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NANDA NIC & NOC A2

Silakan kumpulkan DL nya disini.


1. Lukmania Andriani Putri

pada : 18 September 2017

"Number: 00047
Diagnosis: Risk of Damage to skin integrity

Definition: Changes in the epidermis and dermis
Related factors
External (environment)
• Chemicals
• Humidity
• Hyperthermia
• Hypothermia
• Mechanical factors (truncated, depressed, restrained)
• Drugs
• Skin moisture
• Physical immobilization
• Radiation

Internal (somatic)
• Changes in fluid status
• Changes in pigmentation
• Turgor changes
• Developmental factors
• Nutrition imbalances
• Immunologic deficit
• Circulatory disorders
• Metabolic status disorders
• Disturbance of sensations
• Bony protrusion
Factor development
• Age of young or old exterm


Limitations of characteristics

Objective
• Damage to the skin layer
• Damage to the skin surface
• Invasion of body structure


Results & NOC

NOC:
• Local allergic response; the severity of local immune hypersensitivity to certain environmental antigens
• Access to haemodynamics; functioning of access dialysis area
• Network integrity: skin and mucous membrane; the complete structure and function of normal physiological skin and mucous membranes
• Wound healing: primary; the rate of cell and tissue regeneration after a suspended closure
• Wound healing: secondary; level of cell and tissue regeneration in open wounds

Objectives and evaluation criteria
• Demonstrate tissue integrity: skin and mucous membranes, as well as primary and secondary wound healing, as evidenced by the following indicator:

1. Exterminal disorders
2. heavy
3. medium
4. light
5. no interruption

Indicator 1 2 3 4 5
Temperature, elasticity, hydration and sensation
Network perfusion
Whole skin
Erythema of surrounding skin
The wound smells rotten
Granulation
The formation of scar tissue
Wound shrinkage

• shows the primary wound healing, as evidenced by the following indicator:

1. no
2. a little
3. medium
4. many
5. very much

Indicator 1 2 3 4 5
Skin union
The union of the wound tip
The formation of scar tissue

Pasian will:
• demonstrate optimal skin care or wound care routines
• purulent drainage or minimal wound odor
• no blisters or maceration on the skin
• necrosis, selumur, hole, extension of skin tissue injury, or decreased or absent sinus channel formation
• skin erythema and erythema around minimal wounds


NIC Intervention

See also maintenance activity at the risk of damage to skin integrity

Assessment
• review the functions of tools, such as pressure reduction devices
• incision area treatment (NIC): inspection of redness, swelling or signs of dehisensi or evisceration in the incision area
• wound care (NIC): wound inspection on every dressing
• examine the characteristics of the wound:
• location, breadth and depth
• the presence and character of the exudate, including viscosity, color and odor
• whether or not granulation or epithelialisation is present
• presence or absence of necrotic tissue. Describe the color, baud an number
• presence or tadaknya signs of local wound infection
• the presence or absence of widespread tissue injuries and the formation of sinus ducts

counseling for patients and families
• teach wound care of the surgical incision, including signs and symptoms of infection, how to keep the incision wound dry while bathing, and reduce the emphasis on the area of ​​the incision

collaborative activities
• consult a nutritionist about foods high in protein, minerals, calories and vitamins
• consult a doctor about the implementation of feeding and enteral or parenteral nutrition to increase the potential for wound healing
• refer to enterostma therapy nurse for assistance in assessment, discovery of degree of injury, and documentation of wound care or skin damage
• wound care (NIC): use TENS units to improve wound healing, if necessary

other activities
• the evasiation of treatment measures or topical dressings which may include hydrocolloid dressings, hydrophilic bandages, absorgen dressings and so on
• regular wound or skin care such as:
• change and adjust the patient's position frequently
• keep the surrounding tissue free of drainage and excessive moisture
• Protect patients from contamination of feces or urine
• Protect the patient from excretion of other wounds and drain hose in the wound
• clean and wound the surgical wound area using the following sterile principles or medical precautions, if necessary:
• use disposable gloves
• clean the incision area from the clean area to the dirty using one screen or one side of the screen on each sweep
• clean the area around the stitches or staples by using sterile cotton swabs
• clear around drainage ends, move with rotary motion from center out
• use antiseptic exposure, according to the program
• replace bandages at appropriate time intervals or leave the wound open as per the program
• wound care (NIC):
• remove the palutan and plaster
• wipe with normal saline or nontoxic cleanser, if necessary
• place the area lu"


