Oleh: Septi Dewi Rachmawati

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Review:
Introduction to NIC & NOC

Standardized nursing languages (SNLs)

A recognized pioneer in SNL is NANDA

Internationals (formerly North American
Nursing Diagnosis Association)

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Standardized Nursing Language

Definition of nursing language

... the universe of written terms and their

definitions comprising nomenclature or
thesauria that are used for purposes such as
indexing, sorting, retrieving and classifying
nursing data in clinical records, in information
systems, and in literature and research reports
(NCNR, 1993) cited from (Clark, 1999)

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Standardized terminologies

Focus on health concerns (diagnoses,

interventions and outcomes) consistent with
the scope of practice for nursing
Concept or term used
Representing: nursing data, information, and
knowledge
Organized into: Nomenclatures,
classifications, terminologies and vocabularies

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Why do we need SNL?

If we cannot name it, we cannot control it, finance

it, teach it, research it, or put it into public policy
(Clark and Lang 1992, cited from (Clark, 1999)

We believe that standardized language should be

and will be a source of pride for the professions
(McCloskey & Bulechek, 1994)
WHY
Pengertian yang sama

Berkomunikasi dimengerti di hargai (Clark,

1999).

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Standardized nursing languages (SNLs)
A recognized pioneer in SNL is NANDA Internationals
(formerly North American Nursing Diagnosis Association)
Nursing terminology development timeline

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Several SNLs, including Home Health Care
Classification (HHCC; now Clinical Care
Classification), Nursing Interventions
Classification (NIC), Nursing Outcomes
Classification NOC), Omaha System-Community
Health Classification System (OS), Patient Care
Data Set (PCDS) and Perioperative Nursing Data
Set (PNDS)

Using NANDA, NOC, NIC, Doenges, Carpenito??

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 The combination of NANDA-I nursing
diagnoses, NOC outcomes, and NIC is
recognized by the American Nurses
Association (ANA) and is coded in the
Systematized Nomenclature of Medicine
(SNOMED) in support of the electronic client
record.

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Common Nursing diagnoses
(for respiratory disorders)

NANDA-I

Domain 1: Health promotion

Risk-prone health behaviour
Ineffective health maintenance
Ineffective self-health management
Readiness for enhanced self-health management
Ineffective family therapeutic regimen
management
Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya
Domain 2: Nutrition
Imbalanced nutrition: less than body
requirements
Impaired swallowing
Risk for electrolite imbalance
Deficient fluid volume
Risk for deficient fluid volume

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

Domain 3: Elimination and Exchange
Impaired gas exchange

Domain 4: Activity rest

Imsomnia
Disturbed sleep pattern
Fatique
Activity intolerance
Risk for activity intolerance
Ineffective breathing pattern
Impaired spontaneous ventilation
Ineffective peripheral tissue perfusion
Risk for ineffective cerebral tissue perfusion
Risk for ineffective peripheral tissue perfusion

Class 5: Self-Care
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Domain 5: Perception/ Cognition
Deficient knowledge
Readiness for enhanced knowledge

Domain 6: Self-perception
Chronic low self-esteem
Risk for chronic self-esteem

Domain 7: Role relationship

Caregiver role strain
Risk for caregiver role strain

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

Domain 9: Coping/ stress tolerance
Anxiety
Ineffective coping
Ineffective community coping
Death anxiety

Domain 11: Safety/ protection

Risk for infection
Ineffective airway clearance
Risk for aspiration

Domain 12: Environmental hazards

Hyperthermia

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

Domain 12: Comfort
Acute pain
Chronic pain

Domain 13: Growth/ Development

Risk for disproportionate growth
Delayed growth and development
Risk for delayed development

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Nursing diagnosis

Ineffective airway clearance

Ineffective breathing pattern

Impaired gas exchange

Activity intolerance

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Nursing diagnosis
Imbalanced nutrition: less than
body requirements

Pain (acute; chronic)

Deficit knowledge

Anxiety

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Nursing Diagnoses
Ineffective Airway clearance

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya
Impaired gas Exchange

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 NOC commonly used
(for respiratory system disorders)

NIC Commonly used

(for respiratory system disorders)

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 Applying NANDA NIC NOC

NANDA-I
NANDA NOC/NIC LINKAGE
NOC/NIC SPECIALTY AREA
NOC/NIC DOMAIN

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 NANDA, NOC, NIC LINKAGE
(Examples)
Dx: Ineffective airway clearance Dx: ineffective breathing pattern

NOC:
Respiratory status: airway NOC:
Patency Respiratory status: airway
Respiratory status Patency
Vital signs Respiratory status

NIC: NIC:
Airway management Airway management
Cough enhancement Asthma management
Respiratory monitoring Respiratory monitoring
Chest physiotherapy Allergy management
Airway suctioning Oxygen therapy
Positioning Medication administration
Vital sign monitoring
Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya
 NANDA, NOC, NIC LINKAGE
(Examples)
Dx: Impaired gas exchange Dx: Pain (Acute; chronic)

NOC:
- Respiratory status: gas exchange NOC:
- Respiratory status Pain Level
Pain control
NIC:
Acid Base Management NIC:
Acid Base Management: Respiratory/ Pain management
metabolic asidosis
Airway management
Vital sign monitoring
Respiratory monitoring
Medication administration

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 NANDA, NOC, NIC LINKAGE
(Examples)
Dx: Imbalanced nutrion: less than Dx: Activity intolerance
body requirement

NOC: NOC:
Nutritional status Activity tolerance
Nutritional status: nutrient Endurance
intake
Appetite NIC:
Energy management
NIC: Activity therapy
Nutrition management
Weight gain assistance
Nutrition therapy
Nutritional monitoring

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

 NANDA, NOC, NIC LINKAGE
(Examples)
Dx: Anxiety Dx: Deficient knowledge

NOC: NOC:
Anxiety level Knowledge: disease process
Anxiety self-control Knowledge: Asthma
Vital signs management

NIC: NIC:
Anxiety reduction Teaching: disease process
Relaxation therapy Teaching: prescribed medication
Vital sign monitoring

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya

Jurusan Keperawatan Fakultas Kedokteran Universitas Brawijaya