NANDA NIC & NOC A3

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Komentar (58)

Restu Windi13 September 2017

CHRONIC PAIN
Nursing diagnoses/NANDA Destination / NOC NIC
CHRONIC PAIN
Definition: a sudden or intense attack of mild to severe, constant or recurrent endless that can be anticipated / credited and the duration of time is greater than 6 months.
Limitations of characteristics:
• Changes in weight
• Verbal and non-verbal reports or facts from observations of protective behavior, vigilance, masking, ritability, self-focus, anxiety, depression
• Atrophy involving multiplemuscle
• Changes in sleep patterns
• Fear of back injury
• Reduced interaction with people
• Inability to resume previous activity
• Mediating sympathetic responses (eg cold temperature, body position change, hypersensitivity)
• Anorexia
Related factors: Chronic physical / psychological disability After nursing action during ...... x24 hours patient can control pain with indicator:
• Identify the underlying factors
• Recognizes the onset (duration of pain)
• Use prevention methods
• Using nonanalgetic methods to reduce pain
• Use analgesics as needed
• Seeking the help of health workers
• Report symptoms to health personnel
• Use the available resources
• Recognize the symptoms of pain
• Recording previous pain experiences
• Reporting pain is controlled
After nursing action during ...... x24 hours patient can know level of pain with indicator:
• reported the presence of pain
• the area of the affected body
• frequency of pain
• the length of the episode of pain
• statement of pain
• expression of pain on the face
• Protective body position
• lack of rest
• muscle tension
• changes in respiratory rate
• change of pulse
• changes in blood pressure
• changes in pupil size
• excessive sweating
• loss of appetite MANAGEMENT OF PAIN
Definition: reduce pain and decrease pain level felt by patient.
Intervention:
• perform comprehensive pain assessment including location, characteristics, duration, frequency, quality and precipitation factors
• observation of non-verbal reactions from discomfort
• use therapeutic communication techniques to find out the patient's pain experience
• examine the culture that affects the pain response
• evaluation of past pain experiences
• joint evaluation of patients and other health teams about the ineffectiveness of past pain controls
• help patients and families to seek and find support
• environmental controls that can affect pain such as room temperature, lighting and noise
• reduce precipitation factors
• select and do pain management (pharmacology, non pharmacology and inter personal)
• examine the type and source of pain to determine interventions
• teach about non-pharmacological techniques
• Give analgesics to reduce pain
• evaluation of the effectiveness of pain control
• Increase rest
• collaborate with the doctor if pain complaints and actions fail
ANALGETIC ADMINISTRATION
Definition: use of pharmacological agents to stop or reduce pain
Intervention:
• determine the location, characteristics, quality, and degree of pain prior to administration of the drug
• check doctor's instructions on drug type, dose and frequency
• check allergy history
• select necessary analgesics or combinations of analgesics when administering more than one
• Specify analgetic options depending on the type and severity of pain
• Specify selected analgesic, route of administration and optimal dosage
• select IV delivery route, IM for pain treatment on a regular basis
• monitor vital signs before and after first analgesic
• Give analgesics on time especially when the pain is great
• evaluation of analgesic effectiveness, signs and symptoms (side effects)

Retno Galuh Kusumawardhani14 September 2017

Nama : Retno Galuh Kusumawardhani
NIM : 131611133145
Kelas: A3
Resume:
Nursing assessment
1. Introduction
Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.
2. Aim
The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments. The guideline specifically seeks to provide nurses with: Indications for assessment, Types of assessments, Structure for assessments.
3. Definition of terms
3.1. Admission assessment: Comprehensive nursing assessment including patient history (of current illness/injury, relevant past history, allergies and reactions, medications, maternal history), general appearance (considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, posture and movement, etc.), physical examination and vital signs (such as temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, pain) completed at the time of admission. Must be completed within 24hours of admission. Privacy of the patient needs to be considered all times.
- Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation, inspection, palpation, percussion and auscultation are techniques used to gather information. Assessment information includes, but is not limited to: Airway, Breathing, Circulation, Disability, Focused Assessment, Skin, Input/Nutrition, Output/Elimination, Wellbeing, Social/cultural.
3.2. Shift assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time during your shift. This information is used to develop a plan of care. The Shift Assessment includes: Airway, Breathing, Circulation, Disability, Focused, Pain, Hydration/Nutrition, Output, Risk, Wellbeing, Social, and Review the history of the patient recorded in the IP summary, ask questions to add additional details to the history.