2. Asih Parama Anindhia

pada : 18 September 2017

"NAMA: ASIH PARAMA ANINDHIA
NIM: 131611133075

NANDA: Sleep deprivation is releted to environmental barrier (domain 4, class 1, 00096)
Definition: prolonged periods of time without sleep (sustained natural, periodic of suspension of relative consciousness)

NOC:
0004 Sleep
Definition: natural periodic suspension of consciousnessduring which the body is restored

Linked with prolonged discomfort
2009 Comfort Status: Environmental
Definition: Environmental ease, comfort, and safety of surroundings

Rational of NOC choosen:
1. Patient is expected to increase quality and quantity of sleep after 24 hours that indicated by (5)
2. Patient is expected to produced indicator (5) that consistenly shows compromised status increase from substantially compromised to not compromised by modification environment and monitor the comfort status, after 24 hours.

NIC
1850 Sleep Enchancement
Definiton: Facilitation of regulary sleep or wake cycles
6482 Environmental Management: Comfort
Definition: Group care activities to minimize number of awakenings; allow for sleep cycles of at least 90 minutes

Rational of NIC choosen:
1. Determine patient’s sleep/activity pattern.
2. Monitor/record patient’s sleep patern and number of sleep hours.
3. Monitor patient sleep pattern and note physical and/or psychological circumstance that interrupt sleep.
4. Monitor participation in fatigue-producing activities during wakefulness to prevent overtiredness.
5. Encourage patient to stablish a bedtime routine to facilitate transition from wakefulness to sleep.
6. Assist to eliminate stressful situations before bedtime.
7. Assist patient to limit daytime sleep by providing activity that promotes wakefulness, as appropriate.
8. Group care activities to minimize number of awakenings; allow for sleep cycles of at least 90 minutes.
9. Prevent unnecessary interruptions and allow for rest period
10. Create a calm and supportive environment.
11. Provide a safe and clean environment.
12. Determine sources of discomfort, such as damp dressings, positioning of tubing, constrictive dressings, wrinkled bed linens, and environmental irritants.
13. Adjust room temperature to that most comfortable for the individual, if possible."


3. Galang Hasfiansyah

pada : 18 September 2017

"NAMA : Galang Hashfiansyah
NIM : 131611133051
KELAS : A2-2016

1. Nursing Diagnosis (NANDA)
Nomor: 00103
Impaired swallowing related to Respiratory condition
Definition: Abnormal functioning of the swallowing mechanism associated with
deficits in oral, pharyngeal, or esophageal structure or function.
2. Nursing Outcomes Classification (NOC)
1. [1010] Swallowing Status
Defnition: Safe passage of fluids and/or solids from the mouth to the stomach
- 101010 Timely swallow reflex (5)
- 101015 Maintains neutral head and trunk position (5)
- 101016 Food acceptance (5)
2. [1918] Aspiration Prevention
Definition : Personal actions to prevent the passage of fluid and solid particles into the lung.
- 191804 Selects foods according to swallowingability (5)
- 191805 Positions self on side for eating anddrinking as needed (5)
- 191806 Selects food and fluid of properconsistency (5)
3. [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. Nursing Intervention Classification (NIC)
1. [3160] Airway Suctioning
Defnition: Removal of secretions by inserting a suction catheter into the patient’s oral, nasopharyngeal, or tracheal airway.
Intervention:
Determine the need for oral and/or tracheal suctioning
Rational:
so that patients more comfortable in receiving food and no longer expected the aspiration of food
Intervention:
Auscultate breath sounds before and afer suctioning
Rational:
to know how the development of the patient's respiratory system before taking action
Intervention:
Inform the patient and family about suctioning
Rational:
so that the family understands the importance of suction for the patient

