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1. NURUL HIDAYATI

pada : 15 September 2017

"NAMA : NURUL HIDAYATI
NIM : 131611133022
KELAS : A1-2016
NURSING DIANGNOSIS
1. Nursing Diagnosis (NANDA)
Risk-prone health behavior related to Smoking
Definition: Impaired ability to modify lifestyle/behaviors in a manner that improves health status.
(Domain 1. Health Promotion. Class 2. Health Management. Code 00188)

2. Nursing Outcomes Classification
Aim :
After the nursing action in the time 3 months, expected client can achieve the results criteria:
1) [1600] Adherence Behavior
Definition: Self-initiated actions to promote optimal wellness, recovery, and rehabilitation
Adherence Behavior as evidenced by often demonstrating ability to:
• [163207] Uses strategies to promote safety (5)
• [160004] Weighs risks/benefits of health behavior (5)
• [160008] Uses strategies to eliminate unhealthy behavior (5)
• [160011] Performs activities of daily living consistent with energy and tolerance (5)
• [160013] Describes rationale for deviating from a health regimen (5)

2) [1701] Health Beliefs: Perceived Ability to Perform
Definition: Personal conviction that one can carry out a given health behavior
Health Beliefs: Perceived Ability to Perform as evidenced by often showing the belief to:
• [170102] Perception that health behavior requires reasonable effort (5)
• [170107] Confidence related to observation of successful experiences of others (5)
• [170108] Confidence in ability to perform health behavior (5)

3) [1602] Health Promoting Behavior
Definition: Personal actions to sustain or increase wellness
Health Promoting Behavior as evidence by often demonstrating ability to:
• [160201] Uses risk avoidance behaviors (5)
• [160203] Monitors personal behavior for risks (5)
• [160207] Performs healthy behaviors routinely (5)
• [160216] Uses effective exercise routine (5)

3. Nursing Intervention Classification
1) [4360] Behavior Modification
Definition: Promotion of a behavior change
• Intervention :
Determine patient’s motivation to change.
Rationale :
Motivation can affect the level of the patient's desire to change. Negative factors that may affect patient changes should be eliminated.
• Intervention :
Assist patient to identify strengths, and reinforce these.
Rationale :
The inner strength of the patient is very important, the smoking habit may change if there is a strength of the patient to change.
• Intervention :
Encourage substitution of undesirable habits with desirable habits.
Rationale :
Support from others (nurses) plays an important role in the process of patient change.
• Intervention :
Break down behavior to be changed into smaller, measurable units of behavior (e.g., stopping smoking: number of cigarettes smoked).
Rational :
Reducing the number of cigarettes consumed helps to eliminate the smoking habit.
• Intervention :
Use specific time periods when measuring units of behavior (e.g., number of cigarettes smoked per day).
Rationale :
Patients are trained not to smoke freely.
• Intervention :
Facilitate family involvement in the modification process, as appropriate.
Rationale :
Patients do not feel alone and positive support from the family can motivate the level of patient desire to quit smoking.

2) [5510] Health Education
Definition: Developing and providing instruction and learning experiences to facilitate voluntary adaptation of behavior conducive to health in individuals, families, groups, or communities
• Intervention :
Identify internal or external factors that may enhance or reduce motivation for healthy behavior.
Rationale :
Negative internal and external factors need to be prevented so that no obstacles affect the patient's therapy process.
• Intervention :
Determine current health knowledge and lifestyle behaviors of individual, family, or target group.
Rationale :
Risks of disease one of which is influenced by the level of knowledge of health and lifestyle behavior of patients.
• Intervention :
Teach strategies that can be used to resist unhealthy behavior or risk taking rather than give advice to avoid or change behavior.
Rationale :
Providing strategies are more effective for patients than for advice.
• Intervention :
Use variety of strategies and intervention points in educational program.
Rationale :
Appropriate primary strategies and interventions can maximize the patient's change process.
• Intervention :
Use lectures to convey the maximum amount of information, when appropriate.
Rationale :
Adding and improving understanding of healthy behaviors.

3) [4490] Smoking Cessation Assistance
Definition: Helping another to stop smoking
• Intervention :
Record current smoking status and smoking history.
Rationale :
Patients with heavy smokers are at risk of other diseases related to the respiratory system.
• Intervention :
Give clear, consistent advice to quit smoking.
Rationale :
Consistent and clear suggestions help convince patients to quit smoking.
• Intervention :
Help patient identify reasons to quit and barriers to quitting.
Rationale :
The less convincing reasons and misconceptions about barrier factors may affect the patient's interest to quit smoking.
• Intervention :
Instruct patient on the physical symptoms of nicotine withdrawal (e.g., headache, dizziness, nausea, irritability, and insomnia).
Rationale :
• The nicotine in cigarette smoke is an addictive ingredient, as other addictive groups such as heroin, morphine, marijuana, amphetamines, alcohol, and other psychotrophores. psychological smoking will cause dependency effects (dependence) that causes the smoker to experience a reaction when dropping substances dropped suddenly.
• Intervention :
Reassure patient that physical withdrawal symptoms from nicotine are temporary.
Rationale :
Psychologically, smoking will cause the dependence effect that causes the smoker to experience the reaction of dropping substances if stopped suddenly.
• Intervention :
Inform patient about nicotine replacement products (e.g., patch, gum, nasal spray, inhaler) to help reduce physical withdrawal symptoms.
Rationale :
Nicotine replacement recommended can divert the patient's desire to smoke.
• Intervention :
Assist patient to develop practical methods to resist cravings (e.g., spend time with nonsmoking friends, frequent places where smoking is not allowed, relaxation exercises).
Rationale :
Change must be prioritized realistically to avoid the uncertainty and helplessness of patients.
• Intervention :
Help patient plan specific coping strategies and resolve problems that result from quitting.
Rationale :
Effective coping strategies and action plans to help change the patient's lifestyle in overcoming his illness
• Intervention :
Follow patient for 2 years after quitting if possible, to provide encouragement.
Rationale :
Positive support motivates patients to maintain non-smoking behaviors.

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


2. NURUL HIDAYATI

pada : 15 September 2017

"NAMA : NURUL HIDAYATI
NIM : 131611133022
KELAS : A1-2016
REVISI NURSING ASSESSMENT
1. Nursing Diagnosis (NANDA)
Risk-prone health behavior related to Smoking
Definition: Impaired ability to modify lifestyle/behaviors in a manner that improves health status.
(Domain 1. Health Promotion. Class 2. Health Management. Code 00188)

2. Nursing Outcomes Classification (NOC)
Aim :
After the nursing action in the time 3 months, expected client can achieve the results criteria:
1) [1600] Adherence Behavior
Definition: Self-initiated actions to promote optimal wellness, recovery, and rehabilitation
Adherence Behavior as evidenced by often demonstrating ability to:
• Outcome:
[160004/IV] Weighs risks/benefits of health behavior (5)
Rationale :
Preventing and minimizing the occurrence of unhealthy behavior.
• Outcome :
[160008/IV] Uses strategies to eliminate unhealthy behavior (5)
Rationale :
A good strategy helps patients leave unhealthy behavior.
• Outcome :
[160011/IV] Performs activities of daily living consistent with energy and tolerance (5)
Rationale :
Activity helps the patient in diverting his desire to smoke.
• Outcome :
[160013/IV] Describes rationale for deviating from a health regimen (5)
Rationale :
Patients know the negative effects of deviations from the health regimen.

2) [1701] Health Beliefs: Perceived Ability to Perform
Definition: Personal conviction that one can carry out a given health behavior
Health Beliefs: Perceived Ability to Perform as evidenced by often showing the belief to:
• Outcome :
[170102/IV] Perception that health behavior requires reasonable effort (5)
Rationale :
Real perception and effort determine the success of healthy behaviors.
• Outcome :
[170107/IV] Confidence related to observation of successful experiences of others (5)
Rationale :
To increase the patient's changing desire in behaving healthily.
• Outcome :
[170108/IV] Confidence in ability to perform health behavior (5)
Rationale :
The confidence within the patient is very important, smoking habits can change if there is a belief of the patient to change.

3) [1602] Health Promoting Behavior
Definition: Personal actions to sustain or increase wellness
Health Promoting Behavior as evidence by often demonstrating ability to:
• Outcome :
[160201/IV] Uses risk avoidance behaviors (5)
Rationale :
Healthy behavior can help prevent the occurrence of the risk of disease.
• Outcome :
[160203/IV] Monitors personal behavior for risks (5)
Rationale :
Good self-control makes it easier for patients to avoid risk factors.
• Outcome :
[160207/IV] Performs healthy behaviors routinely (5)
Rationale :
To prevent and minimize the risk of disease.
• Outcome :
[160216/IV] Uses effective exercise routine (5)
Rationale :
Non-smoking routine exercises allow patients to quit smoking.

3. Nursing Intervention Classification (NIC)
1) [4360] Behavior Modification
Definition: Promotion of a behavior change
• Intervention :
Determine patient’s motivation to change.
Rationale :
Motivation can affect the level of the patient's desire to change. Negative factors that may affect patient changes should be eliminated.
• Intervention :
Assist patient to identify strengths, and reinforce these.
Rationale :
The inner strength of the patient is very important, the smoking habit may change if there is a strength of the patient to change.
• Intervention :
Encourage substitution of undesirable habits with desirable habits.
Rationale :
Support from others (nurses) plays an important role in the process of patient change.
• Intervention :
Break down behavior to be changed into smaller, measurable units of behavior (e.g., stopping smoking: number of cigarettes smoked).
Rational :
Reducing the number of cigarettes consumed helps to eliminate the smoking habit.
• Intervention :
Use specific time periods when measuring units of behavior (e.g., number of cigarettes smoked per day).
Rationale :
Patients are trained not to smoke freely.
• Intervention :
Facilitate family involvement in the modification process, as appropriate.
Rationale :
Patients do not feel alone and positive support from the family can motivate the level of patient desire to quit smoking.

2) [5510] Health Education
Definition: Developing and providing instruction and learning experiences to facilitate voluntary adaptation of behavior conducive to health in individuals, families, groups, or communities
• Intervention :
Identify internal or external factors that may enhance or reduce motivation for healthy behavior.
Rationale :
Negative internal and external factors need to be prevented so that no obstacles affect the patient's therapy process.
• Intervention :
Determine current health knowledge and lifestyle behaviors of individual, family, or target group.
Rationale :
Risks of disease one of which is influenced by the level of knowledge of health and lifestyle behavior of patients.
• Intervention :
Teach strategies that can be used to resist unhealthy behavior or risk taking rather than give advice to avoid or change behavior.
Rationale :
Providing strategies are more effective for patients than for advice.
• Intervention :
Use variety of strategies and intervention points in educational program.
Rationale :
Appropriate primary strategies and interventions can maximize the patient's change process.
• Intervention :
Use lectures to convey the maximum amount of information, when appropriate.
Rationale :
Adding and improving understanding of healthy behaviors.

3) [4490] Smoking Cessation Assistance
Definition: Helping another to stop smoking
• Intervention :
Record current smoking status and smoking history.
Rationale :
Patients with heavy smokers are at risk of other diseases related to the respiratory system.
• Intervention :
Give clear, consistent advice to quit smoking.
Rationale :
Consistent and clear suggestions help convince patients to quit smoking.
• Intervention :
Help patient identify reasons to quit and barriers to quitting.
Rationale :
The less convincing reasons and misconceptions about barrier factors may affect the patient's interest to quit smoking.
• Intervention :
Instruct patient on the physical symptoms of nicotine withdrawal (e.g., headache, dizziness, nausea, irritability, and insomnia).
Rationale :
• The nicotine in cigarette smoke is an addictive ingredient, as other addictive groups such as heroin, morphine, marijuana, amphetamines, alcohol, and other psychotrophores. psychological smoking will cause dependency effects (dependence) that causes the smoker to experience a reaction when dropping substances dropped suddenly.
• Intervention :
Reassure patient that physical withdrawal symptoms from nicotine are temporary.
Rationale :
Psychologically, smoking will cause the dependence effect that causes the smoker to experience the reaction of dropping substances if stopped suddenly.
• Intervention :
Inform patient about nicotine replacement products (e.g., patch, gum, nasal spray, inhaler) to help reduce physical withdrawal symptoms.
Rationale :
Nicotine replacement recommended can divert the patient's desire to smoke.
• Intervention :
Assist patient to develop practical methods to resist cravings (e.g., spend time with nonsmoking friends, frequent places where smoking is not allowed, relaxation exercises).
Rationale :
Change must be prioritized realistically to avoid the uncertainty and helplessness of patients.
• Intervention :
Help patient plan specific coping strategies and resolve problems that result from quitting.
Rationale :
Effective coping strategies and action plans to help change the patient's lifestyle in overcoming his illness
• Intervention :
Follow patient for 2 years after quitting if possible, to provide encouragement.
Rationale :
Positive support motivates patients to maintain non-smoking behaviors.

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


3. ISMI SHONATUL CHOFIFAH

pada : 15 September 2017

"Nama: ISMI SHON'ATUL CHOFIFAH
Nim: 131611133118
Introduction : Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The registered nurse assesses, plans, implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and health outcomes.”
Aim : The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
Definition of terms : Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs completed at the time of admission. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.
Admission Assessment : An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is to be documented on the nursing admission form. Privacy of the patient needs to be considered all times.

Patient history : History of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status and family and social history. For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, APGAR score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation)
General appearance : Assessment of the patient’s overall physical, emotional and behavioral state. Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Neonate and Infant Parent-infant, infant-parent interaction
Body symmetry, spontaneous position and movement
Symmetry and positioning of facial features
Strong cry
Young Child Parent-child, child-parent interaction
Mood and affect
Gross and fine motor skills
Developmental milestones
Appropriate speech
AdolescentMood and affect
Personal hygiene
Communication
Vital sign : Temperayure, Respiratory Rate, Heart Rate, Blood Pressure, Pxygen Saturation, Pain.
Additional measurements : Weigh, Height, Head circumference, Blood sugar level (BSL)
Physical assessment : A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment information includes, but is not limited to: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination.
Shift assessment : At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the assessment flow sheet and further assessments or changes to be documented in the assessment progres. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output, Risk, Wellbeing, Social, Review the history of the patient recorded in the IP summary.
Focused assessment : A detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) is required. This may involve one or more body system.
Neurological system : A comprehensive neurological nursing assessment includes neurological observations, cognitive growth and development, fine and gross motor skills, sensory function, seizures and any other concerns.
Respiratory system : Respiratory illness in children is common and many other conditions may also cause respiratory distress.
Cardiovascular : Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
Gastrointestinal : Assessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness. Ensure stomach is not full at time of assessment as this may induce vomiting.
Renal : An assessment of the renal system includes all aspects of urinary elimination.
Musculosekeletal : A musculoskeletal assessment can be commenced while observing the infant/child in bed or as they move about their room. Be aware that during periods of rapid growth, children complain of normal muscle aches. Throughout this assessment limbs/joints should be compared bilaterally.
Ear/Nose/Throat (ENT) : Assessment of throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children. This includes a thorough examination of the oral cavity. The examination of the throat and mouth is completed last in younger, less cooperative children."


4. Nabila Hanin Lubnatsary

pada : 15 September 2017

"Name: Nabila Hanin Lubnatsary
NIM: 131611133011
Class: A1-2016

Nursing Diagnosis
1.Nursing Diagnosis (NANDA)
Dysfunctional Family Processes related to Insufficient Problem-solving Skills (00063)
Definition: Psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem-solving, and a series of selfperpetuating crises.
(Domain 7. Role Relationship. Class 2. Family Relationships)

2.Nursing Outcome Classification
After the nursing action in the time 2 months, expected client can achieve the results criteria:
1.Family Functioning (2602)
Definition: Capacity of a family to meet the needs of its members during developmental transitions.
Family Functioning as evidenced by often demonstrating ability to:
[260213] Involves members in problem solving (5)
[260221] Members receptive to new ideas (5)
[260222] Members support one another (5)
[260217] Members express commitment to family (5)

2.Family Integrity (2603)
Definition: Capacity of family members to maintain cohesion and emotional bonding.
Family Integrity as evidenced by often demonstrating ability to:
[260315] Members provide support during times of crisis (5)
[260306] Members share thoughts, feelings, interests, concerns (5)
[260307] Members communicate openly and honestly with one another (5)

3.Nursing Intervetion Classification
1.[5020] Conflict Mediation
Definition: Facilitation of constructive dialogue between opposing parties with a goal of resolving disputes in a mutually acceptable manner.
Intervention: Provide a private, neutral setting for conversation.
Rational: A comfortable and neutral place will make the client easier to present opinions, and make the client believe that their secret will not be revealed.
Intervention: Facilitate defining the issues.
Rational: When finding the issues, then the client or family will be easy to make decisions.
Intervention: Assist parties to identify possible solutions to the issues.
Rational: Increase family relationship with involves all of family members.

2.[7140] Family Function
Definition: Promotion of family values, interests, and goals.
Intervention: Listen to family concerns, feelings, and questions.
Rational: Increase family trust in existing care.
Intervention: Answer all questions of family members or assist them to get answers.
Rational: Help reduce family anxiety.
Intervention: Assist family members in identifying and resolving a conflict in values.
Rational: Help family members to communicate openly and honestly with one another.
Intervention: Include family members with patient in decision making about care, when appropriate.
Rational: Increase communication among family members in solving problems.

3.[5370] Role Enhancement
Definition: Assisting a patient, significant other, and/or family to improve relationships by clarifying and supplementing specific role behaviors
Intervention: Assist patient to identify usual role in family.
Rational: Realize their role in family, making them to get closer.
Intervention: Facilitate discussion of role adaptations of family to compensate for ill member’s role changes.
Rational: Help family to take the role that was lost, and help them to support each other.

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


5. Reffy Shania Novianti

pada : 15 September 2017

"NAMA: REFFY SHANIA NOVIANTI
NIM: 131611133010
KELAS: A1-2016
NURSING DIANGNOSIS
1. Nursing Diagnosis (NANDA)
Sexual dysfunction related to insufficient knowledge about sexual function
Definition: A state in which an individual experiences a change in sexual function during the sexual response phases of desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, or inadequate.
(Domain 8. Sexuality. Class 2. Sexual Dysfunction. Code (00059)

2. Nursing Outcomes Classification (NOC)
Aim:
After nursing actions within 3x24 hours, the client is expected to know about sexual function well, with the criteria of the results:
a. Knowing the anatomy and function of sexual anatomy (5)
b. Can reach sexual arousal (5)
c. Can express comfort with sexual expression (5)

Sexual Functioning (0119)
Definition: Integration of physical, socioemotional, and intellectual aspects of sexual expression and performance
Sexual functioning behavior as evidence by often demonstrating ability to:
1. Attains sexual arousal (011901/I) [5]
Rational: with the achievement of sexual desire the basic human needs in sexuality can be fulfilled
2. Refrains from substance use that adversely affects sexual function (011906/I) [5]
Rational: Drug is one of the factors causing sexual dysfunction
3. Expresses comfort with sexual expression (011908/I) [5]
Rational: A sense of comfort can improve sexual quality

Knowledge: Sexual Functioning (1815)
Definition: Extent of understanding conveyed about sexual development and responsible sexual practices
Knowledge: Sexual Functioning as evidenced by often showing the belief to:
1. Sexual anatomy (181501/IV) [5]
Rational: Normal sexual anatomy that will make sexual needs are met optimally.
2. Function of sexual anatomy (181502/IV) [5]
Rational: a well-functioning sexual anatomy function will have a positive and proper impact on sexuality

3. Nursing Intervention Classification
1. Sexual Counseling (5248)
Definition: Use of an interactive process focusing on the need to make adjustments in sexual practice or to enhance coping
with a sexual event or disorder
 Intervention:
Establish a therapeutic relationship, based on trust and respect
Rationale:
A trusting atmosphere enables open and honest communication between patient and nurse
 Intervention:
Inform patient early in the relationship that sexuality is an important part of life and that illness, medications, and stress (or other problems and events patient is experiencing) often alter sexual functioning
Rationale
information will help clients understand the situation and disturbances that happened so that it will prevent or limit the dysfunctional behavior.
 Intervention:
Encourage patient to verbalize fears and to ask questions about sexual functioning
Rationale:
Acceptable therapeutic relationships will allow patients to directly ask, grow and seek help related to sexual problems
 Intervention:
Provide information about sexual functioning, as appropriate
Rationale:
Accurate information will help in changing negative thoughts and attitudes about certain aspects of sexuality and will prevent or limit dysfunctional behavior

2. Teaching: Sexuality (5264)
Definition: Assisting individuals to understand physical and psychosocial dimensions of sexual growth and development
 Intervention:
Explain human anatomy and physiology of the male and female body
Rationale:
An understanding of anatomy and physiology can help reduce sexual problems or dysfunction
 Intervention:
Explain the anatomy and physiology of human reproduction
Rationale:
Improving knowledge and justifying errors concept can facilitate the solution of sexual problems


Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


6. ELIESA RACHMA PUTRI

pada : 15 September 2017

"1.Nursing Diagnosis (NANDA)
Insufficient breast milk
Definition: Low production of maternal breast milk.
(Domain 2. Comfort. Class 1. Physical Commfort. Code 00216)

2.Nursing Outcome Classification
Aim :
After the nursing action in the time 3x24 hours, expected client can achieve the results criteria:
Pain Control
a)Milk ejection (let-down) reflex (100104/IV)
Rationale :
Factors that increase let down reflexes on the client are looking at the baby, hear the baby's voice, kissing baby, thinking of breastfeeding a baby for expenditure of breast milk
b)Fluid intake of mother (10120/IV)
Rationale :
Fluid is an important component in the body, lack of fluids can cause the risk of disease disorders
c)Pumping of breast (100123/IV)
Rationale :
Pumping of breast is a mechanical device that extracts milk from the breasts of a lactating woman Clients can meet the needs of breast milk for baby

3.Nursing Intervention Classification
Pain Management
a)Intervention:
Complete a nutritional assessment, as appropriate
Rationale :
Nutritional assessment is to identify the existence of nutritional deficiencies, nutritional deficiencies can affect the health status of clients
b)Monitor food/fluid ingested and calculate daily caloric intake, as appropriate
Rationale:
Fluid intake is the amount of human body's need for fluids, deficiency of fluids can cause the risk of disease
c)Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements, as appropriates
Rationale:
d)Select nutritional supplements, as appropriate
Rationale:
Provision of nutritional supplements to assist metabolic processes in malnourished clients

Bibliography

•Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

•Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver

•Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


7. Novalia Puspitasary

pada : 15 September 2017

"1. Nursing Diagnosis (NANDA)
Defensive coping related to insufficient self-confidence
Definition: Repeated projection of falsely positive self-evaluation based on a selfprotective pattern that defends against underlying perceived threats to positive self-regard.

