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The NANDA International Taxonomy: Taxonomy of Nursing Diagnoses
The NANDA International Taxonomy: Taxonomy of Nursing Diagnoses
Class Class
Axis 7
Status of the diagnosis
(Actual, Health Promotion,
Required Risk, Wellness) Optional
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
Components of a Nursing Diagnosis
Kira-kira
Di kelas itulah diagnosa pasien
Deteksi DEtaiL
1 st step :
Look axis
Axis 1 NYERI : nyeri
Axis 2 NYERI : individu
Axis 3 NYERI : situasional
Axis 4 NYERI : ekstremitas
Axis 5 NYERI : lansia
Axis 6 NYERI : akut
Axis 7 NYERI : aktual
2 nd step :
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).
Penulisan Diagnosa :
Nyeri Akut berhubungan dengan agen cedera
Made a priority
Base on basic human need : individu, family,
community
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).