taxonomy of nursing diagnoses
DESCRIPTION
Taxonomy of Nursing Diagnoses. The NANDA International Taxonomy. Dewi Baririet Baroroh Departement Keperawatan Dasar : Proses Dokumentasi Keperawatan PSIK FIKES UMM. Nurse are diagnosticians. As foundation of nursing care. 2 basics development need of competencies to diagnose : - PowerPoint PPT PresentationTRANSCRIPT
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The NANDA International Taxonomy
Taxonomy of Nursing Diagnoses
Dewi Baririet BarorohDepartement Keperawatan Dasar : Proses Dokumentasi Keperawatan
PSIK FIKES UMM
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Nurse are diagnosticians• As foundation of nursing care.• 2 basics development need of
competencies to diagnose :1.Requires intelectual, interpersonal, technical2.Personal strength of tolerance for ambiguity
(flexibel) and reflective practice (belajar dari pengalaman)
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Critical Thinking (CT)• Thinking (CT) processes can be
improved– Stimulate to use– Expect use– Validate appropriate use– Demonstrate support &
confidence in abilities• CT abilities -essential for accuracy of
diagnoses & use of NOC & NIC
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5 THING
about NURSING DIAGNOSE
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DiagNoSa KeperawatanTERSTANDAR
KALIMATNYA BAKU
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DiagNoSa KeperawatanTERTENTU
ADA SYARAT DAN BATASAN KARAKTERISTIK MASING-MASING DIAGNOSA
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DiagNoSa KeperawatanTIDAK NGAWUR
TIDAK BERDASAR “FEELING” / “KAYAKNYA”
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DiagNoSa KeperawatanTIDAK DIBUAT SENDIRI
SESUAI DENGAN DAFTAR DIAGNOSA NANDA
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DiagNoSa KeperawatanIDENTITAS
TIDAK BISA mendiagnosa ?? Anda BUKAN PERAWAT
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PRINSIP diagnosa ∞ pengkajian
• TIDAK ADA pengkajian TIDAK ADA diagnosa• Pengkajian TIDAK LENGKAP diagnosa
SALAH• Pengkajian LENGKAP BELUM TENTU
diagnosa BENAR
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Data Pengkajian :
Puzzle: What is the Diagnosis?
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Solving the PuzzleIs it this? Or this? Or this?
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NANDA-I Taxonomy II: 2008
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The Diagnoses• NANDA : North American for Nursing
Diagnosis Association• Diagnosis versi NANDA yg sekarang
disusun sesuai dengan Taksonomi/urutan• Kode diagnosa (5 digit) dan multi axial (axis 1-
axis 7).• Tujuan : mudah digunakan, mudah dipahami
dan fleksibel utk dirubah dan di modifikasi
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Structure of Taxonomy II
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NANDA-I Axes
Required Optional
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• Axis 1 Konsep Diagnosa : 136• Axis 2 Subyek yang sakit : individu, klg, klmpk, komnts• Axis 3 Penilaian : terganggu, tdk efektif dll• Axis 4 Lokasi : jantung, pulmo, ekstremitas dll• Axis 5 Usia : janin, bayi ,dewasa, lansia dll• Axis 6 Waktu : kronis, akut, intermitten, kontinyu• Axis 7 Status Diagnosa : aktual, promosi, resiko, potensial
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Components of a Nursing Diagnosis
1. Label or Name and definition2. Related Factors OR Risk Factors3. Defining Characteristics
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• Konstruksi Label diagnosa (masalah keperawatan) :
Axis 1 – Axis 3 – Axis 2 wajib ada Axis 4, 5, 6, 7 lengkap lebih baik
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Contoh :
• Data pengkajian : Ny. J, 72 tahun mengeluh NYERI luka di kaki. ± 6 tahun yang lalu pasien menderita penyakit DM, dan telah melakukan pengobatan secara rutin, dengan glibenkamid sehari 1 kali. Selama ini jarang melakukan pemeriksaan rutin kadar gula darah. ± 8 hari yang lalu telapak kaki kena paku, sudah diperiksakan ke dokter dan diberi obat tetapi sampai obat habis belum sembuh, bahkan dirasakan semakin berat.Terdapat nanah, dan bertambah nyeri nyeri serta demam.Akhirnya dirujuk ke RSUD Dr. Soetomo Surabaya.Telapak kaki kena paku ± 8 hari yang lalu, terdapat nanah dan bengkak.Nyeri telapak kaki semakin nyeri jika kaki digelantungkan .Pasien batuk pilek (-), nyeri dada (-), ulu hati terasa ampek, dan tadi malam muntah 1 kali.(P). Nyeri dirasa panas, senut-senut seperti disedot, bercampur dengan perih seperti teriris (Q). Nyeri dirasakan di telapak kaki yang terdapat luka gangrene (R). nyeri dirasakan skala 7 (S). Nyeri dirasakan terus menerus (T).
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Diagnostic ProcessAssessment
Cluster cues / defining characteristics
Collect additional data to narrow list of potential diagnoses
Generate list of potential diagnoses
Implement plan of care based on identified diagnoses
Evaluate success of plan of care
Determine diagnosis/diagnoses to be treated
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Deteksi Cepat
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1st step :•Look domain
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Domain : 12
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2nd step :•Look KELAS
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Kelas: 1
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3rd step :
Semua diagnosa di kelas tersebut.SPESIFIK ke batasan KARAKTERISTIK
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That’s All
Kira-kira Di kelas itulah diagnosa pasien
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Deteksi DEtaiL
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1st step :•Look axis
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Axis 1 NYERI : nyeri
Axis 2 NYERI : individu
Axis 3 NYERI : situasional
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Axis 4 NYERI : ekstremitas
Axis 5 NYERI : lansia
Axis 6 NYERI : akut
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Axis 7 NYERI : aktual
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2nd step :
Look DEFINISI dan batasan karakteristik
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Lihat data pengkajian; obyektif dan subyektif
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DATA ETIOLOGI Masalah keperawatan
DS : -Ny. J mengeluh nyeri luka di kaki.- ± 8 hari yang lalu telapak kaki kena paku, sudah diperiksakan ke dokter dan diberi obat tetapi sampai obat habis belum sembuh, bahkan dirasakan semakin berat. Terdapat nanah, dan bertambah nyeri nyeri serta demam.Akhirnya dirujuk ke RSUD Dr. Soetomo Surabaya.Telapak -- ± 6 tahun yang lalu pasien menderita penyakit DM, dan telah melakukan pengobatan secara rutin, dengan glibenkamid sehari 1 kali.
DO : -- Selama ini jarang melakukan pemeriksaan rutin kadar gula darah. -kaki kena paku ± 8 hari yang lalu, terdapat nanah dan bengkak-- .Nyeri telapak kaki semakin nyeri jika kaki digelantungkan .-- Nyeri dirasa panas, senut-senut seperti disedot, bercampur dengan perih seperti teriris (Q). -- Nyeri dirasakan di telapak kaki yang terdapat luka gangrene (R). -- nyeri dirasakan skala 7 (S). -Nyeri dirasakan terus menerus (T).
Ketidakberdayaan fisik Nyeri
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Penulisan Diagnosa :Nyeri Akut berhubungan dengan agen cedera
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Made a priority• Base on basic human need : individu, family,
community
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Diagnostic Difficulties• Significant overlap of cues (Defining
Characteristics) to diagnoses • Contextual factors such as culture can change the
perspective on diagnosis• Many studies have verified that interpretations
of clinical cases have the potential to be less accurate than indicated by the data
– (Lunney, 2007).