(Domain 9. Coping/Stress Tolerance. Class 2. Coping Responses. Code 00071)

2. Nursing Outcome Classification

Aim :
After the nursing actions in 2 months, expected client can achieve the results criteria:
Social Interaction Skills [1502]. Definition: Personal behaviour that promote effective relationships
• Coorporates with others (150203). Rationale: to increase patient experiences and get new skills, such as accept other’s opinions (5)
• Engages others (150212). Rationale: to make patients learn about people characters (5)
• Exhibits trust (150213). Rationale: to make patients learn how to appreciate others and being accepted in society (5)

Social Involvement [1503]. Definition: Social interactions with persons, groups, or organizations
• Participates in leisure activities with others (150311). Rationale: to experience the patient about joining a group to increase patient trust to others (5)
• Interacts with close friends (150301). Rationale: to build trust relationship so the patient have courage in society (5)
• Interacts with neighbors (150302). Rationale: to blend in with patient social life (5)

Identity [1202]. Definition: Distinguishes between self and non-self and characterizes one’s essence
• Challenges negative images of self (120210). Rationale: to understand their self and does not underestimate its self
• Verbalizes trust in self (120213). Rationale: to help patient express their feelings and to train facing other people


3. Nursing Intervention Classification
Self-Efficacy Enhancement [5395]
• Intervention :
Explore individual’s perception of benefits of executing the desired behavior
Rationale :
By exploring patient perception of the patient's desire, will provide more motivation to the patient to make it happen
• Intervention :
Identify barriers to changing behavior
Rationale :
Each person has their own problems and obstacles. Identify barriers will help patient to make problem solving of each barriers
• Intervention :
Assist individual to commit to a plan of action for changing behavior
Rationale :
Commitment will improve patient performance to changing behavior
• Intervention :
Assist individual to commit to a plan of action for changing behavior
Rationale :
Consistency will help patient behavior changing faster than no consistency. A plan help patient to through their problems

Self-Awareness Enhancement [5390]
• Intervention :
Encourage patient to recognize and discuss thoughts and feelings
Rational :
By discussing with the patient will reduce the patient's anxiety as well as solve the patient's problem
• Intervention :
Assist patient to realize that everyone is unique
Rationale :
If the patient has understood that each person is unique, the patient can accept the fact that different is not appropriate for fear. It will make a good progress.
• Intervention :
Assist patient to identify source of motivation
Rationale :
Motivation is a person's impulse to do something. if the patient has found the motivation to change, this will facilitate the patient to do the plans that have been made
• Intervention :
Assist patient to identify positive attributes of self
Rationale :
After identify patient ability. will greatly assist the patient in improving self-confidence because the patient has something to be proud of

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


8. NIMATUSH SHOLEHA

pada : 15 September 2017

"NAME: NI’MATUSH SHOLEHA
NIM: 131611133009
CLASS: A1
Nursing Diagnoses

Activity Intolerance Related To Abnormal heart rate response to activity
Definition: insufficient phyiological or psychological energy to endure or complete required or desired daily activities.
(Domain 4. Activity/Rest, Class 3. Cardiovaskular/Pulmonary Responses, Code 00092)

Nursing Outcomes Classification

Goal: after the act of nursing for 3x24 hours the patient condition is expected to be stable during avtivity.

Expected Outcomes:

Activity Tolerance (0005)
Definition: Physiologic response to energy consuming movements with daily activities
1.Oxygen Saturation of the patient when activity within normal limits (95-100%)(000501/I)(5)
Rational: improve the capacity of activity and improve the function of heart.
2.Pulse Rate of the patient when activity within normal limits (60-100/minute)(000502/I)(5)
Rational: patient can perform activities normally.
3.Respiratory Rate of the patient when activity within normal limits (12-20x/minute)(000503/I)(5)
Rational: patient dose not have dysepnia when performing activities.
4.Systolic Blood Pressure of the patient when activity within normal limits (100-120mmHg)(000504/I)(5)
Rational: patient can perform activitiy regularly to train the heart muscle.
5.Diastolic Blood Pressure of the patient when activity within normal limits (60-60mmHg)(000505/I)(5)
Rational: patient can perform incereased activity to train the heart muscle.
6.Electrokardiogram findings of the patient when activity within normal limits (000506/I)(5)
Rational: patient can know the condition of the heart when activity.

Cardiac Pump Effectiveness (0400)
Definition: Adequacy of blood volume ejected from the left ventricle to support systemic perfusion pressure
1.No deviation abnormal heart sound on the patient (040011/II)(5)
Rational: patient can perform activity regularly.
2.No fatigue on the patient (040016/II)(5)
Rational: patient can recognize fatigue during activity .
3.No dysepnia with mild exertion on the patient (040026/II)(5)
Rational: mild exertion help the patient to prevent dysepnia.
4.No activity intolerance on the patient (040030/II)(5)
Rational: patient can performe activites like everyday.

Nursing Intervention Classification

Activity Therapy (4310)
Definition: rescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s or group’s activity
1.Collaborate with occupational, physical, or recreational therapists in planning and monitoring an activity program, as appropriate.
Rational: assesing each aspect of the patient againts planned activity therapy.
2.Assist patient to choose activities and achievement goals for activities consisten with physical, psychological, and social capabilities.
Rational: prevent overactivity which can aggravate tolerance to activity.
3.Assist with regular physical activities as needed.
Rational: train the strenght and rhythm of the hearth during activity.
4.Monitor emosional, physical, social, and spiritual response to activity.
Rational: knowing any developments that airse immediately after activity therapy.

Cardiac Care: Rehabilitative (4044)
Definition: Limitation of complications for a patient recently experiencing an episode of an imbalance between myocar-dial oxygen supply and demand resulting in impaired cardiac function.
1.Encourage gradual increase in activity when condition is stabilized (i.e., encourage slower proced activities or shorter periods of activity with frequent rest periods following exercise.
Rational: maximize patient activity.
2.Monitor ECG for ST changes, as appropriate.
Rational: the ECG provide an accurate description of the heart condition during activity and rest.
3.Monitor vital sign frequently.
Rational: vital signs are a reference to know the general state of the patient.
4.Monitor the patients activity tolerance.
Rational: assesing the extent of increased activity.

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver


"


9. Novalia Puspitasary

pada : 16 September 2017

"Name : Novalia Puspitasary
NIM : 131611133044
Class : A1-2016
1. Nursing Diagnosis (NANDA)
Defensive coping related to insufficient self-confidence
Definition: Repeated projection of falsely positive self-evaluation based on a selfprotective pattern that defends against underlying perceived threats to positive self-regard.

(Domain 9. Coping/Stress Tolerance. Class 2. Coping Responses. Code 00071)

2. Nursing Outcome Classification

Aim :
After the nursing actions in 2 months, expected client can achieve the results criteria:
Social Interaction Skills [1502]. Definition: Personal behaviour that promote effective relationships
• Coorporates with others (150203). Rationale: to increase patient experiences and get new skills, such as accept other’s opinions (5)
• Engages others (150212). Rationale: to make patients learn about people characters (5)
• Exhibits trust (150213). Rationale: to make patients learn how to appreciate others and being accepted in society (5)

Social Involvement [1503]. Definition: Social interactions with persons, groups, or organizations
• Participates in leisure activities with others (150311). Rationale: to experience the patient about joining a group to increase patient trust to others (5)
• Interacts with close friends (150301). Rationale: to build trust relationship so the patient have courage in society (5)
• Interacts with neighbors (150302). Rationale: to blend in with patient social life (5)

Identity [1202]. Definition: Distinguishes between self and non-self and characterizes one’s essence
• Challenges negative images of self (120210). Rationale: to understand their self and does not underestimate its self
• Verbalizes trust in self (120213). Rationale: to help patient express their feelings and to train facing other people


3. Nursing Intervention Classification
Self-Efficacy Enhancement [5395]
• Intervention :
Explore individual’s perception of benefits of executing the desired behavior
Rationale :
By exploring patient perception of the patient's desire, will provide more motivation to the patient to make it happen
• Intervention :
Identify barriers to changing behavior
Rationale :
Each person has their own problems and obstacles. Identify barriers will help patient to make problem solving of each barriers
• Intervention :
Assist individual to commit to a plan of action for changing behavior
Rationale :
Commitment will improve patient performance to changing behavior
• Intervention :
Assist individual to commit to a plan of action for changing behavior
Rationale :
Consistency will help patient behavior changing faster than no consistency. A plan help patient to through their problems

Self-Awareness Enhancement [5390]
• Intervention :
Encourage patient to recognize and discuss thoughts and feelings
Rational :
By discussing with the patient will reduce the patient's anxiety as well as solve the patient's problem
• Intervention :
Assist patient to realize that everyone is unique
Rationale :
If the patient has understood that each person is unique, the patient can accept the fact that different is not appropriate for fear. It will make a good progress.
• Intervention :
Assist patient to identify source of motivation
Rationale :
Motivation is a person's impulse to do something. if the patient has found the motivation to change, this will facilitate the patient to do the plans that have been made
• Intervention :
Assist patient to identify positive attributes of self
Rationale :
After identify patient ability. will greatly assist the patient in improving self-confidence because the patient has something to be proud of

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


10. Regyana Mutiara Guti

pada : 16 September 2017

"Name : Regyana Mutiara Guti
NIM : 131611133013
Class : A1-2016
Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Diarrhea related to increase in stress level (00013)
Definition: Passage of loose, unformed stools.
(Domain 3. Elimination and Exchange. Class 2. Gastrointestinal Function)

2. Nursing Outcome Classification (NOC)
After nursing actions within 3x24 hours, expected client can achieve the results criteria:
a. Stress Level (1212)
Definition: Severity of manifested physical or mental tension resulting from factors that alter an existing equilibrium.
Stress level as evidenced by often demonstrating ability to:
[121209] Diarrhea (5)
[121213] Restlessness (5)
[121222] Anxiety (5)

b. Anxiety Self-Control (1402)
Definition: Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source.
Anxiety Self-Control as evidenced by often demonstrating ability to:
[140202] Eliminates precursors of anxiety (5)
[140205] Plans coping strategies for stressful situations (5)
[140207] Uses relaxation techniques to reduce anxiety (5)
[140217] Controls anxiety response (5)

c. Fluid Balance (0601)
Definition: Water balance in the intracellular and extracellular compartments of the body
Fluid balance as evidenced by often demonstrating ability to:
[060107] 24-hour intake and output balance (5)
[060109] Stable body weight (5)
[060116] Skin turgor (5)

3. Nursing Intervetion Classification (NIC)
a. [0460] Diarrhea Management
Definition: Management and alleviation of diarrhea

Intervention: Teach patient appropriate use of antidiarrheal medications

Rational: Administration of antidiarrheal drugs will decrease bowel movement

Intervention: Instruct patient/family members to record color, volume, frequency, and consistency of stools

Rational: Determine the loss and fluid requirement to evaluate the effectiveness of nutrition delivery

Intervention: Teach patient stress-reduction techniques, as appropriate

Rational: Improve stress management which will help clients understand the situation and the disturbance they will experience

Intervention: Assist patient in performing stress-reduction techniques

Rational: Parts of the brain and gastrointestinal cells in humans is a similar network, so there is a link between stress and diarrhea

b. [5820] Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger

Intervention: Help patient identify situations that precipitate anxiety

Rational: Diarrhea is caused by stress which is a symptom of an anxiety mind

Intervention: Assist patient to articulate a realistic description of an upcoming event

Rational: Realistic to the upcoming events will help the client to understand the situation and the disturbance he experienced so that will strengthen himself for it

Intervention: Instruct patient on the use of relaxation techniques
Rational: Stress management techniques for example breathing relaxation can help to cope with stressful clients



Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


11. Alfera Novitasari

pada : 16 September 2017

"NAME : ALFERA NOVITASARI
NIM : 131611133029
CLASS : A1 2016

Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Imbalanced nutrition: less than body requirements related to Insufficients dietary intake
Definition : Intake of nutrients insufficient to meet metabolic needs.
(Domain 2. Nutrition. Class 1. Ingestion. Code 00002)

2. Nursing Outcomes Classification (NOC)
Aim : After the nursing action for 3x24 hours is expected the client's nutritional needs can be met with the results criteria,

[1014] Appetite
Definition: Desire to eat
[101401] Desire to eat (5)
[101406] Food intake (5)
[101407] Nutrient intake (5)
[101408] Fluid intake (5)
[101409] Stimulus to eat (5)

[1004] Nutritional Status
Definition : Extent to which nutrients are ingested and absorbed to meet metabolic needs [100401] Nutrient intake (5)
[100402] Food intake (5)
[100408] Fluid intake (5)
[100405] Weight/height ratio (5)

3. Nursing Interventions Classification (NIC)

[1030] Eating Disorder Management
Definition : Prevention and treatment of strict diet restrictions and excessive exercise or the behavior of vomiting food and fluids
Intervention : Teach and support good nutrition concepts with clients (and clients closest to clients)
Rationale : Clients can apply the concept of nutrition well in meeting the nutritional needs
Intervention : Monitor intake / intake and fluid intake appropriately
Rationale : The patient's intake and fluid are met as needed
Intervention : Observe clients during and after feeding / snacks to ensure that sufficient intake / intake of food is achieved and maintained
Rationale : Knowing the nutritional needs of clients has been achieved and make reports to be applied to maintain intake / food intake
Intervention : Monitor client behavior associated with diet, weight gain and weight gain
Rationale : Knowing whether a client's behavior is related to nutrition is less than body needs
Intervention : Assist clients (and those closest to clients appropriately) to review and solve personal problems that contribute to eating disorders
Rationale : The client by itself overcome the eating disorder that is facing and can solve the problem

[1120] Nutrition Therapy
Definition: Feeding and fluids to assist metabolic processes in malnourished or high-risk patients suffering from malnutrition
Intervention : Complete nutritional assessment, as needed
Rationale : An important assessment is conducted to determine the nutritional needs of the patient
Intervention : Monitor food / fluid intake and calculate caloric input per day, as needed
Rationale : The patient's intake and calories are met as needed
Intervention : Determine the number of calories and types of nutrients needed to meet nutritional needs by collaborating with nutritionists, as needed
Rationale : Nutritionists are specialists in nutritional science who can assist in determining the nutrients needed by patients
Intervention : Motivate (patient) to bring home cooked food as needed
Rationale : Increase the appetite of the patient
Intervention : Creating an environment that makes the atmosphere pleasant and soothing
Rationale : Make eating time more calm and fun in an effort to increase the patient's appetite

[1240] Weight Loss Assistance
Definition : Facilitate weight gain
Intervention : Monitor daily caloric intake
Rationale : Caloric intake of patients is met
Intervention : Reviewing the patient's favorite food, whether personal or culturally and religiously recommended
Rationale : Assessment is done to improve the appetite of the patient
Intervention : Serve food attractively
Rationale : Increase patient appetite

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


12. Yuliani Puji Lestari

pada : 16 September 2017

"Name : Yuliani puji lestari
Nim : 131611133003/A1

Nursing Diagnosis :
Accute pain related to Biological injury agent (Code 00132, Domain 12, class 1)
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.
Nursing Outcomes Classification :
After treatment for 2x24 hours pain in client can be resolved
Expected results :
1. Pain Control
Outcomes :
1. Client can describes causal factors continuously (160501/IV). Rationale : the nurse can know the factor and take the next action.
2. Recognizes pain onset (160502/IV). Rationale : nurses can take action to relieve pain when pain comes.
3. Reports pain controlled to the nurse (160511/IV). Rationale : The patient can resolve the pain that appears to himself
4. Uses analgesics as recommended when the pain comes (160505/IV). Rationale : when the client comes home from the hospital and the pain comes, he/she is able to handle it without calling the nurse or returning to the hospital.
Nursing Intervention Classification :
• Pain Management
1. Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors. Rationale : nurses are able to recognize the pain felt by the patient properly and precisely and able to determine the next action.
2. Explore with patient the factors that improve/worsen pain. Rationale : patients and nurses are able to work together to reduce or eliminate pain in patients and break the factors that cause pain
3. Control environmental factors that may influence the patient’s response to discomfort (e.g., room temperature, lighting, noise). Rational : increase patient comfort so that pain is not getting worse.
4. Teach the use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy, acupressure, hot/cold application, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures. Rational : patients can do things that can relieve pain without drugs that can cause side effects, if still possible
• Analgesic Administrasi
1. Check history for drug allergies. Rational : avoiding the occurrence of allergic responses to clients that can endanger life.
2. Collaboration with Doctor in administration of analgesics (mefenamic acid, diclofenac sodium). Rational : analgesic drug serves to reduce and relieve pain
"


13. Regyana Mutiara Guti

pada : 16 September 2017

"Name : Regyana Mutiara Guti
NIM : 131611133013
Class : A1-2016
Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Diarrhea related to increase in stress level (00013)
Definition: Passage of loose, unformed stools.
(Domain 3. Elimination and Exchange. Class 2. Gastrointestinal Function)

2. Nursing Outcome Classification (NOC)
After nursing actions within 3x24 hours, expected client can achieve the results criteria:
a. Stress Level (1212)
Definition: Severity of manifested physical or mental tension resulting from factors that alter an existing equilibrium.
Stress level as evidenced by often demonstrating ability to:

[121209] Diarrhea (5)
Rational: Diarrhea makes the body lose a lot of fluids.

[121213] Restlessness (5)
Rational: Restlessness is the characteristics of stress.

[121218] Inability to concentrate on tasks (5)
Rational: Stress makes less concentration on tasks.

b. Anxiety Self-Control (1402)
Definition: Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source.
Anxiety Self-Control as evidenced by often demonstrating ability to:

[140201] Monitors intensity of anxiety (5)
Rational: Anxiety is one factor of stress

[140205] Plans coping strategies for stressful situations (5)
Rational: The individual makes a strategy and planning to eliminate and overcome stress, by involving careful, cautious, gradual and analytical action.

[140207] Uses relaxation techniques to reduce anxiety (5)
Rational: Reduced anxiety is a way to prevent stress

c. Fluid Balance (0601)
Definition: Water balance in the intracellular and extracellular compartments of the body
Fluid balance as evidenced by often demonstrating ability to:

[060107] 24-hour intake and output balance (5)
Rational: The balance of intake and output prevents the occurrence of diarrhea.

[060109] Stable body weight (5)
Rational: The stability of body weight is one of the factors that affect the balance of body fluids and electrolytes.

3. Nursing Intervetion Classification (NIC)
a. [0460] Diarrhea Management
Definition: Management and alleviation of diarrhea

Intervention: Teach patient appropriate use of antidiarrheal medications

Rational: Administration of antidiarrheal drugs will decrease bowel movement

Intervention: Instruct patient/family members to record color, volume, frequency, and consistency of stools

Rational: Determine the loss and fluid requirement to evaluate the effectiveness of nutrition delivery

Intervention: Teach patient stress-reduction techniques, as appropriate

Rational: Improve stress management which will help clients understand the situation and the disturbance they will experience

Intervention: Assist patient in performing stress-reduction techniques

Rational: Parts of the brain and gastrointestinal cells in humans is a similar network, so there is a link between stress and diarrhea

b. [5820] Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger

Intervention: Help patient identify situations that precipitate anxiety

Rational: Diarrhea is caused by stress which is a symptom of an anxiety mind

Intervention: Assist patient to articulate a realistic description of an upcoming event

Rational: Realistic to the upcoming events will help the client to understand the situation and the disturbance he experienced so that will strengthen himself for it

Intervention: Instruct patient on the use of relaxation techniques
Rational: Stress management techniques for example breathing relaxation can help to cope with stressful clients



Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


14. Regyana Mutiara Guti

pada : 16 September 2017

"Name : Regyana Mutiara Guti
NIM : 131611133013
Class : A1-2016
Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Diarrhea related to increase in stress level (00013)
Definition: Passage of loose, unformed stools.
(Domain 3. Elimination and Exchange. Class 2. Gastrointestinal Function)

2. Nursing Outcome Classification (NOC)
After nursing actions within 3x24 hours, expected client can achieve the results criteria:
a. Stress Level (1212)
Definition: Severity of manifested physical or mental tension resulting from factors that alter an existing equilibrium.
Stress level as evidenced by often demonstrating ability to:

[121209] Diarrhea (5)
Rational: Diarrhea makes the body lose a lot of fluids.

[121213] Restlessness (5)
Rational: Restlessness is the characteristics of stress.

[121218] Inability to concentrate on tasks (5)
Rational: Stress makes less concentration on tasks.

b. Anxiety Self-Control (1402)
Definition: Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source.
Anxiety Self-Control as evidenced by often demonstrating ability to:

[140201] Monitors intensity of anxiety (5)
Rational: Anxiety is one factor of stress

[140205] Plans coping strategies for stressful situations (5)
Rational: The individual makes a strategy and planning to eliminate and overcome stress, by involving careful, cautious, gradual and analytical action.

[140207] Uses relaxation techniques to reduce anxiety (5)
Rational: Reduced anxiety is a way to prevent stress

c. Fluid Balance (0601)
Definition: Water balance in the intracellular and extracellular compartments of the body
Fluid balance as evidenced by often demonstrating ability to:

[060107] 24-hour intake and output balance (5)
Rational: The balance of intake and output prevents the occurrence of diarrhea.

[060109] Stable body weight (5)
Rational: The stability of body weight is one of the factors that affect the balance of body fluids and electrolytes.

3. Nursing Intervetion Classification (NIC)
a. [0460] Diarrhea Management
Definition: Management and alleviation of diarrhea

Intervention: Teach patient appropriate use of antidiarrheal medications

Rational: Administration of antidiarrheal drugs will decrease bowel movement

Intervention: Instruct patient/family members to record color, volume, frequency, and consistency of stools

Rational: Determine the loss and fluid requirement to evaluate the effectiveness of nutrition delivery

Intervention: Teach patient stress-reduction techniques, as appropriate

Rational: Improve stress management which will help clients understand the situation and the disturbance they will experience

Intervention: Assist patient in performing stress-reduction techniques

Rational: Parts of the brain and gastrointestinal cells in humans is a similar network, so there is a link between stress and diarrhea

b. [5820] Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger

Intervention: Help patient identify situations that precipitate anxiety

Rational: Diarrhea is caused by stress which is a symptom of an anxiety mind

Intervention: Assist patient to articulate a realistic description of an upcoming event

Rational: Realistic to the upcoming events will help the client to understand the situation and the disturbance he experienced so that will strengthen himself for it

Intervention: Instruct patient on the use of relaxation techniques
Rational: Stress management techniques for example breathing relaxation can help to cope with stressful clients



Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


15. Putri Aulia Kharismawati

pada : 16 September 2017

"Nama: Putri Aulia Kharismawati
NIM: 131611133027
Class: A1 – 2016
1. Nursing Diagnosis (NANDA)
Hopelessness related to chronic stress
Definition: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.
(Domain 6. Self-Perception. Class 1. Self Concept. Code 00124).

2. Nursing Outcomes Classification
Aim:
After the nursing action in the time 1 months, expected client can achieve the results criteria:
1) [1201] Hope
Definition: Optimism that is personally satisfying and life-supporting.
Hope as evidenced by often demonstrating ability to:
[120101] Expresses expectation of a positive future (5).
Rational: Stress due to pressure and negative thinking, then the patient must to think positive so that the results can be better.
[120106] Expresses optimism (5).
Rational: Can reduce the patient's stress when the patient is confident in making good decisions.
[120107] Expresses belief in self (5).
Rational: The patient will believe in his or her own ability.

2) [1209] Motivation
Definition: Inner urge that moves or prompts an individual to positive action(s).
Motivation as evidenced by often demonstrating ability to:
[120910] Expresses belief in ability to perform action (5).
Rational: Patients will become confident and reduce the level of stress they have.
[120911] Expresses that performance will lead to desired outcome (5).
Rational: confident that the results will be obtained in accordance with the desired.
[120912] Completes tasks (5).
Rational: Task is the part that makes the stress but after completing it, the patient will be relieved and calm.
[120913] Accepts responsibility for actions (5).
Rational: The patient can be responsible for any risks and rewards that will be accepted. after taking action.

3) [1206] Will to live
Definition: Desire, determination, and effort to survive.
Will to live as evidenced by often demonstrating ability to:
[120602] Expression of hope (5).
Rational: Patients will believe with miracles.
[120603] Expression of optimism (5).
Rational: Making patients become confident in taking action.
[120605] Expression of feelings (5).
Rational: The patient's feelings will be calm and well.
[120614] Depression (1).
Rational: The confidence and expectations that make the patient believe.
[120616] Pessimistic thoughts (1).
Rational: There is an optimistic thinking in doing the action.