2. [3200] Aspiration Precautions
Definition : Prevention or minimization of risk factors in the patient at risk for aspiration
Intervention:
Keep tracheal cuff inflated, as appropriate
Rational:
if the patient has aspirations so that the patient's body is not affected
Intervention:
Feed in small amounts
Rational:
to avoid the aspirations of food to give food in small amounts but in the period often
Intervention:
Cut food into small pieces
Rational:
to make it easier for patients to eat

3. [0840] Positioning
Definition: Deliberative placement of the patient or a body part to promote physiological and/or psychological well being
Intervention:
Monitor oxygenation status before and afer position change
Rational:
so we know the progress of the patient's breathing
Intervention:
Position in proper body alignment
Rational:
so that the patient can regulate breathing while eating
Intervention:
Encourage the patient to get involved in positioning changes, as
Appropriate
Rational:
so that patients more cooperative to the nurse"


4. Ema Yuliani

pada : 18 September 2017

"Diagnosis: fatigue related to increase in physical exertion as evidenced by tirednes



NOC: Rasional
Fatigue: Disruptive Effects
: client will not happened decreased energy
: client will not happened interference with activities of daily living
: client will not happened impaired physical activity
Activity Tolerance
: client happened ease of perfoming activities of daily living
Endurance
: client can performance of usual routine
: clien can perform energy restored after rest



NIC:Rasional
Exercise Promotion
: Appraise individual’s health beliefs about physical exercise
: Explore barriers to exercise
: Assist client to develop an appropriate exercise program to meet needs
: Perform exercise activities with client, as appropriate
: Include family/caregivers in planning and maintaining the exercise program
: Instruct client about desired frequency, duration, and intensity of the exercise program
: Instruct client about conditions warranting cessation of or alteration in the exercise program
: Provide positive feedback for client’s efforts
Nutrition Management
:Assist patient in determining guidelines or food pyramids (e.g., Vegetarian Food Pyramid, Food Guide Pyramid, and Food Pyramid for Seniors Over 70) most suited in meeting nutritional needs and preferences
Activity Therapy
: Collaborate with occupational, physical, or recreational therapists in planning and monitoring an activity program, as appropriate
: Suggest client about methods of increasing daily physical activity, as appropriate


"


5. Konita Shafira

pada : 18 September 2017

"00041
Latex Allergies Respons
Definition : a hypersensitive reaction to natural lateks rubber product
Associated with hipersensitivity to natural latex rubber proteein with edema
NOC :
Respon alergi lokal
1. Localized edema 1 2 3 4 5
2. Localized pain 1 2 3 4 5
NIC :
Allergy Management
• Environmental Management
• Environmental Risk Protection
Latex Precautions
• Medication Administration
• Medication Administration: Skin
• Risk Identification
• Skin Surveillance
• Teaching: Individual
• Vital Signs Monitoring
Additional Optional Interventions:
• Anaphylaxis Management
• Code Management
• Fluid Management
• Intravenous (IV) Insertion
• Intravenous (IV) Therapy
Rasional :
1. Reduce allergic pain and soreness by doing environmental management
2. Teach how to care for allergies to yourself
3. Reduce edema in body parts
4. Minimize the occurrence of the same allergy
5. Vital signs to measure and monitor body temperature as one sign of the occurrence of allergies
"


6. Fatatin Nazhifah

pada : 18 September 2017

"Name : Fatatin Nazhifah
NIM : 131611133089
Class : A2

Domain 12. Comfort
Class 3. Social Comfort
00053
1982

Nursing Diagnoses :
Social Isolation : withdrawn from around environment built on lack of self confidence


NANDA / Diagnosis :
Social Isolation

Definition :
Alonesness experienced by the individual and perceived as imposed by other and as a negative or threatening state.

