue perfusion (2008, 2010; LOE 2.1)

Definition

Defining Characteristics Absence of peripheral pulses Alteration in motor functioning ■■ Alteration in skin characteristic (e.g., color, elasticity, hair, moisture, nails, sensation, temperature) ■■ Ankle-brachial index <0.90 ■■ Capillary refill time >3 seconds ■■ Color does not return to lowered limb after 1 minute leg elevation ■■ Decrease in blood pressure in extremities ■■ Decrease in pain-free distances achieved in the 6-minute walk test

Decrease in peripheral pulses Delay in peripheral wound healing ■■ Distance in the 6-minute walk test below normal range (400 m to 700 m in adults) ■■ Edema ■■ Extremity pain ■■ Femoral bruit ■■ Intermittent claudication ■■ Paresthesia ■■ Skin color pales with limb elevation

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Related Factors Diabetes mellitus Hypertension ■■ Insufficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility) ■■ ■■

Insufficient knowledge of disease process ■■ Sedentary lifestyle ■■ Smoking ■■

Original literature support available at www.nanda.org Class 4: Cardiovascular/Pulmonary Responses 237

4. Activity/Rest

Decrease in blood circulation to the periphery that may compromise health.

Contoh pilihan NOC dan NIC Impaired skin integrity-Kerusakan integritas kulit Doengoes

Carpenito

Buku NOC

NOC

Wound healing: Secondary intention

Tissue integrity: Skin and Mucous membrane

Integritas Jaringan: Kulit & Membran Mukosa (107)

NIC

Wound care Pressure Infection management control Pressure ulcer care Skin Surveillance Positioning

Buku NIC

Perawatan area sayatan (354) Perawatan luka tekan (376) Pengecekan kulit (311) Perawatan luka (373)

Bagian Tiga | Outcome

Integritas Jaringan: Kulit & Membran Mukosa

107

1101

Definisi: Keutuhan struktur dan fungsi fisiologis kulit dan selaput lendir secara normal SKALA TARGET OUTCOME: Dipertahankan pada______

SKALA OUTCOME KESELURUHAN Indikator: 110101 Suhu kulit 110102 Sensasi 110103 Elastisitas 110104 Hidrasi 110106 Keringat 110108 Tekstur 110109 Ketebalan 110111 Perfusi jaringan 110112 Pertumbuhan rambut pada kulit 110113 Integritas kulit 110105 110115 110116 110117 110118 110119 110120 110121 110122 110123 110124 110125

Pigmentasi abnormal Lesi pada kulit Lesi mukosa membran Jaringan parut Kanker kulit Pengelupasan kulit Penebalan kulit Eritema Wajah pucat Nekrosis Pengerasan [kulit] Abrasi kornea

Ditingkatkan ke_______ Sangat Terganggu 1

Banyak terganggu 2

1 1 1 1 1 1 1 1 1 1 Berat 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 Cukup berat 2 2 2 2 2 2 2 2 2 2 2 2

Cukup Sedikit Tidak terganggu terganggu terganggu 3 4 5 3 3 3 3 3 3 3 3 3 3 Sedang 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 Ringan 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 Tidak ada 5 5 5 5 5 5 5 5 5 5 5 5

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Domain-Kesehatan Fisiologis (II) Kelas-Integritas Jaringan (L) edisi pertama 1997; revisi 2004, 2013 REFERENSI TERKAIT DENGAN ISI DARI OUTCOME: + Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210. Cohen, I. K., Diegelmann, R. F., & Lindblad, W. L. (1992). Wound healing: Biochemical and clinical aspects. Philadelphia: W. B. Saunders. Hardy, M. D. (2001). Impaired skin integrity: Dry skin. In M. Maas, K. Buckwalter, M. Hardy, T. Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes & interventions (pp. 137–144). St. Louis: Mosby. Lazarus, G. S., Cooper, D. M., Knighton, D. R., Margohs, D. J., Pecoraro, R. E., Rodeheaver, G., et al. (1994). Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology, 130(4), 489–493. Maklebust, J., & Sieggreen, M. (1996). Pressure ulcers: Guidelines for prevention and nursing management (2nd ed.). Springhouse, PA: Springhouse. Potter, P. A., & Perry, A. G. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby. Van Rijswijk, L. (1993). Full-thickness leg ulcers: Patient demographics and predictors of healing. The Journal of Family Practice, 36(6), 625–632.


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Jadikan satu berbagai aktivitas perawatan untuk mendukung interval tidur yang paling panjang dan konservasi energi Posisikan bayi untuk tidur di posisi tengkurap di dada orangtua yang tidak mengenakan baju, jika memungkinkan Sediakan kursi yang nyaman di area yang tenang untuk pem berian makan Bergerak pelan dan lembut saat memegang, memberikan makan, dan memberikan perhatian pada bayi Posisikan dan dukung selama memberikan makan dengan memelihara posisi fleksi dan midline (misalnya., dukung bahu and dukungan trunkal, foot bracing, hand holding, penggunaan bunting, atau swaddling) Berikan makan dengan posisi tegak untuk menyokong ekstensi lidah dan menelan Dukung partisipasi orangtua pada saat pemberian makan Dukung [proses] menyusui Monitor asupan dan pengeluaran Penggunaana dot mainan selama makan dan antara pemberian makan untuk penghisapan tanpa nutrisi untuk mendukung stabilitas fisik dan status nutrisi Fasilitasi kondisi transisi dan tenangkan selama kondisi penuh nyeri, prosedur yang penuh stress tetapi diperlukan Tetapkan rutinitas yang konsisten dan dapat diprediksikan untuk mendukung siklus tidur-terjaga yang teratur Beri stimulus dengan menggunakan instrumen musik yang di rekam, telepon genggam, pijat, diayun-ayun dan sentuhan Monitor dan atur kebutuhan akan oksigen Tutup mata dan genitalia dengan penutup kain untuk anak yang dilakukan fototerapi Lepaskan penutup mata selama waktu makan dan secara teratur monitor apa yang dikeluarkan mata dan iritasi korena

• •

Monitor hematokrit dan berikan transfusi darah saat diperlukan Informasikan pada orangtua tentang tindakan pencegahan untuk SIDS (Sudden Infant Death Syndrome)

Edisi ke-enam tahun 2013 Bahan Bacaan: Becker, P. T., Grunwald, P. C., Moorman, J., & Stuhr, S. (1991). Outcomes of developmentally supportive nursing care for very low birth weight infants. Nursing Research, 40(3), 150-155. Brown, G. (2009). NICU noise and the preterm infant.Neonatal Network, 28(3), 165-173. Johnston, A. M., Bullock, C. E., Graham, J. E., Reilly, M. C., Rocha, C., Hoopes, R. D., et al. (2006). Implementation and case study results of potentially better practices for family-centered care: The family-centered care map. Pediatrics, 118(Suppl. 2), S108-S114. Pinelli, J., & Symington, A. J. (2005).Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001071. DOI: 10.1002/ 14651858.CD001071.pub2. Symington, A. J, & Pinelli, J. (2006). Developmental care for promoting development and preventing morbidity in preterm infants.Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001814. DOI: 10.1002/14651858.CD001814.pub2. Wallin, L., & Eriksson, M. (2009).Bayi baru lahir individual developmental care and assessment program (NIDCAP): A systematic review of the literature. Worldviews on Evidence-Based Nursing, 6(2), 54-69. Ward, S. L., & Hisley, S. M. (2009).Caring for the bayi baru lahir at risk. In Maternal-child nursing care: Optimizing outcomes for mothers, children, & families. (pp. 603-637). Philadelphia: F. A. Davis.

Perawatan Daerah (Area) Sayatan

3440

Definisi: Membersihkan, memantau, dan meningkatkan proses penyembuhan luka yang ditutup dengan jahitan, klip, atau steples Aktiftas-aktivitas: • Jelaskan prosedur pada pasien, gunakan persiapan sensorik • Periksa daerah sayatan terhadap kemerahan, bengkak, atau tanda-tanda dehiscence atau eviserasi • Catat karakteristik drainase • Monitor proses penyembuhan di daerah sayatan • Bersihkan daerah sekitar sayatan dengan pembersihan yang tepat • Bersihkan mulai dari area yang bersih ke area yang kurang bersih • Monitor sayatan untuk tanda dan gejala infeksi • Gunakan kapas steril untuk pembersihan jahitan benang luka yang efisien, luka dalam dan sempit, atau luka berkantong • Bersihkan area sekitar drainase atau pada area selang drainase • Jaga posisi selang drainase • Berikan plester untuk menutup • Berikan salep antiseptik • Lepaskan jahitan, steples, atau klip, sesuai indikasi

• • • • •

Ganti pakaian dengan interval [waktu] yang tepat Gunakan pakaian yang sesuai untuk melindungi sayatan Fasilitasi pasien untuk melihat luka insisi Arahkan pasien cara merawat luka insisi selama mandi Arahkan pasien bagaimana meminimalkan tekanan pada daerah insisi • Arahkan pasien dan/atau keluarga cara merawat luka insisi, termasuk tanda-tanda dan gejala infeksi Edisi pertama tahun 1992; direvisi tahun 2000 Bahan Bacaan: Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Perioperative nursing. In Fundamentals of nursing: Concepts, processes, and practice. (7th ed., pp. 896-937). Upper Saddle River, NJ: Prentice Hall. Perry, A. G., & Potter, P. A. (1998).Clinical nursing skills and techniques (4th ed.). St. Louis: Mosby.

376 Nursing Interventions Classification (NIC) Bahan Bacaan: Carroll, M. C., Fleming, M., Chitambar, C. R., & Neuburg, M. (2002). Diagnosis workup and prognosis of cutaneous metastases of unknown primary origin.Dermatologic Surgery, 28(6), 533-535. Cormio, G., Capotorto, M., Vagno, G., Cazzolla, A., Carriero, C., & Selvaggi, L. (2003).Skin metastases in ovarian carcinoma: A report of nine cases and a review of the literature. Gynecologic Oncology, 90(3), 682-685. Emmons, K. R., & Lachman, V. D. (2010).Palliative wound care: A concept analysis. Journal of Wound, Ostomy, and Continence Nursing, 37(6), 639644. Ferris, F. D., Khateib, A., Fromanin, I., Hoplamazian, L., Hurd, T., Krasner, D., et al. (2007).Pallative wound care: Managing chronic wounds across life’s continuum: A consensus statement from the International Palliative Wound Care Initiative. Journal of Palliative Medicine, 10(1), 37-39.

Langemo, D. K., Anderson, J., Hanson, D., Thompson, P., & Hunter, S. (2007). Understanding palliative wound care. Nursing 2007, 37(1), 6566. Lookingbill, D. P., Spangler, N., & Helm, K. F. (1993). Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. Journal of the American Academy of Dermatology, 29(2 Pt 1), 228-236. Lund-Nielsen, B., Müller, K., & Adamsen, L. (2005).Malignant wounds in women with breast cancer: Feminine and sexual perspectives. Journal of Clinical Nursing, 14(1), 56-64. Seaman, S. (2006). Management of malignant fungating wounds in advanced cancer. Seminars in Oncology Nursing, 22(3), 185-193.

Perawatan Luka Tekan

3520

Definisi: Fasilitasi proses penyembuhan luka tekan/dekubitus Aktivitas-aktivitas: • Catat karakteristik luka tekan setiap hari, meliputi ukuran (panjang x lebar x dalam), tingkatan luka (I-IV), lokasi, eksudat, granulasi atau jaringan nekrotik, dan epitelisasi • Monitor warna, suhu, udem, kelembaban, dan kondisi area sekitar luka • Jaga agar luka tetap lembab untuk membantu proses penyem buhan • Berikan pelembab yang hangat di sekitar area luka untuk meningkatkan perfusi darah dan suplai oksigen • Bersihkan kulit sekitar luka dengan sabun yang lembut dan air • Lakukan debridement jika diperlukan • Bersihkan luka dengan cairan yang tidak berbahaya, lakukan pembersihan dengan gerakan sirkuler dari dalam keluar • Gunakan jarum suntik ukuran 19 dan suntikan 35 cc untuk membersihkan luka dalam • Catat karakteristik cairan luka • Pasang balutan adesif yang elastik pada luka, jika memungkinkan • Berikan saline untuk menggosok jika diperlukan • Berikan salep jika dibutuhkan • Lakukan pembalutan dengan tepat • Berikan obat-obatan oral • Monitor tanda dan gejala infeksi di area luka • Ubah posisi setiap 1-2 jam sekali untuk mencegah penekanan • Gunakan tempat tidur khusus anti dekubitus • Gunakan alat-alat pada tempat tidur untuk melindungi pasien • Yakinkan asupan nutrisi yang adekuat • Monitor status nutrisi • Pastikan bahwa pasien mendapat diit tinggi kalori tinggi protein

• Ajarkan pasien dan keluarga akan adanya tanda kulit pecahpecah • Ajarkan pasien dan keluarga mengenai perawatan luka • Fasilitasi pasien agar dapat berkonsultasi dengan perawat ahli luka, jika dibutuhkan Edisi pertama tahun 1992, direvisi tahun 2000 dan tahun 2004 Bahan Bacaan: Bergstrom, N., Bennett, M. A., Carlson, C. E., et al. (1994). Treatments of pressure ulcers: Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Frantz, R. A. & Gardner, S. (1999). Pressure ulcer care. In G. M. Bulechek & J. C. McCloskey (Eds.), Nursing interventions: Effective nursing treatments (3rd ed., pp. 211-223). Philadelphia: Saunders. Frantz, R. A., Gardner, S., Specht, J. K., & McIntire, G. (2001). Integration of pressure ulcer treatment protocol into practice: Clinical outcomes and care environment attributes. Outcomes Management for Nursing Practice, 5(3), 112-120. Hirshberg, J., Coleman, J., Marchant, B., & Rees, R. S. (2001). TGF-[beta]3 in the treatment of pressure ulcers: A preliminary report. Advances in Skin & Wound Care, 14(2), 91-95. Perry, A. G. & Potter, P. A. (2002). Clinical nursing skills and techniques (5th ed., pp. 175-191). St. Louis: Mosby. Spungen, A. M., Koehler, K. M., Modeste-Duncan, R., Rasul, M., Cytryn, A. S., & Bauman, W.A. (2001). 9 clinical cases of nonhealing pressure ulcers in patients with spinal cord injury treated with an anabolic agent: A therapeutic trial. Advances in Skin & Wound Care, 14(3), 139-144. Whitney, J. D., Salvadalena, G., Higa, L., & Mich, M. (2001). Treatment of pressure ulcers with noncontact normothermic wound therapy: Healing and warming effects. Journal of Wound, Ostomi, and Continence Nursing, 28(5), 244-252.