3. Nursing Intervention Classification
1) [5240] Counseling
Definition: Use of an interactive helping process focusing on the needs, problems, or feelings of the patient and significant others to enhance or support coping, problem solving, and interpersonal relationships.
a. Intervention:
Discourage decision-making when the patient is under severe stress, when possible.
Rationale:
The decision will pose a high risk because it is made based on the desired circumstances.

b. Intervention:
Determine how family behavior affects patient.
Rational:
Families are asked to understand the situation experienced by patients and even families can accompany patients to relax.

c. Intervention:
Assist patient to identify the problem or situation that is causing the distress.
Rationale:
Interventions made are intended to focus more on the cause.

d. Intervention:
Assist patient to list and prioritize all possible alternatives to a problem.
Rationale:
Serves as a reference to overcome which problems are solved first from the cause of perceived stress.

2) [0180] Energy Management
Definition: Regulating energy use to treat or prevent fatigue and optimize function
a. Intervention:
Monitor/record patient’s sleep pattern and number of sleep hours.
Rationale:
The perceived stress will have an impact on sleep disorders, such as insomnia.

b. Intervention:
Encourage an afternoon nap, if appropriate.
Rationale:
Napping will make the body fresh and relaxed so it will be easier to do the next job.

c. Intervention:
Plan activities for periods when the patient has the most energy.
Rationale:
Intended so that patients are not tired and depressed so that the level of stress that has become controlled.

d. Intervention:
Assist patient to schedule rest periods.
Rationale:
Make the patient relax and not tired so that the body condition is maintained.

3) [5310] Hope Insspiration
Definition: Enhancing the belief in one’s capacity to initiate and sustain actions
a. Intervention:
Encourage therapeutic relationships with significant others.
Rationale:
Communication that occurs will make the patient feel relaxed and rest for a moment.

b. Intervention:
Facilitate the patient’s/family’s reliving and savoring past achievements and experiences.
Rationale:
Need to remind their positive thing in itself in order to be motivated to survive.

c. Intervention:
Develop a plan of care that involves degree of goal attainment, moving from simple to more complex goals.
Rationale:
As a motivation in dealing with problems that are owned and expected stress will gradually diminish.

d. Intervention:
Teach reality recognition by surveying the situation and making contingency plans.
Rationale:
Aiming to reduce stress on the client and make hope that may be lived by looking at the situation around.

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015-2017. 1ond ed. Oxford: Wiley Blackwell.

Moorhead,S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


16. Indriani Dwi Wulandari

pada : 16 September 2017

"Name : Indriani Dwi Wulandari
NIM : 131611133034
Class : A1 2016

Nursing Diagnosis(NANDA) :
Impaired Physical Mobility Related to Activity Intolerance
Definition : Limitation in independent, purposeful physical movement of the body
or of one or more extremities
(Domain 4. Activity/Rest, 2. Activity/Exercise, code 00085)

NOC:
Goal : After 2x24 hours of action, it is expected that the patient’s condition improves on strength and recovery of body functions and prevention of deterioration
Expected Outcomes :
Mobility (0208)
Definition : Ability to move purposefully in own environment independently with or without assistive device
• Patient balance in good condition (020801)
Rational : patients can adjust the balance in performing daily activities
• Patients do not experience muscle stiffness or muscle weakness (020803)
Rational : patients can move muscles and move normally
• the patient does not experience joint stiffness or joint weakness (020804)
Rational : patients can move joints and move normally
• Coordination of the patient's body under normal conditions (020809)
Rational : patients can coordinate all parts of the body normally and can move normally
• there is no joint or muscle stiffness and the incoordination of body parts that interfere with patient activity (020814)
Rational : patients can move without disturbance of movement
Ambulation (0200)
Definition : Personal actions to walk from place to place independently with or without assistive device
• no weakness of lower extremities and upper part and no joint or muscle stiffness so that the patient can sustain his weight (020001)
Rational : patients can move normally and can sustain their weight
Coordinated Movement (0212)
Definition : Ability of muscles to work together voluntarily for purposeful movement
• no abnormal motion or movement that can’t be controlled and can do well (021205)
Rational : patients can perform activities normally with good motion control
• the patient's body movements are in good condition and normal (021212)
rational : patients can move their body according to desire and accuracy
Activity tolerance (0005)
Definition : Physiologic response to energy-consuming movements with daily activities
• the patient's upper body moves normally and no joint or muscle weakness occurs (00516)
Rational : the patient can move the upper body and can move well
• the patient's lower body moves normally and no joint or muscle weakness occurs (00517)
Rational : patients can move the lower body and can move well
• the patient's daily activity is not disturbed by the distress caused by intolerant activity (00518)
Rational : patients can perform any activity without any hassles or difficulties

NIC
Body Mechanics Promotion (0140)
Definition : Facilitating the use of posture and movement in daily activities to prevent fatigue and musculoskeletal strain
or injury
• Collaborate with physical therapy in developing a body mechanics
promotion plan, as indicated
Rational : the patient is not wrong in doing the activity or exercise so as to achieve good balance of the body
• Instruct patient to move feet first and then body when turning
to walk from a standing position
Rational : the patient's body becomes more balanced and avoid injury
• Assist patient to select warm-up activities before beginning
exercise or work not done routinely
Rational : the patient's body is more trained and ready to perform daily activities
• Assist patient to perform flexion exercises to facilitate back
mobility, as indicated
Rational : flexion exercises can cause the patient's back to avoid injury
Exercise Promotion (0200)
Definition : Facilitation of regular physical activity to maintain or advance to a higher level of fitness and health
• Perform exercise activities with individual, as appropriate
Rational : the nurse can help if the patient is having difficulty doing the exercises and the nurse can also assess the progress of the patient
• Instruct individual about appropriate type of exercise for level of health, in collaboration with physician and/or exercise
Physiologist
Rational : the risk of injury can be avoided
• Instruct individual about desired frequency, duration, and
intensity of the exercise program
Rational : recovery of the condition for the better and avoid injury
• Monitor individual’s adherence to exercise program/activity
Rational : know the patient's progress and patient compliance
• Monitor individual’s response to exercise program
Rational : knowing the outcome of the exercise program and its impact on the patient as well as the patient's development
Exercise Therapy: Ambulation (0221)
Definition : Promotion and assistance with walking to maintain or restore autonomic and voluntary body functions
during treatment and recovery from illness or injury
• Consult physical therapist about ambulation plan, as needed
Rational : accuracy in providing practice and avoid the risk of injury
• Assist patient to transfer, as needed
Rational : patients avoid injury and patient safety
• Encourage patient to be “up ad lib,” if appropriate
Rational : motivated patients and the spirit to do the exercises
"


17. Septin Srimentari LD

pada : 17 September 2017

"Name: Septin Srimentari Lely D.
NIM: 131611133046
Class: A1-2016
Nursing Diagnosis
1. NANDA
Bathing self-care deficit related to musculoskeletal impairment (00108)
Domain 4. Activity/Rest
Class 5. Self-Care
Definition: Impaired ability to perform or complete bathing activities for self.
2. NOC (Nursing Outcome Classification)
Aims: After the nursing action had implemented in a month, client could take a bath independently with the results criteria:
• Self-Care: Bathing (0301)
Definition: Personal actions to cleanse own body independently with or without assistive device
030101 Gets in and out of bathroom (5)
030102 Gets bath supplies (5)
030109 Bathes in shower (5)
030111 Dries body (5)
• Body Mechanics Performance (1616)
Definition: Personal actions to maintain proper body alignment and to prevent musculoskeletal strain
161601 Uses correct standing posture (5)
161614 Maintains joint flexibility (5)
161615 Uses proper body mechanics (5)
• Skeletal Function (0211)
Definition: Ability of the bones to support the body and facilitate movement
021103 Joint movement (5)
021104 Weight bearing (5)
021106 Joint stability (5)
3. NIC (Nursing Intervention Classification)
• Bathing (1610)
Definition: Cleaning of the body for the purposes of relaxation, cleanliness, and healing.
Intervention and Rational:
 Assist with chair shower, tub bath, bedside bath, standing shower, or sitz bath, as appropriate or desired. If client takes a bath according to correct method and position, they will feel comfortable and clean.
 Bathe in water of a comfortable temperature. It makes client’s body feel relax.
 Monitor functional ability while bathing. Family and nurse know the condition of body’s client and decrease the risk for fall.
• Self-Care Assistance: Bathing/Hygiene (1801)
Definition: Assisting patient to perform personal hygiene
Intervention and Rational:
 Place towels, soap, deodorant, shaving equipment, and other needed accessories at bedside or in bathroom. Client can reach out the hygiene equipment easily.
 Facilitate patient bathing self, as appropriate. The patient of musculoskeletal disorders can take a bath easier, if the facility of bathing is prepared by family or nurse.
 Maintain hygiene rituals. Client always keep on their personal hygiene every day.
 Provide assistance until patient is fully able to assume self-care. The client of musculoskeletal disorders can recover within long period, family and nurse help client take a bath for complete their personal hygiene.
• Fall Prevention (6490)
Definition: Instituting special precautions with patient at risk for injury from falling
Intervention and Rational:
 Use proper technique to transfer patient to and from wheelchair, bed, toilet, and so on. The correct technique makes an intervention for client safety and decreases the risk for fall.
 Provide a nonslip surface in bathtub or shower. If client take a bath in a nonslip surface bathtub without despite of their family or nurse, client will be safety and avoid from the risk for fall.
 Instruct family on importance of handrails for stairs, bathrooms, and walkways. It will help the client of musculoskeletal disorders if they take a bath.

Bibliography
Herdman, T.H. & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. Oxford: Wiley Blackwell

Bulechek, G. M. (2013). NURSING INTERVENTIONS CLASSIFICATION (NIC), SIXTH EDITION. The United States of America: Elsevier.
Moorhead, S. e. (2013). NURSING OUTCOMES CLASSIFICATION (NOC). The Unites States of America: Elseivier.

"


18. Ragil Titi Hatmanti

pada : 17 September 2017

"Name: Ragil Titi Hatmanti
NIM: 131611133012
Class: A1-2016

Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Impaired Gas Exchange related to Ventilatin-perfusion imbalance (00030)
Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
(Domain 3. Elimination and Exchange. Class 4. Respiratory Function)

2. Nursing Outcome Classification
After the nursing action in the time 1x24 hour, expected client can achieve the results criteria:

1. Mechanical Ventilation Response : Adult (0411)
Definition: Alveolar exchange and tissue perfusion are effectively supported by mechanical ventilation
Mechanical Ventilation Response : Adult as evidenced by often demonstrating ability to:
[041102] Increasing respiratory rate (5)
[041109] Client can increase PaO2 (partial pressure of oxygen in arterial blood) (5)
[041117] Ventilation perfusion balance (5)

2. Respiratory Status : Ventilation (0403)
Definition: Movement of air in and o ut of the lungs
Respiratory Status : Ventilation as evidenced by often demonstrating ability to:
[040309] Client didn’t use accesory mucle when taking inspiration (5)
[040310] Client didn’t have adventitious breath sounds anymore (5)
[040302] Respiration rhythm recovery (5)





3. Nursing Intervetion Classification
1. [3320] Oxygen Therapy
Definition: Administration of oxygen and monitoring of its effectiveness.

Intervention: Clearing client’s oral, nasal, and tracheal secretions, as appropriate.
Rational: to give a clearer airway so client can breath easily because several secrets can make the client’s airway become blocked so client can’t do a proper ventilation.

Intervention: Setting up oxygen equipment and administer through a heated, humidified system.
Rational: oxygen equipment is a tool to give additional oxygen for some patient that have problem with ventilation, perfusion, and diffusion. So we have to setting up oxygen equipment and client can breath easily.

Intervention: Consulting with other health care personnel regarding use of
supplemental oxygen during activity and/or sleep.
Rational: to give additional oxygen based on client’s need and make some deal with other health care about the additional oxygen so client can breath easily.

Intervention : Arranging for use of oxygen devices that facilitate mobility and teach patient accordingly.
Rational : to give a better mobility to client with oxygen teraphy so client can still do their activty with oxygen equipment.

2. [3390] Ventilation Assessment
Definition: Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs.

Intervention: Make sure the client’s position is right to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table for patient to lean on)
Rational: elevate the head of the bed or semi fowler position is a half sit position with 15-60 degree to reduce shortness of breath. Semi fowler position used gravity to exapand the lung and reduce pressure of abdomen on diaphargm.

Intervention: Auscultating clients to make sure client’s breath sounds, noting areas of decreased or absent ventilation, and presence of adventitious sounds
Rational: auscultation is one of the physical assessment doing by nurse or doctor in case to hear some sound inside client’s body. The purpose of lung auscultation is to determine the presence of changes in the airway and lung expanding. Nurse can hear the sound of breath and additional sounds in client’s airway by doing auscultation.

Intervention: Administering medications according to doctor’s recipt (e.g., bronchodilators and inhalers) that promote airway patency and gas exchange.
Rational : Bronchodilators are medicine that can widen the surface area of the bronchus and bronchiolus in the lungs so the oxygen uptake can increases. If the airway didn’t have some blockade client can’t ventilate easily.

Intervention : Initiating a program of respiratory muscle strength and/or endurance training with physioterapist, as appropriate.
Rational : Respiratory Muscle Training (RMT) can be defined as a technique that aims to improve function of the respiratory muscles through specific exercises. It consists of a series of exercises, breathing and other, to increase strength and endurance of the respiratory muscles and therefore improve respiration.

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


19. CHUSNUL HOTIMAH

pada : 17 September 2017

"Name : Chusnul Hotimah
NIM : 131611133004
Class : A1-2016

DISCOVERY LEARNING
NURSING DIAGNOSIS
1. Nursing Diagnosis (NANDA)
Ineffective airway clearance related to excessive mucus
Definition : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
(Domain 11. Safety/Protection. Class 2. Physical Injury. Code 00031)
2. Nursing Outcomes Classification (NOC)
After 1x24 hours, client are expected to reach the result criteria :
1. [0410] Respiratory Status: Airway Patency
Defnition: Open, clear tracheobronchial passages for air exchange
a) [041004] Respiratory rate (16-20x/minutes) (5)
b) [041005] Respiratory rhythm (5)
c) [041012] Ability to clear secretions (5)
d) [041007] Adventitious breath sounds (5)
e) [041020] Accumulation of sputum (5)
Rational :
In order to make the patient can breathe normally
2. [1924] Risk Control : Infectious Process
Definition: Personal actions to understand, prevent, eliminate or reduce the threat of acquiring an infection.
a) [192425] Seeks current information about infection control (5)
b) [192420] Monitors changes in general health status (5)
Rational :
a. to avoid patients from infectious diseases during treatment
b. to know the change in patient's health status during treatment
Nursing Interventions Classification (NIC) :
1. [3140] Airway management
Definition: Facilitation of patency of air passages
a) Position patient to maximize ventilation potential
b) Encouraging coughing or suctioning
c) Encourage slow, deep breathing; turning; and coughing
d) Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds
e) Administer bronchodilators, as appropriate
f) Monitor respiratory and oxygenation status, as appropriate
Rational :
a. To maximize patient respiratory ventilation
b. To remove secretions by patient’s airway
c. To remove secret that blocks the patient's airway
d. To know breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds
e. To dilute the secretions that block the airway to be removed
f. To know patient’s respiratory and oxygenation status
2. [3350] Respiratory monitoring
Definition: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
a) Monitor rate, rhythm, depth, and effort of respirations
b) Determine the need for suctioning by auscultating for crackles and rhonchi over major airways
c) Auscultate lung sounds after treatments to note results
Rational :
a. To know rate, rhythm, depth, and effort of respirations
b. To find out whether there should be a suctioning action to clean the patient's airway
c. To know the patient's respiratory status after the treatment
3. [6540] Infection control
Definition: Minimizing the acquisition and transmission of infectious agents
a) Change patient care equipment, per agency protocol
b) Limit the number of visitors, as appropriate
c) Wash hands before and after each patient care activity
d) Wear gloves as mandated by universal precaution policy
e) Teach patient and family members how to avoid infections
Rational :
To avoid the risk of infection for the patient
Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


20. Locita Artika Isti

pada : 17 September 2017

"Name : Locita Artika Isti
NIM : 131611133008
Class : A1 2016
NURSING DIAGNOSIS
1. North American Nursing Diagnosis Association (NANDA) / Nursing Diagnosis
Social Isolation related by inability to engage in satisfying personal relationships
Definition : Alloneness experienced by the individual and perceived as imposed by other and as a negative or threatening state.
(Domain 12. Comfort. Class 3. Sosial comfort . Code 00053)

2. NOC (Nursing Outcomes Classification)
Aim : after performing nursing actions for 3 month, clients are expected to reach the result criteria:
1. [1503] Social Involvement
Definition : Social interactions with persons, groups, or organizations
Social engagement as evidenced by often demonstrating ability to:
[150301] Interacts with close friends (5)
[150302] Interacts with neighbors (5)
[150303] Interacts with family members (5)
[150304] Interacts with members of work group(s) (5)
[150307] Participates in organized activity (5)

2. [1502] Social Interaction Skills
Definition : Personal behaviors that promote effective relationships
The proven social interaction as evidenced by often demonstrating ability to:
[150203] Cooperates with others (5)
[150213] Exhibits trust (5)
[150214] Uses compromise as appropriate (5)

3. [1504]Social Support
Definition : Reliable assistance from others
Social supporting as evidenced by often demonstrating ability to:
[150408] Willingness to call on others for assistance (5)
[150404] Information provided by others (5)
[150406] Confidant relationship(s) (5)

3. NIC (Nursing Intervention Classification)
1. [4310]Terapi aktivitas
Definition : Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s or group’s activity
Intervention :
 Assist patient to explore the personal meaning of usual activity (e.g., work) and favorite leisure activities
Rationale : train with preferred activities to help achieve patient goals
Intervention :
 Encourage creative activities, as appropriate
Rationale : creativity makes patients more confident to gather with people around them
Intervention :
 Assist patient and family to adapt environment to accommodate desired activity Rationale: train clients and families to adapt to the surrounding environment
Intervention :
 Encourage involvement in group activities or therapies, as appropriate
Rationale: help the patient in the process of reducing solitude

2. [4362] Behavior Modification: Social Skills
Definition : Assisting the patient to develop or improve interpersonal social skills
Intervention :
 Assist patient to identify interpersonal problems resulting from social skill deficits
Rationale: can help the patient to be able to know the problem of the lack of skilled patients
Intervention :
 Assist patient to identify desired outcomes for problematic interpersonal relationships or situations
Rationale: the achievement of interpersonal relationships or problematic relationships can provide confidence
Intervention :
 Identify a specific social skill(s) that will be the focus of training
Rationale: patients focus more on exercises on their social skills.
Intervention :
 Assist patient to role play the behavioral steps
Rationale: can take a positive role in behaving
Intervention :
 Provide feedback (e.g., praise or rewards) to patient about performance of targeted social skill(s)
Rationale: motivated to be the best

3. [5100] Socialization Enhancement
Definition : Facilitation of another person’s ability to interact with others
Intervention :
 Promote relationships with persons who have common interests and goals
Rationale: can interact with people the same goals
Intervention :
 Encourage participation in group and/or individual reminiscence activities
Rationale: can establish good relations with the group.
Intervention :
 Use role playing to practice improved communication skills and techniques
Rationale : skills and communication techniques can get better so that you can communicate with others with confidence.
Intervention :
 Encourage patient to change environment, such as going outside for walks or to movies
Rationale : by looking at external situations and conditions can provide motivation to be more active in the external environment
Intervention :
 Encourage small group planning for special activities
Rationale : with small activities can create communication and interaction

4. [5430] Support Group
Definition: Use of a group environment to provide emotional support and health-related information for members
Intervention :
 Create a relaxed, accepting atmosphere
Rationale: creates a sense of comfort for the patient
Intervention :
 Attend to the needs of the group as a whole, as well as the needs of individual members
Rationale : patients have a role in a group


"


21. Locita Artika Isti

pada : 17 September 2017

"Name : Locita Artika Isti
NIM : 131611133008
Class : A1 2016
NURSING DIAGNOSIS
1. North American Nursing Diagnosis Association (NANDA) / Nursing Diagnosis
Social Isolation related by inability to engage in satisfying personal relationships
Definition : Alloneness experienced by the individual and perceived as imposed by other and as a negative or threatening state.
(Domain 12. Comfort. Class 3. Sosial comfort . Code 00053)

2. NOC (Nursing Outcomes Classification)
Aim : after performing nursing actions for 3 month, clients are expected to reach the result criteria:
1. [1503] Social Involvement
Definition : Social interactions with persons, groups, or organizations
Social engagement as evidenced by often demonstrating ability to:
[150301] Interacts with close friends (5)
[150302] Interacts with neighbors (5)
[150303] Interacts with family members (5)
[150304] Interacts with members of work group(s) (5)
[150307] Participates in organized activity (5)

2. [1502] Social Interaction Skills
Definition : Personal behaviors that promote effective relationships
The proven social interaction as evidenced by often demonstrating ability to:
[150203] Cooperates with others (5)
[150213] Exhibits trust (5)
[150214] Uses compromise as appropriate (5)

3. [1504]Social Support
Definition : Reliable assistance from others
Social supporting as evidenced by often demonstrating ability to:
[150408] Willingness to call on others for assistance (5)
[150404] Information provided by others (5)
[150406] Confidant relationship(s) (5)

3. NIC (Nursing Intervention Classification)
1. [4310]Terapi aktivitas
Definition : Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s or group’s activity
Intervention :
 Assist patient to explore the personal meaning of usual activity (e.g., work) and favorite leisure activities
Rationale : train with preferred activities to help achieve patient goals
Intervention :
 Encourage creative activities, as appropriate
Rationale : creativity makes patients more confident to gather with people around them
Intervention :
 Assist patient and family to adapt environment to accommodate desired activity Rationale: train clients and families to adapt to the surrounding environment
Intervention :
 Encourage involvement in group activities or therapies, as appropriate
Rationale: help the patient in the process of reducing solitude

2. [4362] Behavior Modification: Social Skills
Definition : Assisting the patient to develop or improve interpersonal social skills
Intervention :
 Assist patient to identify interpersonal problems resulting from social skill deficits
Rationale: can help the patient to be able to know the problem of the lack of skilled patients
Intervention :
 Assist patient to identify desired outcomes for problematic interpersonal relationships or situations
Rationale: the achievement of interpersonal relationships or problematic relationships can provide confidence
Intervention :
 Identify a specific social skill(s) that will be the focus of training
Rationale: patients focus more on exercises on their social skills.
Intervention :
 Assist patient to role play the behavioral steps
Rationale: can take a positive role in behaving
Intervention :
 Provide feedback (e.g., praise or rewards) to patient about performance of targeted social skill(s)
Rationale: motivated to be the best

3. [5100] Socialization Enhancement
Definition : Facilitation of another person’s ability to interact with others
Intervention :
 Promote relationships with persons who have common interests and goals
Rationale: can interact with people the same goals
Intervention :
 Encourage participation in group and/or individual reminiscence activities
Rationale: can establish good relations with the group.
Intervention :
 Use role playing to practice improved communication skills and techniques
Rationale : skills and communication techniques can get better so that you can communicate with others with confidence.
Intervention :
 Encourage patient to change environment, such as going outside for walks or to movies
Rationale : by looking at external situations and conditions can provide motivation to be more active in the external environment
Intervention :
 Encourage small group planning for special activities
Rationale : with small activities can create communication and interaction

4. [5430] Support Group
Definition: Use of a group environment to provide emotional support and health-related information for members
Intervention :
 Create a relaxed, accepting atmosphere
Rationale: creates a sense of comfort for the patient
Intervention :
 Attend to the needs of the group as a whole, as well as the needs of individual members
Rationale : patients have a role in a group

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver

"


22. Hanum Amalia Zulfa

pada : 17 September 2017

"Nursing Diagnosis
1) Nursing Diagnosis (NANDA)
Risk for adverse reaction to iodinated contrast media
Definition :
Vulnerable to noxious or unintended reaction associated with the use of
iodinated contrast media that can occur within seven days after contrast
agent injection, which may compromise health.
(Domain 11. Safety/Protection, Class 5. Defensive Processes, Code 00218)