3.3. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system, ex: Neurological system, Respiratory system, Cardiovascular, Gastrointestinal, Renal, Musculoskeletal, Eye :Inspection of the eye should always be performed carefully and only with a compliant child.
4. Evaluation of assessment
In the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. The nurse must ensure that appropriate action is taken if any abnormal. This may include communicating the findings to the medical team, and the Associate Nurse Unit Manager in charge of the shift.

timotius dwi kurnianto14 September 2017

Nama: Timotius Dwi Kurnianto
NIM: 131611133134
Kelas: A3/2016

Diagnosis : chance infection related with interference skin integrity (Domain: 11, Kelas 1, 00004)
Definition:
Vulnerable to the invasion and multiplication of pathogenic organisms that can interference with health
NOC
tissueIntegrity: Skin & Mucous Membranes
achievement criteria
1. necrosis light
2. skin temperature Slightly undisturbed or 390
3. Abnormal Pigmentation Normal

NIC
Control Infection
1. Make sure the wound care technique is right
2. Provide appropriate antibiotic therapy
3. Wear proper sterile gloves

Rational
1. With the riqght technique of wound so the wound will be easier to cure and doesn’t make new wound, its make decrease chance to infection
2. Therapy antibiotic gives to patient for kill mikroorganisms who near in wound or in wound, its make decrease of infection also can make wound more fast to cure
3. Wear sterile gloves while do nursing actions (wound care) will make patient safe from chance infection while wound care do by nurse

Cici Kurniatil Farhanah14 September 2017

Nama : Cici Kurniatil Farhanah
NIM : 131611133124

Intervention with Sleep Deprivation Patient

Diagnosis : Sleep deprivation related with heightened sensitivity to pain (Domain : 4, Class : 1, Code : 00096)
Definition : Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)

NOC :
After nursing during 3 x 24 hours, hopefully the patient can rest and not feel the pain, with the criteria of the results
Pain Control :
1. Often describes causal factors
2. Often use the diary to monitor symptoms from time to time
3. Often reports changes in pain sympotoms to health professional

NIC :
Pain Management :
1. Perform a comprehensive assesment of pain include location, characteristics, onset/duration, frequency, quality, intensity or severity
2. Utilize a developmentally appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors (e.g., flow chart, daily diary)
3. Reduce or eliminate factors that precipitate or increase the pain experience
4. Colaborate with the patient, significant other health professionals to select and implement nonpharmacological pain relief measures, as appropriate.
Rationale :
1. To find out the assessment of pain patients with comprehensive
2. To monitor the development and changes of pain
3. To eliminate the factors that trigger pain
4. To obtain comprehensive care

Retno Galuh Kusumawardhani14 September 2017

Nama : Retno Galuh Kusumawardhani
NIM : 131611133145

(Impaired Bed Mobility Patient)

Diagnosis :Impaired bed mobility related with physical deconditioning (Domain : 4, Class : 2, Kode : 00091)
Definition : Limitation of independent movement from one bed position to another.

NOC :
After 3x24 hours of nursing action, it is expected that the patient's ability to move actively on the bed without a hitch with the criteria of result:
Physical Fitness:
1.the flexibility of the joints a little distracted
2.the performance of physical activity of the patient is not interrupted
3.the index patient's body undisturbed period
NIC :
Exercise Therapy : Joint Mobility :
1.Collaborate with physical therapy in developing and executing an exercise program
2.Initiate pain control measures before beginning joint exercise
3.Encourage active range-of-motion (ROM) exercise, according to regular, planned schedule
4.Determine progress toward goal achievement
RATIONAL:
•Allow the success of implementing a program of exercise for the patient with an experienced physical therapist or expert in this field.
•Patients can controlling the pain independently before starting the exercise.
•Patients willing to follow regular active exercise as scheduled with a passion because of the high motivation to be able to move freely.
•The patient's goal to be able to move freely over the success of the program of physical exercise that is already given.