Bagian Tiga | Klasifikasi 311

Pengecekan Kulit

3590

Definisi: Pengumpulan dan analisis data pasien untuk menjaga kulit dan integritas membran mukosa Aktivitas-aktivitas: • Periksa kulit dan selaput lendir terkait dengan adanya kemerahan, kehangatan ekstrim, edema, atau drainase • Amati warna, kehangatan, bengkak, pulsasi, tekstur, edema, dan ulserasi pada ekstremitas • Periksa kondisi luka operasi, dengan tepat • Gunakan alat pengkajian untuk mengidentifikasi pasien yang berisiko mengalami kerusakan kulit (misalnya, Skala Braden) • Monitor warna dan suhu kulit • Monitor kulit dan selaput lendir terhadap area perubahan warna, memar, dan pecah • Monitor kulit untuk adanya ruam dan lecet • Monitor kulit untuk adanya kekeringan yang berlebihan dan kelembaban • Monitor sumber tekanan dan gesekan • Monitor infeksi, terutama dari daerah edema • Periksa pakaian yang terlalu ketat • Dokumentasikan perubahan membran mukosa • Lakukan langkah-langkah untuk mencegah kerusakan lebih lanjut (misalnya, melapisi kasur, menjadwalkan reposisi)

• Ajarkan anggota keluarga/pemberi asuhan mengenai tandatanda kerusakan kulit, dengan tepat Edisi pertama tahun 1992; direvisi tahun 2008 Bahan bacaan: McCance, K. L. & Huether, S. E. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis: Mosby. Perry, A. G. & Potter, P. A. (2006). Clinical nursing skills and techniques (6th ed.). St. Louis: Mosby. Potter, P. A. & Perry, A. G. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby. Taylor, C., Lillis, C., & LeMone, P. (2007). Fundamentals of nursing: The art and science of nursing care. Philadelphia: Lippincott Williams and Wilkins. Titler, M. G., Pettit, D., Bulechek, G. M., McCloskey, J. C., Craft, M. J., Cohen, M. Z., et al (1991). Classification of nursing interventions for care of the integument. Nursing Diagnosis, 2(2), 45-56. Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelan’s critical care nursing: Diagnosis and management (5th ed.). St. Louis: Mosby.

Pengekangan fisik

6580

Definisi: Penerapan, monitor dan melepas alat-alat restrain/pengekangan/pengikatan mekanik atau manual yang digunakan untuk membatasi mobilisasi fisik pasien Aktivitas-aktivitas: • Dapatkan order dokter, jika dibutuhkan oleh kebijakan institusi, untuk menggunakan intervensi pembatasan fisik atau untuk mengurangi penggunaan [pengekangan fisik] • Berikan privasi bagi pasien, berikan situasi lingkungan dimana martabat pasien [menjadi] terbatas karena dilakukannya pengekangan fisik • Sediakan staf yang cukup untuk membantu dengan mengguna kan alat-alat pembatasan fisik yang aman atau pengekangan secara manual • Tugaskan satu staf keperawatan untuk mengarahkan staf lain dan berkomunikasi dengan pasien selama [dilakukannya] aplikasi pengekangan fisik • Gunakan pegangan yang sesuai ketika pembatasan pasien dilakukan secara manual dalam situasi emergensi atau selama memindahkan pasien • Identifikasi pasien dan orang yang berarti bagi pasien mengenai perilaku yang menyebabkan diperlukannya intervensi [pengekangan] • Jelaskan prosedur, tujuan dan periode waktu intervensi pada pasien dan keluarga dalam bahasa yang mudah dipahami dan tidak menghukum • Jelaskan pada pasien dan keluarga mengenai perilaku yang dibutuhkan untuk menghentikan intervensi • Monitor respon pasien terhadap prosedur • Hindari pengekangan yang ketat pada pegangan sisi tempat tidur • Amankan pengekangan jauh dari jangkauan pasien

• Berikan supervisi yang sesuai/surveillance yang sesuai untuk memonitor pasien dan memberikan tindakan terapeutik, sesuai kebutuhan • Berikan kenyamanan psikologis pada pasien, sesuai kebutuhan • Berikan aktivitas yang beraneka ragam (misalnya., televisi, bacaan untuk pasien, pengunjung), jika sesuai, untuk mem fasilitasi kerjasama pasien terhadap [dilakukannya] intervensi • Berikan obat PRN untuk mengatasi cemas dan agitasi • Monitor kondisi kulit pada lokasi [yang dilakukan] restraint/ pengekangan/pengikatan • Monitor warna, suhu dan sensasi secara berkala pada ekstremitas yang diikat • Berikan pergerakan dan latihan, sesuai dengan level kontrol mandiri pasien, kondisi pasien dan kemampuan pasien • Atur posisi pasien untuk memfasilitasi kenyamanan dan men cegah aspirasi serta kulit lecet • Berikan kesempatan untuk melakukan pergerakan ekstremitas pada pasien [yang dilakukan] banyak pengikatan dengan cara merotasikan pengekangan/ikatan • Bantu perubahan posisi tubun yang teratur • Sediakan alat pemanggil bantuan (misalnya., bel atau lampu panggilan) bagi pasien yang mengalami ketergantungan dalam hal kebutuhan pasien terkait dengan nutrisi, eliminasi, hidrasi dan kebersihan diri • Evaluasi penggunaan interval yang teratur, terkait dengan kebutuhan pasien untuk melanjutkan intervensi pengekangan • Libatkan pasien dalam aktivitas-aktivitas untuk memperbaiki kekuatan, koordinasi, penilaian dan orientasi

Bagian Tiga | Klasifikasi 373 • Instruksikan pasien menggunakan extended-wear contacts pada situasi dimana pasien berada pada peningkatan risiko (misalnya., ulser pada kornea, infeksi dan erupsi) • Instruksikan pasien menggunakan hard contact pada kondisi dimana terdapat risiko yang meningkat (misalnya., adanya edema kornea dan abrasi kornea) • Instruksikan pasien mengenai gejala-gejala [yang ada] untuk dilaporkan pada profesi perawatan kesehatan (misalnya., kemerahan mata dan konjungtiva, ketidaknyamanan atau nyeri, air mata yang berlebihan, dan perubahan penglihatan) • Instruksikan pasien untuk menggunakan cairan yang di rekomendasikan dalam rangka membersihkan, melembabkan, membilas, dan mendisinfeksi lensa • Instruksikan pasien untuk menggosok dan membilas lensa dengan cairan yang direkomendasikan sebelum penyimpanan • Instruksikan pasien mengenai pentingnya monitor dan penghentian penggunaan produk perawatan kontak lensa yang telah digunakan sebelumnya • Instruksikan pasien untuk tidak menggunakan saliva, air dari keran, atau saline yang steril yang ditemukan dalam agensi perawatan kesehatan untuk membilas atau menyimpan lensa • Instruksikan pasien untuk menghindari paparan pada keran air, kolam renang atau spa basah saat memakai lensa • Instruksikan pasien untuk menyimpan lensa dalam kontainer lensa dengan cairan yang direkomendasikan • Instruksikan perawatan dilakukan pada kontainer lensa (misalnya., dibersihkan setiap hari, dibuka agar terkena udara, dan ganti secara teratur) • Instruksikan pasien mengenai bagaimana memeriksa kerusakan yang terjadi pada lensa • Instruksikan pasien yang menggunakan kosmetik mata agar berhati-hati dalam pemilihan dan pemakaian kosmetik (misal-

•

• • •

nya., pilihan kosmetik tanpa menimbulkan iritasi dan menggunakan kosmetik sebelum memasang lensa) Instruksikan pasien untuk menghindar dari paparan kontaminan yang ada di lingkungan yang akan merusak dan menimbulkan iritasi (misalnya., debu, asap, sabun, lotions, krem, dan sprays) Instruksikan pasien untuk membawa identifikasi yang tepat terhadap tipe dan perawatan untuk lensa Bantu melakukan perawatan lensa untuk pasien yang tidak dapat melakukannya sendiri (misalnya., melepaskan, mem bersihkan, menyimpan dan memasang) Buatlah rujukan untuk spesialis mata, dengan cara yang tepat

Edisi pertama tahun 1992; direvisi tahun 2013 Bahan Bacaan: Craven, R. F. & Hirnle, C. J. (2009). Self-care and hygiene. Fundamentals of nursing: Human health and function (6th ed., pp. 703-755). Philadelphia: Lippincott Williams & Wilkins. Craven, R. F. & Hirnle, C. J. (2009). Sensory perception. Fundamentals of nursing: Human health and function (6th ed., pp. 1216-1236). Philadelphia: Lippincott Williams & Wilkins. Smith, S. F., Duell, D.J., & Martin, B.C. (2008). Personal hygiene. Clinical nursing skills: Basic to advanced skills (7th ed., pp. 208-248). Upper Saddle River, New Jersey: Pearson Prentice Hall. Sweeney, D., Holden, B., Evans, K., Ng, V., & Cho, P. (2009). Best practice contact lens care: A review of the Asia Pacific Contact Lens Care Summit. Clinical & Experimental Optometry, 92(2), 78-89. Workman, M. L. (2010). Care of patients with eye and vision problems. In D. D. Ignatavicius, & M. L. Workman (Eds.), Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 1084-1108). St. Louis: Saunders.

Perawatan Luka

3660

Definisi: Pencegahan komplikasi luka dan peningkatan penyembuhan luka Aktiftas-aktivitas: • Angkat balutan dan plester perekat • Cukur rambut di sekitar daerah yang terkena, sesuai kebutuhan • Monitor karakteristik luka, termasuk drainase, warna, ukuran, dan bau • Ukur luas luka, yang sesuai • Singkirkan benda-benda yang tertanam [pada luka] (misalnya, serpihan, kutu, kaca, kerikil, logam) • Bersihkan dengan normal saline atau pembersih yang tidak beracun, dengan tepat • Tempatkan area yang terkena pada air yang mengalir, dengan tepat • Berikan rawatan insisi pada luka, yang diperlukan • Berikan perawatan ulkus pada kulit, yang diperlukan • Oleskan salep yang sesuai dengan kulit/lesi • Berikan balutan yang sesuai dengan jenis luka • Perkuat balutan [luka], sesuai kebutuhan • Pertahankan teknik balutan steril ketika melakukan perawatan luka, dengan tepat • Ganti balutan sesuai dengan jumlah eksudat dan drainase • Periksa luka setiap kali perubahan balutan • Bandingkan dan catat setiap perubahan luka

• Posisikan untuk menghindari menempatkan ketegangan pada luka, dengan tepat • Reposisi pasien setidaknya setiap 2 jam, dengan tepat • Dorong cairan, yang sesuai • Rujuk pada praktisi ostomy, dengan tepat • Rujuk pada ahli diet, dengan tepat • BeriUnit TENS (stimulasi saraf transkutan listrik) untuk meningkatkan penyembuhan luka, dengan tepat • Tempatkan alat-alat untuk mengurangi tekanan (yaitu, tempat tidur isi udara, busa, atau kasur gel; bantalan tumit atau siku; bantal kursi), dengan tepat • Bantu pasien dan keluarga untuk mendapatkan pasokan • Anjurkan pasien dan keluarga mengenai cara penyimpanan dan pembuangan balutan dan pasokan/suplai • Anjurkan pasien atau anggota keluarga pada prosedur perawatan luka • Anjurkan pasien dan keluarga untuk mengenal tanda dan gejala infeksi • Dokumentasikan lokasi luka, ukuran, dan tampilan Edisi pertama tahun 1992; direvisi tahun 2000 dan 2004

Domain 12. Comfort

Class 1. Physical Comfort

00132

Acute pain

(1996, 2013; LOE 2.2)

Definition

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

Defining Characteristics

12. Comfort

Appetite change Change in physiological parameter (e.g., blood pressure, heart rate, respiratory rate, oxygen saturation, and end-tidal CO2) ■■ Diaphoresis ■■ Distraction behavior ■■ Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally (e.g., Neonatal Infant Pain Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate) ■■ Expressive behavior (e.g., restlessness, crying, vigilance) ■■ Facial expression of pain (e.g., eyes lack luster, beaten look, fixed or scattered movement, grimace) ■■ Guarding behavior

Hopelessness Narrowed focus (e.g., time perception, thought processes, interaction with people and environment) ■■ Positioning to ease pain ■■ Protective behavior ■■ Proxy report of pain behavior/ activity changes (e.g., family member, caregiver) ■■ Pupil dilation ■■ Self-focused ■■ Self-report of intensity using standardized pain scale (e.g., Wong-Baker FACES scale, visual analogue scale, numeric rating scale) ■■ Self-report of pain characteristics using standardized pain instrument (e.g., McGill Pain Questionnaire, Brief Pain Inventory)