2) NOC :
After intervention during 1x24 hours expected to be adequat client engagement mechanism with outcomes:
1. Allergic Response: Localized (0705)
• Headache (70502/IV)
• Localized rash (070513/IV)
Rational :
• The patient's headache is begins to diminish
• The skin rash on the patient begins to diminish

2. Allergic Response: Systemic (0706)
• Generalized itching (070613/IV)
• Increased skin temperature (070618/IV)
Rational :
• The itching is reduced and patients aren’t disturbed by the intense itching
• The temperature on the patient's skin begins to decrease

3) NIC :
Adverse Reaction to Iodinated Contrast Media, Risk for
Defnition: Identifcation, treatment, and prevention of allergic responses to food, medications, insect bites, contrast material, blood, and other substances

1. Allergy Management (6410)
Defnition: Identifcation, treatment, and prevention of allergic responses to food, medications, insect bites, contrast material, blood, and other substances
• Identify known allergies (e.g., medication, food, insect, environmental) and usual reaction
• Notify caregivers and health care providers of known allergies
• Instruct patient/parent to avoid allergic substances, as appropriate
• Provide medication to reduce or minimize an allergic response

Rational :
• To help the nurse know cause of allergies and reactions and to take further action
• In order for service providers and health workers to take action to be taken
• To avoid any allergic continuously
• To reduce the impact of allergies suffered by the patient

2. Risk Identifcation (6610)
Definition: Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
• Review data derived from routine risk assessment measures
• Instruct on risk factors and plan for risk reduction
• Determine compliance with medical and nursing treatments
• Discuss and plan for risk reduction activities in collaboration with individual or group

Rational :
• To know the progress of the risks experienced by the patient
• To reduce the risk factors of prolonged allergies
• To reduce the risk of the patient
• To know what activities can reduce the risk of the patient

3. Medication Management (2380)
Defnition: Facilitation of safe and effective use of prescription and over-the-counter drugs
• Monitor for adverse effects of the drug
• Discard old, discontinued, or contraindicated medications, as appropriate
• Teach patient and/or family members the method of drug administration, as appropriate

Rational :
• To know the incidence of symptoms or allergies of patients when taking drugs
• To avoid exposure to expired drugs
• In order for the patient or family member to be responsive in taking actions incurred from the side effects of the drug


Bibliography
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


23. Sarah Maulida Rahmah

pada : 17 September 2017

"Name: Sarah Maulida Rahmah
NIM: 131611133006
Class A1-2016

Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Hyperthermia related to Dehydration
Definition : Core body temperature above the normal dlurnal range due to fallure of thermoregulation.
(Domain 11. Safety/Protection. Class 6. Thermoregulation Code 00007)

2. Nursing Outcomes Classification (NOC)
After the nursing action in the time 3x24 hours, expected client can achieve the results criteria:
1) [0602] Hydration
Definition: Adequate water in the intracellular and extracellular compartments of the body
Hydration as evidenced by often demonstrating ability to:
[060201] Skin turgor (5)
Rationale: Nurse can know skin turgor to measure the amount of fluid in the patient's body.
[060205] Thirst (5)
Rationale: Patients no feel thirst
[060219] Dark urine (5)
Rationale: The patient's dehydration rate can be determined by urien color
[060227] Body temperature elevation (5)
Rationale: Check body temperature to know the level of hyperthermia

2) [1922] Risk Control: hyperthermia
Definition: Personal actions to understand, prevent, eliminate, or reduce the threat of high body temperature.
Risk Control: Hyperthermia as evidenced by often demonstrating ability to:
[192220] Seeks current information about hyperthermia (5)
Rationale: Patients can find information and knowledge about hypothermia and provide a positive impact on patients
[192221] Identifies risk factors for hyperthermia (5)
Rationale: Patients are able to identify any factors that can cause hypothermia
[192208] Modifies fluid intake as appropriate (5)
Rationale: The fluid intake lasts longer then the patient can be said to be normal

3) [3100] Self-Management: Acute Illness
Definition: Personal actions to manage a reversible illness, its treatment, and to prevent complications.
Self-Management: Acute Illness as evidenced by often demonstrating ability to:
[310019] Adjusts diet during illness (5)
Rationale: Diet can help the patient to balance body fluids
[310015] Monitors medication side effects
Rationale: Patients can monitor the side effects of prescribed medications

3. Nursing Interventions Classification (NIC)
1) [4120] Fluid Management
Definition: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
• Intervention: Monitor vital signs, as appropriate
Rationale: Monitor vital sign can measure and know the normal susceptible vital sign patients
Intervention: Consult physician if signs and symptoms of fluid volume excess persist or worsen
Rationale: To know the right treatment for dehydrating patients
• Intervention: Administer prescribed nasogastric replacement based on output, as appropriate
Rationale: Nasogastric can help patients to meet nutritional needs

2) [3900] Temperature Regulation
Definition: Attaining or maintaining body temperature within a normal range
• Intervention: Monitor temperature at least every 2 hours, as appropriate
Rationale: To know the development of changes in body temperature of the patient
• Intervention: Instruct patient how to prevent heat exhaustion and heat stroke
Rationale: Excessive heat can cause hypothalamic disturbance
• Intervention: Monitor for and report signs and symptoms of hypothermia and hyperthermia
Rationale: Patients can know the signs and symptoms of hyperthermia

3) [3590] Medication Prescribing
Definition: Prescribing medication for a health problem
• Intervention: Evaluate signs and symptoms of current health problem
Rationale: The evaluation of health signs and symptoms to monitor the health status of patients
• Intervention: Consult with physician or pharmacist, as appropriate
Rationale: Consult with your doctor or pharmacist to find out the right medication for the treatment of the patient
• Intervention: Teach patient and/or family members the expected action and side effects of the medication
Rationale: Patients and / or families can know the side effects of medication
Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver."


24. Mudrika Novita Sari

pada : 17 September 2017

"Name: Mudrika Novita Sari
ID Number: 131611133050
Clas: A1-2016

1. Nursing Diagnosis (NANDA)
Impaired verbal communication related to motional disturbance.
Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/
or use a system of symbols
(Domain 5. Perception/Cognition. Class 5. Communication. Code 00051)

2. Nursing Outcome Classification
Aim:
After the nursing action in the time 3x24 hours, expected client can achieve the results criteria:
Communication [0902] Reception, interpretation, and expression of spoken, written and non-verbal messages
• (090202) Use of spoken language (5)
Rationale:
Patient can a language produced by articule sounds and tends to convey on subjective information.
• (090208) Exchanges messages accurately with others (5)
Rationale:
Exchange of messages between patients and nurses will create good communication.

Social Anxiety Level [1216] Severity of irrational avoidance, apprehension, and distress in anticipation of or during social situations
• (121601) Avoidance of social situations (5)
Rationale:
The way patients avoid social situations can reduce their anxiety.
• (121608) Negative self-perceptions of social skills (5)
Rationale:
Patient from the beginning has a negative self-perception it can lead to poor social interaction.

Distorted Thought Self-Control [1403] Self-restraint of disruptions in perception, thought processes, and thought content
• (140303) Refrains from responding to hallucinations or delusions (5)
Rationale:
Hallucinations and delusions change an patient’s experience of environmental stimuli.
• (140314) Exhibits ability to grasp ideas of others (5)
Rationale:
The patient can show confidence with the abilities he has.

3. Nursing Intervention Classification
Art Therapy [4330]
• Intervention:
Provide art supplies appropriate for developmental level and goals for therapy.
Rationale:
Art play vital role in the motor skills and patience of patient.
• Intervention:
Monitor patient’s engagement during the art-making process, including verbal comments and behaviors.
Rationale:
Behavior modification assumes that observable and measurable behaviors are good targets for change.

Presence [5340]
• Intervention:
Verbally communicate empathy or understanding of the patient’s experience.
Rationale:
The burden on the patient can be reduced and find solutions to the problem.
• Intervention:
Offer to remain with patient during initial interactions with others on the unit.
Rationale:
The patient feels comfortable and protected while getting the treatment.

Relocation Stress Reducation [5350]
• Intervention:
Appraise individual’s need/desire for social support.
Rationale:
Social support is very important to assess the needs / wants of patients.
• Intervention:
Assign a “buddy” to the individual to help acquaint them to the new environment.
Rationale:
Patient has friends to help adapt to the new environment.
• Intervention:
Encourage individual and/or family to seek counseling, as appropriate.
Rationale:
Family support can reduce the patient's stress.

Bibliography:
1. Herdman, T. H. and Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions and Classification, 2015-2017. 1ond ed. Oxford: Wiley Blackwell.
2. Moorhead, S., jhonson, M., Maas, M., and Swanson, L. (2013). Nursing Outcones Classification (NOC). 5th ed. United States of America: Mosby Elseiver.
3. Dochteran, J. M., and Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver."


25. Ayu Saadatul Karimah

pada : 17 September 2017

"Nama: Ayu Saadatul Karimah
NIM: 131611133020
Kelas: A-1 2016

Nursing Diagnosis : Ineffective breastfeeding related to insufficient parental knowledge regarding breastfeeding techniques
Definition : difficulty providing milk to an infant or young child directily from the breasts, which may compromise nutritional status of the infant/child.
(Domain 2, Class 1, Code 00104)

Nursing Outcomes Classification (NOC)
[1000] Breastfeeding Establishment: Infant
1. [100001] Proper alignment and latch on [5]
Rational: Appropriate body alignment while breastfeeding will make it easier for the baby to breastfeed, thus maximizing breast milk intake in infants
2. [100013] Correct tongue placement [5]
Rational: The proper placement of the tongue will make the baby suckle optimally &
efficiently and can avoid blisters of the mother's nipple
3. [100014] Suck reflex [5]
Rational: sucking reflexes will make it easier for infants and mothers during breastfeeding because the baby will naturally suck the milk from mother until baby satisfied
4. [100006] Nursing a minimum of 5-10 minutes per breast [5]
Rational: breastfeeding 5-10 minutes per breast to avoid the baby from fatigue
breastfeeding , glut and vomit.

[1800] Knowledge: Breastfeeding
1. [180001] Benefits of breastfeeding [5]
Rational: Parents should know the benefits of breastfeeding, so that parents can meet the intake of breastmilk that should be given to infants according to the age of the baby and can perform proper breastfeeding techniques
2. [180005] Proper technique for attaching infant to the breast [5]
Rational: The right technique to attach the baby to the breast will facilitate the baby during the breastfeeding process and provide a sense of comfort to the mother and baby
3. [180006] Proper infant positioning while nursing [5]
Rational: The appropriate baby position while breastfeeding will provide comfort to the parents and the baby and the baby will feel satisfaction with the breastfeeding process so that breast milk intake can be fulfilled
4. [180009] Proper technique to break infant suction [5]
Rational: Decide suction the baby's at the time of breastfeeding should be with the right technique, because to avoid things that result in injuries such as wounds on the nipple, baby choking, breast milk spilled and others

[1001] Breastfeeding Establihment: Maternal
1. [100101] Comfort of position during nursing [5]
Rational: A comfortable position while breastfeeding will provide a sense of satisfaction and comfort to the baby and mother while breastfeeding
2. [100107] Suction broken before removing infant from breast [5]
Rational: At the time want to move breast, suction must be stopped first, because to avoid baby choking and blisters mother's nipple
3. [100113] Recognition of early hunger cues [5]
Rational: The hunger cue must be recognizable by parents, especially mothers, because to avoid fussy babies and crying, so that babies can be filled with milk intake before the baby cries dan fuss
4. [100118] Satisfaction with breastfeeding process [5]
Rational: If the baby is satisfied with the process of feeding the baby will feel full, no fuss, and infant nutrition from breast milk will be optimal and efficient

Nursing Intervention Classification (NIC)
[6710] Attachment Promotion


1. Encourge mother to breastfeed, if appropriate
Rational: If the mother is breastfeeding properly, the baby will feel satisfaction and comfort during the process of breastfeeding
2. Provide adequate breastfeeding education and support, if appropriate
Rational: Education about breastfeeding will provide benefits to increase knowledge about breastfeeding techniques and benefits to baby's parents
3. Instruct parent on infant cues for feeding (eg.,rooting, sucking on fingers, crying)
Rational: If parents know the signs of baby hungry, then parents will try to calm the baby, one of them by way of breastfeeding
4. Monitor factors that may interfere with optimal attachment (e.g., mental health disturbance in parent, financial strain, parent and child, separation due to medical or surgical intervention, difficulties with breastfeeding, providing foster care and adopting)
Rational: Monitoring factors that disrupt the attachment of the mother and baby will help the nurse to know the cause of the lack of attachment between mother and child, so that the nurse can perform or plan nursing actions to assist the mother in solving the disturbing problems or problems that cause the lack of attachment of mother and child , such as the lack of knowledge of mothers in breastfeeding techniques so that mothers find it difficult to breastfeed

[5244] Lactation Conseling
1. Provide information about psychological ang physiological benefits of breastfeeding
Rational: Provide information on the benefits of breastfeeding to parents, will provide knowledge to parents, so that parents know the benefits of breastfeeding for both physiological and psychological for infants and can provide optimal breastfeeding to infants
2. Assist in ensuring proper infant attachment to breast (i.e., monitor proper infant alignment, areolar grasp and compression, audible swallowing)
Rational: Attachment of the baby to the chest with the right will facilitate the baby at the time of breastfeeding, so that babies and mothers feel comfortable when breastfeeding
3. Instruct on various feeding positions (e.g., cross-cradle, foot-ball hold, and side lying)
Rational: The position varies when the breastfeeding process can help the mother to reduce muscle tension during breastfeeding, because if the mother is breastfeeding in one position will cause fatigue and muscle tension in the body part of the mother
4. Monitor infant’s ability to suck
Rational: Monitor the ability of infants in sucking helps nurses to see the development of the ability of the baby in the breastfeeding process and if the baby is able to suck at the time of breastfeeding then the intake of breastfeeding will be met optimized
5. Demonstrate suck training, if necessary (e.g., use a clean finger to stimulate suck reflex and latch on)
Rational: Sucking exercise will help the baby in the breastfeeding process, so that the baby is able and used to suck milk from the mother's breast during breastfeeding and the baby can suckle optimally and maximally and also can avoid unwanted things like blisters on the nipple, choking, fatigue and others
6. Instruct on how to break suction of nursing infant, if necessary
Rational: Decide on suction precisely when breastfeeding can avoid crying babies, scuffed on mother's nipples, choking, and breast milk spilled
7. Encourage mother to wear a well-fitting, supportive bra
Rational: Clothes that support the process of breastfeeding will facilitate and provide comfort to the mother or baby, so the baby can suckle with satisfaction

Bibliography :

Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


26. Erva Yulinda Maulidiana

pada : 17 September 2017

"Name: Erva Yulinda Maulidiana
NIM: 131611133033

Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Fatigue related to Occupational demands (e.g., shift work, high level of activity, stress) (00093)
Definition: An overwhelming sustained sense of exhaustion and decreased capacity
for physical and mental work at the usual level.
(Domain 4. Activity/Rest. Class 3 . Energy Balance)

2. Nursing Outcomes Classification
After the nursing action in the time.....months, expected client can achieve the result criteria:
- Fatigue Level (0007)
Definition: Severuty of observed or reported prolonged generalized fatigue
[000703] Depressed mood (5)
Rational: In the absence of a sense of depression, the patient can do the occupational casually so as not to experience fatigue

[000707] Decreased motivation (5)
Rational: with motivation given will make the patient more spirit in work and not tired

[000708] Headaches (5)
Rational: by decreasing in headaches which is make fatigue in head or neck, make ADL patient’s keep stabilize.

- Rest (0003)
Definition: Quantity and pattern of dimnished activity for mental and physical rejuvenation
[000301] Amount of rest (5)
Rational: with an uninterrupted amount of rest will keep the patient from exhaustion and can do the occupational well

[000303] Rest quality (5)
Rational: by improving the quality of the patient's rest can reduce the fatigue level so that the work obtained does not feel heavy

[000309] Energy restored after rest (5)
Rational: Rest can help the patient reduce his fatigue level

- Stress Level (1212)
Definition: Severity of manefested physical or mental tension resulting from factors that alter an existing equilibrium
[121201] Increase blood pressure (5)
Rational: reducing stress levels so that blood pressure does not increase

[121206] Tension headache (5)
Rational: by decreasing tension headache make rest quality patient’s better from stress around forehead or the back of the head and neck

[121221] Depression (5)
Rational: if patients have changing mood until depression, it make disturb ADL patient’s such as sleeping, eating, and working

3. Nursing Intervention Classification
- [1850] Skin Surveillance
Definition: Collection an analysis of patient data to maintain skin and mucous membrane integrity

Intervention: Monitor/ record patient’s sleep pattern and number of sleep hours
Rational: maximalize the sleep hours for 8 hours each day make optimal rest and regeneration in blood pressure, dilatation venous, and minimize lactic acid.

Intervention: Instruct patient to monitor sleep patterns
Rational: Good patterns on sleep make good blood pressure in normal range and good for the hearth

Intervention: Assist to eliminate stressful situations before bedtime
Rational: If the patients have stress before they sleep make the sleep patterns disturbed.

- [5820] Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger

Intervention: Provide factual information concerning diagnosis, treatment, and prognosis
Rational: if the patients have the factual information make decrease in anxiety and feel ready if given the treatment by healthcare

Intervention: Provide diversional activities geared toward the reduction of tension
Rational: The choice reduction of tension make patient have optional condition if in stressor

Intervention: Instruct patient on the use of relaxation techniques
Rational: if the patient have in trouble with they stress, patient can use the way who had given by the healthcare
"


27. dinda dhia aldin kholidiyah

pada : 17 September 2017

"Nama: Dinda Dhia Aldin Kholidiyah
NIM: 131611133041
NURSING Diagnosis (NANDA)
Risk for bleeding
Definition
Vulnerable to a decrease in blood volume, which may compromise health.
(domain 11. Safety/Protection. Class 2. Physical Injury. Code 00206)
Nursing Outcomes Classification(NOC)
Aim: After performing the maximum nursing action for 6 hours, the client is expected to achieve the results kreteria:
• (0409) Blood Coagulation
Definition: Extent to which blood clots within normal period of time
Nursing scans are targeted when the indicator is met:
 (040901) Clot formation (5)
Rational: pemebekuan can maximum within 6 hours
 (040913) Hemoglobin (Hgb) (5)
Rationale: after a stop bleeding or blood transfusion, Hbg
 (040909) Plasma fibrinogen (5)
Rationale: bleeding may stop within 6 hours
 (040903) Bruising (5)
Rationale: bruising to the patient is reduced

• (1909) Fall Prevention Behavior
Definition: Personal or family caregiver actions to minimize risk factors that might precipitate falls in the personal environment.
Nursing scans are targeted when the indicator is met:
 (190903) Places barriers to prevent falls (5)
Rational: no more paien falling when standing
 (190915) Uses grab bars as nee(5)
Rational: no more pasie when walking and madiri berjan
 (190914) Uses rubber mats in tub/shower (5)
Rational: no more patients falling while to bathe
 (190922) Provides adequate lighting (5)
Rational: no more psien fall due to lack of lighting


Nursing Intervation Classification
Bleeding, Risk for
Definition
Vulnerable to a decrease in blood volume, which may compromise health.
• Medication Management (2380)
Definition: Facilitation of safe and effective use of prescription and over-the-counter drugs
 Determine what drugs are needed, and administer according to prescriptive authority and/or protocol
Rational: use medicine according to the type of hemorrhage as in psien labor using hemostatic drug to stop the bleeding, according to the prescription of doctor

 Teach patient and/or family members the method of drug administration, as appropriate
Rational: to teach the patient can be independent to achieve health drajat
 Monitor patient for the therapeutic effect of the medication
Response: know the desired effect of continuing intervention or modifying nursing interventions.
 Monitor for signs and symptoms of drug toxicity
Rational: know the effects of toxicity as early as possible to arrange other drug intervention and avoid the occurrence of other disorders due to expired drugs

• Risk Identification (6610)
Definition:
Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
 Review past health history and documents for evidence of existing or previous medical and nursing diagnoses and treatments
Rational: utuk mengetahuai treatment and intervention in accordance with riyat previous illness
 Review data derived from routine risk assessment measures
Rationale: know the cause of the risk incurred to carry out the appropriate intervention
 Determine availability and quality of resources (e.g., psychological, financial, education level, family and other social, and community)
Rational: provide facilities to reduce the risk of falling in accordance with the patient's financial
 Identify biological, environmental, and behavioral risks and their interrelationships
Rational: to reduce the risk caused.


"


28. dinda dhia aldin kholidiyah

pada : 17 September 2017

"Nama: Dinda Dhia Aldin Kholidiyah
NIM: 131611133041
NURSING Diagnosis (NANDA)
Risk for bleeding
Definition
Vulnerable to a decrease in blood volume, which may compromise health.
(domain 11. Safety/Protection. Class 2. Physical Injury. Code 00206)
Nursing Outcomes Classification(NOC)
Aim: After performing the maximum nursing action for 6 hours, the client is expected to achieve the results kreteria:
• (0409) Blood Coagulation
Definition: Extent to which blood clots within normal period of time
Nursing scans are targeted when the indicator is met:
 (040901) Clot formation (5)
Rational: pemebekuan can maximum within 6 hours
 (040913) Hemoglobin (Hgb) (5)
Rationale: after a stop bleeding or blood transfusion, Hbg
 (040909) Plasma fibrinogen (5)
Rationale: bleeding may stop within 6 hours
 (040903) Bruising (5)
Rationale: bruising to the patient is reduced

• (1909) Fall Prevention Behavior
Definition: Personal or family caregiver actions to minimize risk factors that might precipitate falls in the personal environment.
Nursing scans are targeted when the indicator is met:
 (190903) Places barriers to prevent falls (5)
Rational: no more paien falling when standing
 (190915) Uses grab bars as nee(5)
Rational: no more pasie when walking and madiri berjan
 (190914) Uses rubber mats in tub/shower (5)
Rational: no more patients falling while to bathe
 (190922) Provides adequate lighting (5)
Rational: no more psien fall due to lack of lighting


Nursing Intervation Classification
Bleeding, Risk for
Definition
Vulnerable to a decrease in blood volume, which may compromise health.
• Medication Management (2380)
Definition: Facilitation of safe and effective use of prescription and over-the-counter drugs
 Determine what drugs are needed, and administer according to prescriptive authority and/or protocol
Rational: use medicine according to the type of hemorrhage as in psien labor using hemostatic drug to stop the bleeding, according to the prescription of doctor

 Teach patient and/or family members the method of drug administration, as appropriate
Rational: to teach the patient can be independent to achieve health drajat
 Monitor patient for the therapeutic effect of the medication
Response: know the desired effect of continuing intervention or modifying nursing interventions.
 Monitor for signs and symptoms of drug toxicity
Rational: know the effects of toxicity as early as possible to arrange other drug intervention and avoid the occurrence of other disorders due to expired drugs

• Risk Identification (6610)
Definition:
Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
 Review past health history and documents for evidence of existing or previous medical and nursing diagnoses and treatments
Rational: utuk mengetahuai treatment and intervention in accordance with riyat previous illness
 Review data derived from routine risk assessment measures
Rationale: know the cause of the risk incurred to carry out the appropriate intervention
 Determine availability and quality of resources (e.g., psychological, financial, education level, family and other social, and community)
Rational: provide facilities to reduce the risk of falling in accordance with the patient's financial
 Identify biological, environmental, and behavioral risks and their interrelationships
Rational: to reduce the risk caused.