NOC / Outcome:
1. The patient will acknowledge social isolation and identify its causes
2. The patient will verbalize a willingness to seek to end his social isolation
3. The patient will formulate a plan to become more involved with other
4. The patient will become involved in activities with others
5. The Patient will have consistent life motivation
6. The patient axiety will decrease
7. The patient have good confidence and self-esteem.
8. Decrease patient’s stress
9. Family Support

Reational NOC / Outcome :
1. The patient realize with her weakness so he can repair it or solve her problem.
2. With the patient’s confession, nurse know patient’s problem so nurse can help looking for the solutions.
3. Nurse and the patient will on the make success the plan together
4. The problem of social isolation done. The solution success in solve patien’s problem.
5. The patient have meaningfull, colorfull, and spiritfull life. He get his happily life.
6. The patient enjoy his life. He can confront all life challenge with restfull, calm, sober.
7. The patient have same right with other people.
8. Stress makes him have negative perception. Narrow his angle of view.
9. The family patient is people who near with the patient and life friend the patient all long time.

NIC / Intervention :
1. Builth trust relationship.
2. Focus on providing a supportive and consistent environment.
3. Open communication with honest feedback
4. Exploration of perceptions
5. Helping the individual identify the reasons for the isolation and ways to alleviate it.
6. Assist the patient identifying available social networks or in developing the skills.
7. Help the patient improving communication or meeting new people.
8. Assist in identifying acceptable social behaviors can enhance self-esteem and encourage repetition of those behaviors.
9. Give a social skills training program.
10. Variety of intervention including behavior modification techniques, mutual aid group, therapeutic groups, and multipurpose senior centers.
11. Encourage participation in appropriate diversional activity
12. Involvement with other
13. Plant realistic goals with patient
14. Give a knowledge of community resources
15. Support to maintain his or her independence
16. Assessment of the patient’s present social network
17. Enhancing the patien’s social network
18. Encorage of self-care activities and the promotion of functional independence

Rational NIC / Intervention :
1. The trust can help communication between nurse and the patient communicative, effective, comprehensive, complete so nursing care plant more appropriate
2. Help people gain convidence.
3. Builth trust relationship
4. Assist the patient in gaining an understanding about his or her feelings and responses in social situation.
5. This way can open knowledge the patient and try to give his other angle of view so he can wise to make dedicion.
6. This needed because practice needs other people. With the large netwoks, the skill will increase variated. So, he ready dan look full in face variety of people.
7. With this skill he have increased opportunities for and to achieve success in interpersonal involvements.
8. He have spirit and never give up. He keep hand in so he have this skill.
9. Helping improve social skills and decrease axiety in social situation.
10. Effective in decreasing social isolation. Thrnursing interventions that promote confidence and sharing will decrease loneliness and isolation.
11. Enhance the patient’s interaction with other
12. The first step in developing meaningful relationship
13. Recognizing that success may not be achieved immediately
14. Help individual when he has experience physical barriers to social contact
15. Assisntance is sometimes warranted.
16. Indicate the need for more support in a particular area
17. Limit feelings of isolation and help lessness and increase feelings of confidence and independence.
18. Fosters independent actions and decrease helplessness and isolation

Bibliography :
Herdman, T.H &Kamitsuru, S. (Eds.). (2014) NANDA International Nursing Disgnoses : Definitions & Classification, 2015-2017.Oxford : Wiley Blackwell.
McFarland, Geetrude K. and Elizabeth A. McFarlane. (1997). Nursing Diagnosis & Intervention Planning for Patient Care Third Edision. Missouri : Mosby-Year Book.
Moorhead, Sue, Marion Johnson, Meridean L. Maas, and Elizabent Swanson. (2013). Nursing Outcomes Classification (NOC), 5th Edition. EdisiBahasa Indonesia. Indonesia :Mocomedia.
Tim Pokja SDKI DPP PPNI. (2017). Standar Diagnosis Keperawatan Indonesia : DefinisidanIndikatorDiagnostik. DewanPengurusPusatPersatuanPerawatNasional Indonesia.
"