Ainul Fidiatun Nofa14 September 2017

NAMA : AINUL FIDIATUN NOFA
NIM: 131611133123
KELAS : A3 (2016)

Interference Adjustment Individual
Reduction ability to support positive patterns of response to dangerous situations or crises.
Individual Adjustment Disorders Associated With Psychological Disorder Factors (00210)
Domain 9. Koping / Tolerance Stress
Class 2. Koping response

Individual adjustment disorders are caused by (E) the patient's psychological disorders on self-esteem and social involvement.
Symptoms (S) shown by the patient:
• Impaired confidence level
• Impaired self-assessment
• Can not accept criticism
• Less interaction with friends, family and community

NOC
After the nursing action within 6x24 hours, it is expected that the patient's adjustment response to psychological disorders can be adequate with the results:
Self-Esteem (1205)
• The patient's confidence level is consistently positive
• Feelings about the patient's self-worth are consistently positive
• Receive constructive criticism with a consistent positive scale
• Fulfilling a significant role personally is done consistently positive
Social Engagement (1503)
• Patients consistently interact with family members
• Patients consistently interact with close friends
• Patients participate consistently in organized activities
• Patients consistently participate in time-out activities with others Self-Improvement (5326)
• Determine the patient's self-confidence in self-assessment

NIC
Self-Improvement (5326)
• Determine the patient's self-confidence in self-assessment

Rational:
Confidence can only be judged from within oneself
• Helps patients to deal with bullying or ridicule


Rational:
Disorders of self-confidence and self-assessment can be caused by pembullyan both verbal and non verbal
• Support the patient to evaluate his own thoughts

Rational:
Encourage the coping mechanism from within the patient itself to be done independently
• Monitor the level of self-esteem from time to time, appropriately

Rational:
To determine the success rate of nursing care

Socialization Improvement (5100)
• Provide positive feedback when patients are willing to reach out to others

Rational:
Positive feedback can spread a positive effect on the patient's healing process
• Advocating small group planning for specific activities

Rational:
Associations between people with the same problem can open the door of discussion for problem solving.

Ramadhani Wahyuningtyas14 September 2017

NAMA: RAMADHANI WAHYUNINGTYAS
NIM: 131611133110

RISK OF BLEEDING

Definition: At risk of experiencing decrease in blood volume that can interfere with health.

Risk factor:
1. Aneurysm
2. Circumcision
3. Knowledge deficiency
4. Disseminated intravascular coagulopathy
5. History dropped
6. Gastrointestinal disorders (eg, gastric ulcer disease, polyps, varicose veins)
7. Impaired liver function (eg, cirrhosis, hepatitis)
8. Inherent coagulopathy (eg, thrombocytopenia)
9. Postpartum complications (eg, uterine atony, placental retention)
10. Complications related to pregnancy (eg, placenta previa, molar pregnancy, placental abruption)
11. Trauma

NOC
1. Blood loss severity
2. Blood coagulation

Results Criteria:
1. No haematuria and hematemesis occur
2.The loss of visible blood
3. Blood pressure within normal systole and diastole
4. There is no vaginal bleeding
5. There is no abdominal distension
6. Hemoglobin and hematrokrit within normal limits
7. Plasma, PT, PTT within normal limits

NIC
Bleeding Precautions
1. Monitor signs of bleeding
2. Monitor lab values (coagulation) which includes PT, PTT, platelets
3. Record Hb and HT values before and after the occurrence of bleeding
4. Monitor orthostatic vital signs
5. Maintain a bed rest during active bleeding
6. Collaboration in the administration of blood products (platelets or fresh frozen plasma)
7. Protect the patient from trauma that can cause bleeding
8. Avoid measuring the temperature through the rectal
9. Avoid aspirin and anticoagulant
10. Instruct patients to increase the intake of foods that contain lots of vitamin K
11. Avoid the occurrence of constipation by suggesting to maintain adequate fluid intake and fecal softeners

Bleeding Reduction
1. Identify the cause of the bleeding
2. Monitor trend of blood pressure and hemodynamic parameters (CVP, pulmonary capillary / artery wedge pressure
3. Monitor fluid status that includes intake and output
4. Monitor determinant of delivery of oxygen to tissue (PaO2, SaO2 and Hb level and cardiac output)
5. Maintain intravenous patency line