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"

"


29. Hanum Amalia Zulfa

pada : 17 September 2017

"NAMA : HANUM AMALIA ZULFA
NIM : 131611133040
CLASS : A1-2016


NURSING DIAGNOSIS
1) Nursing Diagnosis (NANDA)
Risk for adverse reaction to iodinated contrast media
Definition :
Vulnerable to noxious or unintended reaction associated with the use of
iodinated contrast media that can occur within seven days after contrast
agent injection, which may compromise health.
(Domain 11. Safety/Protection, Class 5. Defensive Processes, Code 00218)

2) Nursing Outcome Classification (NOC) :
After intervention during 1x24 hours expected to be adequat client engagement mechanism with outcomes:
1. Allergic Response: Localized (0705)
• Headache (70502/IV)
• Localized rash (070513/IV)
Rational :
• The patient's headache is begins to diminish
• The skin rash on the patient begins to diminish

2. Allergic Response: Systemic (0706)
• Generalized itching (070613/IV)
• Increased skin temperature (070618/IV)
Rational :
• The itching is reduced and patients aren’t disturbed by the intense itching
• The temperature on the patient's skin begins to decrease

3) Nursing Intervetion Classification (NIC) :
Adverse Reaction to Iodinated Contrast Media, Risk for
Defnition: Identifcation, treatment, and prevention of allergic responses to food, medications, insect bites, contrast material, blood, and other substances

1. Allergy Management (6410)
Defnition: Identifcation, treatment, and prevention of allergic responses to food, medications, insect bites, contrast material, blood, and other substances
• Identify known allergies (e.g., medication, food, insect, environmental) and usual reaction
• Notify caregivers and health care providers of known allergies
• Instruct patient/parent to avoid allergic substances, as appropriate
• Provide medication to reduce or minimize an allergic response

Rational :
• To help the nurse know cause of allergies and reactions and to take further action
• In order for service providers and health workers to take action to be taken
• To avoid any allergic continuously
• To reduce the impact of allergies suffered by the patient

2. Risk Identifcation (6610)
Definition: Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
• Review data derived from routine risk assessment measures
• Instruct on risk factors and plan for risk reduction
• Determine compliance with medical and nursing treatments
• Discuss and plan for risk reduction activities in collaboration with individual or group

Rational :
• To know the progress of the risks experienced by the patient
• To reduce the risk factors of prolonged allergies
• To reduce the risk of the patient
• To know what activities can reduce the risk of the patient

3. Medication Management (2380)
Defnition: Facilitation of safe and effective use of prescription and over-the-counter drugs
• Monitor for adverse effects of the drug
• Discard old, discontinued, or contraindicated medications, as appropriate
• Teach patient and/or family members the method of drug administration, as appropriate

Rational :
• To know the incidence of symptoms or allergies of patients when taking drugs
• To avoid exposure to expired drugs
• In order for the patient or family member to be responsive in taking actions incurred from the side effects of the drug


Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


30. CUCU EKA PERTIWI

pada : 17 September 2017

"NAME : CUCU EKA PERTIWI
NIM : 131611133007
CLASS: A1-2016

NURSING DIAGNOSIS

1. Nursing Diagnosis (NANDA)
Disturbed sleep pattern related to Environmental barrier (e.g., ambient noise, daylight/ darkness exposure, ambient temperature/humidity, unfamiliar setting)
Definition: Time-limited interruptions of sleep amount and quality due to external factors.
(Domain 4. Activity/Rest, Class 1. Sleep/Rest. Code 000198)

2. Nursing Outcomes Classification (NOC)
Aim:
After the nursing action within 3x24 hours, the client is expected to have the quantity and quality of sleep time well, with the criteria of the results:
a. Can have good sleep quality (5)
b. Successfully sleep consistently from start to finish at night (5)
c. Getting a conducive environment during sleep (5)

[0004] Sleep
Definition: Natural periodic suspension of consciousness during which the body is restored.
Sleep as evidence by often demonstrating ability to:
[000403] Have an undisturbed sleep pattern (5)
Rational: by having a sleep pattern that can not be made minimum needs
[000404] Achieving good sleep quality (5)
Rational: have a good sleep quality can achieve uninterrupted sleep patterns.
[000418] Makes sleep consistently from start to finish at night (5)
Rational: having a sleep can not be made of quality.

[2009] Comfort Status: Environment
Definition: Environmental ease, comfort, and safety of surroundings
Comfort status : Environment as evidenced by often demonstrating ability to:
[200903] Conducting a conducive environment during sleep (5)
Rational : get a conducive environment while sleeping
[200902] The result of appropriate room temperature during sleep (5)
Rational: the appropriate room temperature during sleep is comfortable and quality sleep.


3. Nursing Intervention Classification (NIC)
1) [6480] Environmental Management
Definition: Manipulation of the patient’s surroundings for therapeutic benefit, sensory
appeal, and psychological well-being
• Intervention:
Create a safe environment for patients.
Rational: a safe environment can provide a sense of comfort in patients so as to prevent disturbed sleep patterns
• Intervention
Avoids the patient from unnecessary exposure to airflow, too hot or too cold.
Rational: environment that is too hot or too cold and not appropriate can make patients uncomfortable.
• Intervention:
controlling or preventing unwanted or excessive noise, if possible.
Rational: excessive noise and unwanted patients can make patients disturbed so as to have poor sleep quality

2) [6482] Environmental Management: Comfort
Definition: Manipulation of the patient’s surroundings for promotion of optimal comfort
• Intervention:
Create a calm and supportive environment
Rational: a conducive environment atmosphere during sleep can provide a sense of comfort and make patients uninterrupted during sleep
• Intervention:
Adjust the lighting to meet the needs of individual activities, avoid direct light on the eyes
Rational: the lighting is too bright and fixed directly on the eyes can create pain and discomfort so that makes the patient disturbed

3) [1850] Sleep Enhancement
Definition : Facilitation of regular sleep/wake cycles
• Intervention :
Adjust the environment (eg light, noise, temperature, mattress and bedding) to improve sleep
Rational: environmental adjustment can help patients in improving sleep and achieve good sleep quality
• Intervention
Educate patients and people closest to the factors that contribute to the interruption of sleep patterns
Rational: information or knowledge about factors that can cause sleep disorder will help in changing the thoughts and attitudes of the patient and family to prevent things that may interfere with sleep patterns.


Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NIC). 6th ed. America: Mosby Elseiver"
"


31. Desi Choiriyani

pada : 17 September 2017

"NAME : DESI CHOIRIYANI
NIM : 131611133021
CLASS : A1-2016
Nursing Diagnoses :
Impaired urinary elimination related to urinary incontinence
Definition : Dysfunction in urine elimination
(Domain 3. Elimination and Exchange, Class1. Urinary function, code 00016)
Nursing Outcomes Classification(NOC) :
Goal : After intervention for 3x24 hours the client is expected not to experience urinary incontinence.
Expected outcome :
1.Urinary Elimination (0503)
Definition : Collection and discharge of urine
•Elimination pattern (050301/II) (5)
Rational : Assessing the client's elimination pattern
•Urine amount (050303/II) (5)
Rational : The amount of urine issued by the client is used to determine the fluid imbalance
•Urine Color (050304/II) (5)
Rational : The client's urine color check is used to determine the impaired urinary elimination of the client
•Fluid intake (050307/II) (5)
Rational : Knowing the fluid intake on the client's body
•Urinary Frequency (050331/II) (5)
Rational : Knowing the client's urine output frequency
2.Urinary Continence (0502)
Definition : Control of elimination of urine from the bladder
•Maintains predictable pattern of voiding (050202/II) (5)
Rational : Make clients regular in urination
•Responds to urge in timely manner (050203/II) (5)
Rational :The client no longer has impaired urinary elimination
•Voids >150 milliliters each time (050206/II) (5)
Rational : Clients are able to voids > 150 milliliters each time
3.Kidney Function (0504)
Definition : Ability of the kidneys to regulate body fluids, filter blood and eliminate wate products through the formation of urine
•8-hour urine output (050424/II) (5)
Rational : Knowing the client's urine output for 8 hours
•24-hour intake and output balance (050402/II) (5)
Rational : Knowing the balance of client intake and fluid output for 24 hours
Nursing Intervention Classification (NIC) :
1.Fluid Management (4120)
Definition : Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels.
•Maintain accurate intake and output record
Rational : Achieving balance Intake and client fluid output
•Monitor laboratory results relevant to fluid retention (e.g., increased specific gravity, increased BUN, decreased hematocrit, and increased urine osmolality levels)
Rational : Knowing the change of client's fluid retention rate
•Give fluids as appropriate
Rational :To comply the client's fluid balance
2.Fluid Monitoring (4130)
Definition : Collection and analysis of patient data to regulate fluid balance
•Determine history of amount and type of fluid intake and elimination habits
Rational : Clients can balance the need for fluid intake and can perform regular elimination habits
•Monitor intake and output
Rational : Knowing the fluid balance of the client
•Record incontinence episodes in patients requiring accurate intake and output
Rational : Knowing the need for client fluid intake and output
•Monitor color, quantity, and specific gravity of urine
Rational : Assessing client's liquid balance
•Consult physician for urine output less than 0.5ml/kg/hr or adult fluid intake less than 2000 in 24 hours, as appropriate
Rational : Knowing the clients impaired in the imbalance of intake and fluid output
3.Prompted Voiding (0640)
Definition : Promotion of urinary continence through the use of timed verbal toileting reminders and positive social feedback for successful toileting
•Determine ability to recognize urge to void
Rational : The client is able to know the urge to voiding
•Establish interval of initial prompted voiding schedule, based upon voiding pattern
Rational : The client knows the voiding schedule corresponds to the urinary expenditure pattern
•Establish beginning and ending time for the prompted voiding schedule if not for 24 hours
Rational : Help clients to beginning and ending voiding if clients not voiding for 24 hours
•Approach within 15 minutes of prescribed prompted voiding intervals
Rational : Help clients to voiding

Bibliography :
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


32. KUSNUL OKTANIA

pada : 17 September 2017

"NAME : KUSNUL OKTANIA
NIM : 131611133043
CLASS : A1/2016
Nursing Diagnoses
Risk for injury Related to Alteration in psychomotor functioning
Definition: Vulnerable to physical damage due to environmental conditions interacting with the indiviual’s adaptive and defensive resources, which may compromise health
(Domain 11. Safety/Protection, Class 2. Physical Injury, Code 00035)
Nursing Outcomes Classification (NOC)
Goal: After an intervention of 3x24 hours is expected the patient can minimize the occurrence of risk of injury to the outcome criteria:
Falls Occurrence (1912)
Definition: Number of times an individual falls
1.Minimize fall while standing (191201/I)(5)
Rational: The incidence of falling experienced by the patient can exacerbate the risk of injury
2.Reducing fall while walking (191202/I)(5)
Rational: The client shows the effort to avoid injury (fall) or injury
3.Prevent fall from bed (191204/I)(5)
Rational: Prevents the patient from the risk of injury
4.Minimize fall climbing steps (191206/I)(5)
Rational: Helping healthcare workers reduce the risk of injury to the patient from the habits and causes factors
Nursing Interventions Classification (NIC)
Exercise Promotion (0200)
Definition: Facilitation of regular physical activity to maintain or advance to a higher level of fitness and health
1.Determine individual’s motivation to begin/continue exercise program
Rational: Motivation can affect the level of the patient's desire to change. Negative factors that may affect patient changes should be eliminated.
2.Assist individual to set short-term and long-term goals for the exercise program
Rational:
3.Perform exercise activities with individual, as appropriate
Rational: Proper exercise activity can maximize the patient's treatment process from impaired psychomotor function
4.Include family/caregivers in planning and maintaining the exercise program
Rational: Patients do not feel alone and get positive support from the family can motivate the level of desire of the patient to do the exercise program
Fall prevention (6490)
Definition: Instituting special precautions with patient at risk for injury from falling
1.Identify behaviors and factors that affect risk of falls
Rational: To inform the nurse if the patient is fell or not
2.Monitor gait, balance, and fatigue level with ambulation
Rational: knowing any developments that airse immediately after exercise program
3.Teach patient how to fall as to minimize injury
Rational: Education to patients and families should be done to minimize injury
Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


33. Gita Shella Madjid

pada : 17 September 2017

"NAMA : Gita Shella Madjid
NIM : 131611133049
KELAS : A1 - 2016

NURSING DIAGNOSIS
1. Nursing Diagnosis (NANDA)
Grieving related to death of significant other
Definition : A normal complex process that includes emotional, physical, spiritual, social and intellectual responses and behaviours by which individuals, families and communities incorporate an actual, anticipated or perceived loss into their daily lives.
(Domain 9. Coping/Stress Tolerance, Class 2. Coping Responses, Code. 00136)

2. Nursing Outsomes Classification
Aim : After the nursing action in the time 3x24 hours, expected client can achieve the results criteria :
1) [2703] Community Grief Response
Definition : Community response to member grief that involved loss of life or property
Community Grief Response as evidenced by often demonstrating ability to :
 [270303] Cooperation among members (4)
 [270309] Availability of humanitarian aid (4)
 [270316] Psychosocial support systems utilization (4)
 [270319] Availability of coping groups (5)

2) [2608] Family Resiliency
Definition : Capacity of a family to positively adapt and function following a significant adversity or crisis
Family Resiliency as evidenced by often demonstrating ability to :
 [260806] Expresses confidence in overcoming adversities (4)
 [260809] Supports members (4)
 [260816] Shares humors (4)
 [260818] Maintains usual family routines (4)
 [260819] Prepares for future challenges (4)

3) [1304] Grief Resolution
Definiton : Personal actions to adjust thoughts, feelings and behaviors to actual or impending loss
Grief Resolution as evidenced by often demonstrating ability to :
 [130402] Expresses spiritual beliefs about death (3)
 [130404] Verbalizes acceptance of loss (3)
 [130417] Seeks social support (4)
 [130418] Shares loss with significant others (4)
 [130420] Progresses through stages of grief (3)
 [130421] Expresses positive expectations about the future (3)

3. Nursing Intervention Classification
1) [5230] Coping Enhancement
Definition : Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere
with meeting life demands and roles
• Intervention : Assist the patient to solve problems in a constructive manner
Rasional : Help in a constructive way can provide social support to patients
• Intervention : Encaurage patient to identify a realistic description of change in role
Rasional : Describe realistically to express expectations in future roles
• Intervention : Provide factual information concerning diagnosis, tratment, and prognosis
Rasional : Actual information is needed by the patient to face future challenges
• Intervention : Evaluate the patient’s decision-making ability
Rasional : By conducting patient evaluation it is expected that the patient can accept the condition of the loss experienced
• Intervention : Introduce patient to persons (or groups) who have successfully undergone the sam experience
Rasional : Sharing the same experience is expected to form köping groups
• Intervention : Instruct the patient on the use of relaxation techniques, as needed
Rasional : Relaxation is done as needed in order to provide psychosocial support to patients
• Intervention : Assist the patient to grieve and work through the losses of chronic illness and/or disability, if appropriate
Rasional : Provide holistic services to help patients through the grief phase

2) [5270] Emotional Support
Definition : Provision of reassurance, acceptance and encouragement during times of stress
• Intervention : Discuss with the patient the emotional experience
Rasional : The patient can convey emotional experiences to his nearest person to share his feelings of loss
• Intervention : Embrace or touch patient supportively
Rasional : Holistic and teraupetik treatment can provide support to family members, including patients to remain tough during the period of grief
• Intervention : Listen to/ encourage expression of feelings and beliefs
Rasional : Expression shown can mean that the patient has confidence in overcoming difficulties that are facing
• Intervention : Identify the function that anger, frustration and rage serve for the patient
Rasional : Patients can re-express in a state of decline so that the patient is expected to move to look at the future after experiencing difficulties
• Intervention : Provide assistance in decision making
Rasional : The decision is expected that the patient receives the sense of loss of the nearest person and try sincerely
• Intervention : Refer for counseling, as appropriate
Rasional : Patients are expected to be insoluble in grief so that patients can counsel to share jokes or mental developments that are felt after several days of grief

3) [5340] Presence
Definition : Being with another, both physically and psychologically, during times of need
• Intervenstion : Demonstrate accepting attitude
Rasional : The attitude shown by the patient reflects that the patient claims to have accepted the reality of the grief experienced
• Intervenstion : Help patient to realize that you are available, but do not reinforce dependent behaviors
Rasional : A nurse is ready to teach independence to the patients to avoid dependence so that the realization of humanitarian aid
• Intervenstion : Reassure and assist parents in their supportive role with their child
Rasional : It is important that the parent role in providing support to the patient, so that both nurses and parents can work together

4) [5420] Spiritual Support
Definition : Assiting the patient to feel balance and connection with a greater power
• Intervention : Use theraupetic communications to astablish trust and empathetic caring
Rasional : Communicating teraupetik can provide social support to patients in the face of grief due to sorrow
• Intervention : Encourage individual to review past life and focus on events and relationships with provided spiritual strength and support
Rasional : Support and spiritual strength is given in order that the patient can sincerely and run the routine as usual
• Intervention : Encourage life review through reminiscence
Rasional : Patients are allowed to remember their past so that patients can overcome the problem to be strong in facing challenges in the future
• Intervention : Encourage participants in interactions with family members, friends and others
Rasional : The participation of all those close to the patient has the opportunity to support the patient for achieving the work
• Intervention : Teach methods of relaxation, mediation and guided imagery
Rasional : in the period of grief the patient has been too late in the sadness so hopefully the patient can take advantage of the psychosocial support system available
• Intervention : Share own beliefs about meaning and purpose, as appropriate
Rasional : Share and exchange information on her beliefs so that the patient can express a spiritual perspective on life

Bibliography
Gloria M. Bulechek, H. K. (2013). Nursing Interventions Classification (NIC) (Sixth Edition ed.). Amerika: MOSBY ELSEVIER
Sue Moorhead, M. J. (2013). Nursing Outcomes Classification (NOC) (Fifth Edition ed.). Amerika: MOSBY ELSEVIER
T. Heather Herdman, P. R. (Ed.). (2014). NANDA International Nursing Diagnoses : Definitions and Classification, 2015-2017 (Tenth Edition ed.). Oxford: WILEY Blackwell
"


34. Sekar Ayu Pitaloka

pada : 18 September 2017

"NAMA : SEKAR AYU PITALOKA
NIM : 131611133025
KELAS : A1-2016
NURSING DIANGNOSIS
1. Nursing Diagnosis (NANDA)
Impaired skin integrity related to alteration in sensation (resulting from spinal cord injury, diabetes mellitus, etc.)
Definition : Altered epidermis and/or dermis.
(Domain 11. Safety/Protection. Class 2. Physical Injury. Code 00046)

2. Nursing Outcomes Classification (NOC)
Aim :
After nursing actions within 3×24 hours, expected a alteration in sensation of client can be reduced, with the result criteria :
a. Can maintain client sensation (5)
b. Can maintain the client’s normal skin texture (5)
c. Normal client skin integrity (5)
d. Nothing lessions on the client’s skin (5)
Tissue Integrity : Skin & Mocous Membranes (1101)
Definition: Structural intactness and normal physiological function of skin and mucous membranes.
1. Sensation (110102/II) [5]
2. Texture (110108/II) [5]
3. Skin integrity (110113/II) [5]
4. Skin lesions (110115/II) [5]

3. Nursing Intervention Classification (NIC)
1. Skin Surveillance (3590)
Definition : Collection and analysis of patient data to maintain skin and mucous membrane integrity.
• Monitor skin color and temperature
Rational : Redness and high temperature on the wound, indicating an infection.
• Monitor skin for rashes and abrasions  
Rational : Rashes and abrasions can create new injuries to the patient.
• Document skin or mucous membrane changes
Rational : The existence of changes in the skin and mucous membranes indicated a impaired of skin integrity.
• Instruct family member/caregiver about signs of skin breakdown, as appropriate  
Rational : Client knowledge of signs of skin damage can reduce the risk of skin damage and help monitor the patient’s skin condition.
2. Pressure Ulcer Prevention (3540)
Definition : Prevention of pressure ulcers for an individual at high risk for developing them.
• Document skin status on admission and daily
Rational : Knowing the development on the skin of the patient can facilitate the nurse in giving the next patient treatment action.
• Position with pillow to elevate pressure point off the bed
Rational : position the pillow on the heel and elbow can hold the client body so that it can reduce the risk of abrasions and injuries.

3. Infection Protection (6550)
Definition : Prevention and early detection of infection in a patient at risk.
• Monitor for systemic and localized signs and symptoms of infection
Rational : Skin tissue damage can be caused by both systemic and localized infection.
• Teach patient and family members how to avoid infections
Rational : Reducing the risk of infection can be done by giving knowledge about prevention or avoid of infection to patient and patient’s family.
• Promote sufficient nutritional intake
Rational : The compliance of nutrients can improve the sensation of the patient.

Bibliography
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NIC). 6th ed. America: Mosby Elseiver.
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.


"


35. Listya Ernissa Mardha

pada : 18 September 2017

"Name : Listya Ernissa Mardha
NIM : 131611133017
Class : A1-2016
Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Deficient fluid volume related to Active fluid volume loss
(00063)
Definition:
Decreased intravascular, interstitial, and/or intracellular fluid. This refers
to dehydration, water loss alone without change in sodium.
(Domain 2. Nutrition Class 5. Hydration)

2. Nursing Outcome Classification
Definition: At risk for experiencing decreased intravascular, interstitial, and/or intracellular fluid. This refers to a risk for dehydration, water loss alone without change in sodium .
After the nursing action in the time 2 months, expected client can achieve the results criteria:
1. Nausea & Vomiting Severity [2107]
Definition: Severity of signs and symptoms of nausea, retching, and vomiting.
Nausea & Vomiting Severity as evidenced by often demonstrating ability to:
- [210701] frequency of nausea (5)
- [210702] Intensity of nausea (5)
- [210713] weight loss (5)
2. Nutritional Status : Food and Fluid Intake [1008]
Definition: Amount of food and fluid taken into the body over a 24-hour period.
Nutritional Status : Food and Fluid Intake as evidenced by often demonstrating ability to:
- [10081] oral intake food (5)
- [10082] tube feeding intake (5)
- [10083] oral fluid intake (5)

3. Nursing Intervention Classification
1. [4120] Fluid Management
Definition: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels.
- Intervention : Give fluids, as appropriate.
Rational : help patient to get fluid their needed
- intervention : Offer snacks (e.g., frequent drinks and fresh fruits/fruit juice), as appropriate.
Rational : give some variant of food, to increase the patient appetite

2. [1100] Nutrition Management
Definition: Providing and promoting a balanced intake of nutrients
- Intervention : Identify patient’s food allergies or intolerances
Rational : to get information about allergies suffered by the patient
- Intervention : Provide food selection while offering guidance towards healthier choices, if necessary
Rational : to increase the patient appetite


3. [1260] Weight Management
Definition: Facilitating maintenance of optimal body weight and percent body fat.
- Intervention : Discuss with individual the relationship between food intake, exercise, weight gain, and weight loss.
Rational : to provide information about the patient progress, and to advise the patient on what to do next.
- Intervention : Discuss with individual the medical conditions that may affect weight.
- Rational : to provide information about the patient progress, and to advise the patient on what to do next.

4. [4130] Fluid Monitoring
Definition: Collection and analysis of patient data to regulate fluid balance

- Intervention : Monitor intake and output
Rational : to know the condition of the body through the amount of fluid intake and output
- Intervention : monitor weight
Rational : to keep control of the patient weight


Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


36. NAFIDATUN NAAFIA

pada : 18 September 2017

"Name: Nafidatun Naafi’a
NIM: 131611133015
Class: A1.2016

Nursing Diagnosis

Nursing Diagnosis
Impaired Social Interaction related to Disturbance in Self-Concept (00052)
Definition: Insufficient or excessive quantity or ineffective quality of social exchange.
Domain. 7 Role Relationship
Class. 3 Role Performance

Nursing Outcomes Classification
After 6 weeks of nursing process, client are expected to be able to achieve these criteria:

Self-Esteem (1205)
Definition: Personal judgment of self-worth.
Self-Esteem as evidenced by showing the ability to:
• [120505] Describe him/herself (5);
• [120515] Has willingness to confront others (5);
• [120504] Has the ability to maintain eye contact (5); and
• [120519] Has adequate feelings about self-worth (5).