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440 Domain 12: Comfort

Defining characteristi of nursing diagnoses: Ineffective peripheral tissue perfusion Doengoes

Carpenito

NANDA

Tisssue edema, pain Diminished peripheral pulses, slow or diminished capillary refill Skin color changes – pallor, erythema (p. 114 (145)

Halaman 680

Halaman 237 (267)

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INEFFECTIVE PERIPHERAL TISSUE PERFUSION Definition_ _____________________________________________________________ State in which a person experiences or is at risk of experiencing a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary blood supply

Defining Characteristics_ ______________________________________________ Major (Must Be Present, One or More) Presence of one of the following types (see Key Concepts for definitions): Claudication (arterial) Aching pain (arterial or venous) Rest pain (arterial) Diminished or absent arterial pulses (arterial) Skin color changes Pallor (arterial) Reactive hyperemia (arterial) Cyanosis (venous) Skin temperature changes Cooler (arterial) Warmer (venous) Decreased blood pressure (arterial) Capillary refill longer than 3 s (arterial)

Minor (May Be Present) Edema (venous) Change in motor function (arterial) Hard, thick nails Loss of hair Nonhealing wound

Change in sensory function (arterial) Trophic tissue changes (arterial)

Related Factors_ _______________________________________________________ Pathophysiologic Related to compromised blood flow secondary to: Vascular disorders Arteriosclerosis Leriche’s syndrome Raynaud’s disease/syndrome Aneurysm Arterial thrombosis Buerger’s disease Sickle cell crisis Collagen vascular disease Rheumatoid arthritis Alcoholism Diabetes mellitus Hypotension Blood dyscrasias Renal failure Cancer/tumor

Venous hypertension Varicosities Deep vein thrombosis Cirrhosis

Treatment-Related Related to immobilization Related to presence of invasive lines Related to pressure sites/constriction (elastic compression bandages, stockings, restraints) Related to blood vessel trauma or compression

Situational (Personal, Environmental) Related to pressure of enlarging uterus on pelvic vessels

658

Domain 4. Activity/Rest

Class 4. Cardiovascular/Pulmonary Responses

00204

Ineffective peripheral tissue perfusion (2008, 2010; LOE 2.1)

Definition

Defining Characteristics Absence of peripheral pulses Alteration in motor functioning ■■ Alteration in skin characteristic (e.g., color, elasticity, hair, moisture, nails, sensation, temperature) ■■ Ankle-brachial index <0.90 ■■ Capillary refill time >3 seconds ■■ Color does not return to lowered limb after 1 minute leg elevation ■■ Decrease in blood pressure in extremities ■■ Decrease in pain-free distances achieved in the 6-minute walk test

Decrease in peripheral pulses Delay in peripheral wound healing ■■ Distance in the 6-minute walk test below normal range (400 m to 700 m in adults) ■■ Edema ■■ Extremity pain ■■ Femoral bruit ■■ Intermittent claudication ■■ Paresthesia ■■ Skin color pales with limb elevation

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Related Factors Diabetes mellitus Hypertension ■■ Insufficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility) ■■ ■■

Insufficient knowledge of disease process ■■ Sedentary lifestyle ■■ Smoking ■■

Original literature support available at www.nanda.org Class 4: Cardiovascular/Pulmonary Responses 237

4. Activity/Rest

Decrease in blood circulation to the periphery that may compromise health.

Contoh pilihan NOC dan NIC Impaired skin integrity-Kerusakan integritas kulit Doengoes

Carpenito

Buku NOC

NOC

Wound healing: Secondary intention

Tissue integrity: Skin and Mucous membrane

Integritas Jaringan: Kulit & Membran Mukosa (107)

NIC

Wound care Pressure Infection management control Pressure ulcer care Skin Surveillance Positioning

Buku NIC

Perawatan area sayatan (354) Perawatan luka tekan (376) Pengecekan kulit (311) Perawatan luka (373)

Bagian Tiga | Outcome

Integritas Jaringan: Kulit & Membran Mukosa

107

1101

Definisi: Keutuhan struktur dan fungsi fisiologis kulit dan selaput lendir secara normal SKALA TARGET OUTCOME: Dipertahankan pada______

SKALA OUTCOME KESELURUHAN Indikator: 110101 Suhu kulit 110102 Sensasi 110103 Elastisitas 110104 Hidrasi 110106 Keringat 110108 Tekstur 110109 Ketebalan 110111 Perfusi jaringan 110112 Pertumbuhan rambut pada kulit 110113 Integritas kulit 110105 110115 110116 110117 110118 110119 110120 110121 110122 110123 110124 110125

Pigmentasi abnormal Lesi pada kulit Lesi mukosa membran Jaringan parut Kanker kulit Pengelupasan kulit Penebalan kulit Eritema Wajah pucat Nekrosis Pengerasan [kulit] Abrasi kornea

Ditingkatkan ke_______ Sangat Terganggu 1

Banyak terganggu 2

1 1 1 1 1 1 1 1 1 1 Berat 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 Cukup berat 2 2 2 2 2 2 2 2 2 2 2 2

Cukup Sedikit Tidak terganggu terganggu terganggu 3 4 5 3 3 3 3 3 3 3 3 3 3 Sedang 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 Ringan 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 Tidak ada 5 5 5 5 5 5 5 5 5 5 5 5

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Domain-Kesehatan Fisiologis (II) Kelas-Integritas Jaringan (L) edisi pertama 1997; revisi 2004, 2013 REFERENSI TERKAIT DENGAN ISI DARI OUTCOME: + Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210. Cohen, I. K., Diegelmann, R. F., & Lindblad, W. L. (1992). Wound healing: Biochemical and clinical aspects. Philadelphia: W. B. Saunders. Hardy, M. D. (2001). Impaired skin integrity: Dry skin. In M. Maas, K. Buckwalter, M. Hardy, T. Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes & interventions (pp. 137–144). St. Louis: Mosby. Lazarus, G. S., Cooper, D. M., Knighton, D. R., Margohs, D. J., Pecoraro, R. E., Rodeheaver, G., et al. (1994). Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology, 130(4), 489–493. Maklebust, J., & Sieggreen, M. (1996). Pressure ulcers: Guidelines for prevention and nursing management (2nd ed.). Springhouse, PA: Springhouse. Potter, P. A., & Perry, A. G. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby. Van Rijswijk, L. (1993). Full-thickness leg ulcers: Patient demographics and predictors of healing. The Journal of Family Practice, 36(6), 625–632.


• • • • • • • • • • • • • • • •

Jadikan satu berbagai aktivitas perawatan untuk mendukung interval tidur yang paling panjang dan konservasi energi Posisikan bayi untuk tidur di posisi tengkurap di dada orangtua yang tidak mengenakan baju, jika memungkinkan Sediakan kursi yang nyaman di area yang tenang untuk pem berian makan Bergerak pelan dan lembut saat memegang, memberikan makan, dan memberikan perhatian pada bayi Posisikan dan dukung selama memberikan makan dengan memelihara posisi fleksi dan midline (misalnya., dukung bahu and dukungan trunkal, foot bracing, hand holding, penggunaan bunting, atau swaddling) Berikan makan dengan posisi tegak untuk menyokong ekstensi lidah dan menelan Dukung partisipasi orangtua pada saat pemberian makan Dukung [proses] menyusui Monitor asupan dan pengeluaran Penggunaana dot mainan selama makan dan antara pemberian makan untuk penghisapan tanpa nutrisi untuk mendukung stabilitas fisik dan status nutrisi Fasilitasi kondisi transisi dan tenangkan selama kondisi penuh nyeri, prosedur yang penuh stress tetapi diperlukan Tetapkan rutinitas yang konsisten dan dapat diprediksikan untuk mendukung siklus tidur-terjaga yang teratur Beri stimulus dengan menggunakan instrumen musik yang di rekam, telepon genggam, pijat, diayun-ayun dan sentuhan Monitor dan atur kebutuhan akan oksigen Tutup mata dan genitalia dengan penutup kain untuk anak yang dilakukan fototerapi Lepaskan penutup mata selama waktu makan dan secara teratur monitor apa yang dikeluarkan mata dan iritasi korena

• •

Monitor hematokrit dan berikan transfusi darah saat diperlukan Informasikan pada orangtua tentang tindakan pencegahan untuk SIDS (Sudden Infant Death Syndrome)

Edisi ke-enam tahun 2013 Bahan Bacaan: Becker, P. T., Grunwald, P. C., Moorman, J., & Stuhr, S. (1991). Outcomes of developmentally supportive nursing care for very low birth weight infants. Nursing Research, 40(3), 150-155. Brown, G. (2009). NICU noise and the preterm infant.Neonatal Network, 28(3), 165-173. Johnston, A. M., Bullock, C. E., Graham, J. E., Reilly, M. C., Rocha, C., Hoopes, R. D., et al. (2006). Implementation and case study results of potentially better practices for family-centered care: The family-centered care map. Pediatrics, 118(Suppl. 2), S108-S114. Pinelli, J., & Symington, A. J. (2005).Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001071. DOI: 10.1002/ 14651858.CD001071.pub2. Symington, A. J, & Pinelli, J. (2006). Developmental care for promoting development and preventing morbidity in preterm infants.Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001814. DOI: 10.1002/14651858.CD001814.pub2. Wallin, L., & Eriksson, M. (2009).Bayi baru lahir individual developmental care and assessment program (NIDCAP): A systematic review of the literature. Worldviews on Evidence-Based Nursing, 6(2), 54-69. Ward, S. L., & Hisley, S. M. (2009).Caring for the bayi baru lahir at risk. In Maternal-child nursing care: Optimizing outcomes for mothers, children, & families. (pp. 603-637). Philadelphia: F. A. Davis.

Perawatan Daerah (Area) Sayatan

3440

Definisi: Membersihkan, memantau, dan meningkatkan proses penyembuhan luka yang ditutup dengan jahitan, klip, atau steples Aktiftas-aktivitas: • Jelaskan prosedur pada pasien, gunakan persiapan sensorik • Periksa daerah sayatan terhadap kemerahan, bengkak, atau tanda-tanda dehiscence atau eviserasi • Catat karakteristik drainase • Monitor proses penyembuhan di daerah sayatan • Bersihkan daerah sekitar sayatan dengan pembersihan yang tepat • Bersihkan mulai dari area yang bersih ke area yang kurang bersih • Monitor sayatan untuk tanda dan gejala infeksi • Gunakan kapas steril untuk pembersihan jahitan benang luka yang efisien, luka dalam dan sempit, atau luka berkantong • Bersihkan area sekitar drainase atau pada area selang drainase • Jaga posisi selang drainase • Berikan plester untuk menutup • Berikan salep antiseptik • Lepaskan jahitan, steples, atau klip, sesuai indikasi

• • • • •

Ganti pakaian dengan interval [waktu] yang tepat Gunakan pakaian yang sesuai untuk melindungi sayatan Fasilitasi pasien untuk melihat luka insisi Arahkan pasien cara merawat luka insisi selama mandi Arahkan pasien bagaimana meminimalkan tekanan pada daerah insisi • Arahkan pasien dan/atau keluarga cara merawat luka insisi, termasuk tanda-tanda dan gejala infeksi Edisi pertama tahun 1992; direvisi tahun 2000 Bahan Bacaan: Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Perioperative nursing. In Fundamentals of nursing: Concepts, processes, and practice. (7th ed., pp. 896-937). Upper Saddle River, NJ: Prentice Hall. Perry, A. G., & Potter, P. A. (1998).Clinical nursing skills and techniques (4th ed.). St. Louis: Mosby.

376 Nursing Interventions Classification (NIC) Bahan Bacaan: Carroll, M. C., Fleming, M., Chitambar, C. R., & Neuburg, M. (2002). Diagnosis workup and prognosis of cutaneous metastases of unknown primary origin.Dermatologic Surgery, 28(6), 533-535. Cormio, G., Capotorto, M., Vagno, G., Cazzolla, A., Carriero, C., & Selvaggi, L. (2003).Skin metastases in ovarian carcinoma: A report of nine cases and a review of the literature. Gynecologic Oncology, 90(3), 682-685. Emmons, K. R., & Lachman, V. D. (2010).Palliative wound care: A concept analysis. Journal of Wound, Ostomy, and Continence Nursing, 37(6), 639644. Ferris, F. D., Khateib, A., Fromanin, I., Hoplamazian, L., Hurd, T., Krasner, D., et al. (2007).Pallative wound care: Managing chronic wounds across life’s continuum: A consensus statement from the International Palliative Wound Care Initiative. Journal of Palliative Medicine, 10(1), 37-39.

Langemo, D. K., Anderson, J., Hanson, D., Thompson, P., & Hunter, S. (2007). Understanding palliative wound care. Nursing 2007, 37(1), 6566. Lookingbill, D. P., Spangler, N., & Helm, K. F. (1993). Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. Journal of the American Academy of Dermatology, 29(2 Pt 1), 228-236. Lund-Nielsen, B., Müller, K., & Adamsen, L. (2005).Malignant wounds in women with breast cancer: Feminine and sexual perspectives. Journal of Clinical Nursing, 14(1), 56-64. Seaman, S. (2006). Management of malignant fungating wounds in advanced cancer. Seminars in Oncology Nursing, 22(3), 185-193.

