NANDA NIC & NOC A2

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Komentar (55)

Novita Dwi Andriana15 September 2017

Name : Novita Dwi Andriana
NIM : 131611133116

"Constipation"

a. Definition
The decrease in normal defecation accompanied by stool expenditure is difficult and incomplete as well as dry and numerous stools.
b. Cause
Physiological
1. Decreased gastrointestinal motility
2. Incompleteness of tooth growth
3. Diet inadequacy
4. Inadequate fiber intake
5. Inadequate fluid intake
6. Aganglionic (eg Hircsprung disease)
7. Abdominal muscle weakness
Psychological
1. Confusion
2. Depression
3. Emotional Disorder
Situational
1. Changes in food habits (eg food type, food schedule)
2. Inadequate toileting
3. Daily physical activity is less than recommended
4. Laxative abuse
5. Epek pharmacological agents
6. Irregularity of the habit of defecation
7. The habit of resisting the impulse of defecation
8. Environmental change

c. Symptoms and Major Signs

Subjective Objective :
1. Defecation is less than 2 kaliseminggu
2. Expenditure of old and difficult stool 1. Feces hard
2. Peristatic bowel decreases

d. Symptoms and Minor Signs

Subjective Objective :
1. Mengejan moment defekasi 1. Abdominal distension
2. Common weakness
3. Feel the mass on the rectal

e. Clinically Related Conditions

1. Lesions / injuries to the spinal cord
2. Spina bifida
3. Stroke
4. Multiple sclerosis
5. Parkinson's disease
6. Dementia
7. Hyperparathyroidism
8. Hypoparathyroidism
9. Electrolyte imbalances
10. Hemorrhoids
11. Obesity
12. Postoperative bowel obstruction
13. Pregnancy
14. Prostate enlargement
15. Rectal abscess
16. Anorectal fissure
17. Anorectal stricture
18. Rectal prolapse
19. Rectal ulcers
20. Rectocele
21. Tumors
22. Hircsprung disease
23. Impaction of feces


Constipation (00011) associated with irregular defecation habits Definition: Decreased normal frequency of defecation accompanied by difficulties or removal of incomplete and / or stool feces and / or stools,
Domain: 3
Grade : 2

NOC
Aim :
After the patient's nursing action shows no signs and signs of irregular / defective defects at least 2 to 3 times; a. The elmination pattern is not disturbed
b. The controller will be normal colon
c. There is no constipation


NIC
1. Self-care assistance: Elimination: a. Create elimination activities, appropriately and as needed, b. Create an activity schedule related to elimination, appropriately, c. Help the patient to the toilet or elsewhere for elimination at intervals.
2. 2. Management of GI tract: a. Teaches patients about certain foods that support order (activityusus), b. Start a gastrointestinal exercise program, in the right way.
3. Nutrition Management: a. Encourage patients to be associated with specific dietary needs based on progression or age (increased fiber intake to cope with constipation), b. Make sure the diet includes foods high in fiber content to overcome constipation.




REFERENCE

1. a, b. Organize and supervise elimination so as to observe the progress , c. aids the mobilization of patients to easily meet the needs of regular elimination .
2. a. To stabilize intestinal activity; b.to achieve normal motion control faster;
3. a. to meet the fiber needs to overcome the problem of constipation;
b. accelerate healing by consuming fibrous foods.
Daftar Pustaka :
Tim Pokja SDKI DPP PPNI.(2016).Standart Diagnosis Keperawatan Indonesia. Jakarta: Dewan Perawat Nasional Indonesia.
Bulechek , Gloria M dkk. Nursing Intervension Clasification (NIC), Ed.10. Indonesia
Moorhead,Sue dkk.Nursing Outcomes Clasification (NOC) pengukuran Outcomes Kesehatan . Ed. 5 . Indonesia

Eka Hariyanti16 September 2017

[Eka Hariyanti-131611133076/A2]
STANDARDIZED NURSING LANGUAGE
 The reason why introduce standardized language at the undergraduate level are:
• Creates an awareness of Nursing Language
• Supports the learning of the nursing process
• Provides consistency between practicum
• Develops critical thinking skills
• Improves Communication
• Research Based

 Components of Nursing Language:
1. NANDA: Nursing Diagnosis: Definitions and Classification
A nursing diagnosis is defined as “a clinical judgment about an individual, family or community responses to actual and potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”(NANDA, 2009)
 Components of a Nursing Diagnosis:
a. Label or Name and definition
b. Related Factors OR Risk Factors
c. Defining Characteristics
 Definition of the label: At increased risk for being invaded by pathogenic organisms
 Risk Factors:
-Insufficient knowledge to avoid exposure to pathogens (developmental level)
-Inadequate secondary defenses (leukopenia)
-Inadequate primary defenses (broken skin from newly placed central line)
-Pharmaceutical Agents (immunosuppressant, i.e. chemotherapy)
(NANDA,2009)

2. NIC: Nursing Interventions Classification
“The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.” (Iowa Intervention Project, 2008)
Definition: “any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” (Iowa Intervention Project, 2000,p.3)
 Components :
a. Name or label
b. A definition
c. A set of activities the nurse does to carry out the intervention


3. NOC: Nursing Outcomes Classification
The nursing outcomes classification (NOC) is a classification of nurse sensitive outcomes
NOC outcomes and indicators “allow for measurement of the patient, family, or community outcome at any point on a continuum from most negative to most positive and at different points in time.” ( Iowa Outcome Project, 2008)
 Components:
a. A neutral label or name used to characterize the behavior or patient status
b. A list of indicators that describe client behavior or patient status.
c. A five point scale to rate the patient‘s status for each of the indicators



Elyn Zoegestyn16 September 2017

NAMA : ELYN ZOEGESTYN
NIM : 131611133088
Nursing Diagnosis : Perceived Constipation (00012) (1988)
Definition : Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories to ensure a daily bowel movement.
Defining characteristics :
1. Subjective : expectation of a daily bowel movement, expected passage of stool at same time every day
2. Objective : overuse of laxatives, enemes, and suppositories (to induce a daily bowel movement)
Related Factors : cultural and family health beliefs, faulty appraisal (of normal bowel function), impared thought processes
NOC Outcome Label(s) and Indicators:
- 101503 Frequency of stools = 3 (moderately compromised)
- 101505 Consistency of stool = 4 (mildly compromised)
- 101536 Constipation = 3 (moderate)
Rationale for NOC chosen and Indicator score :
- The patient has normal frequency of stools
- The patient has normal consistency of stool
- The patient no constipation

NIC Intervention Label(s) and Nursing Activities:
Constipation/ Impaction Management (0450)
- Monitor bowel movement, including frequency, color, consistency, shape, and volume of stool
- Note preexistent bowel problems, bowel routine, and use of laxatives
- Encourage decreased gas-forming food intake, as appopriate

Fadilah Ramadhan Mushab Rahman17 September 2017

NAME: Fadilah Ramadhan Mush'ab Rahman
STUDENT ID NUMBER: 131611133080
CLASS: A2

Nursing Diagnostic: Pain, Acute (00132) (1996)

Definition: Unpleasant sensory and emotional experience arising from 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 and a duration of less than 6 months.

Defining Characteristics:
- Subjective: Verbal or coded report
- Objective: Antalgic positioning to avoid pain, Autonomic change
in muscle tone (may span from listless to rigid), Autonomic
responses, Changes in appetite and eating, Distraction behavior,
Expressive behavior, Facial mask, Guarding or protective
behavior, Narrowed focus.

NOC Outcomes:
- Comfort Level: Feelings of physical and psychologic ease
- Pain Control: Personal actions to control pain
- Pain: Disruptive Effects: Observed or reported disruptive effects
of pain on emotions and behavior
- Pain Level: Severity of reported or demonstrated pain.

Goals/Evaluation Criteria:
a. Demonstrates Pain: Disruptive effects, as evidenced by the
following indicators (specify 1-5: severe, substantial,
moderate, slight, or none):
- Impaired role performance or interpersonal relationships
- Compromised work, life enjoyment, or sense of control
- Impaired concentration
- Disrupted sleep
- Lack of appetite or difficulty eating
b. Demonstrates Pain Level, as evidenced by the following
indicators (specify 1-5: severe, substantial, moderate, slight,
or none):
- Oral or facial expressions of pain
- Protective body positions
- Restlessness or muscle tension
- Change in respiratory rate, heart rate, or blood pressure

NIC Interventions:
- Analgesic Administration: Use of pharmacologic agents to reduce
or eliminate pain
- Conscious Sedation: Administration of sedatives, monitoring of
the patient’s response, and provision of necessary physiologic
support during a diagnostic or therapeutic procedure
- Medication Management: Facilitation of sale and effective use of
prescription and over-the-counter drugs
- Pain Management: Alleviation of pain or a reduction in pain to a
level of comfort that is acceptable to the patient
- Patient-Controlled Analgesia (PCA) Assistance: Facilitating
patient control of analgesic administration and regulation

Rational for NIC:
- To know the patient's pain level
- To know the level of discomfort felt by the patient
- To distract the patient from the pain
- To find out if the pain felt by the client affects the others
- To reduce the factors that can aggravate the pain felt by the
client

Fajrinandetya P17 September 2017

Nama : Fajrinandetya Paramita
NIM : 131611133082
Kelas : A2 - 2016

NANDA : Rape-trauma syndrome
Rape-trauma syndrome : sustained maladaptive response to a forced, violent, sexual penetration against the victim's will and consent.
Defining characteristics :
1. Low self-esteem
2. Shame
3. Self-blame
4. Embarrassment
5. Humiliation
Related factors : rape

NOC : Self-esteem
Self-esteem : personal judgment of self-worth
outcome overall rating :
1. Verbalizations of self-acceptance (120501) 1,2,3,4,5
2. Acceptance of self-limitations (120502) 1,2,3,4,5
3. Description of self (120505) 1,2,3,4,5
4. Confidence level (120511) 1,2,3,4,5
5. Description of pride in self (120518) 1,2,3,4,5

NIC : self-esteem enhancement
Self-esteem enhancement : assisting a patient to increase his or her personal judgment of self-worth
Activities :
1. Monitor patient's statements of self-worth
2. Determine patient's locus of control
3. Determine patient's confidence in own judgment
4. Encourage patient to identify strengths
5. Assist patient to find self-acceptance

RATIONAL :
1. to know the patient describes them self-esteem
2. to find out if the patient has a low-susceptible gene
3. to encourage confident patients
4. to rebuild the patient's own strengths
5. for the patient to accept them self

Sabila Nisak17 September 2017

Number : 00054
Diagnose : Risk for loneliness related by Social Isolation
Definition : Vulnerable to experiencing discomfort associated with a desire or need for more contact with others, which may compromise health

NOC :
1216 Social Anxiety Level
Definition : Severity of irrational avoidance, apprehension, and distress in anticipation of or during social situation
1= Severe thru 5= None
121601 Avoidance of social situations 1 2 3 4 5
121604 Anxious anticipation of social situations 1 2 3 4 5
121607 Negative self-perceptions of social skills 1 2 3 4 5
121612 Discomfort during social encounters 1 2 3 4 5
121615 Panic symptoms in social situations 1 2 3 4 5

NIC :
4362 Behaviour Modification: Social Skills
• Assist patient to identify interpersonal problems resulting from social skill deficits
• Encourage patient to verbalize feelings associated with interpersonal problems
• Assist patient to identify desired outcomes for problematic interpersonal relationships or situations
• Assist patient to identify possible courses of action and their social/interpersonal consequences
• Identify a specific social skill(s) that will be the focus of training
• Assist patient to identify the behavioral steps for the targeted social skill(s)
• Provide models who demonstrate the behavioral steps in the context of situations that are meaningful to the patient
• Assist patient to role play the behavioral steps
• Provide feedback (e.g., praise or rewards) to patient about performance of targeted social skill(s)
• Educate patient’s significant others (e.g., family, peers, employers), as appropriate, about the purpose and process of social skills training
• Involve significant others in social skills training sessions (e.g., role play) with patient, as appropriate
• Provide feedback to patient and significant others about the appropriateness of their social responses in training situations
• Encourage patients/significant others to self-evaluate outcomes of their social interactions, self-reward for positive outcomes, and problem solve less desirable outcomes

Rationale for NIC chosen :
To familiarize client with socializing
To reduce the feeling of not confidence, panic and discomfort in social situations
To educate the procedures in social situations

Fajrinandetya P17 September 2017

Nama : Fajrinandetya Paramita
NIM : 131611133082
Kelas : A2 - 2016

NANDA : Rape-trauma syndrome
Rape-trauma syndrome : sustained maladaptive response to a forced, violent, sexual penetration against the victim's will and consent.
Defining characteristics :
1. Low self-esteem
2. Shame
3. Self-blame
4. Embarrassment
5. Humiliation
Related factors : rape