Bleeding Reduction: Wound
1. Perform manual pressure (pressure) on the area of bleeding
2. Use the ice pack in the bleeding area
3. Apply pressure dressing on the wound area
4. Elevate the extremity of the bleeding
5. Monitor the size and characteristics of the hematoma
6. Monitor the distal pulse from the wounded area or bleeding
7. Instruct the patient to suppress the wound area during sneezing or coughing
8. Instruct patient to limit activity

Bleeding Reduction: Gastrointestinal
1. Observe the presence of blood in secretion of body fluids: emesis, stool, urine, gastric residue, and wound drainage
2. Monitor complete blood count and leukocyte
3. Collaboration in therapy: lactulose or vasopressin
4. Perform NGT installation to monitor gastric secretion and bleeding
5. Rinse the stomach with cold NaCI
6. Document the color, number and characteristics of the feces
7. Avoid extreme pH with collaborative administration of antacids or histamine blocking agents
8. Reduce stress factors
9. Keep the airway
10. Avoid using anticoagulant
11. Monitor the nutritional status of patients
12. Give Intravenous fluids.

Shavira15 September 2017

Name: Shavira
NIM: 131611133140
Class: A3 2016
Nanda Nursing Diagnosis
Diagnosis: Ineffective Coping (Domain 9, Class 2: Coping Responses, Code: 00069).
Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
Characteristics: Inability to deal with a situation and ineffective coping strategies
Factors: Inadequate opportunity to prepare for stressor,
NOC Outcome Label(s) and Indicators
Coping (1302)
Objectives: After 2x24 care, individual coping is ineffective with the outcome criteria:
1. Identifies the effective coping patterns.
2. Identify ineffective coping patterns.
3. Reports decrease in stress.
4. Modifies lifestyle to reduce stress.
5. Using effective coping strategies.
Rationale for NOC Chosen and Indictor Score
1. Patients can know the effective coping patterns
2. Patients can differentiate ineffective coping patterns
3. Patients can report increased stresses that occur
4. Patients can change their lifestyle to reduce stress
5. Patients can know the effective strategies in managing coping
NIC Intervention Label(s) and Nursing Activities
Coping Enhancement (5230)
1. Encourage family involvement, as appropriate.
2. Encourage the family to verbalize feelings about ill family member.
3. Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes.
4. Assist the patient to clarify misconceptions.
5. Encourage the patient to evaluate own behavior.
Rationale for NIC Chosen
1. The nurse invites the family to become involved in the treatment of the patient.
2. The nurse invites the family to be open in expressing feelings about the illness of other family members.
3. Patients can know the right positive strategies in lifestyle changes.
4. Patient can know the correct concept.
5. Patient can evaluate their own behavior.

Hayu Ulfaningrum15 September 2017

Nama: Hayu Ulfaningrum
NIM: 131611133143
Kelas: A3
Discovery Learning Nanda, NIC & NOC:
Nanda Nursing Diagnostic: Hyperthermia related to high environmental temperature, increase in metabolic rate and vigorous activity ( Domain 11, Class 6, 00007 ).
Definition: Core body temperature above the normal diurnal range due to failure of thermoregulation.
NOC Outcome Label (s) and Indicators:
1922 Risk Control: Hyperthermia
Definition: individual action to understand, prevent, eliminate, or reduce the health threats related with high body temperature.

1. Monitor health status changes for 24 hours
Body Temperature 1 2 3 4 5
Respiratory Rate 1 2 3 4 5
Blood Plessure 1 2 3 4 5
Pulse 1 2 3 4 5
Mucous membrane 1 2 3 4 5
Skin turgor 1 2 3 4 5
Thirst response 1 2 3 4 5
2. Modification and monitor fluid intake as needed for 24 hours
Fluid Intake 1 2 3 4 5
Urine Output 1 2 3 4 5
Specific gravity of urine 1 2 3 4 5
The Color of The Urine is Turbid 1 2 3 4 5
3. Modify physical activity to control the body temperature
Control of symptoms 1 2 3 4 5
Physical well-being 1 2 3 4 5
Body temperature 1 2 3 4 5

Rationable for NOC choosen and indicator score

1.Monitor health status changes patient for 24 hours is expected to produce indicator (5) that consistently shows a good health status change patient such as respiratory rate, pulse, blood plessure, mucous membrane,skin turgor, thirst response is not disturbed and body temperature is normal.
2.With the modification and monitor fluid intake for 24 hours is expected intake and urine expenditure showed balanced results. what is absorbed the same as what is issued and does not interfere with urine color and specific gravity of urine. Indicator number 5.
3.Modify physical activity to control the body temperature for 2 day can a good control of symptoms, increased physical well-being and body temperature is normal. Indicator number 5.