Perawatan Luka Tekan

3520

Definisi: Fasilitasi proses penyembuhan luka tekan/dekubitus Aktivitas-aktivitas: • Catat karakteristik luka tekan setiap hari, meliputi ukuran (panjang x lebar x dalam), tingkatan luka (I-IV), lokasi, eksudat, granulasi atau jaringan nekrotik, dan epitelisasi • Monitor warna, suhu, udem, kelembaban, dan kondisi area sekitar luka • Jaga agar luka tetap lembab untuk membantu proses penyem buhan • Berikan pelembab yang hangat di sekitar area luka untuk meningkatkan perfusi darah dan suplai oksigen • Bersihkan kulit sekitar luka dengan sabun yang lembut dan air • Lakukan debridement jika diperlukan • Bersihkan luka dengan cairan yang tidak berbahaya, lakukan pembersihan dengan gerakan sirkuler dari dalam keluar • Gunakan jarum suntik ukuran 19 dan suntikan 35 cc untuk membersihkan luka dalam • Catat karakteristik cairan luka • Pasang balutan adesif yang elastik pada luka, jika memungkinkan • Berikan saline untuk menggosok jika diperlukan • Berikan salep jika dibutuhkan • Lakukan pembalutan dengan tepat • Berikan obat-obatan oral • Monitor tanda dan gejala infeksi di area luka • Ubah posisi setiap 1-2 jam sekali untuk mencegah penekanan • Gunakan tempat tidur khusus anti dekubitus • Gunakan alat-alat pada tempat tidur untuk melindungi pasien • Yakinkan asupan nutrisi yang adekuat • Monitor status nutrisi • Pastikan bahwa pasien mendapat diit tinggi kalori tinggi protein

• Ajarkan pasien dan keluarga akan adanya tanda kulit pecahpecah • Ajarkan pasien dan keluarga mengenai perawatan luka • Fasilitasi pasien agar dapat berkonsultasi dengan perawat ahli luka, jika dibutuhkan Edisi pertama tahun 1992, direvisi tahun 2000 dan tahun 2004 Bahan Bacaan: Bergstrom, N., Bennett, M. A., Carlson, C. E., et al. (1994). Treatments of pressure ulcers: Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Frantz, R. A. & Gardner, S. (1999). Pressure ulcer care. In G. M. Bulechek & J. C. McCloskey (Eds.), Nursing interventions: Effective nursing treatments (3rd ed., pp. 211-223). Philadelphia: Saunders. Frantz, R. A., Gardner, S., Specht, J. K., & McIntire, G. (2001). Integration of pressure ulcer treatment protocol into practice: Clinical outcomes and care environment attributes. Outcomes Management for Nursing Practice, 5(3), 112-120. Hirshberg, J., Coleman, J., Marchant, B., & Rees, R. S. (2001). TGF-[beta]3 in the treatment of pressure ulcers: A preliminary report. Advances in Skin & Wound Care, 14(2), 91-95. Perry, A. G. & Potter, P. A. (2002). Clinical nursing skills and techniques (5th ed., pp. 175-191). St. Louis: Mosby. Spungen, A. M., Koehler, K. M., Modeste-Duncan, R., Rasul, M., Cytryn, A. S., & Bauman, W.A. (2001). 9 clinical cases of nonhealing pressure ulcers in patients with spinal cord injury treated with an anabolic agent: A therapeutic trial. Advances in Skin & Wound Care, 14(3), 139-144. Whitney, J. D., Salvadalena, G., Higa, L., & Mich, M. (2001). Treatment of pressure ulcers with noncontact normothermic wound therapy: Healing and warming effects. Journal of Wound, Ostomi, and Continence Nursing, 28(5), 244-252.


Pengecekan Kulit

3590



Pengekangan fisik

6580



Bagian Tiga | Klasifikasi 373 • Instruksikan pasien menggunakan extended-wear contacts pada situasi dimana pasien berada pada peningkatan risiko (misalnya., ulser pada kornea, infeksi dan erupsi) • Instruksikan pasien menggunakan hard contact pada kondisi dimana terdapat risiko yang meningkat (misalnya., adanya edema kornea dan abrasi kornea) • Instruksikan pasien mengenai gejala-gejala [yang ada] untuk dilaporkan pada profesi perawatan kesehatan (misalnya., kemerahan mata dan konjungtiva, ketidaknyamanan atau nyeri, air mata yang berlebihan, dan perubahan penglihatan) • Instruksikan pasien untuk menggunakan cairan yang di rekomendasikan dalam rangka membersihkan, melembabkan, membilas, dan mendisinfeksi lensa • Instruksikan pasien untuk menggosok dan membilas lensa dengan cairan yang direkomendasikan sebelum penyimpanan • Instruksikan pasien mengenai pentingnya monitor dan penghentian penggunaan produk perawatan kontak lensa yang telah digunakan sebelumnya • Instruksikan pasien untuk tidak menggunakan saliva, air dari keran, atau saline yang steril yang ditemukan dalam agensi perawatan kesehatan untuk membilas atau menyimpan lensa • Instruksikan pasien untuk menghindari paparan pada keran air, kolam renang atau spa basah saat memakai lensa • Instruksikan pasien untuk menyimpan lensa dalam kontainer lensa dengan cairan yang direkomendasikan • Instruksikan perawatan dilakukan pada kontainer lensa (misalnya., dibersihkan setiap hari, dibuka agar terkena udara, dan ganti secara teratur) • Instruksikan pasien mengenai bagaimana memeriksa kerusakan yang terjadi pada lensa • Instruksikan pasien yang menggunakan kosmetik mata agar berhati-hati dalam pemilihan dan pemakaian kosmetik (misal-

•

• • •

nya., pilihan kosmetik tanpa menimbulkan iritasi dan menggunakan kosmetik sebelum memasang lensa) Instruksikan pasien untuk menghindar dari paparan kontaminan yang ada di lingkungan yang akan merusak dan menimbulkan iritasi (misalnya., debu, asap, sabun, lotions, krem, dan sprays) Instruksikan pasien untuk membawa identifikasi yang tepat terhadap tipe dan perawatan untuk lensa Bantu melakukan perawatan lensa untuk pasien yang tidak dapat melakukannya sendiri (misalnya., melepaskan, mem bersihkan, menyimpan dan memasang) Buatlah rujukan untuk spesialis mata, dengan cara yang tepat

Edisi pertama tahun 1992; direvisi tahun 2013 Bahan Bacaan: Craven, R. F. & Hirnle, C. J. (2009). Self-care and hygiene. Fundamentals of nursing: Human health and function (6th ed., pp. 703-755). Philadelphia: Lippincott Williams & Wilkins. Craven, R. F. & Hirnle, C. J. (2009). Sensory perception. Fundamentals of nursing: Human health and function (6th ed., pp. 1216-1236). Philadelphia: Lippincott Williams & Wilkins. Smith, S. F., Duell, D.J., & Martin, B.C. (2008). Personal hygiene. Clinical nursing skills: Basic to advanced skills (7th ed., pp. 208-248). Upper Saddle River, New Jersey: Pearson Prentice Hall. Sweeney, D., Holden, B., Evans, K., Ng, V., & Cho, P. (2009). Best practice contact lens care: A review of the Asia Pacific Contact Lens Care Summit. Clinical & Experimental Optometry, 92(2), 78-89. Workman, M. L. (2010). Care of patients with eye and vision problems. In D. D. Ignatavicius, & M. L. Workman (Eds.), Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 1084-1108). St. Louis: Saunders.

Perawatan Luka

3660

Definisi: Pencegahan komplikasi luka dan peningkatan penyembuhan luka Aktiftas-aktivitas: • Angkat balutan dan plester perekat • Cukur rambut di sekitar daerah yang terkena, sesuai kebutuhan • Monitor karakteristik luka, termasuk drainase, warna, ukuran, dan bau • Ukur luas luka, yang sesuai • Singkirkan benda-benda yang tertanam [pada luka] (misalnya, serpihan, kutu, kaca, kerikil, logam) • Bersihkan dengan normal saline atau pembersih yang tidak beracun, dengan tepat • Tempatkan area yang terkena pada air yang mengalir, dengan tepat • Berikan rawatan insisi pada luka, yang diperlukan • Berikan perawatan ulkus pada kulit, yang diperlukan • Oleskan salep yang sesuai dengan kulit/lesi • Berikan balutan yang sesuai dengan jenis luka • Perkuat balutan [luka], sesuai kebutuhan • Pertahankan teknik balutan steril ketika melakukan perawatan luka, dengan tepat • Ganti balutan sesuai dengan jumlah eksudat dan drainase • Periksa luka setiap kali perubahan balutan • Bandingkan dan catat setiap perubahan luka

• Posisikan untuk menghindari menempatkan ketegangan pada luka, dengan tepat • Reposisi pasien setidaknya setiap 2 jam, dengan tepat • Dorong cairan, yang sesuai • Rujuk pada praktisi ostomy, dengan tepat • Rujuk pada ahli diet, dengan tepat • BeriUnit TENS (stimulasi saraf transkutan listrik) untuk meningkatkan penyembuhan luka, dengan tepat • Tempatkan alat-alat untuk mengurangi tekanan (yaitu, tempat tidur isi udara, busa, atau kasur gel; bantalan tumit atau siku; bantal kursi), dengan tepat • Bantu pasien dan keluarga untuk mendapatkan pasokan • Anjurkan pasien dan keluarga mengenai cara penyimpanan dan pembuangan balutan dan pasokan/suplai • Anjurkan pasien atau anggota keluarga pada prosedur perawatan luka • Anjurkan pasien dan keluarga untuk mengenal tanda dan gejala infeksi • Dokumentasikan lokasi luka, ukuran, dan tampilan Edisi pertama tahun 1992; direvisi tahun 2000 dan 2004


Pembatasan Setting

4380

Definisi: Membangun parameter terkait dengan tingkah laku pasien yang diinginkan dan dapat diterima Aktivitas-aktivitas: • Gunakan pendekatan yang sesuai dengan fakta, bukan pen dekatan yang menghakimi • Tetapkan batasan, atau identifikasi perilaku pasien yang tidak diinginkan (menggunakan input/masukan dari pasien, pada saat yang tepat) • Komunikasikan batasan dengan istilah yang positif (misalnya., “baju tetap dipakai”, dari pada “perilaku tersebut tidak tepat”) • Diskusikan perhatian pasien mengenai tingkah lakunya • Tetapkan konsekuensi (berdasarkan masukan pasien, jika tepat) terkait dengan tingkah laku yang dilakukan atau tidak dilakukan yang diinginkan • Diskusikan dengan pasien, dengan cara yang tepat, [seperti] apa tingkah laku yang dinginkan dalam situasi atau tatanan yang diberikan • Berikan harapan yang beralasan terkait dengan tingkah laku pasien yang didasarkan pada situasi dan pasien • Hindari mendebat atau tawar menawar dengan pasien mengenai konsekuensi dan harapan dari perilaku yang telah di tetapkan • Komunikasikan harapan mengenai tingkah laku dan konsekuensi yang telah ditetapkan dalam bahasa yang mudah dimengerti dan tidak menghukum • Komunikasikan harapan tingkah laku dan konsekuensi yang telah ditetapkan pada staf lain yang merawat pasien sehingga tetap ada konsistensi dan keberlanjutan perawatan

• Bantu pasien, bila diperlukan dan tepat, untuk menunjukkan tingkah laku yang diinginkan • Monitor pasien mengenai dilakukan atau tidak dilakukannya tingkah laku yang diinginkan • Mulai membangun konsekuensi mengenai dilakukan atau tidak dilakukannya tingkah laku yang diinginkan • Modifikasi tingkah laku yang diharapkan dan konsekuensinya sesuai kebutuhan, untuk mengakomodasi perubahan yang beralasan dalam situasi pasien • Turunkan batasan seting jika pasien menunjukkan tingkah laku yang diinginkan Edisi pertama tahun 1992; direvisi tahun 2008 Bahan Bacaan: Deering, C. (2006). Therapeutic relationships and communication.In W. Mohr (Ed.), Psychiatric mental health nursing (6th ed., pp. 55-78). Philadelphia: Lippincott Williams & Wilkins. Lowe, T., Wellman, N., & Taylor, R. (2003).Limit-setting and decisionmaking in the management of aggression.Journal of Advanced Nursing, 41(2), 154-161. Rickelman, B. L. (2006). The client who displays angry, aggressive, or violent behavior.In W. Mohr (Ed.), Psychiatric mental health nursing (6th ed., pp. 659-686). Philadelphia: Lippincott Williams & Wilkins. Videbeck, S. L. (2006). Psychiatric mental health nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.