NOC : Self-esteem
Self-esteem : personal judgment of self-worth
outcome overall rating :
1. Verbalizations of self-acceptance (120501) 1,2,3,4,5
2. Acceptance of self-limitations (120502) 1,2,3,4,5
3. Description of self (120505) 1,2,3,4,5
4. Confidence level (120511) 1,2,3,4,5
5. Description of pride in self (120518) 1,2,3,4,5

RATIONAL NOC :
1. to know how far patien's verbalizations of self-acceptance
2. To make sure that patient had acceptance of self-limitations
3. To know patient know them self
4. To know that patient had confidence in their self
5. To know that patient had pride in self

NIC : self-esteem enhancement
Self-esteem enhancement : assisting a patient to increase his or her personal judgment of self-worth
Activities :
1. Monitor patient's statements of self-worth
2. Determine patient's locus of control
3. Determine patient's confidence in own judgment
4. Encourage patient to identify strengths
5. Assist patient to find self-acceptance

RATIONAL NIC:
1. to know the patient could describes them self-esteem
2. to find out if the patient has a low-susceptible gene
3. to encourage confident patients
4. to rebuild the patient's own strengths
5. for the patient to accept them self

Elyn Zoegestyn17 September 2017

NAMA : ELYN ZOEGESTYN
NIM : 131611133088
Nursing Diagnosis : Perceived Constipation (00012) (1988)
Definition : Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories to ensure a daily bowel movement.
Related Factors : cultural and family health beliefs, faulty appraisal (of normal bowel function), impared thought processes
NOC Outcome Label(s) and Indicators:
- 101503 Frequency of stools = 3 (moderately compromised)
- 101505 Consistency of stool = 4 (mildly compromised)
- 101536 Constipation = 3 (moderate)
Rationale for NOC chosen and Indicator score :
- The patient has normal frequency of stools
- The patient has normal consistency of stool
- The patient no constipation

NIC Intervention Label(s) and Nursing Activities:
Constipation/ Impaction Management (0450)
- Monitor bowel movement, including frequency, color, consistency, shape, and volume of stool
- Note preexistent bowel problems, bowel routine, and use of laxatives
- Encourage decreased gas-forming food intake, as appropriate
Rationale for NIC chosen :
- By monitoring the client's defecation, it can be seen whether the client has completely changed the bad habits to usually ignore the urge to defecate
- Because the regularity of intestinal activity can provide comfort defecation in patients
- To launch a bowel movement

Alfiana Nur Halimah17 September 2017

Name/student number : Alfiana Nur Halimah/131611133063
Class : A2 2016

NANDA Nursing Diagnoses :
Risk for bleeding (00206) related to postpartum complications.
Definition : at risk for a decrease in blood volume that may compromise health
Domain 11: Safety/Protection
Class 2: Physical Injury

NOC Outcome Label(s) and indicators :
Maternal Status: Postpartum (2511)
Definition : extent to which maternal well-being is within normal limits from delivery of placenta to completion of involution.
After 1x24 care, bleeding can be stopped with the outcome criteria :
1. Perineal healing (251110) – 4 (mild deviation from normal range)
2. Vaginal bleeding (251127) – 4 (mild)
Rationale for NOC Chosen and Indicator Score
Patient with postpartum hemorrhage should be treated in two components :
- Resuscitation and treatment of obstetric hemorrhage and possible hypovolemic shock
- Identification and treatment of the causes of postpartum hemorrhage

NIC Intervention label(s) and nursing activities
Bleeding reduction : postpartum uterus
- Review obstetrical history and labor record for risk factors for postpartum hemorrhage
- Evaluate for bladder distention
- Observe characteristics of lochia (e.g., color, clots, and volume)
- Weigh amount of blood loss
- Initiate IV infusion
- Monitor maternal vital signs every 15 minutes or more frequently
- Assist primary practitioner with packing uterus, evacuating hematoma, or suturing lacerations
- Provide perineal care
Postpartal care
- Monitor vital signs
- Monitor perineum or surgical incision and surrounding tissue (i.e., monitor for redness, edema, ecchymosis, discharge, and approximation of wound edges)
- Monitor patient’s pain
- Instruct patient on perineal care to prevent infection and reduce discomfort
- Monitor bladder, including intake and output
- Monitor for symptoms of postpartum depression or psychosis
Rationale for NIC Chosen
- Anticipation of HB deficiency
- Stop bleeding and avoids wound expansion
- Monitor the fluid or blood lost
- Preventing fluid volume deficit
- To know the emergency alert
- Balance the fluid/blood lost with infusion

Yuniar rahma shofroin17 September 2017

Name : Yuniar Rahma Shofro'in
NIM : 131611133069

NANDA
Grieving related to Death of significant other
Definition
A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.
(domain9. Grieving, class 2. Death of significant other, code 00136)


NOC
Grief Resolution 1304
1. Verbalizes acceptance of loss 130404 (5)
Rational: sincerity makes the client more calm and comfortable
2. Reports increased involvement in social activities 130419 (5)
Rational: by doing normal activities, the client has passed the phase of grief
3. Progresses through stages of grief 130420 (5)
Rational: by feeling sincere, the client has passed the grieving phase

Anger Self-Restraint 1410
1. Identifies when angry 141001 (5)
Rational: knowing the client's situation can withstand emotions
2. Identifies the basis of angry feelings 141006 (5)
Rational: the client thinks the reason before getting angry to prevent the occurrence of negative things
3. Uses physical activity to reduce repressed anger 141013 (5)
Rational: self-employed with positive things for the outrage of the client's anger

Depression Self-Control 1409
1. Monitors behavioral manifestations of depression 140905 (5)
Rational: self-control to prevent negative effects of depression
2. Avoids recreational drug use 140922 (5)
Rational: stay away from drugs to prevent physical and mental damage to the client
3. Participates in enjoyable activities 140926 (5)
Rational: fun activities can make clients reduce their depression


NIC
Anger Control Assistance 4640
1. Prevent physical harm if anger is directed at self or others (e.g., restrain and remove potential weapons)
Rationale: keeping something dangerous can prevent unwanted things from happening
2. Assist patient in identifying the source of anger
Rational: by looking for the background of the patient's problem, the nurse can help the client to control her anger
3. Instruct on use of calming measures (e.g., time outs and deep breaths)
Rational: can reduce the anger on the client so that clients can think positive and more able to control his anger

Support System Enhancement 5440
1. Encourage the patient to participate in social and community activities
Rational: busy activities make the client can vent his emotions because of his sense of loss
2. Provide services in a caring and supportive manner
Rational: With a caring attitude to support the client, the client will be able to feel stronger and be able to accept the loss of the nearest person

Substance Use Prevention 4500
1. Assist individual to tolerate increased levels of stress, as Appropriate
Rational: if the client can tolerate an increased level of stress, the client will not dissolve in his grief
2. Reduce irritating or frustrating environmental stress
Rational: by not offending the client, the client will not increase stress so the client will not to use prohibited substances
3. Encourage responsible decision making about lifestyle choices
Rational: provides information about the consequences that will occur after using the prohibited substances so that the client can make healthy lifestyle choices and not use prohibited substances.

MARATUS SHOLIHAH RAMADHANI17 September 2017

NAME : MARATUS SHOLIHAH RAMADHANI
NIM : 131611133096
CLASS : A2 2016

1. NANDA Nursing Diagnosis
Anxiety related to Major change (e.g., economic status, environment, health status, role function, role status)
Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknow 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.
(Domain 9. Coping/Stress Tolerance, Class 2. Coping Responses, Code 00146)

2. NOC Outcome and Indicator
After intervention during 1 month, expected clients doesn’t experience Anxiety with outcomes:
a. Social Anxiety Level (1216)
Definition: Severity of irrational avoidance, apprehension, and distress in anticipation of or during social situations
• (121602) Avoidance of unfamiliar people [5]
• (121612) Discomfort during social encounters [5]
• (121615) Panic symptoms in social situations [5]
[NOC, 2013 p. 515]
Rational:
• The avoidance of unfamiliar people is begins to diminish
• Client begin to feel comfortable during social encounters
• The panic symptoms in social situations is begins to diminish
b. Social Interaction Skills (1502)
Definition: Personal behaviors that promote effective relationships
• (150203) Cooperative with others [5]
• (150216) Uses conflict resolution strategies [5]
[NOC, 2004 p. 516]
Rational :
• Consistenly client able to cooperative with others
• Client able to uses conflict resolution strategies

3. NIC Intervention Label and Nursing Activities
a. (5820) Anxiety Reduction
Definition: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger
Activities:
• Use a calm, reassuring approach
• Seek to understand the patient’s perspective of a stressful situation
• Encourage family to stay with patient, as appropriate
• Listen attentively
• Help patient identify situations that precipitate anxiety
• Determine patient’s decision-making ability
Rational :
• A calm and reassuring approach will make the client believe that their secret will not be disclosed
• The client can reveal the cause of his anxiety so that the nurse can determine the client's anxiety level and determine the next intervention.
• Family support can strengthen client coping mechanisms so that anxiety levels are reduced

b. (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.
Activities :
• Establish a therapeutic relationship based on trust and respect
• Provide privacy and ensure confidentialy
• Assist patient to identify the problem or situation that is causing the distress
• Encourage new skill development, as appropriate
Rational :
• A good therapeutic relationship helps the patient be more openly related to the anxiety to the nurse
• Provide privacy helps maximize the patient’s change process
• Problem identification helps the nurse analyze the cause of anxiety in the patient and help determine the next steps
• New skills can reduce patient anxiety

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

Fathma Hanifati17 September 2017

Name : Fathma Hanifati
NIM : 131611133084
Class : A2-2016

1. NURSING DIAGNOSIS
Ineffective infant feeding pattern related inability to coordinate sucking, swallowing, and breathing
Definition : Impaired abilitiy of an infant to suck or coordinate the suck/swallow response resulting in inadequate oral nutrition for metabolic needs.
(Domain 2. Nutrition. Class 1. Ingestion. Code 00107)
2. NURSING OUTCOMES CLASSIFICATION
After the nursing action in the 1 months, expected client can achive the result criteria :
1. (1819) Knowledge : Infant Care
Definition : Extent ro understanding conveyed about caring for a baby from birth to first bierthday
- (181902) Normal growth and development (5)
- (181908) Nutritive versus non nutritive sucking (5)
- (181909) Pros and cons of infant feeding choice (5)
- (181910) Infant feedings technique (5)
Rationale : as knowledge for parents to be able to meet the nutritional
needs of the infant well
2. (1016) Bottle Feeding Establishment : Infant
Definition : Establishment of bottle feeding for hydration and nourishment of an infant
- (101602) Suck reflex (5)
- (101603) Ability to consume milk or formula from bottlr (5)
- (101605) Audible swallow (5)
Rationale : improve infant’s ability to suck and swallow
3. (1800) Knowledge : Breastfeeding
Definition : Extent of understanding conveyed about lactation and nourishment of an infant through breasfeeding
- (180005) Proper technique for attaching infant to the breast (5)
- (180008) Evaluation of infant swallowing (5)
- (180009) Proper technique to break infant suction (5)
Rationale : to improve infant’s ability to breastfeeding and infant can get benefits well


3. NURSING INTERVENTION CLASSIFICATION
1. (6820) Infant Care
Definition : Provision of developmentally-appropriate, family-centered care to the child under 1 year age
- Feed Infant foods that are developmentally appropriate
Rationale : Proper feeding will optimize infant growth and prevent contradictions
- Provide information to parent about child development and child rearing
Rationale : Parents as the closest to the infant should have parents know all the needs for growth and development of infants, especially in infan
- Encourage parent to participate in care activities (e.g.,feeding)
Rationale : motivate parents to pay attention to food that is eaten and in accordance with its development
2. (1052) Bottle Feeding
Definition : Preparation and administration of fluids to an infant via a bottle
- Position infant in a sent-Fowler’s position for feeding
Rationale : make baby comfortable and relax him for breastfeeding
- Hold infant during feeding
Rationale : so when the baby is sucking the nipple is not easy to escape

3. (6900) Nonnutritive Sucking
Definition : Provision of sucking opportunities for the infant
- Move infant’s tongue rhytmically with the pacifier if need to encourage sucking
Rationale : to train infant’s tongue to keep it rigid and get used to sucking
- Inform parents of alternative to nipple sucking (e.g., thumb, parent’s finger, pacifier)
Rationale : make the infant who does not like the nipples can still learn to stuck and then at least make the infant want to suck the nipple at the next time
- Rock and hold infant while infant sucks on pacifier, when possible
Rationale : so as not to easily escape


Bibliography
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.
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Silvia Farhanidiah17 September 2017

NAME: SILVIA FARHANIDIAH
NIM: 131611133072
CLASS: A2-2016

DIARRHEA
Diagnoses : Diarrhea (Domain 3. Elimination and Exchange Class 2. Gastrointestinal Function. Code 00013)
Definition : Passage of loose unformed stools
NOC :
After 1x24 hours of nursing action, it is expected that the level of pain felt decreased and the frequency of defecation is reduced (at least 3 times a day) with the consistency of normal defecation.
Gastrointestinal Function (1015) :
Definition : Ability of the gastrointestinal tract to ingest and digest food products, absorb nutrients, and eliminate waste.
1.Frequency of stools (101503)
1 2 3 (4) 5
2.Consistency of stool (101505)
1 2 3 (4) 5
3.Abdominal pain (101513)
1 2 3 (4) 5
NIC :
Diarrhea Management (0460)
Definition : Management and alleviation of diarrhea
1.Teach patient appropriate use of antidiarrheal medication
2.Instruct patient/family members to record color, volume, frequency, and consistency of stools
3.Teach patient to eliminate gas-forming and spicy foods from diet
RATIONALE:
1.Enable successful treatment of gastrointestinal irritation experienced by the patient
2.To know the level of diarrhea in the patient's natural so that can be given appropriate treatment
3.To reduce the possibility of increased frequency of bowel movements and so as not to increase the pain experienced by the patient.