7. Grace Marcellina B

pada : 18 September 2017

"Name : Grace Marcellina B
NIM : 131611133061
Class : A2 2016
Nanda Nursing Diagnosis

Diagnosis : Deficient fluid volume (Domain 2. Nutrition, class 5. Hydration)
Related Factors : Active fluid volume loss
Definition : Decresea intravascular interstitial, and/or intracellular fluid.
this refers to dehydration, water loss alone without change in sodium.
outcomes to measure resolution of diagnosis :
1. to make patient's fluid balance
2. to make patient's hydration enough
3. patient ability to thermoregulation
4. patient skin and mucous membrane being well
5. patien urinary elimination being normal.
rational to noc chosen:
1. to make sure the fluid volume balance the things that can being seen is the patient ability
to thermoegulation
2. when the fluid was deficient the skin and mucous membrane would be dry, and when patient has
been given the intervation, hope that patien skin and mucous membrane can being well
3. when the fluin has been balance the urinary elimination would be better. there's no pain and
the colour would being brightened, and there's no need to used the urinary chatheter.
NIC :
1.Fluid/ eleectrolyte management (potassium, magnesium, kalsium)
2.Fluid monitoring
3. Vital sign monitoring
4. Urinary catheterization
rational to NIC chosen
1. when the fluid wad deficient, the electrolit ould being unnormal,
so beside manage the fluid, the thing that should be done is manage the electrolyte
2. monitoring the fluid, is the fluid already balance or not from the colour of urine, intensity of
urinary elimination, and the pain tha the patient feel when urin excretion
3. ask and checked is he patient ned to used the chatheter or not. "


8. khoirun niswatul ulfa

pada : 18 September 2017

"nama : khoirun Niswatul ulfa
nim : 131611133098
kelas : A2

Diagnosis
00066 Spiritual distress
Definition : a state of suffering related to the impaired ability to experience meaning in life through connections with self, other, the world, or a superior being.
Defining characteristics : Anxiety
Outcome
Spiritual distress
Definition : impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself.
1208 Depression level
Definition : severity of melancholic mood and loss of interest in life events
120801 maintain at Depressed mood increase to 5
120807 maintain at feeling of worthlessness increase to 5
120835 maintain at recurrent thoughts of death increase to 5
120814 maintain at sadness increase to 5
1402 Anxiety self control
Definition : personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source.
140201 maintain at Monitors intensity of anxiety increase to 5
140202 maintain at Eliminates precursors of anxiety increase to 5
140204 maintain at Seeks information to reduce anxiety increase to 5
140207 maintain at Uses relaxation techniques to reduce anxiety increase to 5

Intervention
Spiritual distress
Definition : impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself.
Emotional support

5270 Emotional support
Definition : provision of reassurance, acceptance, and encouragement during times of stress.
Discuss with the patient the emotional experience
Explore with patient what has triggered emotions
Listen to/encourage expressions of feeling and belief
Stay with the patient and provide assurance of safety and security during periods of anxiety

5820 Anxiety reduction
Definition : minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger
Help patient identify situations that precipitate anxiety
Instruct patient on the use relaxation techniques
Administer medications to reduce anxiety, as appropriate
Assess for verbal and nonverbal signs of anxiety

"


9. BLANDINA EASTER GRACE WAIRATA

pada : 18 September 2017

"1.NANDA Nursing Diagnosis
Chronic Low Self-Esteem related to repeated failures (1988, 1996, 2008; LOE 2.1)
Definiton: Longstanding negative self-evaluating/feelings about self or selfcapabilities

2.NOC Outcome Labels and indicators
Self-Esteem : Personal judgement of self worth (1205)
After 3 days of nursing intervention, the patient will be able to describe himself in pride and the level of confidence will increase to consistenly postive scale (5)

Rationale for NOC chosen and indicator score : The chronic low self-esteem patient may judge her or himself with no pride and over feel guilty caused his repeated failures. The patient will be unconfidence with his personal.