NIC intervention label(s) and nursing activities
3786 Treatment of hyperthermia
1.Determine the amount and type of intake / fluid intake as well as the habit of elimination patient for 24 hours
2.Monitor mucous membrane, skin turgor, thirst response, color, quantity and specific gravity of urine.
3.Monitor blood pressure,body temperature, pulse, and before breathing, during and after activity.
4.Monitor and report signs and symptoms of hypothermia and hyperthermia.
5.Instruct to the patient about the initial signs and symptoms of the heat-related illness and when to seek help from a health worker.
6.Instruct the patient's risk factors from conditions related to heat such as heat environmental temperature, high humidity, dehydration, physical exertion, obesity, extreme age, certain drugs and heart diseases.
7.Apply fluids appropriately.

Rational of NIC choosen
1. 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.
2. Monitor mucous membrane, skin turgor, thirst response, color, quantity and specific gravity of urine patient to prevent any fluid imbalances that lead to changes in the patient's health status.
3. Monitor blood pressure,body temperature, pulse, and before breathing, during and after activity to prevent the increase in body temperature of the patient.
4. Explain the signs and symptoms for patient and patient’s family about hypothermia and hyperthermia and instruct the patient or patient's family to report any signs and symptoms to the health worker as soon as possible.
5. Teach to the patient or patient’s family about the initial signs and symptoms of the heat-related illness and when to seek help from a health worker.
6. Explain the patient's risk factors from conditions related to heat such as heat environmental temperature, high humidity, dehydration, physical exertion, obesity, extreme age, certain drugs and heart diseases.
7. 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.











Endah Desfindasari15 September 2017

Nama : Endah Desfindasari
NIM : 131611133119
Kelas: A3 A16
Discovery Learning:
Nursing Diagnosis : Nutrition less than body requirements related to inadequate nutrient input
NOC :
Objective: The patient is able to control the pain
Expected outcomes:
1. Being able to recognize when pain occurs (160 502 / IV)
2. Being able to describe the factors causing pain (160 501 / IV)
3. Being able to use pain relief without the analgesic action (160 504 / IV)

NIC :
1. Identification of any allergies or food intolerance owned patients
2. Determine the number of calories and types of nutrients needed to meet nutrient requirements
3. Monitor the calories and food intake
4. Instruct patients about nutritional needs
5. Monitor tendency for reduction and weight gain

RATIONAL :
1. To determine the presence of food allergy in the client
2. To help meet the nutritional needs required by the patient.
3. To find out the calories and food intake in patients.
4. The information provided can motivate patients to improve nutritional intake

ARDINA NADYA WAHYUHERMANTO15 September 2017

NAMA: ARDINA NADYA WAHYUHERMANTO
NIM: 131611133120
KELAS: A3 2016
Nursing Diagnoses : Spiritual distress (Domain 10. Life Principles, Class 3. Value/Belief/Action Congruence. Code00067)
Definition: A state of suffering related to the impaired ability to experience meaning in life trough connections with self, others, the world, or a superior being.
May be related to:
ilness
Possibly evidenced by:
- inability to participate in religious activities
- inability to pray
- inability to experience the transcendent
NOC:
1. Spiritual Health (2001)
- Quality of hope (200102) : 5 (not compromised)
- Ability to pray (200109) : 5 (not compromised)
- Ability to worship (200110) : 5 (not compromised)
2. Outcome Overall Rating (1300)
- Recognizes reality of health situation (130008) : 5 (consistently demonstrated)
- Adjusts to change in health status (130017) : 5 (consistently demonstrated)
- Pursues information about health (130009) : 5 (consistently demonstrated)
NIC:
1. Spiritual Growth Facilitation (5426)
- Encourage conversation that assists the patient in sorting out spiritual concerns
- Encourage participation in devotional services, retreats, and special prayer/study programs
- Encourage patient’s examination of his/her spiritual commitment based on beliefs and values
2. Hope Inspiration (5310)
- Help the patient expand spiritual self
- Develop a plan of care that involves degree of goal attainment, moving from simple to more complex goals
- Encourage therapeutic relationships with significant others
Rationale for NIC choosen:
1. Spiritual Growth Facilitation (5426)
- To know what kind of things the patients are concern
- To make patients not feels lonely, then he/she are motivated to pray
- To know the levels commitment of patients spirituality, then can provide the appropriate support
2. Hope Inspiration (5310)
- The patient will feel peacefully and can focus on how to resolve their spiritual distress
- To make the nursing plan same with the health goal of patients, so the patient will be able to accept their change of health
- Therapeutic support from nearest person effectively motivate patients and accelerate healing