Silvia Farhanidiah17 September 2017

NAME: SILVIA FARHANIDIAH
NIM: 131611133072
CLASS: A2-2016

DIARRHEA
Diagnoses : Diarrhea (Domain 3. Elimination and Exchange Class 2. Gastrointestinal Function. Code 00013)
Definition : Passage of loose unformed stools
NOC :
After 1x24 hours of nursing action, it is expected that the level of pain felt decreased and the frequency of defecation is reduced (at least 3 times a day) with the consistency of normal defecation.
Gastrointestinal Function (1015) :
Definition : Ability of the gastrointestinal tract to ingest and digest food products, absorb nutrients, and eliminate waste.
1.Frequency of stools (101503)
1 2 3 (4) 5
2.Consistency of stool (101505)
1 2 3 (4) 5
3.Abdominal pain (101513)
1 2 3 (4) 5
NIC :
Diarrhea Management (0460)
Definition : Management and alleviation of diarrhea
1.Teach patient appropriate use of antidiarrheal medication
2.Instruct patient/family members to record color, volume, frequency, and consistency of stools
3.Teach patient to eliminate gas-forming and spicy foods from diet
RATIONALE:
1.Enable successful treatment of gastrointestinal irritation experienced by the patient
2.To know the level of diarrhea in the patient's natural so that can be given appropriate treatment
3.To reduce the possibility of increased frequency of bowel movements and so as not to increase the pain experienced by the patient.

Silvia Farhanidiah17 September 2017

NAME: SILVIA FARHANIDIAH
NIM: 131611133072
CLASS: A2-2016

DIARRHEA
Diagnoses : Diarrhea (Domain 3. Elimination and Exchange Class 2. Gastrointestinal Function. Code 00013)
Definition : Passage of loose unformed stools
NOC :
After 1x24 hours of nursing action, it is expected that the level of pain felt decreased and the frequency of defecation is reduced (at least 3 times a day) with the consistency of normal defecation.
Gastrointestinal Function (1015) :
Definition : Ability of the gastrointestinal tract to ingest and digest food products, absorb nutrients, and eliminate waste.
1.Frequency of stools (101503)
1 2 3 (4) 5
2.Consistency of stool (101505)
1 2 3 (4) 5
3.Abdominal pain (101513)
1 2 3 (4) 5
NIC :
Diarrhea Management (0460)
Definition : Management and alleviation of diarrhea
1.Teach patient appropriate use of antidiarrheal medication
2.Instruct patient/family members to record color, volume, frequency, and consistency of stools
3.Teach patient to eliminate gas-forming and spicy foods from diet
RATIONALE:
1.Enable successful treatment of gastrointestinal irritation experienced by the patient
2.To know the level of diarrhea in the patient's natural so that can be given appropriate treatment
3.To reduce the possibility of increased frequency of bowel movements and so as not to increase the pain experienced by the patient.

Eka Hariyanti17 September 2017

[Eka Hariyanti – 131611133076 – A2]

• NANDA Diagnosis : Risk for overweight (2013; LOE 2.2)
00234
Domain 2. Nutrition / Class 1. Ingestion
Definition : Vulnerable to abnormal or excessive fat accumulation for age and gender, which may compromise health.

Risk Factors:
1. Obesity in childhood
2. Parental obesity
3. Rapid weight gain during childhood
4. Genetic disorder
5. Disordered eating perceptions

• NOC
1. Identify inappropriate behaviors and consequences associated with overeating or weight gain.
2. Demonstrate change in eating patterns and involvement in individual exercise program.
3. Display weight loss with optimal maintenance of health.

• Rational NOC
1. Patients can behave and have the right consequences of eating
2. Diet changes and doing individual exercise program
3. Patients has optimal weight

• NIC
Weight Management (1260)
1. Discuss with individual the relationship between food intake and factors that influence weight
2. Determine individual motivation for changing eating habits and encourage individual to write down realistic weekly goals for food intake and exercise
3. Determine individual’s ideal body weight and determine individual’s ideal percent body fat

• Rational NIC
1. Food intake can be a factor that affects weight gain
2. Motivation to change eating habits and exercise can lose weight
3. To get the ideal weight should understand ideal body weight and ideal body fat

Siti Nur Cahyaningsih18 September 2017

Number: 00038
Diagnose: Risk for Trauma
Definition: Vulnerable to accidental tissue injury (e.g., wound, burn, fracture), which may compromise health.
NOC: 1104 Bone Healing
Definition: Extent of regeneration of cells and tissues following bone injury
1= Severe thru 5= None
110401 Hematoma 1 2 3 4 5
110407 Pain 1 2 3 4 5
110408 Edema 1 2 3 4 5
110410 Infection in surrounding tissue 1 2 3 4 5
110411 Infection in bone 1 2 3 4 5
NIC : 5326 Life Skills Enhancement
Definition: Developing an individual’s ability to independently and effectively deal with the demands and challenges
of everyday life
• Establish rapport by using empathy, warmth, spontaneity, organization, patience, and persistence
• Determine the life skill learning needs of the patient, family, group, or community
• Appraise the patient’s educational level
• Determine level of knowledge of the life skill
• Appraise the patient’s current level of skill and understanding of the content
• Appraise the patient’s learning style
• Mutually agree upon goals for the life skills program
• Determine number of sessions and length of time of the program
• Enhance motivation by setting achievable incremental goals
• Appraise the patient’s cognitive, psychomotor, and affective abilities and disabilities
• Determine the patient’s ability to learn specific information (i.e., consider the patient’s developmental level, physiological status, orientation, pain, fatigue, unfulfilled basic needs, emotional state, and adaptation to illness)
• Determine the patient’s motivation to learn specific information (i.e., consider the patient’s health beliefs, past noncompliance, bad experiences with health care or learning, and conflicting goals)
• Select appropriate teaching methods and strategies
• Select appropriate educational materials
• Tailor the content to the patient’s cognitive, psychomotor, and affective abilities and disabilities
• Break more complex skills into their stepwise components to enable incremental progress
• Adjust instruction to facilitate learning, as appropriate
• Provide an environment conducive to learning
• Use role-playing of appropriate behaviors with scenarios that simulate real life interpersonal interactions
• Provide positive feedback contingent on improvements in the patient’s improved learning skill
• Use assignments to practice and enhance the performance of new skills in real life situations
• Instruct on strategies designed to enhance communication skills, if needed
• Provide assertiveness training, if needed
• Use strategies to enhance the patient’s self awareness
• Provide appropriate social skills training, if needed
• Assist the patient to solve problems in a constructive manner
• Instruct patient how to manage conflict, if needed
• Instruct patient in setting priorities and decision making
• Assist patient in values clarification
• Provide instruction on time management, if needed
• Provide instruction on diet, nutrition, and food preparation, if needed
• Instruct patient in the use of stress management techniques, as appropriate
• Instruct patient on how to manage their illness symptoms, if appropriate
• Instruct patient on medication management, if appropriate
• Instruct the patient on workplace fundamentals (e.g., improving job performance, leaning about specific workplace and performance expectations, making friends and appropriate socializing)
• Identify and arrange for participation in leisure activities
• Provide assistance in managing finances and creating a budget, if indicated
• Include the family or significant others, as appropriate

Rationale for NIC chosen :
• Determine the patient's ability to learn specific information especially on his pain and emotional state
• giving knowledge about the nutritious food needed for recovery
• teaches patients about stress management techniques

tantya edipeni putri18 September 2017

NAMA : TANTYA EDIPENI PUTRI
NIM : 131611133074
KELAS : A2/2016

Nanda Nursing Diagnosis : Ineffective breathing pattern related to hyperventilation as evidenced by abnormal breathing pattern

NOC Outcome Label(s) and indicators :
NOC Label : Respiratory status
Indicators :
a. Respiratory rate, respiratory rhythm, depth of inspiration, auscultated breath sounds : no deviation from normal range (scale 5)
b. Accessory muscle use, chest retraction : none (scale 5)

Rationale for NOC Chosen and Indicator Score
NOC LABEL : Respiratory status
RASIONALE :
a. An effective breathing pattern is charactized by normal respiration rate, reguler respiratoty rhythm, normal depth of inspiration, and vesikuler breath sounds.
b. Accessory muscle use is not work when breathing is effective, there is no chest retraction on effective breathing pattern.

NIC Intervention label(s) and nursing activities
1. NIC LABEL : Respiratory monitoring
Nursing activities :
a. Monitor rate, rhythm, depth, and effort of respirations.
b. Note chest movement, watching for symmetry, use of accessory muscles, and suraclavicular and intercostal muscle retactions.
c. Monitor breathing patterns
d. Auscultate breath sounds, nothing area of decreased or absent ventilation and presence of adventitious
2. NIC LABEL : Ventilation assistance
Nursing activities :
a. Position to minimize respiratory efforts
b. - Monitor for respiratory muscle fatigue

Rationale for NIC Chosen
1. NIC LABEL : Respiratory monitoring
RATIONALE :
a. Adequate breathing is assesed from rate, rhythm, depth, and effort of respirations.
b. To find out if there is ventilation problem with note chest movement, watching for symmetry, use of accessory muscles, and suraclavicular and intercostal muscle retactions.
c. To know client’s breathing pattern with monitoring.
d. Obstruction of the airway will be known with auscultate breath sounds
2. NIC LABEL : Ventilation assistance
a. Position to minimize respiratory efforts can maximize ventilation potential.
b. Monitor respiratory muscle fatigue to prevent shortness of breath.

Khosnul Khotimah18 September 2017

Diagnosis: Risk for aspiration (Domain: 11, Class: 2, Code: 00039)
Definition: Vulnerable to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobronchial passages, which may compromise health
Risk factor:
- Barrier to elevating upper body
- Decrease in gastrointestinal motility
- Decrease in level of consciousness
- Delayed gastric emptying
- Depressed gag reflex
- Enteral feedings
- Facial surgery
- Facial trauma
- Impaired ability to swallow
- Incompetent lower esophageal sphincter
- Increase in gastric residual
- Increase in intragastric pressure
- Ineffective cough
- Neck surgery
- Neck trauma
- Oral surgery
- Oral trauma
- Presence of oral/nasal tube (e.g., tracheal, feeding)
- Treatment regimen
- Wired jaw
NOC:
- Respiratory status: ventilation
- Swallowing status
- Aspiration prevention
191801 Identifies risk factors (4)
191802 Avoids risk factors (4)
191804 Selects foods according to swallowing ability (4)
191806 Selects food and fluid of proper consistency (4)
191810 Remains upright for 30 minutes after eating (4)
Rationale for NOC:
- Clients can breathe easily, not rhythm, normal breathing frequency
- Patients are able to swallow, chew without aspiration, and can oral hygiene
- Road patent breath, easy to breathe, do not feel choked and no abnormal breath sounds
NIC:
Aspiration precaution
Definition: Prevention or minimization of risk factors in the patient at risk for aspiration
- Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability
- Maintain airway
- Monitor pulmonary status
- Monitor bowel care needs
- Position upright equal to or greater than 30 (NG feedings) to 90 degrees or as far as possible
- Keep head of bed elevated 30 to 45 minutes after feeding
- Keep tracheal cuff inflated, as appropriate
- Supervise eating or assits as necessary
- Feed in small amounts
- Provide oral care
-
Rationale for NIC:
- Examine how much risk of aspiration is occurring
- Ensure the airway remains patent
- Prevent choking and reflux
- Prevent food reflux or stomach fluids

Nabiela Audina18 September 2017

Nanda Nursing Diagnosis : Impaired swallowing related to laryngeal abnormality as evidence by inadequate laryngeal elevation.