3.NIC Intervention labels and nursing activities

Self-Esteem Enhancement - Assisting patient to increase his or her personal judgement of self-worth (5400)
Activities:
-Encourage patient to engage in self-talk and verbalize positive affirmations to self daily
Rational : Verbalize positive affirmation needed to increase patient’s confidence.
-Reward or praise patient’s progress toward reaching goals
Rational : Helpful in making patient feel recognized in his environment and forget about repeated failures.
-Explore previous achievments of success
Rational : Help patient to find his strength and be more confidence.

Guilt Work Facilitation - Helping another to cope with painful feelings of actual or percieved responsibility (5300)
Activities:
-Help patient/family understand that guilt is common reaction to trauma, abuse, grief, catasthropic illness, or accidents.
Rational : To gain family’s support for coping based on personal strengths. Improves the patient’s self concepts.
-Facilitate spiritual support, as appropriate
Rational : Spiritual support may reduce stress in a personal. This support improves self concept and sense of personal ability to manage the patient’s guilty of the repeated failures."


10. Fatatin Nazhifah

pada : 18 September 2017

"Name : Fatatin Nazhifah
NIM : 1316111330789
Class : A2


Nursing Diagnoses :
Social Isolation : withdrawn from around environment built on lack of self confidence

Domain 12. Comfort
Class 3. Social Comfort
00053
1982

NANDA / Diagnosis :
Social Isolation

Definition :
Alonenes experienced by the individual and perceived as imposed by other and as a negative or threatening state

NOC / Outcome
1.The patient will acknowledge social isolation and identify its causes
2.The patient will verbalize a willingness to seek to end his social isolation
3.The patient will formulate a plan to become more involved with other
4.The patient will become involved in activities with others
5.The Patient will have consistent life motivation
6.The patient axiety will decrease
7.The patient have good confidence and self-esteem
8.Decrease patient’s stress
9.Family Support

Reational NOC / Outcome
1.The patient realize with her weakness so he can repair it or solve her problem.
2.With the patient’s confession, nurse know patient’s problem so nurse can help looking for the solutions
3.Nurse and the patient will on the make success the plan together
4.The problem of social isolation done. The solution success in solve patien’s problem.
5.The patient have meaningfull, colorfull, and spiritfull life. He get his happily life.
6.The patient enjoy his life. He can confront all life challenge with restfull, calm, sober.
7.The patient have same right with other people.
8.Stress makes him have negative perception. Narrow his angle of view.
9.The family patient is people who near with the patient and life friend the patient all long time.

NIC / Intervention
1.Builth trust relationship.
2.Focus on providing a supportive and consistent environment.
3.Open communication with honest feedback
4.Exploration of perceptions
5.Helping the individual identify the reasons for the isolation and ways to alleviate it.
6.Assist the patient identifying available social networks or in developing the skills.
7.Help the patient improving communication or meeting new people.
8.Assist in identifying acceptable social behaviors can enhance self-esteem and encourage repetition of those behaviors.
9.Give a social skills training program.
10.Variety of intervention including behavior modification techniques, mutual aid group, therapeutic groups, and multipurpose senior centers.
11.Encourage participation in appropriate diversional activitiea
12.Involvement with other
13.Plant realistic goals with patient
14.Give a knowledge of community resources
15.Support to maintain his or her independence
16.Assessment of the patient’s present social network
17.Enhancing the patien’s social network
18.Encorage of self-care activities and the promotion of functional independence