Social Involvement (1503)
Definition: Social interactions with persons, groups, or organizations
Social Involvement as evidenced by showing the ability to:
• [150301] Interacts with close friend (5);
• [150302] Interacts with neighbour (5);
• [150303] Interacts with family members (5);
• [150304] Interacts with members of work group(s) (5); and
• [150307] Participates in organized activity (5).

Nursing Intervention Classification
[5100] Socialization Enhancement
Definition: Facilitation of another person’s ability to interact with others.
• Use role playing to practice improved communication skills and techniques.
Rational: Role playing has function to develop client’s interpersonal communication skills.
• Encourage social and community activities.
Rational: By following some social and community activities, the client’s socialization will be enhanced, so does the self-concept.
• Explore strengths and weaknesses of current network of relationships.
Rational: The disturbance in self-concept and impaired social interaction could be started from the network of relationship. The strength of network of relationship helps client to enhance the socialization.
• Give positive feedback when client reaches out to others.
Rational: To motivate client to always improve his/her communication skills or experience a conversation with others. The feedback must be realistic. This intervention can make client less anxiety.

[5400] Self-Esteem Enhancement
Definition: Assisting a client to increase his or her personal judgment of self-worth.
• Monitor client’s statements of self-worth.
Rational: The client’s statement of self-worth is defining what is client think about him/herself, and this can affect their self-concept. The negative statement should be changed into the positive one during the nursing process.
• Encourage eye contact in communicating with others.
Rational: To motivate client to make a good interpersonal communication with another, little by little.
• Facilitate an environment and activities that will increase self-esteem.
Rational: Client needs a suitable environment and activities for him or her as one of the support system to increase self-esteem. Suitable environment and activities can maximize the increase of self-esteem.
• Monitor levels of self-esteem over time, as appropriate.
Rational: Monitoring self-esteem level to measure the success of the intervention, because self-esteem is the main indicator of the nursing care planning.

[5440] Support System Enhancement
Definition: Facilitation of support to client by family, friends, and community.
• Identify psychological response to situation and availability of support system.
Rational: The client’s responses to situation and availability of support system decides what support system suitable for the intervention. This help nurse to decides which one is better to help client.
• Involve family, significant others, and friends in the care and planning.
Rational: A support from a close ones relatives or friends can motivate the client, so client doesn’t feel alone. Beside, involving family or friends in the care planning can makes them able to treat client at home.


Sources:
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

"


37. NOVIA TRI HANDIKA

pada : 18 September 2017

"Name : Novia Tri Handika
NIM : 131611133042
Class : A1 2016
Nursing Diagnosis :
Post-trauma Syndrome related to history of abuse (e.g., physical, psychological, sexual)
Definition:
Sustained maladaptive response to a traumatic, overwhelming event.
(Domain 9. Coping/Stress Tolerance. Post-Trauma Responses, code: 00141)
Nursing Outcomes Classification
Goals : after 2 weeks of action, it is expected that patient to Improve on self-confidence and psychological
Expected Outcomes :
Mood Equilibrium (1204)
Definition : Appropriate adjustment of prevailing emotional tone in respons to circumstances
•Client exhibits non-labile mood (120402/III) (5)
Rational : patient can control feelings and emotions well
•Flight of ideas (120407/ III) (5)
Rational : patient show the appropriate topic of conversation
•Suicide ideation (120416/ III) (5)
Rational : patient does’t think to end life
•Depression (120420/ III) (5)
Rational : patient show a happy facial expression
Depression Level (1208)
Definition : severity of melancholic mood and loss of interest in life
•Depressed mood (120801/ III) (5)
Rational : patient does’t show depression
•Feelings of worthlessness (120807/ III) (5)
Rational : the patient can show its existence
•Sadness (120814/ III) (5)
Rational : patient can change facial expression
•Low self-esteem (120819/ III) (5)
Rational : patient can improves self-confidence

Nursing Intervention Classification
Anxiety Reduction (5820)
Definition : Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger.
1.Stay with patient to promote safety and reduce fear
Rational : Because in the presence of nurses, patient will feel comfortable and reduce fear
2.Encourage family to stay with patient, as appropriate
Rational : patient do not feel alone and family can motivate
3.Nurse listen attentively
Rational : the nurse can get information related to the state of the patient and feels considered
4.Identify when level of anxiety changes
Rational : with identify the level of anxiety, the nurse can handle the client from anxiety high appropriately

Support System Enhancement (5440)
Definition : Facilitation of support to patient by family, friend, and community
1.Identify psychological response to situation and availability of support system
Rational : Nurse to know the patient response to psychological problems
2.Encourage the patient to participate in social and community activities
Rational : because by encouraging patient to participate in social and community activities, so that patient can interact and divert the problems experienced
3.Provide services in a caring and supportive manner
Rational : Caring and supportive attitude, patient will be comfortable and trust nurse
4.Involve family, significant others, and friends in the care and planning
Rational : patient can feel comfort and not anxious in the process of care and planning

Bibliography:
1.Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015-2017. 10nd ed. Oxford:Wiley Blackwell
2.Moorhead, S., Jhonson, M., Maas, M. & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3.Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classsification (NIC). 6th ed. America: Mosby Elseiver"


38. Dwi Utari Wahyuning Putri

pada : 18 September 2017

"NAME : DWI UTARI WAHYUNING PUTRI
NIM : 131611133019

Nursing Diagnosis (NANDA) : Constipation related to insufficient fiber intake.
(Domain 3. Elimination and Exchange. Class 2. Gastrointestinal Function. Code 00011)
Definition : Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

NOC :
After 3x24 hours of nursing interventions the patient will achieve the results criteria :
1. Bowel Elimination (0501)
Definition : Formation and evacuation of stool.
Bowel elimination as evidenced by not compromised ability to :
[050105] Stool soft and formed (4)
[050112] Ease of stool passage (4)
[050121] Passage of stool without aids (4)
2. Knowledge : Healthy Diet (1854)
Definition:Extent of understanding conveyed about a balanced nutritious diet.
Knowledge : Healthy Diet as evidenced by substantial knowledge ability to:
[185404] Fluid intake appropriate for metabolic needs (4)
[185413] Guidelines for food portions (4)
[185417] Recommended daily fruit servings (4)
[185418] Recommended daily vegetable servings (4

NIC :
1. Constipation/Impaction Management (0450)
Definition : Prevention and alleviation of constipation/impaction.
• Identify factors (e.g. medications, bed rest, diet) that may cause or contribute to constipation.
Rationale :Assessing causative factors is an essential first step in teaching and planning for improved bowel elimination.
• Evaluate increased fluid intake, unless contraindicated. ( 2 until 3 liters per day)
Rationale : Sufficient fluid intake is necessary for the bowel to absorb sullficient amounts of liquid to promote proper stool consistency.
• Teach patient/family how to keep food diary.
Rationale : An appraisal of food intake will help indentify if patient is eating a well-balanced diet and consuming adequate amounts of fluid and fiber. Excessive meat or refined food intake will produce small, hard stools.
• Instruct patient/family on the relationship of diet, exercise, and fluid intake to constipation and impaction.
Rationale : Fiber without adequate fluid can aggravate, not facilitate, bowel function.
• Instruct patient/family on a high-fiber diet, as appropriate.
Rationale : Fiber absorbs water, which adds bulk and softness to the stool and speeds up passage through the intestines.

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


39. Erlina Dwi Kurniasari

pada : 18 September 2017

"NAME : ERLINA DWI KURNIASARI
NIM : 131611133028
CLASS : A1-2016
Discovery Learning
NURSING DIAGNOSIS :
1. Nursing Diagnosis (NANDA)
Fatigue related by sleep deprivation
Definition :
An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual
(Domain 4. Activity/rest. Class 3 Energy balance, code 00093)
2. Nursing Outcomes Classificatin (NOC) :
Aim : after the nurse action for 1 month, the patient is expected to :

1. (0008) Fatigue : Disruptive effects
Definition : Severity of observed or reported disruptive effects of chronic fatigue on daily functioning
Fatigue : Disruptive effects as evidence by often demonstrating ability to :
- 000803 Decrease energy [5]
- 000806 Disruption of routine [5]
- 000804 Interference with activities of daily living [5]
2. (1208) Depression Level
Definiton : Severity of melancholic mood and loss of interest in life events
Depression level as evidence by often demonstrating ability to :
- 120801 Depressed mood [5]
- 120806 Fatigue [5]
- 120809 Insomnia [5]
3. (0003) Rest
Definiton : Quantity and pattern of diminished activity for mental and physical rejuvenation
- 000301 Amount of rest [5]
- 000302 Rest pattern [5]
- 000304 Physically rested [5]

3. Nursing Intervention Classification (NIC) :
1. (0180) Energy Management
Definition : Regulating energy use to treat or prevent fatigue and optimize function
• Intervention : Assess patient’s physiologic status for deficits resulting in fatigue within the context of age and development
Rationale : the nurse can know what causes the patient to experience fatigue
• Intervention : Consult with dietitian about ways to increase intake of high energy foods
Rationale : nutritional needs of clients can be fulfilled
• Intervention : Encourage the patient to choose activities that gradually build endurance
Rationale : build a high endurance
• Intervention : Assist the patient to identify tasks that family and friends can perform in the home to prevent/relieve fatigue
Rationale : with the help of the nearest person, can reduce client fatigue
2. (1850) Sleep Enhancement
Definiton : Facilitation of regular sleep/wake cycles
• Intervention : Monitor/record patient’s sleep pattern and number of sleep hours
Rationale : making sleep patterns of patients at least 8 hours per day
• Intervention : Instruct patient to avoid bedtime foods and beverages that interfere with sleep
Rational : there are foods and drinks that can make a person difficult to sleep
• Intervention : Adjust environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep
Rationale : environment is one factor that can affect the convenience of the client
• Intervention : Discuss with patient and family sleep-enhancing techniques
Rationale : family can assist clients in overcoming sleep disorders
3. (6480) Environmental Management
Definiton : Manipulation of the patient’s surroundings for therapeutic benefit, sensory appeal, and psychological well-being
• Intervention : Create a safe environment for the patient
Rationale : a safe environment can make the patient easy to relax and finally fall asleep
• Intervention : Individualize visiting restrictions to meet patient’s and/or family’s/significant other’s needs
Rationale : so that patient rest time isn’t disturbed
• Intervention : Provide a clean, comfortable bed and environment
Rationale : helping clients reach the comfort zone





"


40. Erlina Dwi Kurniasari

pada : 18 September 2017

"NAME : ERLINA DWI KURNIASARI
NIM : 131611133028
CLASS : A1-2016
NURSING DIAGNOSIS :
1. Nursing Diagnosis (NANDA)
Fatigue related by sleep deprivation
Definition :
An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual
(Domain 4. Activity/rest. Class 3 Energy balance, code 00093)
2. Nursing Outcomes Classificatin (NOC) :
Aim : after the nurse action for 1 month, the patient is expected to :

1. (0008) Fatigue : Disruptive effects
Definition : Severity of observed or reported disruptive effects of chronic fatigue on daily functioning
Fatigue : Disruptive effects as evidence by often demonstrating ability to :
- 000803 Decrease energy [5]
- 000806 Disruption of routine [5]
- 000804 Interference with activities of daily living [5]
2. (1208) Depression Level
Definiton : Severity of melancholic mood and loss of interest in life events
Depression level as evidence by often demonstrating ability to :
- 120801 Depressed mood [5]
- 120806 Fatigue [5]
- 120809 Insomnia [5]
3. (0003) Rest
Definiton : Quantity and pattern of diminished activity for mental and physical rejuvenation
- 000301 Amount of rest [5]
- 000302 Rest pattern [5]
- 000304 Physically rested [5]

3. Nursing Intervention Classification (NIC) :
1. (0180) Energy Management
Definition : Regulating energy use to treat or prevent fatigue and optimize function
• Intervention : Assess patient’s physiologic status for deficits resulting in fatigue within the context of age and development
Rationale : the nurse can know what causes the patient to experience fatigue
• Intervention : Consult with dietitian about ways to increase intake of high energy foods
Rationale : nutritional needs of clients can be fulfilled
• Intervention : Encourage the patient to choose activities that gradually build endurance
Rationale : build a high endurance
• Intervention : Assist the patient to identify tasks that family and friends can perform in the home to prevent/relieve fatigue
Rationale : with the help of the nearest person, can reduce client fatigue
2. (1850) Sleep Enhancement
Definiton : Facilitation of regular sleep/wake cycles
• Intervention : Monitor/record patient’s sleep pattern and number of sleep hours
Rationale : making sleep patterns of patients at least 8 hours per day
• Intervention : Instruct patient to avoid bedtime foods and beverages that interfere with sleep
Rational : there are foods and drinks that can make a person difficult to sleep
• Intervention : Adjust environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep
Rationale : environment is one factor that can affect the convenience of the client
• Intervention : Discuss with patient and family sleep-enhancing techniques
Rationale : family can assist clients in overcoming sleep disorders
3. (6480) Environmental Management
Definiton : Manipulation of the patient’s surroundings for therapeutic benefit, sensory appeal, and psychological well-being
• Intervention : Create a safe environment for the patient
Rationale : a safe environment can make the patient easy to relax and finally fall asleep
• Intervention : Individualize visiting restrictions to meet patient’s and/or family’s/significant other’s needs
Rationale : so that patient rest time isn’t disturbed
• Intervention : Provide a clean, comfortable bed and environment
Rationale : helping clients reach the comfort zone
Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver





"


41. YENNI NISTYASARI

pada : 18 September 2017

"NAME: YENNI NISTYASARI
NIM: 131611133035
CLASS: A1
Nursing Diagnosis
Fear related to Unfamiliar setting
Definition: Response to perceived threat that is consciously recognized as a danger.
(Domain 9. Coping/Stres Tolerance, class 2. Coping Responses, code 00148)

Nursing Outcomes Classification
Expected Outcomes:
Fear Self-Control (1404)
Definition: Personal actions to eliminate or reduce disabling feelings of apprehension, tension, or uneasiness from an identifiable source
1.Eliminates precursors of fear (140402/III) (5)
Rational: Patients can recognize factors that cause fear
2.Avoids source of fear when possible (140404/III) (5)
Rational: Patients can divert attention that creates fear
3.Plans coping strategies for fearful situations (140405/III) (5)
Rational: Build self-esteem to reduce the fear that dominates the mind
4.Uses relaxation techniques to reduce fear (140407/III) (5)
Rational: Patients can do meditation and yoga which are activities to overcome fear
5.Controls fear response (140417/III) (5)
Rational: patients can stop excessive fear

Anxiety Self- Control (1402)
Definition: Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source
1.Eliminates precursors of anxiety (140202/III) (5)
Rational: Reduce threats or unreal hazards
2.Decreases environmental stimulus when anxious (140203/III) (5)
Rational: Patients can avoid crowded places
3.Uses relaxation techniques to reduce anxiety (140207/III) (5)
Rational : Helping the patient to soothe body and mind
4.Maintains adequate sleep (140214/III) (5)
Rational: The level of fatigue can affect anxiety
5.Controls anxiety response (140217/III) (5)
Rational : Monitoring yourself to reduce stress and tension from the pressure that has been panic

Social Anxiety Level (1216)
Definition: Severity of irrational avoidance, apprehension, and distress in anticipation of or during social situations
1.Avoidance of social situations (121601/III) (5)
Rational: Avoid crowds
2.Avoidance of unfamiliar people (121602/III) (5)
Rational: Preventing fears that can worsen anxiety levels
3.Anxious anticipation of encountering unfamiliar people (121605) (5)
Rational: Patient can think positively to an unknown person
4.Discomfort during social encounters (121612/III) (5)
Rational: People become uncomfortable usually occur when teased, criticized, and the center of attention
5.Panic symptoms in social situations (121615/III) (5)
Rational: Patient will feel nauseous, nervous, and uncomfortable

Nursing Intervention Classification
Anxiety Reduction (5820)
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger
1.Use a calm, reassuring approach
Rational: The patient feels someone is paying attention
2.Provide objects that symbolize safeness
Rational: Avoiding anxiety increase
3.Help patient identify situations that precipitate anxiety
Rational: Patient can recognize the cause of anxiety in him
4.Instruct patient on the use of relaxation techniques
Rational: reducing anxiety with deep breathing techniques

Coping Enhancement (5230)
Definition: Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere with meeting life demands and roles
1.Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness
Rational: Family support can strengthen the patient's coping mechanism so that the anxiety level is reduced
2.Encourage social and community activities
Rational: Support the patient for activity by sharing activities to strengthen socially productive behavior
3.Assist patient in identifying positive responses from others
Rational: To know the alarm is anxious and can be determined what action will be done
4.Instruct the patient on the use of relaxation techniques, as needed
Rational: Relaxation techniques given to clients can reduce anxiety
5.Encourage the patient to evaluate own behavior
Rational: Evaluation relates to the patient's ability to self-behavior by increasing coping

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NIC). 6th ed. America: Mosby Elseiver"


42. Arinda Naimatuz Zahriya

pada : 18 September 2017

"Nama : Arinda Naimatuz Zahriya
NIM : 131611133024
Class : A1/2016

Nursing Diagnosis
1. Nursing Diagnosis (NANDA)
Nausea related to Pregnancy (00134)
Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not result in vomiting.
(Domain 12. Comfort Class 1. Physical Comfort)

2. Nursing Outcomes Classification (NOC)
Aim : After the nursing action in the time 1x24 hours, expected client can achieve the results criteria :
1. (2102) Pain Level
Definiton: Severity of observed or reported pain
The severity of the sides is evidenced by the decrease
• (210212) Blood pressure
Rationale: Blood pressure decreases, reduces the body's abnormal condition
• (210208) Restlessness
Rationale: The client's face feels pleasure, does not feel anxious inside
• (210227) Nausea
Rationale: The client feels relax and doesn’t feel sick.

2. (2107) Nausea & Vomiting Severity
Definition: Severity of signs and symptoms of nausea, retching, and vomiting.
The severity of nausea and vomiting as evidenced by the decrease:
• (210701) Frequency of nausea
Rationale : Expenditure of vomiting can be controlled every time
• (210707) Frequency of vomiting
Rationale : Expenditure of nausea can be controlled every time

3. (2109) Discomfort Level
Definition: Severity of observed or reported mental or physical discomfort
The severity of mental discomfort or discomfort as evidenced by the decrease:
• (210928) Nausea
Rationale : The client's face can be controlled at the time of feeling nauseated
• (210920) Vomiting
Rationale : The client's face can be restrained at the time of vomiting
• (210905) Restless legs syndrome
Rationale : feel comfortable when the body condition is pregnant

3. Nursing Intervention Classification (NIC)
1. (1450) Nausea management
Definition: Prevention and alleviation of nausea
• Intervention :
Encourage patient to learn strategies for managing own nausea
• Rationale :
Helping clients to achieve better goals
• Intervention:
Identify strategies that have been successful in relieving nausea
• Rationale :
Allows the client to maintain the conditions and run in the right way
• Intervention
Promote adequate rest and sleep to facilitate nausea relief
• Rationale
Clients can reduce activities that should not be done by minimizing previous activities
• Intervention
Reduce or eliminate personal factors that precipitate or increase
the nausea (anxiety, fear, fatigue, and lack of knowledge)
• Rationale
helps clients to accept and reduce factors that cause nausea

2. (1570) Vomiting Management
Definition: Prevention and alleviation of vomiting
• Intervention :
Encourage rest
• Rationale :
Clients can meet the rest needs used to improve the health of the body
• Intervention:
Monitor effects of vomiting management throughout
• Rational :
the client determines sustainability in order to identify optimal prevention efforts
• Intervention:
Teach the use of nonpharmacological techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery, music therapy, distraction, acupressure) to manage vomiting
• Rationale
Help clients in improving their health and check all the actions of nausea for the better

3.(6040) Relaxation Therapy
Definition: Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety
• Intervention :
Invite the patient to relax and let the sensations happen
• Rationale :
Helping clients keep things good so do not think too hard
• Intervention:
Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, orpeaceful imaging
• Rational :
Helping clients in carrying out self-relaxation without causing burden within
• Intervention:
Develop a tape of the relaxation technique for the individual to use, as appropriate
• Rationale
The client performs the same activity to keep the body well conditioned
"


43. RIZKI JIAN UTAMI

pada : 18 September 2017

"NAMA : RIZKI JIAN UTAMI
NIM : 131611133032
CLASS : A1-2016
Nanda Nursing Diagnoses: Ineffective breathing pattern related to Neuromuscular impairment
(Domain 4, class 4, code 00032)
Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Noc outcome Label (s) and indicators
Respiratory Status (0415)
- 041501 Respiratory rate (4)
- 041502 Respiratory rhythm (4)
- 041532 Airway patency (5)
- 041507 Vital capacity (5)
- 041508 Oxygen saturation (5)

NIC Intervention Label (s) and Nursing Activity
Airway Management (3140)
• Position patient to maximize ventilation potential
Help the patient to get the right breathing mechanism
• Identify patient requiring actual/potential airway insertion
Help patient fulfill the need for respiratory disorders
• Encourage slow, deep breathing; turning; and coughing
helps the patient breathe independently

Oxygen Therapy (3320)
• Maintain airway patency
To give normal breathing pattern
• Administer supplemental oxygen as ordered
To fulfill the need for oxygen, and help the client breathing normally
• Monitor the oxygen liter flow
Ensure the oxygen liter flow for the client



Rational for NIC choosen and indicator score
Airway Management (3140)
• Help the patient to get the right breathing mechanism
• Help patient fulfill the need for respiratory disorders
• helps the patient breathe independently

Oxygen Therapy (3320)
• To give normal breathing pattern
• To fulfill the need for oxygen, and help the client breathing normally
• Ensure the oxygen liter flow for the client"


44. Ayu Saadatul Karimah

pada : 18 September 2017

"Nama: Ayu Saadatul Karimah
NIM: 131611133020
Kelas: A-1 2016

Nursing Diagnosis : Ineffective breastfeeding related to insufficient parental knowledge regarding breastfeeding techniques
Definition : difficulty providing milk to an infant or young child directily from the breasts, which may compromise nutritional status of the infant/child.
(Domain 2, Class 1, Code 00104)

Nursing Outcomes Classification (NOC)
[1000] Breastfeeding Establishment: Infant
1. [100001] Proper alignment and latch on [5]
Rational: Appropriate body alignment while breastfeeding will make it easier for the baby to breastfeed, thus maximizing breast milk intake in infants
2. [100013] Correct tongue placement [5]
Rational: The proper placement of the tongue will make the baby suckle optimally &
efficiently and can avoid blisters of the mother's nipple
3. [100014] Suck reflex [5]
Rational: sucking reflexes will make it easier for infants and mothers during breastfeeding because the baby will naturally suck the milk from mother until baby satisfied
4. [100006] Nursing a minimum of 5-10 minutes per breast [5]
Rational: breastfeeding 5-10 minutes per breast to avoid the baby from fatigue
breastfeeding , glut and vomit.