NOC Outcome Label(s) and indicators
neurological status: cranial sensory / motor function
- taste, swallowing, gag reflex, tongue movement : no deviation from normal range (scale 5)
Respiratory Status : Airway patency
- ability to clear secretions : no deviation from normal range (scale 5)
- Choking, coughing, accumulation of sputum : none (scale 5)

Rationale for NOC chosen and indicator scale
Neurological status can describe the ability of the cranial nerve to impart sensory and motor impulses
- cranial nerves that capable to delivering impulses will increase the ability of muscle to work normally.
Respiratory status can used to see any problem on airway for example the secretion in the airway that also can disturb the process to swallow
- ability to clear secretions, choking, coughing and accumulation of sputum can be used as an indicator

NIC Intervention label(s) and nursing activities
1. NIC Label : Swallowing Therapy
Nursing activities :
- Explain rationale of swallowing regimen to patient/family
- Assist patient to sit inn an erect position (as close to 90 degrees as possible) for feeding/exercise
- Assist Patient to position head in forward flexion in preparation for swallowing
- Assist to maintain sittig position for 30 minutesafer completing meal
- Instruct patiet to open and close in preparation foor food manipulation
2. NIC Label : Sucking of Mucus on The Airway
Nursing activities :
- enter the nasopharyngeal airway to perform the nasotracheal suction as needed
- instruct the patient to take a deep breath before a nasotracheal suction is performed and use oxygen as needed
- monitor the presence of pain
Rationale for NIC Chosen
1. Swallowing Therapy
- to improve the ability of existing muscles in the larynx
- to assist patients in treating pain during swallowing
2. Sucking of Mucus on The Airway
- to monitor the presence of pain
- to clear the airway from mucus
- monitor patient oxygenation status

SABRINA SHEILA UMAR18 September 2017

LABOR PAIN
(Nyeri Persalinan)
1. Case
Mrs Sabrina, 27 years old with pregnancy, admitted to start feeling pain in the stomach since at 00.00 a.m, September 15th, 2017, irregular contractions, mucus and blood has started out. Furthermore, in the morning, into the VK room at 06.00 with a stomach complaints feel tight, mucus (+), blood (+), edema (-), feel uncomfortable at the waist to the belly, BP 112/64 mmHg, pulse 112 x / min , RR 20 x / min, temperature 36.2 C, patient appearing in pain and moaning.
NANDA Nursing Diagnosis :
Pain related to labor as evidenced by alteration in blood pressure, heart rate, muscle tension, RR, facial expression of pain (moaning), and uterine contraction.
NOC Outcome Label and Indicator(s) :
1605 Pain Control
Definition : Personal actions to control pain
Outcome overall rating
1 = Never demonstrated thru 5 = Consistently demonstrated
Recognizes pain onset (labor pain)
1 2 3 4 5
Describe causal factors
1 2 3 4 5
Reports changes in pain symptoms to health professional (changes in tension or contraction of uterine muscles, vital signs)
1 2 3 4 5
Reports uncontrolled symptoms to health professional
1 2 3 4 5
Reports pain controlled
1 2 3 4 5
Rationale :
1. To know the patient's ability to recognize when the pain occurred
2. To identify the factors that cause pain in these patients
3. know the change of pain symptoms
4. knowing the patient's level of defense against pain
2102 Pain Level
Definitions : severity of observed or reported pain
Outcome Overall Rating
1 = severe thru 5 = none
Reported pain
1 2 3 4 5
Length of pain episodes
1 2 3 4 5
Moaning and crying
1 2 3 4 5
Facial expressions of pain
1 2 3 4 5
Wincing
1 2 3 4 5
Muscle tension
1 2 3 4 5
Respiratory Rate
1 2 3 4 5
Apical Heart Rate
1 2 3 4 5
Radial Pulse Rate
1 2 3 4 5
Blood Pressure
1 2 3 4 5
Rationale :
1. to know the intensity of reported pain
2. know the period of pain
3. know the intensity of pain expression
4. know the alteration of vital sign
3016 Client Satisfaction : Pain Management
Definitions: extent of positive of nursing care to relieve pain
Outcome Overall Rating ( 1 = not all satisfied thru 5 = completely satisfied)
Pain controlled
1 2 3 4 5
Pain management consistent with cultural beliefs
1 2 3 4 5
Rationale :
1. know the level of client satisfaction to the handling of pain
2. the response to labor is culturally dependent, previous experience, and emotional support including the desired person
2010 Comfort Status : Physical
1 = severely compromised thru 5 = not compro
Missed
Symptom control
1 2 3 4 5
Muscular relaxation
1 2 3 4 5
Comfortable position
1 2 3 4 5
Body temperature
1 2 3 4 5
Rationale :
1. reduce the cause of pain
2. anticipate muscular tension
3. determine the patient's comfortable position
4. know the alteration of vital signs

1843 Knowledge : Pain Management
Definitions : extent of understanding conveyed about causes, symptomps, and tratment of pain
1 = No Knowledge thru 5 = extensive knowledge
Signs and symptoms of pain
1 2 3 4 5
Effective positioning technique
1 2 3 4 5
Effective relaxation techniques
1 2 3 4 5
When to obtain assistance from a health professional
1 2 3 4 5
Rationale :
1. educating clients about the severity of pain
2. helps to facilitate and educate the relaxed body position in patients who are in labor
3. provide quick treatment when patients need it

NIC Interventions Label and Nursing Activities
6482 Environmental Management: Comfort
Definition: Manipulation of the patient’s surroundings for promotion of optimal comfort
Activities
1. Give consideration to the placement of patients in multiplebedded rooms (roommates with similar environmental concerns when possible)
2. Create a calm and supportive environment
3. Provide a safe and clean environment
4. 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)
Rationale
1. prevent psychological disturbances in the mother giving birth
2. prevent excessive stress and anxiety in the mother giving birth
3. prevent infection
4. relax the patient to ease the labor process
6400 Pain Management
Definition: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Activities
1. Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors
2. Observe for nonverbal cues of discomfort, especially in those unable to communicate effectively
3. Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient’s response to pain
4. Consider cultural influences on pain response
5. Control environmental factors that may influence the patient’s response to discomfort (e.g., room temperature, lighting, noise)
Rationale :
1. to know the patient's pain level
2. to know the level of discomfort felt by the patient
3. to distract the patient from the pain
4. to see if the pain felt by the client affects the culture
5. to reduce the level of patient discomfort
6834 Intrapartal Care: High-Risk Delivery
Definition: Assisting with vaginal delivery of multiple or malpositioned fetuses
Activities
Assist with administration of maternal anesthesic, as needed (e.g., intubation)
Rationale :
reduce the pain felt by the patient during childbirth
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
Activities :
1. Describe the rationale for relaxation and the benefits, limits, and types of relaxation available (e.g., music, meditation, rhythmic breathing, jaw relaxation, and progressive muscle relaxation)
2. Suggest that the individual assume a comfortable position, with unrestricted clothing and eyes closed
3. Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging
4. Invite the patient to relax and let the sensations happen
5. Demonstrate and practice the relaxation technique with the patient
Rationale :
1. improve client comfort
2. preventing the loss of much energy used during childbirth so that the intensity of pain that is felt is not too high
3. help the patient ease the birth process
6680 Vital Signs Monitoring
Definition: Collection and analysis of cardiovascular, respiratory, and body temperature data to determine and prevent complications
Activities
1. Monitor blood pressure, pulse, temperature, and respiratory status, as appropriate
2. Monitor blood pressure, pulse, and respirations before (antepartum), during (perinatal), and after activity, as appropriate
3. Monitor for and report signs and symptoms of hypothermia and hyperthermia
4. Monitor respiratory rate and rhythm (e.g., depth and symmetry
5. Monitor for presence of Cushing triad (e.g., wide pulse pressure, bradycardia, and increase in systolic BP, cyanosis)
6. Identify possible causes of changes in vital signs
Rationale
Pulse, blood pressure, and RR can be an indicator of maternal hydration and energy status




LAILA MUFIDA 18 September 2017

NAME : LAILA MUFIDA
NIM : 131611133095
CLASS : A2-2016
ANSWER :
1. Nursing Diagnosis (NANDA)
Impaired Urinary Elimination
Definition : Dysfunction in Urine Elimination
(Domain 3. Elimination and Exchange Class: 1. Urinary Function 00016)

2. Nursing Outcome Classification (NOC)
1) (0502) Urinary Continence
Definition : Control of elimination of urine from the bladder
• (050208) starts and stop stream (5)
• (050209) Empties bladder completely (5)
• (050215) Ingests adequate amount of fluid (5)
2) (1813) Knowledge: Treatment Regimen
Definition : Extent of understanding conveyed about a specific treatment regimen
• (181302) Self-care responsibilities for ongoing treatment (5)
• (181315) Self-monitoring techniques (5)
• (181316) Benefits of disease management (5)


3. Nursing Intervention Classification (NIC)
1) Urinary Incontinence Care (0610)
Definition : Assistance in promoting continence and maintaining perineal skin integrity
- Intervention:
Monitor urinary elimination, including consistency, odor, volume, and color
- Rationale :
These parameters help determine adequacy of urinary tract function
- Intervention:
Assist to select appropriate incontinence garment or pad for short-term management while more definitive treatment is designed
- Rationale :
Appropriate undergarments can help diminish the embarrassing aspects of urinary incontinence
- Intervention:
Limit fluid for 2 or 3 hours before bedtime, as appropriate
- Rationale :
Decreased fluid intake several hours before bedtime will decrease the incidence of urinary retention and overflow incontinence, and promote rest
- Intervention:
Instruct patient to drink a minimum of 1500 cc fluids a day
- Rationale :
Increased fluids during the day will increase urinary output and discourage bacterial growth
- Intervention :
Limit ingestion of bladder irritants (e.g., coals, coffee, tea, and chocolate)
- Rationale :
Alcohol, coffee, and tea have a natural diuretic effect and are bladder irritants
2) Urinary Retention Care (0620)
Definition : assistance in relieving bladder distention
- Intervention :
Instruct patient/family to record urinary output, as appropriate
- Rationale :
Serves as an indicator of urinary tract and renal function and of fluid balance
- Intervention :
Catheterize for residual urine, as appropriate
- Rationale :
An enlarged prostate compresses the urethra so that urine is retained. Checking for residual urine provides information about bladder emptying.
- Intervention :
Implement intermittent catheterization, as appropriate
- Rationale :
Helps maintain tonicity of the bladder muscle by preventing overdistention and providing for complete emptying
- Intervention :
Provide enough time for bladder emptying (10 minutes)
- Rationale :
In addition to the effect of an enlarged prostate on the bladder, stress or anxiety can inhibit relaxation of the urinary sphincter. Sufficient time should be allowed for micturition
- Intervention :
Instruct the patient in ways to avoid constipation or stool impaction
- Rationale :
Impacted stool msy place pressure on the bladder outlet, causing urinary retention
3) Teaching : Disease process (5602)
Definition : Assisting the patient to understand information related to a specific disease process
- Intervention :
Appraise the patient’s current level of knowledge related to specific disease process
- Rationale :
Assessing the client’s knowledge wil provide a foundation for building a teaching plan based on his present understanding of his condition
- Intervention :
Explain the pathophysiology of the disease and how it relates to urinary anatomy and function
- Rationale :
Urinary retention and overflow incontinence are caused by obstruction of the bladder neck by an enlarged prostate gland
- Intervention :
Describe the rationale behind management, theraphy, and treatment recommendations
- Rationale :
Adequate information about treatment options is important to diminish anxiety, promote compliance, and enhance decision making
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


LAILA MUFIDA18 September 2017

NAME : LAILA MUFIDA
NIM: 131611133095
CLASS : A2-2016
ANSWER :

1. Nursing Diagnosis (NANDA)
Impaired Urinary Elimination
Definition : Dysfunction in Urine Elimination
(Domain 3. Elimination and Exchange Class: 1. Urinary Function 00016)

2. Nursing Outcome Classification (NOC)
1) (0502) Urinary Continence
Definition : Control of elimination of urine from the bladder
• (050208) starts and stop stream (5)
• (050209) Empties bladder completely (5)
• (050215) Ingests adequate amount of fluid (5)
2) (1813) Knowledge: Treatment Regimen
Definition : Extent of understanding conveyed about a specific treatment regimen
• (181302) Self-care responsibilities for ongoing treatment (5)
• (181315) Self-monitoring techniques (5)
• (181316) Benefits of disease management (5)