Pemberian Analgesik

2210

Definisi: Penggunaan agen farmakologi untuk mengurangi atau menghilangkan nyeri Aktivitas-aktivitas: • Tentukan lokasi, karakteristik, kualitas dan keparahan nyeri sebelum mengobati pasien • Cek perintah pengobatan meliputi obat, dosis, dan frekuensi obat analgesik yang diresepkan • Cek adanya riwayat alergi obat • Evaluasi kemampuan pasien untuk berperan serta dalam pemilihan analgetik, rute dan dosis dan keterlibatan pasien, sesuai kebutuhan • Pilih analgesik atau kombinasi analgesik yang sesuai ketika lebih dari satu diberikan • Tentukan pilihan obat analgesik (narkotik, non narkotik, atau NSAID), berdasarkan tipe dan keparahan nyeri • Tentukan analgesik sebelumnya, rute pemberian, dan dosis untuk mencapai hasil pengurangan nyeri yang optimal • Pilih rute intravena daripada rute intramuskular, untuk injeksi pengobatan nyeri yang sering, jika memungkinkan • Tinggalkan narkotik dan obat-obat lain yang dibatasi, sesuai dengan aturan rumah sakit • Monitor tanda vital sebelum dan setelah memberikan analgesik narkotik pada pemberian dosis pertama kali atau jika ditemu kan tanda-tanda yang tidak biasanya

• Berikan kebutuhan kenyamanan dan aktivitas lain yang dapat membantu relaksasi untuk memfasilitasi penurunan nyeri • Berikan analgesik sesuai waktu paruhnya, terutama pada nyeri yang berat • Susun harapan yang positif mengenai keefektifan analgesik untuk mengoptimalkan respon pasien • Berikan analgesik tambahan dan/atau pengobatan jika diperlu kan untuk meningkatkan efek pengurangan nyeri • Pertimbangkan penggunaan infus terus-menerus, baik sendiri atau digabungkan dengan opioid bolus, untuk mempertahankan level serum • Jalankan tindakan keselamatan pada pasien yang menerima analgesik narkotika, sesuai kebutuhan • Mintakan pengobatan nyeri PRN sebelum nyeri menjadi parah • Informasikan pasien yang mendapatkan narkotika bahwa rasa mengantuk kadang terjadi selama 2-3 hari pertama pemberian dan selanjutnya akan menghilang • Perbaiki kesalahan pengertian/mitos yang dimiliki pasien dan anggota keluarga yang mungkin keliru tentang analgesik • Evaluasi keefektifan analgesik dengan interval yang teratur pada setiap setelah pemberian khususnya setelah pemberian pertama kali, juga observasi adanya tanda dan gejala efek samping (misalnya, depresi pernafasan, mual dan muntah,


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sakit (yaitu: untuk pasien dengan penyakit ginjal, pembatasan natrium, kalium, protein, dan cairan) Anjurkan pasien terkait dengan kebutuhan makanan tertentu berdasarkan perkembangan atau usia (misalnya., peningkatan kalsium, protein, cairan, dan kalori untuk wanita menyusui; peningkatan asupan serat untuk mencegah konstipasi pada orang dewasa yang lebih tua) Tawarkan makanan ringan yang padat gizi Pastikan diet mencakup makanan tinggi kandungan serat untuk mencegah konstipasi Monitor kalori dan asupan makanan Monitor kecenderungan terjadinya penurunan dan kenaikan berat badan Anjurkan pasien untuk memantau kalori dan intake makanan (misalnya., buku harian makanan) Dorong untuk [melakukan] bagaimana cara menyiapkan makanan [dengan] aman dan teknik teknik pengawetan makanan Bantu pasien untuk mengakses program-program gizi komunitas (misalnya., Perempuan, Bayi, dan Anak, kupon makanan,

dan makanan yang diantar ke rumah) • Berikan arahan, bila diperlukan Edisi pertama tahun 1992; direvisi tahun 2013 Bahan Bacaan: Craven, R. F., & Hirnle, C. J. (2009). Nutrition. In Fundamentals of nursing: Human health and function (6th ed., pp. 947-988). Philadelphia: Lippincott Williams & Wilkins. Ignatavicius, D. D. (2010). Care of patients with malnutrition and obesity. In D. D. Ignatavicius & M. L. Workman (Eds.), Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 1386-1410). St. Louis: Saunders. Kaiser, L., Allen, L. H., & American Dietetic Association. (2008). Position of the American Dietetic Association: Nutrition and lifestyle for a healthy pregnancy outcome. Journal of the American Dietetic Association, 108(3), 553-561. U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS). (2010). Dietary guidelines for Americans, 2010 (7th ed.). Washington, DC: Government Printing Office.

Manajemen Nyeri

1400

Definisi: Pengurangan atau reduksi nyeri sampai pada tingkat kenyamanan yang dapat diterima oleh pasien Aktivitas-aktivitas: • Lakukan pengkajian nyeri komprehensif yang meliputi lokasi, karakteristik, onset/durasi, frekuensi, kualitas, intensitas atau beratnya nyeri dan faktor pencetus • Observasi adanya petunjuk nonverbal mengenai ketidaknyamanan terutama pada mereka yang tidak dapat berkomunikasi secara efektif • Pastikan perawatan analgesik bagi pasien dilakukan dengan pemantauan yang ketat • Gunakan strategi komunikasi terapeutik untuk mengetahui pengalaman nyeri dan sampaikan penerimaan pasien terhadap nyeri • Gali pengetahuan dan kepercayaan pasien mengenai nyeri • Pertimbangkan pengaruh budaya terhadap respon nyeri • Tentukan akibat dari pengalaman nyeri terhadap kualitas hidup pasien (misalnya., tidur, nafsu makan, pengertian, perasaan, hubungan, performa kerja dan tanggung jawab peran) • Gali bersama pasien faktor-faktor yang dapat menurunkan atau memperberat nyeri • Evaluasi pengalaman nyeri di masa lalu yang meliputi riwayat nyeri kronik individu atau keluarga atau nyeri yang menyebab kan disability/ketidakmampuan/kecatatan, dengan tepat • Evaluasi bersama pasien dan tim kesehatan lainnya, mengenai efektifitas tindakan pengontrolan nyeri yang pernah digunakan sebelumnya • Bantu keluarga dalam mencari dan menyediakan dukungan • Gunakan metode penilaian yang sesuai dengan tahapan per kembangan yang memungkinkan untuk memonitor perubahan nyeri dan akan dapat membantu mengidentifikasi faktor pencetus aktual dan potensial (misalnya., catatan perkembangan, catatan harian) • Tentukan kebutuhan frekuensi untuk melakukan pengkajian ketidaknyamanan pasien dan mengimplementasikan rencana monitor

• Berikan informasi mengenai nyeri, seperti penyebab nyeri, berapa lama nyeri akan dirasakan, dan antisipasi dari ketidak nyamanan akibat prosedur • Kendalikan faktor lingkungan yang dapat mempengaruhi respon pasien terhadap ketidaknyamanan (misalnya., suhu ruangan, pencahayaan, suara bising) • Kurangi atau eliminasi faktor-faktor yang dapat mencetuskan atau meningkatkan nyeri (misalnya., ketakutan, kelelahan, ke adaan monoton dan kurang pengetahuan) • Pertimbangkan keinginan pasien untuk berpartisipasi, kemam puan berpartisipasi, kecenderungan, dukungan dari orang terdekat terhadap metode dan kontraindikasi ketika memilih strategi penurunan nyeri • Pilih dan implementasikan tindakan yang beragam (misalnya., farmakologi, nonfarmakologi, interpersonal) untuk memfasilitasi penurunan nyeri, sesuai dengan kebutuhan • Ajarkan prinsip-prinsip manajemen nyeri • Pertimbangkan tipe dan sumber nyeri ketika memilih strategi penurunan nyeri • Dorong pasien untuk memonitor nyeri dan menangani nyeri nya dengan tepat • Ajarkan penggunaan teknik non farmakologi (seperti, biofeedback, TENS, hypnosis, relaksasi, bimbingan antisipatif, terapi musik, terapi bermain, terapi aktivitas, akupressur, aplikasi panas/dingin dan pijatan, sebelum, sesudah dan jika memungkinkan, ketika melakukan aktivitas yang menimbulkan nyeri; sebelum nyeri terjadi atau meningkat; dan bersamaan dengan tindakan penurun rasa nyeri lainnya) • Gali penggunaan metode farmakologi yang dipakai pasien saat ini untuk menurunkan nyeri • Ajarkan metode farmakologi untuk menurunkan nyeri • Dorong pasien untuk menggunakan obat-obatan penurun nyeri yang adekuat • Kolaborasi dengan pasien, orang terdekat dan tim kesehatan


• • • • • • • • • • • • •

lainnya untuk memilih dan mengimplementasikan tindakan penurun nyeri nonfarmakologi, sesuai kebutuhan Berikan individu penurun nyeri yang optimal dengan pe resepan analgesik Implementasikan penggunaan pasien - terkontrol analgesik (PCA), jika sesuai Gunakan tindakan pengontrol nyeri sebelum nyeri bertambah berat Berikan obat sebelum melakukan aktivitas untuk meningkatkan partisipasi, namun [lakukan] evaluasi [mengenai] bahaya dari sedasi Pastikan pemberian analgesik dan atau strategi nonfarmakologi sebelum dilakukan prosedur yang menimbulkan nyeri Periksa tingkat ketidaknyamanan bersama pasien, catat per ubahan dalam catatan medis pasien, informasikan petugas kesehatan lain yang merawat pasien Evaluasi keefektifan dari tindakan pengontrol nyeri yang di pakai selama pengkajian nyeri dilakukan Mulai dan modifikasi tindakan pengontrol nyeri berdasarkan respon pasien Dukung istirahat/tidur yang adekuat untuk membantu pe nurunan nyeri Dorong pasien untuk mendiskusikan pengalaman nyerinya, sesuai kebutuhan Beri tahu dokter jika tindakan tidak berhasil atau jika keluhan pasien saat ini berubah signifikan dari pengalaman nyeri sebelumnya Informasikan tim kesehatan lain/anggota keluarga mengenai strategi nonfarmakologi yang sedang digunakan untuk men dorong pendekatan preventif terkait dengan manajemen nyeri Gunakan pendekatan multi disiplin untuk manajemen nyeri, jika sesuai

• Pertimbangkan untuk merujuk pasien, keluarga dan orang terdekat pada kelompok pendukung dan sumber-sumber lain nya, sesuai kebutuhan • Berikan informasi yang akurat untuk meningkatkan penge tahuan dan respon keluarga terhadap pengalaman nyeri • Libatkan keluarga dalam modalitas penurun nyeri, jika me mungkinkan • Monitor kepuasan pasien terhadap manajemen nyeri dalam interval yang spesifik Edisi pertama tahun 1992; direvisi tahun 1996 dan tahun 2004 Bahan Bacaan: Herr, K. A., & Mobily, P. R. (1992). Interventions related to pain. In G. M. Bulechek & J. C. McCloskey (Eds.), Symposium on nursing interventions. Nursing Clinics of North America,27(2), 347-370. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed.). St. Louis: Mosby. McGuire, L. (1994). The nurse’s role in pain relief. MEDSURG Nursing,3(2), 94-107. Mobily, P. R. & Herr, K. A. (2000). Pain. In M. Maas, K. Buckwalter, M. Hardy, T. Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing diagnosis, interventions, and outcomes for elders (2nd ed., pp. 455-475). Thousand Oaks, CA: Sage. Perry, A. G., & Potter, P. A. (2000). Clinical nursing skills and techniques (pp. 84-101). St. Louis: Mosby. Rhiner, M., & Kedziera, P. (1999). Managing breakthrough pain: A new approach. American Journal of Nursing, (Suppl.), 3-12. Titler, M. G., & Rakel, B. A. (2001). Nonpharmacologic treatment of pain. Critical Care Nursing Clinics of North America,13(2), 221-232. Victor, K. (2001). Properly assessing pain in the elderly. RN,64(5), 45-49.

Manajemen Obat

2380

Definisi: Fasilitasi penggunaan dan efektifitas resep yang aman serta penggunaan obat bebas Aktivitas-aktivitas: • Tentukan obat apa yang diperlukan, dan kelola menurut resep dan/atau protokol • Diskusikan masalah keuangan yang berkaitan dengan regimen obat • Tentukan kemampuan pasien untuk mengobati diri sendiri dengan cara yang tepat • Monitor efektifitas cara pemberian obat yang sesuai • Monitor pasien mengenai efek terapeutik obat • Monitor tanda dan gejala toksisitas obat • Monitor efek samping obat • Monitor level serum darah (misalnya, elektrolit, protrombin, obat-obatan) yang sesuai • Monitor interaksi obat yang non terapeutik • Kaji ulang pasien dan/atau keluarga secara berkala mengenai jenis dan jumlah obat yang dikonsumsi • Buang obat yang sudah kadaluarsa, yang sudah diberhentikan atau yang mempunyai kontraindikasi obat • Fasilitasi perubahan pengobatan dengan dokter • Monitor respon terhadap perubahan pengobatan dengan cara yang tepat • Pertimbangkan pengetahuan pasien mengenai obat-obatan • Pantau kepatuhan mengenai regimen obat • Pertimbangkan faktor-faktor yang dapat menghalangi pasien

untuk mengkonsumsi obat yang diresepkan • Kembangkan strategi bersama pasien untuk meningkatkan kepatuhan mengenai regimen obat yang diresepkan • Konsultasi dengan profesional perawatan kesehatan lainnya untuk meminimalkan jumlah dan frekuensi obat yang di butuhkan agar didapatkan efek terapeutik • Ajarkan pasien dan/atau anggota keluarga mengenai metode pemberian obat yang sesuai • Ajarkan pasien dan/atau anggota keluarga mengenai tindakan dan efek samping yang diharapkan dari obat • Berikan pasien dan anggota keluarga mengenai informasi tertulis dan visual untuk meningkatkan pemahaman diri mengenai pemberian obat yang tepat • Kembangkan strategi untuk mengelola efek samping obat • Dapatkan resep dokter bagi pasien yang melakukan pengobatan sendiri dengan cara yang tepat • Buat protokol untuk penyimpanan, penyimpanan ulang, dan pemantauan obat yang tersisa untuk tujuan pengobatan sendiri • Selidiki sumber-sumber keuangan yang memungkinkan untuk memperoleh obat yang diresepkan dengan cara yang tepat • Tentukan dampak penggunaan obat pada gaya hidup pasien • Berikan alternatif mengenai jangka waktu dan cara pengobatan mandiri untuk meminimalkan efek gaya hidup • Bantu pasien dan anggota keluarga dalam membuat penye

74

Nursing Interventions Classification (NIC)