[1800] Knowledge: Breastfeeding
1. [180001] Benefits of breastfeeding [5]
Rational: Parents should know the benefits of breastfeeding, so that parents can meet the intake of breastmilk that should be given to infants according to the age of the baby and can perform proper breastfeeding techniques
2. [180005] Proper technique for attaching infant to the breast [5]
Rational: The right technique to attach the baby to the breast will facilitate the baby during the breastfeeding process and provide a sense of comfort to the mother and baby
3. [180006] Proper infant positioning while nursing [5]
Rational: The appropriate baby position while breastfeeding will provide comfort to the parents and the baby and the baby will feel satisfaction with the breastfeeding process so that breast milk intake can be fulfilled
4. [180009] Proper technique to break infant suction [5]
Rational: Decide suction the baby's at the time of breastfeeding should be with the right technique, because to avoid things that result in injuries such as wounds on the nipple, baby choking, breast milk spilled and others

[1001] Breastfeeding Establihment: Maternal
1. [100101] Comfort of position during nursing [5]
Rational: A comfortable position while breastfeeding will provide a sense of satisfaction and comfort to the baby and mother while breastfeeding
2. [100107] Suction broken before removing infant from breast [5]
Rational: At the time want to move breast, suction must be stopped first, because to avoid baby choking and blisters mother's nipple
3. [100113] Recognition of early hunger cues [5]
Rational: The hunger cue must be recognizable by parents, especially mothers, because to avoid fussy babies and crying, so that babies can be filled with milk intake before the baby cries dan fuss
4. [100118] Satisfaction with breastfeeding process [5]
Rational: If the baby is satisfied with the process of feeding the baby will feel full, no fuss, and infant nutrition from breast milk will be optimal and efficient

Nursing Intervention Classification (NIC)
[6710] Attachment Promotion


1. Encourge mother to breastfeed, if appropriate
Rational: If the mother is breastfeeding properly, the baby will feel satisfaction and comfort during the process of breastfeeding
2. Provide adequate breastfeeding education and support, if appropriate
Rational: Education about breastfeeding will provide benefits to increase knowledge about breastfeeding techniques and benefits to baby's parents
3. Instruct parent on infant cues for feeding (eg.,rooting, sucking on fingers, crying)
Rational: If parents know the signs of baby hungry, then parents will try to calm the baby, one of them by way of breastfeeding
4. Monitor factors that may interfere with optimal attachment (e.g., mental health disturbance in parent, financial strain, parent and child, separation due to medical or surgical intervention, difficulties with breastfeeding, providing foster care and adopting)
Rational: Monitoring factors that disrupt the attachment of the mother and baby will help the nurse to know the cause of the lack of attachment between mother and child, so that the nurse can perform or plan nursing actions to assist the mother in solving the disturbing problems or problems that cause the lack of attachment of mother and child , such as the lack of knowledge of mothers in breastfeeding techniques so that mothers find it difficult to breastfeed

[5244] Lactation Conseling
1. Provide information about psychological ang physiological benefits of breastfeeding
Rational: Provide information on the benefits of breastfeeding to parents, will provide knowledge to parents, so that parents know the benefits of breastfeeding for both physiological and psychological for infants and can provide optimal breastfeeding to infants
2. Assist in ensuring proper infant attachment to breast (i.e., monitor proper infant alignment, areolar grasp and compression, audible swallowing)
Rational: Attachment of the baby to the chest with the right will facilitate the baby at the time of breastfeeding, so that babies and mothers feel comfortable when breastfeeding
3. Instruct on various feeding positions (e.g., cross-cradle, foot-ball hold, and side lying)
Rational: The position varies when the breastfeeding process can help the mother to reduce muscle tension during breastfeeding, because if the mother is breastfeeding in one position will cause fatigue and muscle tension in the body part of the mother
4. Monitor infant’s ability to suck
Rational: Monitor the ability of infants in sucking helps nurses to see the development of the ability of the baby in the breastfeeding process and if the baby is able to suck at the time of breastfeeding then the intake of breastfeeding will be met optimized
5. Demonstrate suck training, if necessary (e.g., use a clean finger to stimulate suck reflex and latch on)
Rational: Sucking exercise will help the baby in the breastfeeding process, so that the baby is able and used to suck milk from the mother's breast during breastfeeding and the baby can suckle optimally and maximally and also can avoid unwanted things like blisters on the nipple, choking, fatigue and others
6. Instruct on how to break suction of nursing infant, if necessary
Rational: Decide on suction precisely when breastfeeding can avoid crying babies, scuffed on mother's nipples, choking, and breast milk spilled
7. Encourage mother to wear a well-fitting, supportive bra
Rational: Clothes that support the process of breastfeeding will facilitate and provide comfort to the mother or baby, so the baby can suckle with satisfaction

Bibliography :

Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


45. DITA FAJRIANTI

pada : 18 September 2017

"NAME : DITA FAJRIANTI
NIM : 131611133014
CLASS : A1 – 2016
NURSING DIAGNOSIS
1.Nursing Diagnosis (NANDA)
Insomnia related with Depression
(00095)
Definition : A disruption in amount and quality of sleep that Impairs functioning.
(Domain 4. Activity/Rest. Class 1. Sleep/Rest)

2.Nursing Outcome Classification
After the nursing action in the time 2 weeks, expected client can achieve the results criteria:
1). Sleep (0004)
Definition : Natural periodic suspension of consciousness during which the body is restored
[000401] patient Increase hours of sleep (5)
Rationale : The patient sleep needs are sufficient
[000403] patient can be improve sleep pattern (5)
Rationale : The patient can regulate sleep patterns and provide better sleep quality
[000404] Patient sleep quality is not disturbed (5)
Rationale : Patients feel comfortable and free from stress
2). Mood Equilibrium (1204)
Definition : Appropriate adjustment of prevailing emotional tone in respone to circumstances.
[120402] Patients can consistently perform exhibits non-labile mood (5)
Rationale : unstable emotions of the patient can lead to lower depression levels
[120404] Patient can be reports adequate sleep (5)
Rationale : the patient shows an increase that the patient's sleep time has been fulfilled
[120415] Patient can shows interest in surroundings (5)
Rationale : Showing an interest in the society will help the patient in improving confidence and to adapt to the surroundings

3. Nursing Intervention Classification
1). Sleep Enhancement (1850)
Definition : Facilitation of regular sleep/wake cycles
• Intervention : Determine patient’s sleep/activity pattern
Rationale : Determine the next action
• Intervention : Monitor/record patient’s sleep pattern and number of sleep hours
Rationale : To find out how long hours of sleep the patient and to set the patient's sleep clock to be fulfilled
• Intervention : Adjust environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep
Rationale : Patients get comfort and giving motivation to sleep
• Intervention : Instruct patient how to perform autogenic muscle relaxation or other non pharmacological forms of sleep inducement
Rationale : Teach patients performing autogenic relaxation or other non-pharmacological forms to induce sleep
2). Mood Management (5330)
Definition : Providing for safety, stabilization, recovery, and maintenance of a patient who is experiencing dysfunctionally depressed or elevated mood
• Intervention : Assist patient to maintain a normal cycle of sleep/wakefulness (e.g., scheduled rest times, relaxation techniques, sedating medications, limit caffeine)
Rationale : maintaining the normal sleep cycle of the patient can regulate the emotion so as not to depression
• Intervention : Manage and treat hallucinations and/or delusions that may accompany the mood disorder
Rationale : patients can control emotions
• Intervention : Evaluate mood (e.g., signs, symptoms, personal history) initially, and on a regular basis, as treatment progresses
Rationale : Determine the success of the interventions that have been made
3). Relaxation Therapy (6040)
Definition : Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety.
• Intervention : Demonstrate and practice the relaxation technique with the patient
Rationale : Patients can simulate relaxation techniques to improve sleep quality
• Intervention : Provide undisturbed time, because patient may fall asleep
Rationale : The patient can sleep quietly and there is no disturbance
• Intervention : Create a quiet, non disrupting environment with dim lights and comfortable temperature, when possible
Rationale : A tranquil and peaceful atmosphere will help patients get to bed fast and reduce stress levels
4). Calming Technique (5880)
• Intervention : Reduce or eliminate stimuli creating fear or anxiety
Rationale : To make patient comfortable
• Intervention : Stay with patient
Rationale : Prevent patient from feeling alone
• Intervention : Identify significant others whose presence can assist patient
Rationale : The closest people also play a role in improving client health"


46. NESYA ELLYKA

pada : 18 September 2017

"NAMA : NESYA ELLYKA
NIM : 131611133038
KELAS : A1-2016
NURSING DIAGNOSIS :

1. Nursing Diagnosis (NANDA)
Risk for Falls related to Use of assistive device (e.g., walker, cane, wheelchair)
Definition: Vulnerable to increased susceptibility to falling, which may cause physical harm and compromise health.
(Domain 11. Safety/Protection. Class 2. Physical Injury. Code 00155)

2. Nursing Outcomes Classification
After the nursing action in the time 2 months, expected client can achieve the results criteria:
1.) [1828] Knowledge: Fall Prevention
Definition: Extent of understanding conveyed about prevention of falls
Knowledge: Falls Prevention as evidenced by often demonstrating ability to:
• [182801] Correct use of assistive devices (5)
• [182809] Use of safe transfer procedure (5)
• [182817] Strategies to safely ambulate (5)
• [182818] Importance of maintaining clear walkway (5)
Rational:
Patients know factors that may increase the risk of falling.
2.) [1632 ] Compliance Behavior: Prescribed Activity
Definition: Personal actions to follow daily physical activities recommended by a health professional for a specific health condition
Compliance Behavior: Prescribed Activity as evidenced by often demonstrating ability to:
• [163201] Discusses activity recommendations with health professional (5)
• [163202] Identifies expected benefits of physical activity (5)
• [163203] Identifies barriers to implement prescribed physical activity (5)
• [163207] Uses strategies to promote safety (5)
Rational:
The patient can determine the purpose of the exercise. the patient can behavior with the prescribed activity.
3.) [1909] Fall Prevention Behavior
Definition: Personal or family caregiver actions to minimize risk factors that might precipitate falls in the personal environment
Fall Prevention Behavior as evidenced by often demonstrating ability to:
• [190923] Asks for assistance (5)
• [190901] Uses assistive devices correctly (5)
• [190919] Uses safe transfer procedure (5)
Rational:
Patients can avoid behaviors that can increase the risk of falls.

3. Nursing Intervention Classification
1.) [0222] Exercise Therapy: Balance
Definition: Use of specific activities, postures, and movements to maintain, enhance, or restore balance
• Intervention:
Provide opportunity to discuss factors that influence fear of falling
Rational:
Patient can know the factors that influence fear for falling. That patient fears will decrease and may reduce the risk for falling.
• Intervention:
Instruct patient on the importance of exercise therapy in maintaining and improving balance
Rational:
Patients know the importance of exercise therapy in maintaining and improving balance. Patients are willing to do exercise therapy
• Intervention:
Provide assistive devices (e.g., cane, walker, pillows, or pads) to support patient in performing exercise
Rational:
Assistive devices can make patients feel more secure. Patients can do exercise therapy without fear for falling
2.) [0200] Exercise Promotion
Definition: Facilitation of regular physical activity to maintain or advance to a higher level of fitness and health
• Intervention:
Assist individual to set short-term and long-term goals for the exercise program
Rational:
Patients can determine short-term and long-term goals for this exercise
• Intervention:
Monitor individual’s adherence to exercise program/activity
Rational:
The patient adherence to the procedure of exercise program correctly according to the instructor's instructions.
• Intervention:
Assist individual to prepare and maintain a progress graph/ chart to motivate adherence with the exercise program
Rational:
Patient can see a progress graph of self after doing this exercises

3.) [6490] Fall Prevention
Definition: Instituting special precautions with patient at risk for injury from falling
• Intervention:
Identify behaviors and factors that affect risk of falls
Rational:
Identify behaviors and factors that affect risk of falls can help the patients to avoid activities that can increase the risk of falls.
• Intervention:
Monitor gait, balance, and fatigue level with ambulation
Rational:
helping patients not to feel tired quickly in their daily activities
• Intervention:
Instruct patient about use of cane or walker, as appropriate
Rational:
Patients can use of cane or walker appropriately. Using the assistive device as appropriate can help to reduce the risk of falls.
• Intervention:
Teach patient how to fall as to minimize injury
Rational:
Patients can overcome the risk of falling to reduce injury.

Bibliography :
• Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
• Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
• Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


47. Verantika Setya Putri

pada : 18 September 2017

"Name : Verantika Setya Putri
Class : A1 2016
NIM : 131611133026

1. Nursing Diagnoses : Dysfunctional ventilator weaning response related to Insufficient knowledge of weaning process
Definition : inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning process. (00034)
(Domain 4. Activity/ Rest, Class 4. Cardiovascular/Pulmonary Responses)
2. Nursing Outcomes Classification
AIM: After getting 2 weeks of nursing action, the client is expected to achieve the results criteria :
 (0412) Mechanical Ventilation Weaning Response: Adult
Definition: Respiratory and psychological adjustment to progressive removal of mechanical ventilation

 (041202/4) Spontaneous respiratory rate
Rational : Spontaneous breathing will make the client more independent and does not require breathing equipment


 (041203/4) Spontaneous respiratory rhythm
Rational : The release of the ventilator is expected the client can breathe normally, seen from the spontaneous breathing rhythm


 (041204/4) Spontaneous respiratory depth
Rational : The release of ventilator is expected the client can breathe normally, seen from the depth of spontaneous respiration




 (1814) Knowledge: Treatment Procedure
Definition: Extent of understanding conveyed about a procedure required as part of a treatment regimen

 (181401/5) Treatment procedure
Rational : Knowing the existing handling procedures will ease the weaning process

 (181402/5) Purpose of procedure
Rational : Knowing the purpose of the procedure will make the client more confident in the weaning process

 (181403/4) Steps in procedure
Rational : Step procedure steps must be known by the client so that clients know what actions will be given

 (181405/4) Precautions related to procedure
Rational : Precautions need to be done in an effort to speed up the weaning process

3. Nursing Interventions Classification
 (3310) Mechanical Ventilatory Weaning
Definition: Assisting the patient to breathe without the aid of a mechanical ventilator

 Determine patient readiness for weaning (e.g., hemodynamically stable, condition requiring ventilation resolved, current condition optimal for weaning)
Rational : In the process of weaning required client readiness because the client no longer use breathing aids

 Monitor predictors of ability to tolerate weaning based on agency protocol (e.g., degree of shunt, vital capacity, Vd/Vt, MVV, inspiratory force, FEV1, negative inspiratory pressure)
Rational : Weaning process must go through several procedures to keep the patient in stable condition

 Monitor to assure patient is free of significant infection prior to weaning
Rational : Infection can cause bacterial development on the client ventilator so, we need to weaning

 (5230) Coping Enhancement
Definition: Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere with meeting life demands and roles

 Assist the patient in identifying appropriate short- and longterm goals
Rational : Appropriate long-term and short-term goals can help to ensure and maximize the process of ventilator weaning therapy in client

 Use a calm, reassuring approach
Rational : A quiet approach will make the patient feel protected and confident that everything said will be kept confidental

 Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes
Rational : Strategy in the positive will make the client more confident in living his life with the limitations that he has"


48. ANGGA KRESNA PRANATA

pada : 18 September 2017

"
NAMA : ANGGA KRESNA PRANATA
NIM : 131611133030
KELAS : A1-2016
NURSING DIAGNOSIS
1. Nursing Diagnosis (NANDA)
No : 00214
Impaired Comfort related to illnes-related symptoms.
Definition : Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural, and/or social dimensions.
Nursing Outcomes Classification
1) [2010] Comfort Status : Physical
Definition : Physical ease related to bodily sensations and homeostatic mechanisms
• 201001 Control Sypmtom (5)
• 201002 Physical well-being (5)
• 201018 Headache (5)
2) [2101] Pain : Distruptive Effect
Definition : Severity of observed or reported disruptive effects of chronic pain on daily functioning.
• 210127 Discomfort (5)
• 210113 impaired physical mobility (5)
• 210134 impaired physical activity (5)
3) [2102] Pain level
Definition : Severity of observed or reported pain
• 210201 Reported pain (5)
• 210214 lenght of pain episode (5)



2. Nursing Intervention Classification
1) [6482] Environmental Management : Comfort
Definition : Manipulation of the patient’s surroundings for promotion of optimal comfort
- Intervention :
Determine sources of discomfort, such as damp dressings, positioning of tubing, constrictive dressings, wrinkled bed linens,
and environmental irritants
Rational : Decrease and anticipate a risk of discomfort to clients.

- Intervention :
Facilitate hygiene measures to keep the individual comfortable
(e.g., wiping brow, applying skin creams, or cleaning body, hair,
and oral cavity)
Rational : Minimize the level of discomfort

- Intervention :
Position patient to facilitate comfort (e.g., using principles of
body alignment, support with pillows, support joints during
movement, splint over incisions, and immobilize painful body
part)
Rational : Make client feel comfort during treatment.

2) [1400] Pain Management
Definition : Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient.
- Intervention :
Provide information about the pain, such as causes of the
pain, how long it will last, and anticipated discomforts from
procedures
Rational : improve client understanding and knowledge about cause of pain, how long pain feel and anticipation of discomfort due to the procedure

- Intervention :
Teach principles of pain management
Rational : client knows what actions are taken when in controlling the pain.

- Intervention :
Consider type and source of pain when selecting pain relief strategy
Rational : : Minimize the risk of pain on the client and anticipate the occurence of pain

- Intervention :
Encourage patient to monitor own pain and to intervene appropriately
Rational : help clients know the intensity of pain and know how to handle the pain appropriately

Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


"


49. Ni Putu Neni Indriyani

pada : 18 September 2017

"NAME : NI PUTU NENI INDRIYANI
NIM : 131611133031 – A1 2016
NURSING DIAGNOSIS
1. Nursing diagnosis (NANDA)
Nausea related to Treatment regimen [00134]
Definition : A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not result in vomiting.
(Domain 12. Comfort. Class 1. Physical Comfort)

2. Nursing Outcome Classification
After the nursing action in the time 5 until 7 days, expected client can achieve the results criteria:

a. Nausea & Vomiting Severity 2107
Definition : Severity of signs and symptoms of nausea, retching, and vomiting
Nausea & vomiting severity as evidenced by often demonstrating ability to:

1) [210701] Frequency of nausea (5)
2) [210704] Frequency of retching (5)
3) [210713] Weight loss (4)
4) [210720] Electrolyte imbalance (5)

b. Nutritional Status: Food & Fluid Intake [1008]
Definition : Amount of food and fluid taken into the body over a 24-hour period
Nutritional Status: Food & Fluid Intake as evidenced by often demonstrating ability to:
1) [100801] Oral food intake (5)
2) [100803] Oral fluid intake (5)
3) [100804] Intravenous fluid intake (5)

c. Anxiety Level [1211]
Definition : Severity of manifested apprehension, tension, or uneasiness arising from an unidentifiable source.
Anxiety Level as evidenced by often demonstrating ability to:
1) [121105] Uneasiness (5)
2) [121119] Increased blood pressure (5)
3) [121120] Increased pulse rate (5)
4) [121131] Change in eating pattern (5)


3. Nursing Intervetion Classification

a. Nutritional Monitoring [1160]
Definition : Collection and analysis of patient data pertaining to nutrient intake
- Activities : Weigh patient
Rational : measure the weight of patients with ideal body weight
BMI (according to WHO) : WB / (HBxHB)
Result :
IMT value = 30.0 = Very Fat

- Activities : Monitor for nausea and vomiting.
Rational : Know the symptoms when the patient feels nauseated or will vomit

- Activities : Monitor mental state (e.g., confusion, depression, and anxiety)
Rational : Avoid the patient anxiety about the treatment process because it will reduce the appetite.


b. Nausea Management [1450]
Definition : Prevention and alleviation of nausea.
- Activities : Perform complete assessment of nausea, including frequency, duration, severity, and precipitating factors, using such tools as Self-Care Journal, Visual Analog Scales, Duke Descriptive Scales, and Rhodes Index of Nausea and Vomiting (INV) Form 2
Rational : Identify the effect of nausea on the quality of life of the patient.

- Activities : Control environmental factors that may evoke nausea (e.g., aversive smells, sound, and unpleasant visual stimulation)
Rational : Helps avoid nausea and give comfort situation for patient

- Activities : Promote adequate rest and sleep to facilitate nausea relief
Rational : Rest to relieve nausea with its central action on the hypothalamus, encourage the patient to sleep 6-8 hours in one day.

- Activities : Encourage eating small amounts of food that are appealing to the nauseated person.
Rational : reduce the intake of excessive eating and avoid the nausea due to too full

- Activities : Provide information about the nausea, such as causes of the nausea and how long it will last
Rational : Helps reduce the anxiety of patients in the perception of nausea and gives strength to undergoing the treatment.

c. Relaxation Therapy [6040]
Definition : Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety

- Activities : Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging
Rational : Taking a deep breath in a slow way can also be one way to overcome and eliminate nausea, and do it repeatedly.

- Activities : Provide undisturbed time, because patient may fall asleep
Rational : sleep resting activity will overcome the nausea
"


50. ANNISA FIQIH ILMAFIANI

pada : 18 September 2017

"
Name : ANNISA FIQIH ILMAFIANI
NIM : 131611133045
Class : A1-2017
NURSING DIAGNOSE
1. Nursing Diagnosis (NANDA)
Number : 00146
Anxiety related to Threat of death.
Definition : Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with that threat.
2. Nursing Outcomes Classification
1) [1210] Fear Level
Definition : Severity of manifested apprehension, tension, or uneasiness arising from an identifiable source.
• 121001 Distress (5)
• 121020 sweating (5)
• 121026 Inability to sleep (5)
• 121034 Panic (5)
2) [2008] Comfort Status
Definition : Overall physical, psychospiritual, sociocultural, and environmental ease and safety of an individual.
• 200806 Social Support from family (5)
• 200807 Social support from friends (5)
• 200808 Social Relationship (5)
3) [2001] Spritual Health
Definition : Connectedness with self, others, higher power, all life, nature, and the universe that transcends and empowers the self
• 200101 Qualty of faith (5)
• 200102 Quality of hope (5)
• 200109 Ability to pray (5)

3. Nursing Intervention Classification
1) [5820] Anxiety Reduction
Definition : Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger.
- Intervention :
Use a calm, reassuring approach.
- Rational :
with a convincing approach, the patient will entrust his recovery to a nurse
- Intervention :
Encourage family to stay with patient, as appropriate.
- Rational :
by encouraging families to always accompany the patient. so patients feel more cared for by family. and so patients feel calm
- Intervention :
Listen attentively
- Rational :
When the nurse patient listening intently, making the patient feel comfortable andable to deliver what is wanted and felt
2) [5230] Coping Enhancement
Definition : Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere with meeting life demands and roles.
- Intervention :
Assist the patient in identifying appropriate short- and longterm goals.
- Rational :
Realize their short and lomgterm goals , making them have a goals in their life.
- Intervention :
Help patient to identify the information he/she is most interested in obtaining
- Rational :
with the help of information from the nurse. patients can find out what he knows. so the patient can get a lot of information
- Intervention :
Encourage patience in developing relationships
- Rational :
help passien in establishingrelationships with people around. so that patients can be more sociable

3) [5270] Emotional Support
Definition : Provision of reassurance, acceptance, and encouragement during times of stress
- Intervention :
Embrace or touch patient supportively.
- Rasionals :
with the support of, the patient felt more confidence. with the belief that patients will always obey the instructions of nurses.
- Intervention :
Assist patient in recognizing feelings, such as anxiety, anger, or sadness.
- Rasionals :
by expressing the feelings of the client, clients feel more relieved
- Intervention :
Stay with the patient and provide assurance of safety and security
during periods of anxiety
- Rasionals :
by becoming a friend of the patient in a time when anxios. Patients feel more safe and comfortable.