3. Nursing Intervention Classification (NIC)
1) Urinary Incontinence Care (0610)
Definition : Assistance in promoting continence and maintaining perineal skin integrity
- Intervention:
Monitor urinary elimination, including consistency, odor, volume, and color
- Rationale :
These parameters help determine adequacy of urinary tract function
- Intervention:
Assist to select appropriate incontinence garment or pad for short-term management while more definitive treatment is designed
- Rationale :
Appropriate undergarments can help diminish the embarrassing aspects of urinary incontinence
- Intervention:
Limit fluid for 2 or 3 hours before bedtime, as appropriate
- Rationale :
Decreased fluid intake several hours before bedtime will decrease the incidence of urinary retention and overflow incontinence, and promote rest
- Intervention:
Instruct patient to drink a minimum of 1500 cc fluids a day
- Rationale :
Increased fluids during the day will increase urinary output and discourage bacterial growth
- Intervention :
Limit ingestion of bladder irritants (e.g., coals, coffee, tea, and chocolate)
- Rationale :
Alcohol, coffee, and tea have a natural diuretic effect and are bladder irritants
2) Urinary Retention Care (0620)
Definition : assistance in relieving bladder distention
- Intervention :
Instruct patient/family to record urinary output, as appropriate
- Rationale :
Serves as an indicator of urinary tract and renal function and of fluid balance
- Intervention :
Catheterize for residual urine, as appropriate
- Rationale :
An enlarged prostate compresses the urethra so that urine is retained. Checking for residual urine provides information about bladder emptying.
- Intervention :
Implement intermittent catheterization, as appropriate
- Rationale :
Helps maintain tonicity of the bladder muscle by preventing overdistention and providing for complete emptying
- Intervention :
Provide enough time for bladder emptying (10 minutes)
- Rationale :
In addition to the effect of an enlarged prostate on the bladder, stress or anxiety can inhibit relaxation of the urinary sphincter. Sufficient time should be allowed for micturition
- Intervention :
Instruct the patient in ways to avoid constipation or stool impaction
- Rationale :
Impacted stool msy place pressure on the bladder outlet, causing urinary retention
3) Teaching : Disease process (5602)
Definition : Assisting the patient to understand information related to a specific disease process
- Intervention :
Appraise the patient’s current level of knowledge related to specific disease process
- Rationale :
Assessing the client’s knowledge wil provide a foundation for building a teaching plan based on his present understanding of his condition
- Intervention :
Explain the pathophysiology of the disease and how it relates to urinary anatomy and function
- Rationale :
Urinary retention and overflow incontinence are caused by obstruction of the bladder neck by an enlarged prostate gland
- Intervention :
Describe the rationale behind management, theraphy, and treatment recommendations
- Rationale :
Adequate information about treatment options is important to diminish anxiety, promote compliance, and enhance decision making
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

Fatur Rizal Pratama18 September 2017

NANDA
Death anxiety (00147)
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)

NOC
Comfortable Death (2007)
Comfortable position (200705)
Psychological well-being (200722)
Support from family (200724)
Spiritual life (200726)
Expression of readiness for impending death (200727)
Dignified Life Closure (1307)
Puts affairs in order (130701)
Expresses hopefulness (130702)
Shares feelings about dying (130711)
Completes meaningful goals (130713)
Expresses readiness for death (130725)
Hope (1201)
Expresses will to live (120103)
Expresses meaning in life (120105)
Expresses inner peace (120109)
Expresses sense of self-control (120110)
Spiritual Health (2001)
Meaning and purpose in life (200103)
Feelings of peacefulness (200105)
Ability to forgive (200107)
Ability to pray (200109)
Spiritual experiences (200108)

Rational NOC
patient can get physical, psychospiritual, sociocultural and environmental ease with the impending end of life
patients can actions to maintain control when approaching end of life
patient have optimism that is personally satisfying and life-supporting
patients have connectedness with self, others, higher power, all life, nature, and the universe that transcends and empowers the self

NIC

Dying Care

Activities:
• Identify the patient’s care priorities
• Communicate willingness to discuss death
• Encourage patient and family to share feelings about death
• Assist patient and family to identify a shared meaning of death
• Seek to understand patient’s actions, feelings, and attitudes
• Monitor patient for anxiety
• Stay physically close to frightened patient
• Monitor deterioration of physical and/or mental capabilities
• Reduce demand for cognitive functioning when patient is ill or fatigued
• Monitor mood changes
• Respect the patient’s and family’s specific care requests
• Include the family in care decisions and activities, as desired
• Support patient and family through stages of grief
• Monitor pain
• Minimize discomfort, when possible
• Medicate by alternate route when swallowing problems develop
• Postpone feeding when patient is fatigued
• Offer fluids and soft foods frequently
• Offer culturally appropriate foods
• Provide frequent rest periods
• Assist with basic care, as needed
• Respect the need for privacy
• Modify the environment, based on patient’s needs and desires
• Support the family’s efforts to remain at the bedside
• Facilitate obtaining spiritual support for patient and family
• Facilitate care by others, as appropriate
• Facilitate referral to hospice, as desired
• Facilitate discussion of funeral arrangements

Anxiety Reduction
Activities:
• Use a calm, reassuring approach
• Clearly state expectations for patient’s behavior
• Explain all procedures, including sensations likely to be experienced during the procedure
• Seek to understand the patient’s perspective of a stressful situation
• Provide factual information concerning diagnosis, treatment, and prognosis
• Stay with patient to promote safety and reduce fear
• Encourage family to stay with patient, as appropriate
• Provide objects that symbolize safeness
• Administer back rub/neck rub, as appropriate
• Encourage noncompetitive activities, as appropriate
• Keep treatment equipment out of sight
• Listen attentively
• Reinforce behavior, as appropriate
• Create an atmosphere to facilitate trust
• Encourage verbalization of feelings, perceptions, and fears
• Identify when level of anxiety changes
• Provide diversional activities geared toward the reduction of tension
• Help patient identify situations that precipitate anxiety
• Control stimuli, as appropriate, for patient needs
• Support the use of appropriate defense mechanisms
• Assist patient to articulate a realistic description of an upcoming event
• Determine patient’s decision-making ability
• Instruct patient on the use of relaxation techniques
• Administer medications to reduce anxiety, as appropriate
• Assess for verbal and nonverbal signs of anxiety

3. Spiritual Support
Activities:
• Use therapeutic communications to establish trust and empathetic caring
• Utilize tools to monitor and evaluate spiritual well-being, as appropriate
• Encourage individual to review past life and focus on events and relationships that provided spiritual strength and support
• Treat individual with dignity and respect
• Encourage life review through reminiscence
• Encourage participation in interactions with family members, friends, and others
• Provide privacy and quiet times for spiritual activities
• Encourage participation in support groups
• Teach methods of relaxation, meditation, and guided imagery
• Share own beliefs about meaning and purpose, as appropriate
• Share own spiritual perspective, as appropriate
• Provide opportunities for discussion of various belief systems and worldviews
• Be open to individual’s expressions of concern
• Arrange visits by individual’s spiritual advisor
• Pray with the individual
• Provide spiritual music, literature, or radio or television programs to the individual
• Be open to individual’s expressions of loneliness and powerlessness
• Encourage chapel service attendance,ifdesired
• Encourage the use of spiritual resources, if desired
• Provide desired spiritual articles, according to individual preferences
• Refer to spiritual advisor of individual’s choice
• Use values clarification techniques to help individual clarify beliefs and values, as appropriate
• Be available to listen to individual’s feelings
• Express empathy with individual’s feelings
• Facilitate individual’s use of meditation, prayer, and other religious traditions and rituals
• Listen carefully to individual’s communication, and develop a sense of timing for prayer or spiritual rituals
• Assure individual that nurse will be available to support individual in times of suffering
• Be open to individual’s feelings about illness and death
• Assist individual to properly express and relieve anger in appropriate ways

Rational NIC
Promotion of physical comfort and psychological peace in the final phase of life
Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger
Assisting the patient to feel balance and connection with a greater power

DEVI RAHMANINGRUM WARDANI18 September 2017

Name: Devi Rahmaningrum Wardani
NIM: 131611133099
Class : A-2
Nursing Diagnosis: risk of allergic response (Domain 11.Security or protection, class 5. Code 00217)
Definition : susceptible to response or immune reaction to a substance which is exacerbated, which can harm the healthikmm
Risk Factor :
1. allergic insect bites
2. food allergies (eg avocados, bananas, nuts, mussels, mushrooms, tropical fruit)
3. recurrent exposure to the substance of the allergen-producing environment
4. exposure to allergens (eg, pharmaceuticaluticals)
5. Exposure to environmental allergens (eg, dandruff, dust, mold, pollen)
6. Exposure to toxic chemicals
NOC:
Allergic response; local(0705): the severity of localized hypersensitive immune response against a specific antigen outside
Allergic response: local
1. Headache(070502/IV)
2. Sneeze(070506/IV)
3. The local itching(070512/IV)
Rational of NOC:
1. The patient's headache is reduced and the patient improves
2. The patient doesn’t sneeze continuously and the patient is comfortable
3. The itching is reduced and patients aren’t disturbed by the intense itching
NIC:
Allergy management(6410): identification, treatment and prevention of allergic response to foods, medications, insect bites, contrast materials, blood and other substances
Allergy management:
1. Identification of known allergies (eg, pharmaceuticals, food, insects, environment) and unusual reactions
2. Instruct the patient to avoid substances that cause allergies, as appropriate
3. Help with doing allergy tests, as appropriate
Rational of NIC:
Allergy management:
1. To assist the nurse in taking further action
2. To avoid any allergic continuously
3. To determine the presence of allergic patient

Faizatul Ummah18 September 2017

NAME : FAIZATUL UMMAH
NIM : 131611133097
CLASS : A2

STUDY CASE
Patient named An.M male sex came on Sunday, March 9, 2017 at 20:00 pm. Medical diagnosis Epilepsy. Main Complaint, Children say often experience a sudden stun. Patients say fainting and seizures for the second time when they start entering grade 1 and from then on patients are often suddenly unconscious and convulsive. Patient appears weak. Vital signs: blood pressure = 100 / 70mmHg, pulse = 100x / min, respiration rate = 24x / min, temperature = 36 C.

NANDA NURSING DIAGNOSIS
Risk of Injury related to seizures.

NOC OUTCOME LABEL(S) AND INDICATORS
 Parenting: Social Safety: Parental actions to avoid social relationships that might cause harm or injury
 Risk control: Actions to eliminate or reduce actual, personal, and modifiable health threats
 Safety Behavior: Home Physical Environment: Individual or caregiver actions to minimize environmental factors that might cause physical harm or injury in the home
 Safety Behavior: Personal: Individual or caregiver efforts to control behaviors that might cause physical injury
 Safety Status: Falls Occurance: Number of falls in the past week
 Safety Status: Physical Injury: Severity of injuries from accidents and trauma

RATIONALE FOR NOC CHOSEN AND INDICATORSCORE
 Risk for injury will be decreased, as evidenced by Parenting: Social Safety and Safety Behavior: Fall Prevention.
 Risk control will be demonstrated, as evidenced by the following indicators (specify 1-5; never, rarely, sometimes, often, or consistenly demonstrated):
Monitors environmental and personal behavior risk factors
Develops and follows selected risk control strategies
Modifies lifestyle to reduce risk
 Patient and family will:
- Provide a safe environment
- Identify risks that increase susceptibility to injury
- Avoid physical injury
 Parents will:
- Recognize risk of and monitor for abuse
- Screen playmates, caregivers, and other social contacts
- Recognize signs of gang membership and other high-risk social behaviors.

NIC INTERVENTION LABEL(S) AND NURSING ACTIVITIES
 Environmental Management: Safety: Monitoring and manipulation of the physical environment to promote safety. Implementation: Synchronizing furniture that can injure clients.
 Fall Prevention: Instituting special precautions with patient at risk for injury from falling. Example: Protect your head and pads.
 Parent Education: Childrearing Family: Assisting parents to understand and promote the physical, psychological, and social growth and development. Implementation: assess the nature and characteristics of seizures, during a spasm releasing tight clothes and guard privacy and protect clients from curious people.

RATIONALE FOR NIC CHOSEN
 Synchronizing furniture that can injure clients with rational furnishings that exist around clients who experience seizure attacks can injure clients, such as lights If the client is in bed, remove the pillow and install the bed fence with rationale the installation of the bed fence can prevent injury fall.
 Protect your head and pads to prevent injury with the purpose of protecting clients from capitis trauma.
 Assess the nature and characteristics of seizures rationally to recognize the patient's seizure type. During a spasm releasing tight clothes with rational tight clothes will disrupt the respiratory system and guard privacy and protect clients from curious people with rational patients when seizures occur, clothing clients can be exposed, so it needs to be kept private.




Rahmatul Habibah18 September 2017

Name : Rahmatul Habibah
NIM : 131611133079
Class : A2-2016
A. Nanda Nursing Diagnosis:
Hypothermia related to low environmental temperature, decrease in metabolic rate and inactivity (Domain 11, Class 6, 00007)
Definition: Core body temperature below the normal diurnal range due to failure of thermoregulation.
B. NOC Outcome Label (s) and Indicators:
1923 Risk Control: Hypothermia
Definition: Personal actions to understand, prevent, eliminate, or reduce the threat of low body temperature
- (192321)Monitors environment for factors that decrease body temperature
- (192309) Modifies physical activity to maintain body temperature
- (192322) Monitors changes in general health status
- (192314) Modifies fluid intake as appropriate

C. Rational of NOC choosen:
1. Nurse must give a fluids appropriately to the patient with the patient's condition in order to balance the fluid and monitor for 24 hours
2. Monitor health status changes patient for 24 hours is expected to produce indicator (5) that consistently shows a good health status change patient.