• Dorong pasien untuk menyesuaikan rencana yang sudah dibentuk untuk meningkatkan perubahan perilaku, jika diperlukan (misalnya, ukuran langkah/tahapan atau penghargaan) • Bantu pasien untuk mengidentifikasi keadaan maupun situasi dimana perilaku terjadi (misalnya, [ada] penanda, [ada] pemicu) • Bantu pasien untuk mengindentifikasi meskipun hanya suatu kesuksesan kecil • Jelaskan pada pasien mengenai fungsi dari tanda dan pemicu yang menyebabkan terjadinya perilaku • Bantu pasien untuk menilai seting secara fisik, sosial dan interpersonal terhadap adanya penanda dan pemicu [perilaku] • Dorong pasien mengembangkan “lembar analisis penanda/cue analysissheet yang menunjukkan hubungan antara penanda dan perilaku • Instruksikan pasien mengenai penggunaan “ekspansi isyarat/ cue expansion”, yang meningkatkan jumlah isyarat dan pemicu perilaku yang diinginkan • Instruksikan pasien mengenai penggunaan “batasan isyarat/ cue restriction or limitation”, yang mengurangi frekuensi penanda yang menghasilkan perilaku yang tidak diinginkan • Bantu pasien untuk mengidentifikasi metode untuk mengontrol penanda perilaku • Bantu pasien untuk mengidentifikasi perilaku yang ada yang merupakan kebiasaan atau [bersifat] otomatis (misalnya, menyikat gigi dan memakai sepatu) • Bantu pasien mengidentifikasi stimuli yang berpasangan dengan perilaku yang menjadi kebiasaaan (misalnya, menyikat gigi setelah makan) • Dorong pasien untuk memasangkan perilaku yang diinginkan dengan stimuli/penanda yang ada (misalnya, olahraga sepulang kerja setiap harinya) • Dorong pasien untuk terus melanjutkan pemasangan perilaku yang diinginkan dengan stimuli yang ada, sampai hal ini menjadi kebiasaan

• Eksplorasi bersama pasien pilihan untuk menggunakan teknologi dalam mengorganisir lembaran kode, data-data perubahan, analisis terhadap penanda dan pengukuran secara visual terhadap perubahan (misalnya, komputer, smart phone) • Eksplorasi bersama pasien penggunaan imagery/imajinasi, meditasi atau relaksasi otot progresif dalam mengusahakan perubahan perilaku • Eksplorasi bersama pasien kemungkinan untuk menggunakan bermain peran dalam mengklarifikasi perilaku Edisi pertama tahun 1992; direvisi tahun 2013 Bahan Bacaan: Antony, M. M. (2005). Cognitive behavior therapy. In M. Hersen & J. Rosqvist (Eds.), Encyclopedia of behavior modification and cognitive behavior therapy (pp. 186-195). Thousand Oaks, CA: Sage. Franklin, P. D., Farzanfar, R., & Thompson, D. D. (2008). E-health strategies to support adherence. In S. A. Shumaker, J. K. Ockene, & K. A. Riekert (Eds.), Handbook of health behavior change (3rd ed., pp. 169-190). New York: Springer. Karoly, P. (2005). Self-control. In M. Hersen & J. Rosqvist (Eds.), Encyclopedia of behavior modification and cognitive behavior therapy (pp. 504-508). Thousand Oaks, CA: Sage. Karoly, P. (2005). Self-monitor. In M. Hersen & J. Rosqvist (Eds.), Encyclopedia of behavior modification and cognitive behavior therapy (pp. 521-525). Thousand Oaks, CA: Sage. Prochaska, J. O., Johnson, S., & Lee. P. (2008). The transtheoretical model of behavior change. In S. A. Shumaker, J. K. Ockene, & K. A. Riekert (Eds.), Handbook of health behavior change (3rd ed., pp. 59-84). New York: Springer. Stuart, G. W. (2009). Principles and practice of psychiatric nursing (9th ed.). St. Louis: Mosby. Watson, D. L. & Tharp, R. G. (2006). Self-directing behavior: Self-modification for personal adjustment (9th ed.). Belmont, CA: Wadsworth.

Bantuan Pasien untuk Mengontrol Pemberian Analgesik

2400

Definisi: Memfasilitasi proses pemberian dan regulasi dalam hal pemberian analgesik terkontrol Aktivitas-aktivitas: • Berkolaborasi dengan dokter, pasien dan anggota keluarga dalam memilih jenis narkotik yang akan digunakan • Rekomendasikan pemberian aspirin dan obat-obat anti-inflamasi nonsteroid sebagai pengganti narkotik, sesuai kebutuhan • Rekomendasikan penghentian pemberian opioid melalui jalur lain • Hindari penggunaan meperidine hydrochloride (Demerol) • Pastikan bahwa pasien tidak alergi terhadap analgesik yang akan diberikan • Instruksikan pasien dan keluarga untuk memonitor intensitas, kualitas dan durasi nyeri • Instruksikan pasien dan keluarga untuk memonitor laju per napasan dan tekanan darah • Pasang akses nasogastrik, vena, subkutan atau spinal, sesuai kebutuhan • Validasi bahwa pasien dapat menggunakan alat PCA (misalnya.,

• • • • • • • •

mampu berkomunikasi, memahami penjelasan dan mengikuti arahan) Kolaborasi dengan pasien dan keluarga untuk memilih tipe alat infus PCA yang sesuai Instruksikan pasien dan anggota keluarga mengenai bagaimana cara menggunakan alat PCA Bantu pasien dan keluarga untuk menghitung konsentrasi yang tepat antara obat dan cairan, menetapkan jumlah cairan yang mengalir setiap jam melalui alat PCA Bantu pasien dan keluarga untuk memberikan dosis bolus analgesik yang tepat Instruksikan pasien dan keluarga untuk mengatur laju dasar infus yang tepat pada alat PCA Bantu pasien dan keluarga untuk mengatur interval peng hentian yang tepat pada alat PCA Bantu pasien dan keluarga untuk mengatur dosis tepat yang dibutuhkan pada alat PCA Konsultasikan dengan pasien, anggota keluarga dan dokter

Bagian Tiga | Klasifikasi

• • • •

•

untuk menyesuaikan interval penghentian, laju dasar dan dosis yang dibutuhkan sesuai dengan respon pasien Instruksikan pasien bagaimana meningkatkan atau menurun kan titrasi dosis, sesuai dengan laju pernapasan, intensitas dan kualitas nyeri Instruksikan pasien dan anggota keluarga terkait reaksi dan efek samping dari agen pengurang rasa nyeri Dokumentasikan nyeri pasien, jumlah dan frekuensi dosis obat dan respon terhadap pengobatan nyeri dalam catatan per kembangannya Monitor ketat ada tidaknya depresi pernapasan pada pasien yang berisiko (misalnya., usia lebih dari 70 tahun; riwayat henti napas saat tidur; penggunaan bersama PCA dengan agen penekan fungsi sistem saraf pusat, obesitas, pembedahan abdomen bagian atas atau pembedahan thorak dan pemberian bolus PCA lebih dari 1 mg; riwayat kerusakan ginjal, hati, paruparu dan jantung) Rekomendasikan rejimen bowel untuk menghindari konstipasi

75

• Konsultasikan dengan ahli nyeri di klinik bagi pasien yang mengalami kesulitan dalam mencapai pengontrolan nyeri Edisi pertama tahun 1992; direvisi tahun 2013 Bahan Bacaan: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Pain management. In Kozier & Erb’sfundamentals of nursing: Concepts, processes, and practice. (8th ed., pp. 1187-1230). Upper Saddle River, NJ: Prentice Hall. Chumbley, G., & Mountford, L. (2010). Patient-controlled analgesia infusion pumps for adults. Nursing Standard,25(8), 35-40. Craft, J. (2010). Patient-controlled analgesia: Is it worth the painful prescribing process?Baylor University Medical Center Proceedings,23(4), 434-438. Franson, H. (2010). Postoperative patient-controlled analgesia in the pediatric population: A literature review. AANA Journal,78(5), 374-378. Patient Rights Protection (7460)

Bantuan Pembedahan

2900

Definisi: Membantu dokter bedah atau dokter gigi melalui prosedur operasi dan perawatan pasien bedah Aktivitas-aktivitas: • Lakukan cuci tangan steril untuk pembedahan sesuai dengan protokol atau aturan rumah sakit • Kenakan jubah steril dan sarung tangan dengan menggunakan teknik aseptik • Bantu tim bedah sewaktu mereka mengenakan jubah dan sarung tangan • Ambil posisi yang memungkinkan untuk menjaga bidang pembedahan terlihat secara keseluruhan • Antisipasi dan berikan alat, bahan serta instrumen yang diperlukan selama prosedur pembedahan • Pastikan bahwa instrumen, perlengkapan, dan peralatan steril yang sesuai berada dalam kondisi baik • Oper pisau bedah atau pensil dermatographic kepada dokter bedah dengan baik • Sediakan instrumen dengan cara yang aman dan tepat • Pegang jaringan dengan baik • Potong jaringan dengan tepat • Airi dan suksion luka bedah dengan tepat • Lindungi jaringan dengan tepat • Sediakan cairan hemostasis yang sesuai • Jaga kesterilan bidang pembedahan selama prosedur, membuang bagian-bagian yang sudah terkontaminasi dan mengambil langkah-langkah untuk menjaga keutuhan dan kondisi aseptik selama pembedahan • Angkat spons kotor dan simpan di tempat yang tepat serta menggantinya dengan yang bersih • Bersihkan tempat sayatan dan keringkan dari darah, sekresi, dan kulit sisa antiseptik • Bantu dalam penutupan luka bedah • Keringkan kulit pada lokasi sayatan dan pada drainase

• Pakaikan perekat, balutan, atau perban untuk luka bedah • Bantu dalam memperkirakan kehilangan darah • Hubungkan drainase ke kantung pengumpulannya, rekatkan dan jaga tetap berada pada posisi yang sesuai • Siapkan dan urus spesimen dengan baik • Komunikasikan seluruh informasi kepada tim bedah dengan tepat • Komunikasikan status dan kemajuan pasien pada keluarga dengan baik • Atur peralatan yang dibutuhkan segera setelah operasi • Bantu dalam memindahkan pasien ke ranjang atau tempat tidur dan membawa pasien ke tempat paska anastesi atau area paska operasi • Lapor pada perawat di ruang paska anastesi atau paska operasi mengenai pasien dan prosedur yang dilakukan • Dokumentasikan informasi sesuai dengan kebijakan lembaga Edisi kedua tahun 1996; direvisi tahun 2013 Bahan Bacaan Association of periOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Fuller, J. (2008). Surgical technology: Principles and practice (4th ed.) Madrid: Panamericana. Phippen, M., Ulmer, B. C., & Wells, M. M. (2009). Competency for safe patient care during operative and invasive procedures. Denver: Competency & Credentialing Institute. Rothrock, J. C. (2010). Alexander’s care of the patient in surgery (14th ed.). St. Louis: Elsevier Mosby. Rothrock, J. C. & Siefert, P. C. (2009). Assisting in surgery: Patient centered care. Denver: Competency & Credentialing Institute.


Manajemen Sedasi

2260

Definisi: Pemberian sedatif, pemantauan respon klien dan pemberian dukungan psikologis selama prosedur terapi dan diagnostik Aktivitas-aktivitas: • Review riwayat kesehatan klien dan hasil pemeriksaan diagnostik untuk mempertimbangkan apakah klien memenuhi kri-teria untuk dilakukan pembiusan parsial oleh perawat yang telah teregistrasi • Tanyakan klien atau keluarga mengenai pengalaman pembiusan parsial sebelumnya • Periksa alergi terhadap obat • Pertimbangkan intake cairan dan intake terakhir makan • Review obat-obatan lain yang dikonsumsi klien dan verifikasi ada tidaknya kontraindikasi terhadap pembiusan • Instruksikan klien dan/atau keluarga mengenai efek pembiusan • Dapatkan persetujuan tertulis • Evaluasi tingkat kesadaran klien dan reflexs protektif sebelum pembiusan • Dapatkan data tanda-tanda vital, saturasi oksigen, EKG, tinggi dan berat badan • Pastikan peralatan resusitasi gawat darurat tersedia ditempat, khususnya sumber pemberian oksigen 100%, obat-obatan kegawatdaruratan dan defibrillator • Inisiasi pemasangan infus • Berikan obat-obatan sesuai protokol yang diresepkan dokter, titrasi dengan hati hati sesuai dengan respon klien • Monitor tingkat kesadaran dan tanda-tanda vital klien, saturasi oksigen dan EKG sesuai dengan panduan protokol • Monitor klien mengenai efek lanjut obat termasuk agitasi, depresi pernafasan, hipotensi, mengantuk berlebihan, hipoksemia, aritmia, apnea, atau eksaserbasi dari kondisi sebelumnya • Pastikan ketersediaan dan pemberian antagonis sesuai dengan

prosedur protokol dan diresepkan dokter dengan benar • Pertimbangkan jika pasien memenuhi persyaratan untuk dipulangkan atau dipindahkan sesuai dengan prosedur protokol (misalnya, skala Aldrete) • Dokumentasikan tindakan dan respon klien sesuai prosedur • Pulangkan atau pindahkan pasien sesuai prosedur • Berikan instruksi kepulangan secara tertulis sesuai prosedur Edisi kedua tahun 1996; direvisi tahun 2000, 2004 Bahan Bacaan: American Academy of Pediatrics. (1992). Guidelines for monitor and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics, 89(6), 1110-1114. Holzman, R. S., Cullen, D. J., Eichron, J. H., & Philip, J. J. (1994). Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures. Clinical Anesthesia 6(4), 265-276. Karch, A. M. (2007). 2007 Lippincott’s nursing drug guide. Philadelphia: Lippincott Williams & Wilkins. Somerson, S. J., Husted, C. W., & Sicilia, M. R. (1995). Insights into conscious sedation. American Journal of Nursing 95(6), 25-32. Somerson, S. J., Somerson, S. W., & Sicilia, M. R. (1999). Conscious sedation. In G. M. Bulechek & J. C. McCloskey (Eds.), Nursing interventions: Effective nursing treatments (3rd ed., pp. 297-310). Philadelphia: W. B. Saunders. Watson, D. (1990). Monitor the patient receiving local anesthesia. Denver, CO: Association of Operating Room Nurses.