Bibliography

Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


51. Ni Putu Neni Indriyani

pada : 18 September 2017

"NAME : NI PUTU NENI INDRIYANI
NIM : 131611133031 – A1 2016
NURSING DIAGNOSIS
1. Nursing diagnosis (NANDA)
Nausea related to Treatment regimen [00134]
Definition : A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not result in vomiting.
(Domain 12. Comfort. Class 1. Physical Comfort)

2. Nursing Outcome Classification
After the nursing action in the time 5 until 7 days, expected client can achieve the results criteria:

a. Nausea & Vomiting Severity 2107
Definition : Severity of signs and symptoms of nausea, retching, and vomiting
Nausea & vomiting severity as evidenced by often demonstrating ability to:

1) [210701] Frequency of nausea (5)
2) [210704] Frequency of retching (5)
3) [210713] Weight loss (4)
4) [210720] Electrolyte imbalance (5)

b. Nutritional Status: Food & Fluid Intake [1008]
Definition : Amount of food and fluid taken into the body over a 24-hour period
Nutritional Status: Food & Fluid Intake as evidenced by often demonstrating ability to:
1) [100801] Oral food intake (5)
2) [100803] Oral fluid intake (5)
3) [100804] Intravenous fluid intake (5)

c. Anxiety Level [1211]
Definition : Severity of manifested apprehension, tension, or uneasiness arising from an unidentifiable source.
Anxiety Level as evidenced by often demonstrating ability to:
1) [121105] Uneasiness (5)
2) [121119] Increased blood pressure (5)
3) [121120] Increased pulse rate (5)
4) [121131] Change in eating pattern (5)


3. Nursing Intervetion Classification

a. Nutritional Monitoring [1160]
Definition : Collection and analysis of patient data pertaining to nutrient intake
- Activities : Weigh patient
Rational : measure the weight of patients with ideal body weight
BMI (according to WHO) : WB / (HBxHB)
Result :
IMT value = 30.0 = Very Fat

- Activities : Monitor for nausea and vomiting.
Rational : Know the symptoms when the patient feels nauseated or will vomit

- Activities : Monitor mental state (e.g., confusion, depression, and anxiety)
Rational : Avoid the patient anxiety about the treatment process because it will reduce the appetite.


b. Nausea Management [1450]
Definition : Prevention and alleviation of nausea.
- Activities : Perform complete assessment of nausea, including frequency, duration, severity, and precipitating factors, using such tools as Self-Care Journal, Visual Analog Scales, Duke Descriptive Scales, and Rhodes Index of Nausea and Vomiting (INV) Form 2
Rational : Identify the effect of nausea on the quality of life of the patient.

- Activities : Control environmental factors that may evoke nausea (e.g., aversive smells, sound, and unpleasant visual stimulation)
Rational : Helps avoid nausea and give comfort situation for patient

- Activities : Promote adequate rest and sleep to facilitate nausea relief
Rational : Rest to relieve nausea with its central action on the hypothalamus, encourage the patient to sleep 6-8 hours in one day.

- Activities : Encourage eating small amounts of food that are appealing to the nauseated person.
Rational : reduce the intake of excessive eating and avoid the nausea due to too full

- Activities : Provide information about the nausea, such as causes of the nausea and how long it will last
Rational : Helps reduce the anxiety of patients in the perception of nausea and gives strength to undergoing the treatment.

c. Relaxation Therapy [6040]
Definition : Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety

- Activities : Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging
Rational : Taking a deep breath in a slow way can also be one way to overcome and eliminate nausea, and do it repeatedly.

- Activities : Provide undisturbed time, because patient may fall asleep
Rational : sleep resting activity will overcome the nausea

Bibliography :
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


52. Verantika Setya Putri

pada : 18 September 2017

"Name : Verantika Setya Putri
Class : A1 2016
NIM : 131611133026

1. Nursing Diagnoses : Dysfunctional ventilator weaning response related to Insufficient knowledge of weaning process
Definition : inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning process. (00034)
(Domain 4. Activity/ Rest, Class 4. Cardiovascular/Pulmonary Responses)
2. Nursing Outcomes Classification
AIM: After getting 2 weeks of nursing action, the client is expected to achieve the results criteria :
 (0412) Mechanical Ventilation Weaning Response: Adult
Definition: Respiratory and psychological adjustment to progressive removal of mechanical ventilation

 (041202/4) Spontaneous respiratory rate
Rational : Spontaneous breathing will make the client more independent and does not require breathing equipment


 (041203/4) Spontaneous respiratory rhythm
Rational : The release of the ventilator is expected the client can breathe normally, seen from the spontaneous breathing rhythm


 (041204/4) Spontaneous respiratory depth
Rational : The release of ventilator is expected the client can breathe normally, seen from the depth of spontaneous respiration




 (1814) Knowledge: Treatment Procedure
Definition: Extent of understanding conveyed about a procedure required as part of a treatment regimen

 (181401/5) Treatment procedure
Rational : Knowing the existing handling procedures will ease the weaning process

 (181402/5) Purpose of procedure
Rational : Knowing the purpose of the procedure will make the client more confident in the weaning process

 (181403/4) Steps in procedure
Rational : Step procedure steps must be known by the client so that clients know what actions will be given

 (181405/4) Precautions related to procedure
Rational : Precautions need to be done in an effort to speed up the weaning process

3. Nursing Interventions Classification
 (3310) Mechanical Ventilatory Weaning
Definition: Assisting the patient to breathe without the aid of a mechanical ventilator

 Determine patient readiness for weaning (e.g., hemodynamically stable, condition requiring ventilation resolved, current condition optimal for weaning)
Rational : In the process of weaning required client readiness because the client no longer use breathing aids

 Monitor predictors of ability to tolerate weaning based on agency protocol (e.g., degree of shunt, vital capacity, Vd/Vt, MVV, inspiratory force, FEV1, negative inspiratory pressure)
Rational : Weaning process must go through several procedures to keep the patient in stable condition

 Monitor to assure patient is free of significant infection prior to weaning
Rational : Infection can cause bacterial development on the client ventilator so, we need to weaning

 (5230) Coping Enhancement
Definition: Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere with meeting life demands and roles

 Assist the patient in identifying appropriate short- and longterm goals
Rational : Appropriate long-term and short-term goals can help to ensure and maximize the process of ventilator weaning therapy in client

 Use a calm, reassuring approach
Rational : A quiet approach will make the patient feel protected and confident that everything said will be kept confidental

 Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes
Rational : Strategy in the positive will make the client more confident in living his life with the limitations that he has

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


53. FITRIANTI UMAYROH MAHARDIKA

pada : 18 September 2017

"NAMA : FITRIANTI UMAYROH MAHARDIKA
NIM : 131611133047
KELAS : A1 - 2016

NURSING DIAGNOSIS
1. Nursing Diagnosis (NANDA)
Death anxiety related to near-death experience.
Definition : Vague, uneasy feeling of discomfort or dread generated by perceptions
of a real or imagined threat to one’s existence.
(Domain 9. Coping/Stress Tolerance, Class 2. Coping Responses, Code. 00147)

2. Nursing Outsomes Classification
Aim : After the nursing action in the time 3x24 hours, expected client can achieve the results criteria :
1) [2007] Comfortable Death
Definition : Physical, psychospiritual, sociocultural and environmental ease with the impending end of life.
Comfortable Death as evidenced by often demonstrating ability to :
 [200701] calm effect (5)
 [200705] comfortable position(5)
 [200724] support from family (5)
 [200327] restlessness (4)
2) [2011] Comfort Status: Psychospiritual
Definition : Psychospiritual ease related to self-concept, emotional well-being, source of inspiration, and meaning and purpose in one’s life
Comfort Status: Psychospiritual as evidenced by often demonstrating ability to :
 [201101] Psychological well-being (5)
 [201103] hope (5)
 [201107] Expressions of optimism (5)
 [201113] anxiety (4)
 [201115] fear (5)

3) [1402] Anxiety Self-Control
Definiton : Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifable source.
Anxiety Self-Control as evidenced by often demonstrating ability to :
 [140201] Eliminates precursors of anxiety (4)
 [140207] Uses relaxation techniques to reduce anxiety (5)
 [140214] Maintains adequate sleep (4)
 [140217] Controls anxiety response (4)
3. Nursing Intervention Classification
1) [5820] Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentifed source of anticipated danger.
Intervention: Seek to understand the patient’s perspective of a stressful situation
Rasional : Understand the patient’s perspective of a stressful situation can provide social support to patients
Intervention : Stay with patient to promote safety and reduce fear
Rasional : By being on the patient side is expected the patient can feel safe and comfortable.
Intervention : Listen attentively
Rasional : Listen attentively is needed by the patient to provide psychosocial support to patients.
Intervention : Create an atmosphere to facilitate trust
Rasional : by increasing confidence in the client's expectations he is able to accept the situation
Intervention : Provide diversional activities geared toward the reduction of tension.
Rasional : diversional activities is needed by the patient to make the patient active and increase feelings of pleasure.
2) [5230] Coping Enhancement
Definition: Facilitation of cognitive and behavioral efforts to manage perceived stressors, changes, or threats that interfere with meeting life demands and roles
Intervention : Use a calm, reassuring approach
Rasional : calm and reassuring approach as needed in order to provide psychosocial support to patients
Intervention : Provide factual information concerning diagnosis, treatment, and prognosis
Rasional : Actual information is needed by the patient to face future
Intervention : Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness
Rasional : realistic hope is needed by the patient to increase confidence
Intervention : Encourage family involvement, as appropriate
Rasional : The family involvement is needed by the patient to increase life expectancy and desire to live.

3) [5424] Religious Ritual Enhancement
Definition : Facilitating participation in religious practices
Intervenstion : Identify patient’s concerns regarding religious expression (e.g., lighting candles, fasting, circumcision ceremonies, or food practices)
Rasional : religious expression is needed by the patient to reduce fear and make the heart calm.
Intervenstion : Encourage the use of and participation in usual religious rituals or practices that are not detrimental to health
Rasional : patient can reducing his fear of death with participation in usual religious rituals
Intervenstion : Listen and develop a sense of timing for prayer or ritual
Rasional : It is important that the patient can express his anxiety and his fear of death.


Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.
Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


54. Adelia Dwi Lailyvira Ramadhania

pada : 18 September 2017

"
NAMA : Adelia Dwi Lailyvira Ramadhania
NIM : 131611133005
KELAS : A1
NURSING DIAGNOSIS
1. Nursing Diagnosis (NANDA)
Nomor : 00103
Impaired swallowing related to behavioral feeding problem
Definition : Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
2. Nursing Outcomes Classification
1) [1918] Aspiration Prevention
Definition : Personal actions to prevent the passage of fluid and solid particles into the lung.
- 191804 Selects foods according to swallowing ability (5)
- 191805 Positions self on side for eating and drinking as needed (5)
- 191806 Selects food and fluid of proper consistency (5)
2) [1008] Nutritional Status: Food & Fluid Intake
Definition : Amount of food and fluid taken into the body over a 24-hour period
- 100801 Oral food intake (5)
- 100803 Oral fluid intake (5)
3) [1009] Nutritional Status: Nutrient Intake
Definition : Nutrient intake to meet metabolic needs 200101 Qualty of faith (5)
- 100901 Caloric intake (5)
- 100906 Mineral intake (5)
- 100910 Fiber intake (5)

3. Nursing Intervention Classification
1) [3200] Aspiration Precautions
Definition : Prevention or minimization of risk factors in the patient at risk for aspiration
- Intervention :
Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability
- Rational :
so that we can know the progress of the patient's condition, if in case of a decline in conditions we can make other plans
- Intervention :
Feed in small amounts
- Rational :
in order to prevent food being re-issued, but on a regular basis
- Intervention :
Cut food into small pieces
- Rational :
to make it easier to get into the digestion
2) [0840] Positioning
- Definition: Deliberative placement of the patient or a body part to promote physiological and/or psychological well being
- Intervention :
Place on an appropriate therapeutic mattress/bed
- Rational :
to facilitate the patient more comfortable
- Intervention :
Apply a footboard to the bed
- Rational :
a comfortable bed then makes the patient can be more comfortable with his position, it is expected the patient does not feel nauseous with a comfortable position
- Intervention :
Provide appropriate support for the neck
- Rational :
if there is aspiration in the food then keep the patient's personal hygiene, and immediately replace it with a new one
3) [1860] Swallowing Therapy
Definition: Facilitating swallowing and preventing complications of impaired swallowing.
- Intervention :
Provide/use assistive devices, as appropriate
- Rational :
aids for therapy so as to facilitate the nurse to teach the patient
- Intervention :
Monitor for signs and symptoms of aspiration
- Rational :
to see if the patient feels nauseated so that no aspiration occurs and the patient feels comfortable during the meal
- Intervention :
Monitor for sealing of lips during eating, drinking, and swallowing
- Rational :
to know the state of the patient during the meal and expected no more food aspirations

"


55. muhammad hidayatullah al muslim

pada : 18 September 2017

"Nama: Muhammad hidayatullah al muslim
Kelas: A1-2016

1.Nursing Diagnosis (NANDA)
Risk for impaired liver function releated substance abuse
(00178)
Definition:vulnerable to a decrease in liver function,which may compromise health.
(Domain 2. Nutrition. Class 4. Metabolism)

2. Nursing Outcome Classfication
1. liver function (0803)
definition: ability of the liver to manufacture,store,alter and secrete substances essential for metabolism and other body. (0803)
increase consciousness (080307) (5)
rationale: patients taking illegal drugs have a low level of consciousness as one of the side effects of the drug
increase stamina (080304) (5)
rationale: one of the side effects of using illegal drugs causes decreased body stamina
reduce tremor (080320) (5)
rationale: patients who take drugs will experience anxiety that causes tremor

2. Drug Abuse Cessation Behavior (1630)
Definition: personal actions to elimanate drug use that poses a threat to health (1630)
Expresses willingness to stop drug use (163001)
Rationale: if the patient already declared want to stop using drugs will facilitate the process of treatment
Expresses belief in the ability to stop drug use (163002)
Rationale: in the treatment of patients is expected to do a positive thing
Identifies benefits of eliminating harmful drug use (163003)
Rationale: educate patients about the harmful effects of drug use

3. Nursing Intervention Classfication
1. substance use treatment: Drug Withdrawal (4514)
Definition: Care of patient experiencing drug detoxification (4514)
Monitor vital signs
Rationale: to monitor the patient's condition on a regular basic
Monitor for changes in level of consciousness
Rationale: to monitor the patient's condition on a regular basic
Monitor for suicidal tendencies
Rationale: to prevent patient for doing suicidal

2.Substance Use Prevention (4500)
Definition: Prevention of an alcoholic or drug use lifestyle. (4500)
Assist individual to tolerate increased levels of stress, as appropriate
Rationale: increased stress can lead to patients wanting to take illegal drugs
Prepare individual for difficult or painful events
Rationale: to prevent the patient from experiencing excessive stress
Recommend responsible changes in the alcohol and drug and alcohol as recreational activities
Rationale: increased stress can lead to patients wanting to take illegal drugs

"


56. Rufaidah Fikriya

pada : 18 September 2017

"Name: Rufaidah Fikriya
NIM: 131611133018
Class: A1-2016

Nursing Diagnosis
1. Nursing Diagnosis (NANDA-I)
Risk for constipation related to Insufficient fluid intake (00015)
Definition: Vulnerable to a decrease in normal frequency of defecation accompa- nied by difficult or incomplete passage of stool, which may compromise health. (Domain 3. Elimination and Exchange Class 2. Gastrointestinal Function)

2.Nursing Outcome Classification
After the nursing action in the time 8 hours, expected client can achieve the results criteria:
1.(1622) Adherence Behavior: Healthy Diet
Definition: Self­initiated actions to monitor and optimize a balanced nutritional dietary regimen.
Adherence Behavior of Healthy Diet as evidenced by often demonstrating ability to:
• (162101) Sets achievable dietary goals
• (162111) Eats recommended servings of fruits per day
• (162115) Balances fluid intake and fluid loss
• (162116) Maintains hydration
2. (1411) Eating Disorder Self-Control

Definition: Personal actions to eliminate maladaptive behaviors and to adopt and maintain healthy eating patterns and optimum body weight
Eating Disorder Self-Control as evidenced by often demonstrating ability to:
• (141107) Follows a healthy eating plan
• (141110) Plans strategies for situations that a affect food and fluid intake
• (141115) Identifes daily food and fluid intake that meets nutritional needs
3. (1854) Knowledge: Healthy Diet
Definition: Extent of understanding conveyed about a balanced nutritious diet
Knowledge of Healthy Diet as evidenced by often demonstrating ability to:
• (185404) Fluid intake appropriate for metabolic needs
• (185417) Recommended daily fruit servings
• (185418) Recommended daily vegetable servings

3. Nursing Interventions Classification
1. (4120) Fluid Management
Definition: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
Intervention: Maintain accurate intake and output record

Rational: to know about the patient’s fluid balance
Intervention: Monitor vital signs, as appropriate
Rational: blood pressure and body temperature can be indication that indicate fluid balance
Intervention: Give fluids, as appropriate

Rational: help patient reach their goal of fluid intake a day


2. (4130)Fluid Monitoring

Definition: Collection and analysis of patient data to regulate fluid balance
Intervention: Determine history of amount and type of fluid intake and elimination habits
Rational: to know if the risk of constipation caused by patient’s habbits
Intervention: Monitor intake and output
Rational: to keep patient’s fluid balance
Intervention: Audit intake and output graphs periodically to ensure good practice patterns
Rational: help both of nurse and patient to know the progress
3. (5246) Nutritional Counseling
Definition: Use of an interactive helping process focusing on the need for diet modi cation
Intervention: Determine patient’s food intake and eating habits

Rational: patient’s eating habbits help the nurse to calculate patient’s fluid intake
Intervention: Discuss nutritional requirements and patient’s perceptions of prescribed/recommended diet
Rational: patient’s perceptions considered to make diet program
Intervention: Discuss patient’s food likes and dislikes

Rational: patient’s food like increases obedience
Intervention: Discuss food buying habits and budget constraints

Rational: diet plan must be adapted with patient’s finance

Bibliography
Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.

Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver.

Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


57. Marcelien Putri Chrisdianti

pada : 18 September 2017

"Nama: Marceline Putri Chrisdianti
Kelas : A1
NIM : 131611133023

Situasional Low Self-Esteem related to alteration in body image
Definition : Development of a negative perception of self worth in response to a current situation
NOC (Nursing Outcomes Classification):
1. Body Image (1200)
• (120001) Internal picture of self (5)
• (120005) Satisfaction with body appearance(5)
• (120007) Adjustment to changes in physical appearance (5)
• (120017) Attitude toward using strategies to enhance function(5)
• (120002) Congruence betwwen body reality, body ideal, and body presentation (5)
2. Coping (1302)
Definisi : tindakan pribadi untuk mengelola stres yang membebani kemampuan individu
• (130201) Identifies Effective Coping Petterns (5)
• (130204) Reports decrease in Stress (5)
• (130207) modifies lifestyle to reduce stress (5)
• (130208) Adapts to life changes(5)
• (130212) Uses effective coping strategies (5)
NIC (Nursing Intervention Classification)
1. Improved Body Image
Intervention:
1) the use of anticipatory guidance with predicted changes in the personality of the body
Rational: Patient is ready to accept changes to body image
2) Help the patient to cope with the developing stressors of self-image associated with congenital conditions, injury, illness or surgery
Rational: Patients may receive stress or stress symptoms
3) Help the patient to. Body parts that have positive perceptions related to the physical
Rational: Patients can live confidently or not
4) Assist patients for action actions that will enhance self-appearance
Rational: The patient keeps the activity normal
5) Determine expectations of the patient's self-image on development
Rationale: Prepare the patient in the stage of development that occurred

2. Increased Coping
Intervention:
1) Help the patient to break down complex goals into smaller ones with manageable steps
Rational: Reduce stress levels in patients
2) Support the relationship of patients with people who have the same interests and goals
Rational: relieve pasie
3) Help the patient to solve the problem in a constructive way
Rational: the patient can easily solve the problem
4) Patient support for. Relating to changes in roles
Rational: preparing patients for change
5) Pebble atmosphere acceptance
Rational: provide support for patients to receive easily



"


58. Marcelien Putri Chrisdianti

pada : 18 September 2017

"Situasional Low Self-Esteem related to alteration in body image
Definition : Development of a negative perception of self worth in response to a current situation
NOC (Nursing Outcomes Classification):
1. Body Image (1200)
• (120001) Internal picture of self (5)
• (120005) Satisfaction with body appearance(5)
• (120007) Adjustment to changes in physical appearance (5)
• (120017) Attitude toward using strategies to enhance function(5)
• (120002) Congruence betwwen body reality, body ideal, and body presentation (5)
2. Coping (1302)
Definisi : tindakan pribadi untuk mengelola stres yang membebani kemampuan individu
• (130201) Identifies Effective Coping Petterns (5)
• (130204) Reports decrease in Stress (5)
• (130207) modifies lifestyle to reduce stress (5)
• (130208) Adapts to life changes(5)
• (130212) Uses effective coping strategies (5)
NIC (Nursing Intervention Classification)
1. Improved Body Image
Intervention:
1) the use of anticipatory guidance with predicted changes in the personality of the body
Rational: Patient is ready to accept changes to body image
2) Help the patient to cope with the developing stressors of self-image associated with congenital conditions, injury, illness or surgery
Rational: Patients may receive stress or stress symptoms
3) Help the patient to. Body parts that have positive perceptions related to the physical
Rational: Patients can live confidently or not
4) Assist patients for action actions that will enhance self-appearance
Rational: The patient keeps the activity normal
5) Determine expectations of the patient's self-image on development
Rationale: Prepare the patient in the stage of development that occurred

2. Increased Coping
Intervention:
1) Help the patient to break down complex goals into smaller ones with manageable steps
Rational: Reduce stress levels in patients
2) Support the relationship of patients with people who have the same interests and goals
Rational: relieve pasie
3) Help the patient to solve the problem in a constructive way
Rational: the patient can easily solve the problem
4) Patient support for. Relating to changes in roles
Rational: preparing patients for change
5) Pebble atmosphere acceptance
Rational: provide support for patients to receive easily
Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver
"


59. Marcelien Putri Chrisdianti

pada : 18 September 2017

"Nama : Marceline Putri Chrisdianti
NIM : 131611133023
Kelas : A1
Situasional Low Self-Esteem related to alteration in body image
Definition : Development of a negative perception of self worth in response to a current situation
NOC (Nursing Outcomes Classification):
1. Body Image (1200)
• (120001) Internal picture of self (5)
• (120005) Satisfaction with body appearance(5)
• (120007) Adjustment to changes in physical appearance (5)
• (120017) Attitude toward using strategies to enhance function(5)
• (120002) Congruence betwwen body reality, body ideal, and body presentation (5)
2. Coping (1302)
Definisi : tindakan pribadi untuk mengelola stres yang membebani kemampuan individu
• (130201) Identifies Effective Coping Petterns (5)
• (130204) Reports decrease in Stress (5)
• (130207) modifies lifestyle to reduce stress (5)
• (130208) Adapts to life changes(5)
• (130212) Uses effective coping strategies (5)
NIC (Nursing Intervention Classification)
1. Improved Body Image
Intervention:
1) the use of anticipatory guidance with predicted changes in the personality of the body
Rational: Patient is ready to accept changes to body image
2) Help the patient to cope with the developing stressors of self-image associated with congenital conditions, injury, illness or surgery
Rational: Patients may receive stress or stress symptoms
3) Help the patient to. Body parts that have positive perceptions related to the physical
Rational: Patients can live confidently or not
4) Assist patients for action actions that will enhance self-appearance
Rational: The patient keeps the activity normal
5) Determine expectations of the patient's self-image on development
Rationale: Prepare the patient in the stage of development that occurred

2. Increased Coping
Intervention:
1) Help the patient to break down complex goals into smaller ones with manageable steps
Rational: Reduce stress levels in patients
2) Support the relationship of patients with people who have the same interests and goals
Rational: relieve pasie
3) Help the patient to solve the problem in a constructive way
Rational: the patient can easily solve the problem
4) Patient support for. Relating to changes in roles
Rational: preparing patients for change
5) Pebble atmosphere acceptance
Rational: provide support for patients to receive easily
Bibliography :
1. Herdman, T.H. & Kamitsuru, S. (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. 10nd ed. Oxford: Wiley Blackwell.
2. Moorhead, S., Jhonson, M., Maas, M., & Swanson, L. (2013). Nursing Outcomes Classification (NOC). 5th ed. United states of America: Mosby Elseiver
3. Dochteran, J. M., & Bulechek, G. M. (2013). Nursing Interventions Classification (NOC). 6th ed. America: Mosby Elseiver"


60. Charla

pada : 29 November 2017

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