D. NIC intervention label(s) and nursing activities:
1. (3800) Hypothermia treatment
- Apply passive rewarming
- Apply active external rewarming
- Monitor for symptoms associated with mild hypothermia
2. (3790) Hypothermia Induction Therapy
- Institute active external cooling measures
- Use facial or hand warming or insulative wraps to diminish shivering response, as appropriate
- Monitor intake and output

E. Rational of NIC choosen:
1. Use of heating pads is placed on top truncal areas before extremities, hot water bottles, forced air warm, warm blankets, light beaming, warm packs, and convective air heater
2. Use of Blanket, head cover, and warm clothes
3. Monitor the amount and type of intake / fluid intake as well as the habit of elimination patient for 24 hours to knowen the fluid balance and patient's healthy status changes.
4. Explain the signs and symptoms for patient and patient’s family about hypothermia and instruct the patient or patient's family to report any signs and symptoms to the health worker as soon as possible.

Bibliography
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.

Dessy Syahfitri Pohan18 September 2017

NAME : DESSY SYAHFITRI POHAN
NIM : 131611133060
CLASS : A2

Disturbed Sleep Pattern
Diagnose :
Disturbed Sleep Pattern related to nonrestrorative sleep pattern (i.e., due to caregiver responsibilities, parenting practices, sleep partner).( Domain : 4, Class : 1, Kode : 000198)
Definition :
Time-limited interruptions of sleep amount and quality due to external factors.
NOC :
The ability of the patient after doing the nursing action.
1. Trouble getting started sleep (000421)
1 2 3 (4) 5
2. Sleep cut off (000406)
1 2 3 (4) 5
3. Sleeping errors (000409)
1 2 3 (4) 5
4. Sleep apnea (000416)
1 2 3 (4) 5
5. Dependance on sleep aid (000417)
1 2 3 (4) 5
6. Nightmare (000422)
1 2 3 (4) 5
7. Urinate at night (000423)
1 2 3 (4) 5
8. Snoring (000424)
1 2 3 (4) 5
9. Pain (000425)
1 2 3 (4) 5
RATIONALE:
1. The patient usually getting trouble when they will start to sleep,which is make them can’t to sleep.
2. The patient with disturbed sleep pattern will experience unconstant sleep or we called sleep cut off.
3. The patient with disturbed sleep pattern will experience sleeping errors, they can’t to sleep correctly.
4. Apnea experienced by the people has disturbed sleep pattern.
5. Dependance someone on sleep aid is also the trouble of disturbed sleep pattern. The patient with this condition will always felt uncomfortable with arround him.
6. Nightmare is one of disturbance, which is will cut off patient’s sleep. Usually when the patient has did this, it will difficult to start sleep again.
7. To avoid urinate at night, the patient have to urinate first before going to bed.
8. Snoring is the effect of disturbance respiratory when someone getting sleep.
9. The patient will have disturbance in sleep pattern when they felt pain on their body.
NIC :
Exercise Promotion
Definition : increasing participation in physical activity, enviromental.
1. Asses with person, family, or parents the usual bedtime routine-time, hygiene practice, rituals (reading,toy)-and adhere to it as closely as possible.
2. Encourage or provide evening care.
a. Bathroom or bedpan
b. Personal hygiene (mouth care, bath, shower, partial bath).
c. Clean linen and badclothes (freshly made bed, sufficient blankets)
3. Use sleep aids.
a. Warm bath
b. Desired bedtime snack (avoid highly seasoned and high-roughage foods)
c. Reading materials
d. Back rub or massage
e. Milk
f. Soft music or tape recorder story
g. Relaxation/breathing exercises
4. Use pillows for support (painful limb, pregnant or obese abdomen, back)
5. Discourage naps longer than 90 minutes
6. Ensure that the person has at least four to five periods of at least 90 minutes each of uninterrupted sleep every 24 hours.
RATIONALE :
1. To feel rested, a person usually must complete an entire sleep cycle (70-100 minutes) four or five times a night (Cohen&Merrit, 1992).
2. A familiar bedtime ritual may promote relaxation and sleep (Cohen & Merrit, 1992)
3. Warm milk contains L-tryptophan, which is a sleep inducer (Hammer,1991)
4. Pillow can give the comfortable to sleep.
5. Early morning naps produce more REM sleep than do afternoon naps. Naps over 90 minutes long decrease the stimulus for longer sleep cycles in which REM sleep is obtained (Thelan et a;., 1998).

Ishomatul Faizah18 September 2017

NANDA:
Ineffective Coping

Definition: Inability to form valid appraisal of the stressor, inadequate choices of practiced responses, and/or inability to use available resources.
Defining Characteristics: Fatigue
Related Factors: Inadequate opportunity to prepare for stressor

NOC:
Additional Outcomes to Measure Defining

Characteristics:
Anger Self-restrain
Outcomes Associated with Related Factors or Intermediate Outcomes:
Caregiver Stressor

NIC:
Suggested Nursing Interventions for Problem Resolution

Counseling

Definition: use of an interactive helping process focusing on the need, problems, or feelings of the patient and significant others to enhance or support coping, problem solving, and interpersonal relationship.
Activity:
- Ask patient/significant others to identify what they can/cannot do about what is happening
- Assist patient to identify the problem or situation that is causing the distress
- Encourage new skill development, as appropriate
- Reinforce new skill
- Discourage decision-making when the patient is under severe stress, when possible

Progressive Muscle Relaxation

Definition: Facilitating the tensing and releasing of successive muscle groups while attending to the resulting differences in sensation.
Activity:
- Instruct the patient to breathe deeply and to slowly let the breathe and tension out
- Terminate the relaxation session gradually
- Allow time for the patient to express feelings concerning the intervention
- Encourage the patient to practice between regular sessions with the nurse.

Annisa Fitriani Purnamasari18 September 2017

Breastfeeding, Ineffective
Nanda Nursing Diagnostic: Breastfeeding, Ineffective (Domain 2. Class 1 . 00104)
Definition : Difficulty providing milk to an infant or young child directly from the breasts, which may compromise nutritional status of the infant/child.
Defining Characteristics : Infant crying at the breast, Infant inability to latch on to maternal breast correctly, Infant unresponsive to other comfort measures, Insufficient infant weight gain, Perceived inadequate milk supply, Sore nipples persisting beyond first week, Sustained infant weight loss, Unsustained suckling at the breast.
Related Factors : Inadequate milk supply, Insufficient family support, Insufficient parental knowledge regarding breastfeeding techniques, Insufficient parental knowledge regarding importance of breastfeeding, Maternal anxiety, Maternal fatigue, Maternal obesity, Maternal pain, Poor infant sucking reflex, Prematurity, Previous history of breastfeeding failure.
NIC (Nursing Interventions Classification)
Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process
Rationale : Doing the Effective breastfeeding by mothers to infants by Lactation Counseling,
Suggested Nursing Interventions for Problem Resolution:
1. Lactation Counseling. (Code : 5244) (Definition: Assisting in the establishment and maintenance of successful breastfeeding).
A) Provide information about psychological and physiological benefits of breastfeeding
B) Encourage mother’s significant other, family, or friends to provide support (i.e., offer praise, encouragement, and reassurance, perform household tasks, and ensure that mother is receiving adequate rest and nutrition)
C) Discuss ways to facilitate milk transfer (e.g., relaxation techniques, breast massage, and a quiet environment)
D) Monitor infant’s ability to suck
E) Instruct mother on nipple care
F) Discuss techniques to avoid or minimize engorgement and associated discomfort (e.g., frequent feedings, breast massage, warm compresses, milk expression, ice packs applied after feeding or pumping, and antiinflammatory medications)
G) Discuss needs for adequate rest, hydration, and well-balanced diet
H) Encourage mother to wear a well-fitting, supportive bra
I) Discuss strategies aimed at optimizing milk supply (e.g., breast massage, frequent milk expression, complete emptying of breasts, kangaroo care, and medications)
J) Provide instruction and support in accordance with healthcare institution’s policy on lactation for the mother of preterm infant (i.e., instruct on frequency of pumping, when to expect milk supply to increase, normal feeding patterns based on gestational age, and weaning from pump when infant is able to nurse well)
K) Provide discharge instructions and arrange for follow-up care tailored to patient’s specific needs (e.g., mother of healthy term infant, multiples, preterm infant, or ill infant)
L)Refer to a lactation consultant
M) Assist with relactation, if needed
N) Discuss options for weaning
O) Instruct mother to consult her healthcare practitioner before taking any medications while breastfeeding, including over-thecounter medications and oral contraceptives
P) Encourage employers to provide opportunities for lactating mothers to express and store breast milk during the workday
Additional Optional Interventions:
1. Bottle Feeding. (Code: 1052). (Definition: Preparation and administration of fluids to an infant via a bottle.
2. Sleep Enhancement. (Code: 1850). (Definition: Facilitation of regular sleep/wake cycles).
3. Weight Management. (Code: 1260). (Definition: Facilitating maintenance of optimal body weight and percent body fat).
NOC (Nursing Outcomes Classification)
Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process
Rationale : Infants satisfied breastfeeding process, and the mother did not feel any pain in the breast
Outcomes to Measure Resolution of Diagnosis
1. Breastfeeding Establishment: Maternal.( Code : 1001). (Definition: Maternal establishment of proper attachment of an infant to and sucking from the breast for nourishment during the first 3 weeks of breastfeeding).
Additional Outcomes to Measure Defining Characteristics
1. Breastfeeding Maintenance. (Code : 1002). (Definition: Continuation of breastfeeding from establishment to weaning for nourishment of an infant/toddler)
2. Infant Nutritional Status. (Code : 1020). (Definition: Amount of nutrients ingested and absorbed to meet metabolic needs and foster growth of an infant)
3. Nutritional Status: Food & Fluid Intake.(Code: 1008). (Definition: Amount of food and fluid taken into the body over a 24-hour period)
Outcomes Associated with Related Factors or Intermediate Outcomes
1. Family Integrity
2. Fatigue Level
3. Hydration
4. Knowledge: Breastfeeding
5. Knowledge: Infant Care
6. Pain Level
7. Social Support

Annisa Fitriani Purnamasari18 September 2017

Breastfeeding, Ineffective
Nanda Nursing Diagnostic: Breastfeeding, Ineffective (Domain 2. Class 1 . 00104)
Definition : Difficulty providing milk to an infant or young child directly from the breasts, which may compromise nutritional status of the infant/child.
Defining Characteristics : Infant crying at the breast, Infant inability to latch on to maternal breast correctly, Infant unresponsive to other comfort measures, Insufficient infant weight gain, Perceived inadequate milk supply, Sore nipples persisting beyond first week, Sustained infant weight loss, Unsustained suckling at the breast.
Related Factors : Inadequate milk supply, Insufficient family support, Insufficient parental knowledge regarding breastfeeding techniques, Insufficient parental knowledge regarding importance of breastfeeding, Maternal anxiety, Maternal fatigue, Maternal obesity, Maternal pain, Poor infant sucking reflex, Prematurity, Previous history of breastfeeding failure.
NIC (Nursing Interventions Classification)
Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process
Rationale : Doing the Effective breastfeeding by mothers to infants by Lactation Counseling,
Suggested Nursing Interventions for Problem Resolution:
1. Lactation Counseling. (Code : 5244) (Definition: Assisting in the establishment and maintenance of successful breastfeeding).
A) Provide information about psychological and physiological benefits of breastfeeding
B) Encourage mother’s significant other, family, or friends to provide support (i.e., offer praise, encouragement, and reassurance, perform household tasks, and ensure that mother is receiving adequate rest and nutrition)
C) Discuss ways to facilitate milk transfer (e.g., relaxation techniques, breast massage, and a quiet environment)
D) Monitor infant’s ability to suck
E) Instruct mother on nipple care
F) Discuss techniques to avoid or minimize engorgement and associated discomfort (e.g., frequent feedings, breast massage, warm compresses, milk expression, ice packs applied after feeding or pumping, and antiinflammatory medications)
G) Discuss needs for adequate rest, hydration, and well-balanced diet
H) Encourage mother to wear a well-fitting, supportive bra
I) Discuss strategies aimed at optimizing milk supply (e.g., breast massage, frequent milk expression, complete emptying of breasts, kangaroo care, and medications)
J) Provide instruction and support in accordance with healthcare institution’s policy on lactation for the mother of preterm infant (i.e., instruct on frequency of pumping, when to expect milk supply to increase, normal feeding patterns based on gestational age, and weaning from pump when infant is able to nurse well)
K) Provide discharge instructions and arrange for follow-up care tailored to patient’s specific needs (e.g., mother of healthy term infant, multiples, preterm infant, or ill infant)
L)Refer to a lactation consultant
M) Assist with relactation, if needed
N) Discuss options for weaning
O) Instruct mother to consult her healthcare practitioner before taking any medications while breastfeeding, including over-thecounter medications and oral contraceptives
P) Encourage employers to provide opportunities for lactating mothers to express and store breast milk during the workday
Additional Optional Interventions:
1. Bottle Feeding. (Code: 1052). (Definition: Preparation and administration of fluids to an infant via a bottle.
2. Sleep Enhancement. (Code: 1850). (Definition: Facilitation of regular sleep/wake cycles).
3. Weight Management. (Code: 1260). (Definition: Facilitating maintenance of optimal body weight and percent body fat).
NOC (Nursing Outcomes Classification)
Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process
Rationale : Infants satisfied breastfeeding process, and the mother did not feel any pain in the breast
Outcomes to Measure Resolution of Diagnosis
1. Breastfeeding Establishment: Maternal.( Code : 1001). (Definition: Maternal establishment of proper attachment of an infant to and sucking from the breast for nourishment during the first 3 weeks of breastfeeding).
Additional Outcomes to Measure Defining Characteristics
1. Breastfeeding Maintenance. (Code : 1002). (Definition: Continuation of breastfeeding from establishment to weaning for nourishment of an infant/toddler)
2. Infant Nutritional Status. (Code : 1020). (Definition: Amount of nutrients ingested and absorbed to meet metabolic needs and foster growth of an infant)
3. Nutritional Status: Food & Fluid Intake.(Code: 1008). (Definition: Amount of food and fluid taken into the body over a 24-hour period)
Outcomes Associated with Related Factors or Intermediate Outcomes
1. Family Integrity
2. Fatigue Level
3. Hydration
4. Knowledge: Breastfeeding
5. Knowledge: Infant Care
6. Pain Level
7. Social Support