Manajemen Sensasi Perifer

2660

Definisi: Mencegah atau meminimalisir cedera dan ketidaknyamanan pada pasien yang mengalami gangguan ketidaknyamanan Aktivitas-aktivitas: • Monitor sensasi tumpul atau tajam dan panas dan dingin [yang dirasakan pasien] • Monitor adanya parasthesia dengan tepat (misalnya., mati rasa, tingling, hipertesia, hipotesia, dan tingkat nyeri) • Dorong pasien menggunakan bagian tubuh yang tidak ter ganggu untuk mengetahui suhu makanan, cairan, air mandi, dan lain-lain • Dorong pasien untuk menggunakan bagian tubuh yang tidak terganggu dalam rangka mengetahui tempat dan permukaan suatu benda • Instruksikan pasien dan keluarga untuk menjaga posisi tubuh ketika sedang mandi, duduk, berbaring, atau merubah posisi • Intruksikan pasien dan keluarga untuk memeriksa adanya kerusakan kulit setiap harinya

• Monitor adanya penekanan dari gelang, alat-alat medis, sepatu dan baju • Instruksikan pasien dan keluarga untuk mengukur suhu air dengan termometer • Dorong penggunaan sarung tangan anti panas pada saat me megang alat-alat masak • Dorong penggunaan sarung tangan atau alat pelindung lain pada bagian tubuh yang terganggu saat harus bersentuhan dengan benda-benda yang panas, permukaan berbahaya, atau benda lain yang berpotensi menyebabkan kerusakan • Hindari dan selalu monitor penggunaan terapi kompres panas atau dingin seperti penggunaan bantalan panas, botol berisi air panas atau dengan kantong es • Dorong pasien menggunakan sepatu dengan ukuran yang pas, berhak pendek, dan berbahan lembut

Contoh pilihan NOC dan NIC Ineffective peripheral tissue perfussion Doengoes

Carpenito

Buku NOC

Buku NIC

NOC

Knowledge: Diabetes management

Sensory Functions: cutaneous Tissue integrity Tissue perfusion: peripheral

Perfusi Jaringan: Perifer (447)

NIC

Circulatory care: arterial insufficiency

Peripheral sensation management Circulatory care: Venous insufficiency Circulatory care: arterial insufficiency Positioning Exercise promotion

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Perawatan sirkulasi: Insufisiensi Arteri (390-391) Perawatan sirkulasi: Insufisiensi vena (391) Manajemen sensasi perifer (207) Pengecekan kulit (311)

Bagian Tiga | Outcome 447 Deviasi berat dari kisaran normal 1

SKALA OUTCOME KESELURUHAN Indikator: 040419 Nitrogen urea darah 040420 Kreatinin plasma 040421 Temuan tes fungsi hati 040422 Enzim pankreas 040407 040408 040409 040410 040411 040412 040413 040414 040415 040416 040417 040427 040428

1 1 1 1 Berat 1 1 1 1 1 1 1 1 1 1 1 1 1

Haus abnormal Sakit perut abnormal Mual Muntah Defisiensi malabsorpsi Gastritis kronis Distensi abdomen Asites Varises gastrointestinal Sembelit Diare Perubahan keseimbangan cairan Kehilangan selera makan

Deviasi yang Deviasi cukup besar sedang dari dari kisaran kisaran normal normal 2 3 2 2 2 2 Cukup berat 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 Sedang 3 3 3 3 3 3 3 3 3 3 3 3 3

Deviasi ringan dari kisaran normal 4

Tidak ada deviasi dari kisaran normal 5

4 4 4 4 Ringan 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 Tidak ada 5 5 5 5 5 5 5 5 5 5 5 5 5

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Domain-Kesehatan Fisiologis (II) Kelas-Jantung Paru (E) edisi pertama 1997; revisi 2004, 2008 REFERENSI TERKAIT DENGAN ISI DARI OUTCOME: Lewis, S. M., Collier, I. C., Heitkemper, M. M., & Dirksen, S. R. (2000). Medical-surgical nursing: Assessment & management of clinical problems (5th ed.). St. Louis: Mosby. McCance, K. L., & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults and children (4th ed.). St. Louis: Mosby. Smeltzer, S. C., & Bare, B. G. (2004). Brunner & Suddarth’s textbook of medical surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Perfusi Jaringan: Perifer

0407

Definisi: Kecukupan aliran darah melalui pembuluh kecil di ujung kaki dan tangan untuk mempertahankan fungsi jaringan SKALA TARGET OUTCOME: Dipertahankan pada______

SKALA OUTCOME KESELURUHAN Indikator: 040715 Pengisian kapiler jari 040716 Pengisian kapiler jari kaki 040710 Suhu kulit ujung kaki dan tangan 040730 Kekuatan denyut nadi karotis (kanan)

Ditingkatkan ke_______ Deviasi berat dari kisaran normal 1 1 1 1 1

Deviasi yang Deviasi cukup besar sedang dari dari kisaran kisaran normal normal 2 3 2 2 2 2

3 3 3 3

Deviasi ringan dari kisaran normal 4

Tidak ada deviasi dari kisaran normal 5

4 4 4 4

5 5 5 5

NA NA NA NA


• • • •

ketiadaan pulsasi pada kaki, jari kaki menghitam, hipertensi, kemerahan di sekitar umbilikus, dan pembekuan terlihat dalam kateter) Cabut kateter, sesuai perintah atau sesuai protokol, dengan menarik kateter perlahan-lahan selama 5 menit Berikan tekanan pada umbilikus atau jepit pembuluh darah dengan hemostat Biarkan umbilikus terbuka Amati perdarahan

Bahan Bacaan : Merenstein, G. B., & Gardner, S. L. (1993). Handbook of neonatal intensive care. St. Louis: Mosby. Pernoll, M. L., Benda, G. I., & Babson, S. G. (1986). Diagnosis and management of the fetus and neonate at risk: A guide for team care. St. Louis: Mosby. Pillitteri, A. (2007). Nursing care of high-risk newborn and family. In Maternal and child health nursing: Care of the childbearing and childrearing family (5th ed., pp. 747-795). Philadelphia: Lippincott Williams & Wilkins.

Edisi kedua tahun 1996

Perawatan Sirkulasi: Alat Bantu Mekanik

4064

Definisi: Bantuan sementara pada sirkulasi darah melalui penggunaan alat bantu mekanik atau pompa Aktivitas-aktivitas: • Lakukan penilaian sirkulasi perifer secara komprehensif (seperti; mengecek nadi perifer, edema, waktu pengisian kapiler, warna dan suhu ektremitas) • Monitor kemampuan sensori dan kognitif • Monitor tingkat ketidaknyamanan atau nyeri dada • Evaluasi tekanan arteri pulmonal, tekanan darah sistemik, kardiak output, dan tahanan pembuluh darah sistemik, seperti yang diindikasikan • Bantu memasukkan atau menanam alat bantu • Observasi tanda-tanda hemolisis yang dapat diketahui dengan ada tidaknya darah dalam urin, pengecekan indikator hemolisis dalam darah, peningkatan serum Hb harian, perdarahan massif, hiperkalemia • Observasi apakah kanul bengkok atau terputus sambungannya • Tentukan masa pembekuan darah setiap jam, jika diperlukan • Berikan antikoagulan dan antitrombolitik, sesuai instruksi • Monitor alat bantu secara rutin untuk meyakinkan fungsinya benar • Selalu sediakan alat bantu cadangan setiap waktu • Berikan agen inotropik positif yang sesuai • Monitor profil pembekuan darah setiap 6 jam sekali, sesuai keadaan pasien • Berikan tranfusi darah yan sesuai • Monitor output urin setiap jam • Monitor nilai elektrolit, BUN, dan kreatinin setiap hari • Monitor berat badan setiap hari

• • • • • • • • • • •

Monitor intake dan output cairan Lakukan pemeriksaan rontgen dada setiap hari Pertahankan teknik aseptik pada saat perawatan balutan luka Berikan antibiotik profilaksis Monitor terjadinya demam dan leukositosis Lakukan pemeriksaan kultur darah, urin, sputum, dan dasar luka jika suhu diatas 38o C Berikan obat kumur anti jamur Berikan nutrisi parenteral total dengan cara yang tepat Berikan obat pengurang nyeri jika diperlukan Jelaskan kepada pasien dan keluarga mengenai alat yang digunakan Berikan dukungan emosional kepada pasien dan keluarga

Edisi kedua tahun 1996; direvisi tahun 2000 Bahan Bacaan: LeMone, P. & Burke, K. M. (2000). Medical-surgical nursing: Critical thinking in client care (2nd ed., pp. 1110-1112). Upper Saddle River, NJ: Prentice Hall. Ruzevich, S. (1993). Cardiac assist devices. In J. M. Clochesy, C. Breu, S. Cardin, E. B. Rudy, & A. A. Whittaker (Eds.), Critical care nursing (pp. 183-192). Philadelphia: Saunders.

Perawatan Sirkulasi: Insufisiensi Arteri

4062

Definisi: Meningkatkan sirkulasi arteri Aktiftas-aktivitas: • Lakukan pemeriksaan fisik sistem kardiovaskuler atau penilaian yang komprehensif pada sirkulasi perifer (misalnya, memeriksa denyut nadi perifer, edema, waktu pengisian kapiler, warna, dan suhu) • Tentukan indeks ankle brachial (ankle brachial index) dengan tepat • Evaluasi edema dan denyut pada

• Inspeksi kulit untuk adanya luka pada arteri [arterial ulcers] atau kerusakan jaringan • Monitor tingkat ketidaknyamanan atau nyeri saat melakukan olahraga di malam hari atau saat beristirahat • Tempatkan ujung kaki dan tangan dalam posisi tergantung dengan tepat • Berikan obat antiplatelet (penurun agregasi platelet) atau antikoagulan (pengencer darah), dengan tepat • Ubah posisi pasien setidaknya setiap 2 jam, dengan tepat

Bagian Tiga | Klasifikasi 391 • Dukung pasien untuk melakukan kegiatan olahraga walaupun [pasien] tidak suka • Lindungi ujung kaki dan tangan dari cedera (misalnya, kain tebal di bawah kaki dan kaki bagian bawah, alas di kaki ranjang, sepatu longgar) • Berikan kehangatan (misalnya, tambahan pakaian tidur, meningkatkan suhu kamar) dengan tepat • Instruksikan pasien mengenai faktor-faktor yang mengganggu sirkulasi darah (misalnya, merokok, pakaian ketat, terlalu lama di dalam suhu dingin, dan menyilangkan kaki) • Instruksikan pada pasien mengenai perawatan kaki yang tepat • Hindari menempelkan panas langsung ke ujung kaki dan tangan • Pelihara hidrasi yang memadai untuk menurunkan kekentalan

darah • Monitor jumlah cairan yang masuk dan yang keluar • Lakukan perawatan luka, dengan tepat Edisi ketiga tahun 2000; direvisi tahun 2004 Bahan Bacaan : Anonymous. (2001). Arterial vs. venous ulcers: Diagnosis and treatment. Advances in Skin & Wound Care, 14(3), 146-149. Hayward, L. (2002). Wound care. Patient-centered leg ulcer care. Nursing Times, 98(2), 59, 61. Hiatt, W. R. & Regensteiner, J. G. (1993). Nonsurgical management of peripheral arterial disease. Hospital Practice, 28(2), 59-70.

Perawatan Sirkulasi: Insufisiensi Vena

4066

Definisi: Peningkatan sirkulasi aliran vena Aktivitas-aktivitas: • Lakukan penilaian sirkulasi perifer secara komprehensif (misalnya., mengecek nadi perifer, udem, waktu pengisian kapiler, warna dan suhu kulit) • Nilai udem dan nadi perifer • Inspeksi kulit apakah terdapat luka tekan dan jaringan yang tidak utuh • Jika diperlukan lakukan perawatan luka (debridemen, terapi antimikroba) • Lakukan pembalutan yang tepat sesuai dengan tipe dan ukuran luka • Monitor level ketidaknyamanan atau nyeri • Instruksikan pasien mengenai terapi kompresi/penekanan • Lakukan terapi modalitas penekanan dengan cara yang tepat (apakah menggunakan balutan yang pendek atau panjang) • Tinggikan kaki 20o atau lebih tinggi dari jantung • Ubah posisi pasien setiap 2 jam sekali • Dukung latihan ROM pasif dan aktif, terutama pada ektremitas bawah, selama beristirahat • Berikan obat antiplatelet atau antikoagulan dengan cara yang tepat

• Lindungi ekstremitas dari trauma (misalnya., meletakkan bantalan di bawah kaki dan betis, meletakan footboard untuk menopang kaki, menggunakan sepatu sesuai ukuran) • Instruksikan pasen melakukan perawatan kaki yang benar • Pertahankan hidrasi yang cukup untuk menurunkan viskositas darah Edisi ketiga tahun 2000; direvisi tahun 2004 Bahan Bacaan: Anonymous. (2001). Arterial vs. venous ulcers: Diagnosis and treatment. Advances in Skin & Wound Care, 14(3), 146-149. Hayward, L. (2002). Wound care. Patient-centered leg ulcer care. Nursing Times, 98(2), 59, 61. Hess, C. T. (2001). Clinical management extra: Management of a venous ulcer: A case study approach. Advances in Skin & Wound Care, 14(3), 148-149. Kunimoto, B. T. (2001). Management and prevention of venous leg ulcers: A literature-guided approach. Ostomy/Wound Management, 47(6), 36-49.