Rational NIC / Intervention
1.The trust can help communication between nurse and the patient communicative, effective, comprehensive, complete so nursing care plant more appropriate.
2.Help people gain convidence.
3.Builth trust relationship
4.Assist the patient in gaining an understanding about his or her feelings and responses in social situation.
5.This way can open knowledge the patient and try to give his other angle of view so he can wise to make dedicion.
6.This needed because practice needs other people. With the large netwoks, the skill will increase variated. So, he ready dan look full in face variety of people.
7.With this skill he have increased opportunities for and to achieve success in interpersonal involvements
8.He have spirit and never give up. He keep hand in so he have this skill.
9.Helping improve social skills and decrease axiety in social situation.
10.Effective in decreasing social isolation. Thr nursing interventions that promote confidence and sharing will decrease loneliness and isolation.
11.Enhance the patient’s interaction with other
12.The first step in developing meaningful relationship
13.Recognizing that success may not be achieved immediately
14.Help individual when he has experience physical barriers to social contact
15.Assisntance is sometimes warranted.
16.Indicate the need for more support in a particular area
17.Limit feelings of isolation and help lessness and increase feelings of confidence and independence.
18.Fosters independent actions and decrease helplessness and isolation

Bibliography :
Herdman, T.H & Kamitsuru, S. (Eds.). (2014) NANDA International Nursing Disgnoses : Definitions & Classification, 2015-2017. Oxford : Wiley Blackwell.
McFarland, Geetrude K. and Elizabeth A. McFarlane. (1997). Nursing Diagnosis & Intervention Planning for Patient Care Third Edision. Missouri : Mosby-Year Book.
Moorhead, Sue, Marion Johnson, Meridean L. Maas, and Elizabent Swanson. (2013). Nursing Outcomes Classification (NOC), 5th Edition. Edisi Bahasa Indonesia. Indonesia : Mocomedia.
Tim Pokja SDKI DPP PPNI. (2017). Standar Diagnosis Keperawatan Indonesia : Definisi dan Indikator Diagnostik. Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia."


11. Mutiara Citra Dewi

pada : 18 September 2017

"Name : Mutiara Citra Dewi
NIM : 131611133078
Class : A2 2016

NANDA
Activity intolerance related to fatigue
Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities
Domain 4. Activity intolerance related to fatigue,Class 4. 00094, Cardiovascular/pulmonary responses
NOC
A. Energy conservation
Definition : Personal actions to manage energy for initiating and sustaining activity
1. Balances activity and rest (000201/I) (5)
Rational : so that activities that have been done do not make excessive fatigue
2. Organizes activities to conserve energy (000209/I) (5)
Rational : conduct activities with due regard to their effectiveness

B. Rest
Definition : Quantity and pattern of diminished activity for mental and physical rejuvenation
1. Energy restored after rest (000309/I) (5)
Rational : every activity takes sufficient time to be able to restore energy by resting
2. Physically rested (000304/I) (5)
Rational : to be able to restore the condition of fatigue can do a physical break
NIC
A. Sleep Enhancement (1850)
Definition : Facilitation of regular sleep/wake cycles
1. Monitor participation in fatigue-producing activities during  wakefulness to prevent overtiredness
Rational : doing activities that do not cause excessive fatigue
2. Adjust environment (e.g., light, noise, temperature, mattress,  and bed) to promote sleep
Rational : provide a comfortable atmosphere in the room before bed, during sleep and after sleep to make the client comfortable and fresh again when waking up
B. Energy management (0180)
Definition : Regulating energy use to treat or prevent fatigue and optimize function
1. Assess patient’s physiologic status for deficits resulting in fatigue within the context of age and development
Rational : looking at the physical condition of patients based on their age because everyone has different fatigue level, although doing the same activity but the effect must be different
2. Determine patient/significant other’s perception of causes of fatigue
Rational : the patient can know the cause of fatigue and know how to overcome or prevent it in the future



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
"


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