Dewi Indah Kumalasari18 September 2017

NANDA
Diagnose : Insomnia
Definition : A disruption in amount and quality of sleep that impairs functioning.
(Domain 4. Activity/Rest. Class 1. Sleep/Rest. Code 00095)
NOC : 0004 Sleep
Definition: Natural periodic suspension of consciousness during which the body is restored
1= Severely compromised 5= Not Compromised
000401 Hours of sleep 1 2 3 4 5
000403 Sleep pattern 1 2 3 4 5
000404 Sleep quality 1 2 3 4 5
000418 Sleeps thourgh the night consistently 1 2 3 4 5
000419 Comfortable bad 1 2 3 4 5

NIC
• 1850 Sleep Enhancement
- Determine patient’s sleep/activity pattern
Rasionale : To identify the appropriate action
- Monitor/record patient’s sleep pattern and number of sleep hours
Rasionale : Individual sleep patterns can be collected through a comprehensive and holistic assessment, needed to determine the cause of the disorder.
-Assist to eliminate stressful situations before bedtime
Rasionale : Enhance client's sense of comfort and reduce feelings of disturbance to clients


• 5820 Anxiety Reduction
- Use a calm, reassuring approach
Rasionale : a quiet and comfortable environment can reduce anxiety
- Seek to understand the patient’s perspective of a stressful situation
Rasionale : Improve client sleep patterns
- Listen attentively
Rasionale : This action helps to detect any symptoms on the client


• 4400 Music Therapy
- Identify the individual’s musical preferences
Rasionale : Environmental noise that can not be eliminated or reduced can be covered with "soft sounds"
- Assist the individual in assuming a comfortable position
Rasionale : Improving sleep comfort as well as physiological / psychological support
- Avoid turning music on and leaving it on for long periods
Rasionale : Excessive anxiety can make sleep difficult.



Mitha Permata Dini18 September 2017

Mitha Permata Dini
131611133057-A2

NANDA
Hopelessness related to chronic stress factors

Definition :
Subjective state in which an individual sees is limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.
(Domain 6, hopelessness, class 1. Chronic stress, code 00124)
NOC
 Child Development: Adolescence 0109
1. Vents negative feelings in a non-destructive manner 010920
Rational: clients think of causation to prevent negative things from happening
2. Participates in extracurricular school activities 010923
Rational: Following extracurricular activities can help build social relationships
3. Avoids recreational drugs use 010919
Rational: to prevent physical and psychological disturbance to the client
 Fear Level
1. Perceived inadequacy in interpersonal relationships 121012
Rational: Client less comfortable feeling
2. Exaggerated concern about life events 121013
Rational: The client is traumatized by an event
3. Avoidance behavior 121030
Rational: the client is afraid to connect with the environment
 Social Interaction Skills 1502
1. Cooperates with others 150203
Rational: Clients can establish good relationships with others
2. Exhibits Consideration 150207
Rational: Clients feel cared for
3. Exhibits Genuineness 150208
Rational: With sincerity, clients feel safe and comfortable
NIC

 Behavior Modification : Social Skills 4362
1. Assist patient to identify interpersonal problems resulting from social skill deficits
Rational: Patient is aware of the importance of social skills
2. Assist patient to identify desired outcomes for problematic interpersonal relationships or situations
Rational: The patient can resolve the situation according to what is desired
3. Assist patient to identify possible courses of action and their social/interpersonal consequences
Rational: Patient can understand the good of the action
 Counseling 5240
1. Demonstrate empathy, warmth, and genuineness
Rational: Clients feel affectionate
2. Provide privacy and ensure confidentiality
Rational: Clients feel safe
3. Determine how family behavior affects patient
Rational: With good family behavior, clients will feel comfortable
 Emotional Support 5270
1. Explore with patient what has triggered emotions
Rational: By knowing the things that trigger emotions, the patient can control his emotions
2. Embrace or touch patient supportively
Rational: Patients feel helpful and will build positive thoughts
3. Encourage the patient to express feelings of anxiety, anger, or sadness
Rational: By expressing feelings, the patient will feel calm

Maulidiyah Mahayu Nilam Anindy18 September 2017

Name : Maulidiyah Mahayu Nilam Anindy
NIM : 131611133067
Class : A2

Risk for adverse reaction to Stress Urinary Incontinence (00017)
Definition: Sudden leakage of urine with activities that increase intra-abdominal pressure.

NOC (Nursing Outcomes Classification)
Symptom Control (1608)
Definition: Personal actions to minimize perceived adverse changes in physical and emotional functioning
1) Monitors symptom onset
2) Monitors symptom persistence
3) Monitors symptom severity
4) Monitors symptom frequency
5) Monitors symptom relief measures
6) Obtains health care when warning signs occur
7) Uses available resources
8) Reports symptoms controlled

Rationale for NOC Chosen and Indictor Score:
1. Monitoring of the appearance of symptoms and redness will be seen in less than 1x24 hours
2. Monitoring how much variation of symptoms will be seen within 2x24 hours
3. Precautions and minimize symptoms will be visible within 6-12 weeks

NIC (Nursing Intervention Classification)

Pelvis Muscle Exercise (0560)
Definition: Strengthening and training the levator ani and urogenitalmuscles through voluntary, repetitive contraction to descrease stress, urge, or mixed type of urinary incontinence
Activity:
1) Determine ability to recognize urge to void
2) Instruct individual to tighten, then relax, the ring of muscle around urethra and anus, as if trying to prevent urination or bowel movement
3) Instruct individual to avoid contracting the abdomen, thinghs, and buttocks, holding breath; or straining down during the exercise
4) Assure that the individual can differentiate between the desired drawing up-and-in muscle contraction and the undesired bearing down effort
5) Inform individual that it takes 6 to 12 weeks for exercises to be effective
6) Provide positive feedback for doing exercises as prescribed

Rationale for NIC Chosen and Indictor Score:
1. To know the ability of urinary urgency patients
2. To train the patient to be able to perform maintenance actions
3. To build patient confidence and trust in carrying out treatment actions
4. To provide information about treatment actions
5. To give hope that what is lived during the treatment will have a positive impact

Nahdiya Rosa A18 September 2017

NANDA (Nursing Diagnoses) :
Diarrhea related to infection : abdominal pain (00013)
Definition : passage of loose, unformed stools
Domain 3 : Ellimination and Exchange
Class 2 : Gastrointestinal Function

NOC (Nursing Outcomes Classification :
Maternal Status : Pain Level
Definition : Severity of observed or reported pain

Rational NOC
Reported Pain (210201) 1 2 3 (4) 5
Length of pain episodes (210204 1 2 3 (4) 5

NIC (Nursing Interventions Classification)
Infection Control
Activities :
• Institute universal precautions
• Encourage rest
• Administer antibiotic therapy, as appropriate
• Teach patient and family about signs and symptoms of infection and when to report them to the health care provider
• Teach patient and family members how to avoid infections
• Promote safe food preservation and preparation

Rationale NIC for chosen
• by providing education to families able to reduce the risk of infection
• rest can help the recovery process
• education, can help patients and families to reduce further negative impacts
• taking medication regularly can speed healing

Neisya Nabila Pawestri18 September 2017

NAME: NEISYA NABILA PAWESTRI
NIM: 131611133058
CLASS: A2

NANDA Nursing Diagnoses:
Hyperthermia (00007) related to illness.
Definition: core body temperature above the normal diurnal range due to failure of thermoregulation.
Domain 11: Safety/Protection ---- Class 6: Thermoregulation

NOC Outcome Label(s) and indicators:
Knowledge: thermoregulation (0800)
Definition: Balance among heat production, heat gain, and heat loss.
Indicators:
1. Sweating when hot (080010) – 3 (moderately compromised)
2. Hyperthermia (080019) – 1 (severe)
Rational for NOC Chosen and Indicator Score
- Sweating is one effort in the body to normalize the temperature in the body
- When the body temperature exceeds 40 ° C and a central nervous system occurs, the patient is said to have a heat stroke condition

NIC Intervention label(s) and nursing activities
1. Fever Treatment
- Monitor temperature and other vital signs
- Cover the patient with blanket or light clothing, depending on phase of fever
- Facilitate rest, applying activity restrictions if needed
- Increase air circulation

2. Temperature Regulation
- Monitor temperature at least every 2 hours, as appropriate
- Promote adequate fluid and nutritional intake
- Instruct patient how to prevent heat exhaustion and heat stroke
- Adjust environmental temperature to patient needs
Rational for NIC Chosen
- Monitoring temperature and other vital signs needed to check that temperature and vital sign is in normal condition.
- Adequate nutritional intake, rest enough are needed to help thermoregulation system.
- Appropriate environmental temperature can make the patient feel comfort and normalize the temperature.

Mutiara Citra Dewi18 September 2017

I. 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

II. 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

III. 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

Gita Aula Tribuana18 September 2017

Diagnosis: Sexual dysfunction (Domain: 8, Class: 2, Code: 00059)
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.
Defining Characteristics
Alteration in sexual activity
Alteration in sexual excitation
Alteration in sexual satisfaction
Change in interest toward others
Change in self-interest
Change in sexual role
Decrease in sexual desire
Perceived sexual limitation
Seeks confirmation of desirability
Undesired change in sexual function
Related Factors
Absence of privacy
Absence of significant other
Alteration in body function (due to anomaly, disease, medication, pregnancy, radiation, surgery, trauma, etc.)
Alteration in body structure (due to anomaly, disease, pregnancy, radiation, surgery, trauma, etc.)
Inadequate role model
Insufficient knowledge about sexual function
Misinformation about sexual function
Presence of abuse (e.g., physical, psychological, sexual)
Psychosocial abuse (e.g., controlling, manipulation, verbal abuse)
Value conflict
Vulnerability
NOC
Sexuality pattern, ineffective
Self-esteem situasional low
Rape trauma syndrome silent
Knowledge: sexual functioning
Rationale for NOC
Recorvery and sexual abuse
Physical changes with with the aging of woman
Recognition and acceptance of personal sexual identity
Know the problem of reproduction
Control of the risk of sexually transmitted disease

NIC
Definition: The 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.
Building a therapeutic relationship based on trust and respect
Establish length of counseling relationship
Providing privacy and ensuring confidentiality
Provide information about sexual function
Decision-Making Support
Energy Management
Family Planning: Contraception
Family Planning: Infertility
Family Process Maintenance
Fertility Preservation
Hormone Replacement Therapy
Pain Management
Postpartal Care
Premenstrual Syndrome (PMS) Management
Teaching: Individual
Therapy Group
Rationale for NIC
Can improve sexual function
Increase hormones

Neisya Pratiwindya Sudarsiwi18 September 2017

Name : Neisya Pratiwindya Sudarsiwi
NIM : 131611133092
Class : A2 2016

Nursing Diagnosis : Fatigue related to occupational demand (e,g. Shift work, high level of activity, stress) [Domain: 4. Activity/Rest; Class 3. Energy Balance, Code:00093]

Definition : An overwhelming sustained sense of exhaustion and decresease capacity for physical and mental work at the usual level

NOC:
1.Stress level (1212)
-Increased muscle tension in neck, shoulders and back ( (121205) [4: mild]
-Depression (121221) [5: none]
-Decreased Productivity (121232) [4: mild]