Perawatan Sirkumsisi

3000

Definisi: Dukungan sebelum dan setelah prosedur pada pria yang dilakukan sirkumsisi Aktivitas-aktivitas: • Verifikasi bahwa ijin untuk dilakukan pembedahan telah di tandatangani • Verifikasi indentifikasi pasien yang benar • Berikan pengontrol nyeri sebelum prosedur sekitar 1 jam sebelum dilakukan prosedur (misalnya, acetaminophen) • Posisikan pasien pada posisi yang nyaman selama prosedur • Gunakan kursi lembut untuk sirkumsisi bagi bayi • Gunakan alat penghangat untuk memelihara suhu tubuh selama prosedur • Tutup mata bayi dari sinar yang langsung memancar • Gunakan kempong yang dicelupkan pada sukrosa selama

• • • • • • •

prosedur dan sampai pemberian makan selanjutnya atas ijin dari orangtua/pangasuh Swaddle tubuh bayi bagian atas selama dilakukan sirkumsisi Mainkan musik yang lembut selama dilakukan prosedur Monitor tanda-tanda vital Berikan agen analgesik topikal (misalnya., eutectic mixture of local anesthetics [EMLA]), sesuai dengan yang diinstruksikan) Bantu dokter dengan dorsal penile nerve block, dengan tepat Berikan white petroleum jelly dan/atau balutan, dengan tepat Monitor adanya perdarahan setiap 30 menit untuk setiap dua jam setelah prosedur Sediakan pengontrol nyeri setelah prosedur setiap 4 sampai 6

Bagian Tiga | Klasifikasi 391 • Dukung pasien untuk melakukan kegiatan olahraga walaupun [pasien] tidak suka • Lindungi ujung kaki dan tangan dari cedera (misalnya, kain tebal di bawah kaki dan kaki bagian bawah, alas di kaki ranjang, sepatu longgar) • Berikan kehangatan (misalnya, tambahan pakaian tidur, meningkatkan suhu kamar) dengan tepat • Instruksikan pasien mengenai faktor-faktor yang mengganggu sirkulasi darah (misalnya, merokok, pakaian ketat, terlalu lama di dalam suhu dingin, dan menyilangkan kaki) • Instruksikan pada pasien mengenai perawatan kaki yang tepat • Hindari menempelkan panas langsung ke ujung kaki dan tangan • Pelihara hidrasi yang memadai untuk menurunkan kekentalan

darah • Monitor jumlah cairan yang masuk dan yang keluar • Lakukan perawatan luka, dengan tepat Edisi ketiga tahun 2000; direvisi tahun 2004 Bahan Bacaan : Anonymous. (2001). Arterial vs. venous ulcers: Diagnosis and treatment. Advances in Skin & Wound Care, 14(3), 146-149. Hayward, L. (2002). Wound care. Patient-centered leg ulcer care. Nursing Times, 98(2), 59, 61. Hiatt, W. R. & Regensteiner, J. G. (1993). Nonsurgical management of peripheral arterial disease. Hospital Practice, 28(2), 59-70.

Perawatan Sirkulasi: Insufisiensi Vena

4066

Definisi: Peningkatan sirkulasi aliran vena Aktivitas-aktivitas: • Lakukan penilaian sirkulasi perifer secara komprehensif (misalnya., mengecek nadi perifer, udem, waktu pengisian kapiler, warna dan suhu kulit) • Nilai udem dan nadi perifer • Inspeksi kulit apakah terdapat luka tekan dan jaringan yang tidak utuh • Jika diperlukan lakukan perawatan luka (debridemen, terapi antimikroba) • Lakukan pembalutan yang tepat sesuai dengan tipe dan ukuran luka • Monitor level ketidaknyamanan atau nyeri • Instruksikan pasien mengenai terapi kompresi/penekanan • Lakukan terapi modalitas penekanan dengan cara yang tepat (apakah menggunakan balutan yang pendek atau panjang) • Tinggikan kaki 20o atau lebih tinggi dari jantung • Ubah posisi pasien setiap 2 jam sekali • Dukung latihan ROM pasif dan aktif, terutama pada ektremitas bawah, selama beristirahat • Berikan obat antiplatelet atau antikoagulan dengan cara yang tepat

• Lindungi ekstremitas dari trauma (misalnya., meletakkan bantalan di bawah kaki dan betis, meletakan footboard untuk menopang kaki, menggunakan sepatu sesuai ukuran) • Instruksikan pasen melakukan perawatan kaki yang benar • Pertahankan hidrasi yang cukup untuk menurunkan viskositas darah Edisi ketiga tahun 2000; direvisi tahun 2004 Bahan Bacaan: Anonymous. (2001). Arterial vs. venous ulcers: Diagnosis and treatment. Advances in Skin & Wound Care, 14(3), 146-149. Hayward, L. (2002). Wound care. Patient-centered leg ulcer care. Nursing Times, 98(2), 59, 61. Hess, C. T. (2001). Clinical management extra: Management of a venous ulcer: A case study approach. Advances in Skin & Wound Care, 14(3), 148-149. Kunimoto, B. T. (2001). Management and prevention of venous leg ulcers: A literature-guided approach. Ostomy/Wound Management, 47(6), 36-49.

Perawatan Sirkumsisi

3000

Definisi: Dukungan sebelum dan setelah prosedur pada pria yang dilakukan sirkumsisi Aktivitas-aktivitas: • Verifikasi bahwa ijin untuk dilakukan pembedahan telah di tandatangani • Verifikasi indentifikasi pasien yang benar • Berikan pengontrol nyeri sebelum prosedur sekitar 1 jam sebelum dilakukan prosedur (misalnya, acetaminophen) • Posisikan pasien pada posisi yang nyaman selama prosedur • Gunakan kursi lembut untuk sirkumsisi bagi bayi • Gunakan alat penghangat untuk memelihara suhu tubuh selama prosedur • Tutup mata bayi dari sinar yang langsung memancar • Gunakan kempong yang dicelupkan pada sukrosa selama

• • • • • • •

prosedur dan sampai pemberian makan selanjutnya atas ijin dari orangtua/pangasuh Swaddle tubuh bayi bagian atas selama dilakukan sirkumsisi Mainkan musik yang lembut selama dilakukan prosedur Monitor tanda-tanda vital Berikan agen analgesik topikal (misalnya., eutectic mixture of local anesthetics [EMLA]), sesuai dengan yang diinstruksikan) Bantu dokter dengan dorsal penile nerve block, dengan tepat Berikan white petroleum jelly dan/atau balutan, dengan tepat Monitor adanya perdarahan setiap 30 menit untuk setiap dua jam setelah prosedur Sediakan pengontrol nyeri setelah prosedur setiap 4 sampai 6


Manajemen Sedasi

2260

Definisi: Pemberian sedatif, pemantauan respon klien dan pemberian dukungan psikologis selama prosedur terapi dan diagnostik Aktivitas-aktivitas: • Review riwayat kesehatan klien dan hasil pemeriksaan diagnostik untuk mempertimbangkan apakah klien memenuhi kri-teria untuk dilakukan pembiusan parsial oleh perawat yang telah teregistrasi • Tanyakan klien atau keluarga mengenai pengalaman pembiusan parsial sebelumnya • Periksa alergi terhadap obat • Pertimbangkan intake cairan dan intake terakhir makan • Review obat-obatan lain yang dikonsumsi klien dan verifikasi ada tidaknya kontraindikasi terhadap pembiusan • Instruksikan klien dan/atau keluarga mengenai efek pembiusan • Dapatkan persetujuan tertulis • Evaluasi tingkat kesadaran klien dan reflexs protektif sebelum pembiusan • Dapatkan data tanda-tanda vital, saturasi oksigen, EKG, tinggi dan berat badan • Pastikan peralatan resusitasi gawat darurat tersedia ditempat, khususnya sumber pemberian oksigen 100%, obat-obatan kegawatdaruratan dan defibrillator • Inisiasi pemasangan infus • Berikan obat-obatan sesuai protokol yang diresepkan dokter, titrasi dengan hati hati sesuai dengan respon klien • Monitor tingkat kesadaran dan tanda-tanda vital klien, saturasi oksigen dan EKG sesuai dengan panduan protokol • Monitor klien mengenai efek lanjut obat termasuk agitasi, depresi pernafasan, hipotensi, mengantuk berlebihan, hipoksemia, aritmia, apnea, atau eksaserbasi dari kondisi sebelumnya • Pastikan ketersediaan dan pemberian antagonis sesuai dengan

prosedur protokol dan diresepkan dokter dengan benar • Pertimbangkan jika pasien memenuhi persyaratan untuk dipulangkan atau dipindahkan sesuai dengan prosedur protokol (misalnya, skala Aldrete) • Dokumentasikan tindakan dan respon klien sesuai prosedur • Pulangkan atau pindahkan pasien sesuai prosedur • Berikan instruksi kepulangan secara tertulis sesuai prosedur Edisi kedua tahun 1996; direvisi tahun 2000, 2004 Bahan Bacaan: American Academy of Pediatrics. (1992). Guidelines for monitor and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics, 89(6), 1110-1114. Holzman, R. S., Cullen, D. J., Eichron, J. H., & Philip, J. J. (1994). Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures. Clinical Anesthesia 6(4), 265-276. Karch, A. M. (2007). 2007 Lippincott’s nursing drug guide. Philadelphia: Lippincott Williams & Wilkins. Somerson, S. J., Husted, C. W., & Sicilia, M. R. (1995). Insights into conscious sedation. American Journal of Nursing 95(6), 25-32. Somerson, S. J., Somerson, S. W., & Sicilia, M. R. (1999). Conscious sedation. In G. M. Bulechek & J. C. McCloskey (Eds.), Nursing interventions: Effective nursing treatments (3rd ed., pp. 297-310). Philadelphia: W. B. Saunders. Watson, D. (1990). Monitor the patient receiving local anesthesia. Denver, CO: Association of Operating Room Nurses.

Manajemen Sensasi Perifer

2660

Definisi: Mencegah atau meminimalisir cedera dan ketidaknyamanan pada pasien yang mengalami gangguan ketidaknyamanan Aktivitas-aktivitas: • Monitor sensasi tumpul atau tajam dan panas dan dingin [yang dirasakan pasien] • Monitor adanya parasthesia dengan tepat (misalnya., mati rasa, tingling, hipertesia, hipotesia, dan tingkat nyeri) • Dorong pasien menggunakan bagian tubuh yang tidak ter ganggu untuk mengetahui suhu makanan, cairan, air mandi, dan lain-lain • Dorong pasien untuk menggunakan bagian tubuh yang tidak terganggu dalam rangka mengetahui tempat dan permukaan suatu benda • Instruksikan pasien dan keluarga untuk menjaga posisi tubuh ketika sedang mandi, duduk, berbaring, atau merubah posisi • Intruksikan pasien dan keluarga untuk memeriksa adanya kerusakan kulit setiap harinya

• Monitor adanya penekanan dari gelang, alat-alat medis, sepatu dan baju • Instruksikan pasien dan keluarga untuk mengukur suhu air dengan termometer • Dorong penggunaan sarung tangan anti panas pada saat me megang alat-alat masak • Dorong penggunaan sarung tangan atau alat pelindung lain pada bagian tubuh yang terganggu saat harus bersentuhan dengan benda-benda yang panas, permukaan berbahaya, atau benda lain yang berpotensi menyebabkan kerusakan • Hindari dan selalu monitor penggunaan terapi kompres panas atau dingin seperti penggunaan bantalan panas, botol berisi air panas atau dengan kantong es • Dorong pasien menggunakan sepatu dengan ukuran yang pas, berhak pendek, dan berbahan lembut


Pengecekan Kulit

3590



Pengekangan fisik

6580



Cara lain mendiagnosis dan menentukan rencana asuhan keperawatan? Diagnostic reasoning process

Menentukan NOC dan NIC

Menggunakan 6 tahap dalam mendiagnosis

Menggunakan ICRM (Intan’s Clinical Reasoning Model)

Enam Tahap dalam ‘diagnostic reasoning’ menurut Nurjannah’s method (Nurjannah, 2012): •

• • • • • • • • • • • • • • • • • • • •

1. Mengklasifikasikan data menggunakan ISDA, jika data tidak didapatkan dalam ISDA bisa ditelusuri dengan menggunakan buku ‘The Fast Method of Formulating Nursing Diagnoses for Diagnostic Reasoning in Nursing’ 2. Tetapkan kemungkinan diagnosa keperawatan atau diagnosa kolaborasi (activated possible diagnoses) 3. Baca/pelajari informasi tentang diagnosa keperawatan/diagnosa kolaboratif terutama definisinya (menggunakan taksonomi NANDA dan referensi yang membahas mengenai diagnosa kolaborasi), tetapkan apakah diagnosa tersebut dikategorikan pada: A. Dapat ditegakkan B. Dianulir (digugurkan) C. Memerlukan pengkajian lanjutan dan tetapkan apa pengkajian lanjutannya 4. Menentukan kemungkinan dignosa keperawatan dan hubungan antara satu diagnosa dengan diagnosa yang lain (Menggunakan ‘The Map of Nursing Diagnoses’) pada diagnosa keperawatan kategori A (telah ditegakkan), kegiatan no 4 ini dilakukan setiap diagnosa keperawatan telah di tetapkan (kategori A) 5. Menggunakan fokus pengkajian lanjutan jika diperlukan untuk memverifikasi diagnosa yang ditetapkan sebelumnya (Dapat menggunakan NANDA taxonomi dan referensi yang membahas diagnosa kolaborasi) 6. Label diagnoses

Saya pakai DOENGOES, Dia pakai CARPENITO Mereka pakai NANDA, NOC dan NIC (NNN) apakah bedanya? Intansari Nurjannah, SKp, MNSc

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