2.Physical Fitness
-Joint flexibility (200403) [5: not compromised]
-Performance of physical activities (200404) [5: not compromised]
-Performance of routine exercise (200405) [5: not compromised]

3.Pain Level
-Facial expressions of pain (210206) [4: mild]
-Restlessness (210208) [5: none]
-Muscle tension (210209) [4:mild]

NIC:
1.Relaxation Therapy (6040)
-Describe the rationale for relaxation and the benefits, limit, and types of relaxation available (e.g music, meditation, rhythmic breathing, jaw relaation and progressive muscle relaxation)
-Invite the patient to relax and let the sensations happen
-Encourage return demonstrations of technique, if possible

2.Energy Management (0590)
-Assess patient’s physiologic status for deficit resulting in fatigue within the context of age and development
-Select intervention for fatigue reduction using combinations of pharmacologic and non pharmacologic categories, as appropiate
-Monitor/record patient sleep pattern and number of sleep hours
-Monitor location and nature of discomfort or pain during movement/activity
-Limit enviromental stimuli (e.g light and noise) to facililitate relaxation
-Assist patient to schedule rest periode

3.Exercise Therapy: Muscle Control (0226)
-Determine patient’s readiness t engage in activity or exercise protocol
-Consult physical therapy to determine optimal position for patient during exercise and number of repetittion for each movement pattern
-Assist to maintain trunk and/or proximal joint stability during motor activity
-Encourage patient to practice exercise independently, as indicate

Rationale for NIC Chosen:
1.Relaxation Therapy (6040)
-To make sure that the patient know the rationale and benefits, limit, and types of relaxation available (e.g music, meditation, rhythmic breathing, jaw relaation and progressive muscle relaxation)
-To make a comfort situation for the patient
-To give an example technique of relaxation so the patient can follow nurse instruction and do it by them self

2.Energy Management (0590)
-To know the relationship between context of age with patient’s physiologic
-To make sure that the chosen intervention is appropiate with the patient’s condition
-To know patient sleep pattern and number of sleep hours so a nurse can dicide what kind of intervention that will given to the patient
-To minimize over mobility that can disturb the patient comfort
-To minimize the enviromental stimuli that can disturb patient comfort and make a comfartable situation for relaxation
-To full fill the human needed (rest periode) so can help patient in the better condition (recovery)

3.Exercise Therapy: Muscle Control (0226)
-To know the readiness from the patient body
-To give the right physical therapy position so can minimize injury posibility
-To make sure that the patient’s safety
-To know the patient’s understanding about practice exercise and help the patient maintain in better condition

Mochammad Nur Cahyono18 September 2017

Number: 00085
Diagnose: impaired physical mobility related by Decrease in endurance secondary of Uncoordinated movement
Definition:. Limitation in independent, purposeful physical movement of the body or of one or more extremities
NOC:
0212 Coordinated Movement
Definition: Ability of muscles to work together voluntarily for purposeful movement
1= Severely compromised thru 5= Not compromised
021205 Control of movement 1 2 3 4 5
021207 Balanced movement 1 2 3 4 5
021206 Steadiness of movement 1 2 3 4 5
NIC :
0222 Exercise Therapy: Balance
Definition: Use of specific activities, postures, and movements to maintain, enhance, or restore balance

• Determine patient’s ability to participate in activities requiring balance
• Collaborate with physical, occupational, and recreational therapists in developing and executing exercise program, as appropriate
• Provide safe environment for practice of exercises
• Instruct patient on the importance of exercise therapy in maintaining and improving balance
• Instruct patient on balance exercises, such as standing on one leg, bending forward, stretching and resistance, as appropriate
• Assist with ankle strengthening and walking programs
• Provide information on alternative therapies such as yoga and Tai Chi
• Adjust environment to facilitate concentration
• Reinforce or provide instruction about how to position self and perform movements to maintain or improve balance during exercises or activities of daily living
• Provide resources for balance, exercise, or fall-education programs
• Monitor patient’s response to balance exercises

Rationale for NIC chosen :
• in order to balance the patient regularly or stable
• to exercise the balance regulated by the hypothalamus
• let the body strong can also be monitored with the monitoring well

Mochammad Nur Cahyono18 September 2017

Number: 00085
Diagnose: impaired physical mobility related by Decrease in endurance secondary of Uncoordinated movement
Definition:. Limitation in independent, purposeful physical movement of the body or of one or more extremities
NOC:
0212 Coordinated Movement
Definition: Ability of muscles to work together voluntarily for purposeful movement
1= Severely compromised thru 5= Not compromised
021205 Control of movement 1 2 3 4 5
021207 Balanced movement 1 2 3 4 5
021206 Steadiness of movement 1 2 3 4 5
NIC :
0222 Exercise Therapy: Balance
Definition: Use of specific activities, postures, and movements to maintain, enhance, or restore balance

• Determine patient’s ability to participate in activities requiring balance
• Collaborate with physical, occupational, and recreational therapists in developing and executing exercise program, as appropriate
• Provide safe environment for practice of exercises
• Instruct patient on the importance of exercise therapy in maintaining and improving balance
• Instruct patient on balance exercises, such as standing on one leg, bending forward, stretching and resistance, as appropriate
• Assist with ankle strengthening and walking programs
• Provide information on alternative therapies such as yoga and Tai Chi
• Adjust environment to facilitate concentration
• Reinforce or provide instruction about how to position self and perform movements to maintain or improve balance during exercises or activities of daily living
• Provide resources for balance, exercise, or fall-education programs
• Monitor patient’s response to balance exercises

Rationale for NIC chosen :
• in order to balance the patient regularly or stable
• to exercise the balance regulated by the hypothalamus
• let the body strong can also be monitored with the monitoring well

Ida Nurul Fadilah18 September 2017

Name/student number : Ida Nurul Fadilah / 1316
Class : A2 2016

NANDA Nursing Diagnoses :
Risk for imbalanced body temperature (00005)
Definition : Vulnerable to failure to maintain body temperature within normal parameters, wich may compromise health
Domain 11 Safety / Protection
Class 6 Thermoregulation

NOC Outcomes :
1. Newborn adaptation (0118)
Definition : Adaptive response to the extrauterine environment by a physiologically mature newborn during the first 28 day
a. Apical heart rate (100-160) (011803) – 4 ( mild deviation from normal range)
b. Respiratory rate (30-60) (011804) – 4 (mild deviation from normal range)

2. Immune Status (0702)
Definition : Natural and acquired appropriately targeted resistance to internal and external antigens
a. Body temperature (070207) – 4 (mildly compromised)
b. Antibody titers (070212) – 4 (mildly compromised)
NIC :
1. Temperature regulation
Definition : Attaining or maintaining body temperature within normal range
- Prewarm items (e.g., blankets, snugglies) placed next to infant in incubator
- Wrap infant immediately after birth to prevent heat loss
- Monitor newborn’s temperature until stabilized
- Institude a continuous core temperature monitoring device, as appropriate
- Monitor skin color and temperature
- Monitor for and report signs and symtoms of hypothermia and hyperthermia
- Place newborn in isolette or under warmer, as needed
2. Vital sign monitoring
Definition : Collection and analysis of cardiovascular, respiratory, and body temperature data to determine and prevent complications
- Monitor blood pressure, pulse, temperature, and respiratory status, as appropriate
- Identify possible causes of changes in vital signs
- Check periodically the accuracy of instruments used for acquisition of patient data
Rationale for NIC
1. to ensure normality & detect deviations
2. there can be an indication of how the babies make adjustments to life outside the uterus

Soura Kristiani Tarigan18 September 2017

Name :Soura Kristiani Tarigan
NIM : 131611133059

Nursing Care Plan for Stroke
Cerebrovascular accident or stroke is the primary cerebrovascular disorder in the United States. A cerebrovascular accident is a sudden loss of brain functioning resulting from a disruption of the blood supply to a part of the brain.It is a functional abnormality of the central nervous system.Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.
The diagnosis for stroke
1. Cerebral tissue perfusion changed which associated with blood flow interruptions, occlusive and hemorrhagic disorders, cerebral vasospasm, and cerebral edema, preserved by decreased awareness, headaches, and spoiledness.
NOC :
a. No pain in the extremities,
b. Peripheral tissue pefusion,
c. No widening of the veins,
d. No peripheral edema
Rational for NOC : Awareness level improved, Vital sign are stable, There are signs of increased intracranial pressure
NIC :
a. Monitor BP, pulse, temperature, RR every 6 hours
b. Monitor sound of the heart
c. Monitor the frequency and rhythm of the breathing
d. Monitor neurogical status
e. Monitor awareness level
f. Monitor respiratory status
Rational for NIC : To monitor awareness level and ensuring vital signs are stable

2. Acute pain related to hemiplegia and disuse
NOC:
a. Shoulder mobilization, shoulder exercises
b. Arms and hands can raised at intervals
Rational for NOC: Hope patient can maintain optimal position, increase the strength and function of affected body parts and demonstrate behaviors that enable activitiy
NIC :
a. Do pain assessment include characteristic location, onset, frequency and duration, coality, pain intensity, and precipitation factor
b. Observe non verbal signs of discomfort
c. Use therapeutic communication so that patients can express pain
d. Assess the patient's cultural background
e. Control of environmental factors that may affect the patient's response to discomfort
f. Provide information about pain
g. Encourage the patient to monitor the pain sensation
h. Enhance enough resting sleep
Rational for NIC : To train patient’s mobilization without pain

3. Impaired verbal communication related to brain damage
NOC :
a. Patient can put the sign language correctly
b. No misunderstanding of communication between client, nurse, and family
Rational for NOC : Patient can communicate well.
NIC :
a. Assess the type of disfunction such as the patient doesnt seem to understand the word or have difficulty speaking or making own sense
b. Show the object and ask patient the name of the object
c. Say directly with the patient, speak slowly and quietly
Speak in a normal tone and avoid fast conversation
Rational for NIC : Patient know how to order if they want something

4. Deficient self-care related to stroke sequelae
NOC :
a. Demonstrate techniques or lifestyle changes to meet self-care needs
b. Conducting self-care activities and own ability level
c. Identify personal sources / communications, provide assistance as needed
Rational for NOC : Patient still want to communicate with his inner circle even the situation changed. Patient can express acceptance to self in this situation
NIC :
a. Assess the ability and the level of shortcomings to perform daily needs
b. Provide assistance as needed
c. Maintain support, firm attitude. Give the patient enough time to do his job
d. Use personal tools such as a combination of bamboo shaft, long stalk to take something from the floor
e. Identify previous devocation habits and restore the normal pattern habits. The content of the food is tight, encourage a lot of drinking and activity
Rational for NIC : To help the patient to encourage good dress and dress habits, we provide support for they behaviors or businesses such as increased interest or participation in rehabilitation activities. Encourage the nearest person to allow the patient to do as much for themself as possible



Nophyaningtias Tri Widya Ningsih18 September 2017

Nama: Nophyaningtias Tri Widya Ningsih
Nim: 131611133056
Kelas: A2/2016
NANDA
Defining charachteristics: Reports feelings that reflect an altered view one’s body (e.g apperance, structure, function)
Objective:
Behaviors of monitoring one's body
Intentional hiding of body part
Not looking body part
Subjective:
Reports change in lifestyle
Report fear of reaction by others
Reports negative feeling about body (e.g feeling of helplessness, hopelessness, powerlessness)
Related Factors:
Illness
Psychosocial
Surgery

NOC
Outcomes to measure resolution of diagnosis:
Body image
Additional outcomes to measure defining characteristics:
Identity
Self esteem
Social anxiety level
Outcomes associated with related factors or intermediate oucomes:
Abuse recovery: emotional
Psychosocial adjustment: life change
Surgical recovery: convalescene
Surgical recovery: convalescene
Pain
Anxiety
Adjustment to body changes due to surgery
Rational:
So that patients can control their emotions about unwanted body parts
In order to change patient's life better than ever
In order for the patient to recover the former surgery
NIC
Body image disturbed:
Body image enhancement
Body image enhancement:
Definition: Improving a patients conscious and unconscious perceptions and attitudes toward his/her body
Activities:
Assist patient to discuss changes caused by illness or surgery, as appropriate
Assist the patient to discuss stressors, affecting body image due to congenital condition, injury, disease,or surgery
Assist patient in identifying parts of his/her body that have positive perceptions associated with them
Rational:
So that the nurse knows what to do next
Because the nurse not only helps physical recovery but also emotionally
So that nurses can change negative perceptions about unwanted body parts through other parts of the body that are considered better

Lukmania Andriani Putri18 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

Asih Parama Anindhia18 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.

Galang Hasfiansyah18 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

Ema Yuliani18 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


Konita Shafira18 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

Fatatin Nazhifah18 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.

Grace Marcellina B 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.

khoirun niswatul ulfa18 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

BLANDINA EASTER GRACE WAIRATA18 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.

Fatatin Nazhifah18 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.

Mutiara Citra Dewi18 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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