RENDHY RIAN KOESMA BACHTIAR15 September 2017

Name: Rendhy Rian Koesma Bchtiar
NIM: 131611133121
Class: A3
NANDA NIC NOC
• Diagnosis: Inneffective Relationship
A pattern of mutual partnership that is insufficient to provide for each other’s needs.
• Related Factor:
a. Alteration in cognitive functioning in one partner
b. Incarceration of one partner
c. Ineffective communication skills
d. Stressors
e. Unrealistic expectations
• Defining Characteristics:
a. Dissatisfaction with complementary relationship between partners
b. Dissatisfaction with emotional need fulfillment between partners
c. Dissatisfaction with idea sharing between partners
d. Dissatisfaction with information sharing between partners
e. Inadequate understanding of partner’s compromised functioning (e.g., physical, psychological, social)
f. Insufficient mutual support in daily activities between
• NOC
220803-Psychological limitations for caregiving-Substantial
220805-Role conflict-Severe
220816-Loss of personal time-Moderate
• Describe : Psychological exhausted could be affect relationship between partner about there role.
• NIC
5230 -Use a calm, reassuring approach
- Provide an atmosphere of acceptance
- Appraise the patient’s understanding of the disease process
• Describe: Calm and reassuring approach is needed for provide an atmosphere of acceptance so the nurse can appraise the patient’s understanding of the disease process.
References : NANDA. (2015). Nursing Diagnoses: definitions & classification 2015-2017. Philadelphia: NANDA Iternational.

Bulechek,Gloria,Howard,Joanne,Dochterman,Cheryl.(2016).Nursing Interventions Classifications.Edisi 6, Editor Intansari Nurjannah. Jakarta : EGC.

Moorhead,Sue.Marion.Mendean.Maas.Elizabeth.(2016). Nursing Outcome Classification.Edisi 5. Editor Intansari Nurjannah. Jakarta : EGC.








timotius dwi kurnianto15 September 2017

Nama: Timotius Dwi Kurnianto
NIM: 131611133134
Kelas: A3/2016

Diagnosis : chance infection related with interference skin integrity (Domain: 11, Kelas 1, 00004)
Definition:
Vulnerable to the invasion and multiplication of pathogenic organisms that can interference with health
NOC
tissueIntegrity: Skin & Mucous Membranes
achievement criteria
1. Necrosis Light
2. Skin temperature Slightly undisturbed or 390
3. Abnormal Pigmentation Normal

Rational NOC
1. Necrosis is make wound longer to cure, if longer to cure its will be danger because microorganisa have ma long time to infected wound and make infection
2. A warm temperature is make a comfortable environment for microorganisms to infected, so good temperature will decrease a number of infected
3. Pigmentation or colour of the skin is indicated the infected if colour of skin in normal there is no infected

NIC
Control Infection
1. Make sure the wound care technique is right
2. Provide appropriate antibiotic therapy
3. Wear proper sterile gloves

Rational NIC
1. With the riqght technique of wound so the wound will be easier to cure and doesn’t make new wound, its make decrease chance to infection
2. Therapy antibiotic gives to patient for kill mikroorganisms who near in wound or in wound, its make decrease of infection also can make wound more fast to cure
3. Wear sterile gloves while do nursing actions (wound care) will make patient safe from chance infection while wound care do by nurse

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

Handini Indah Rahmawati15 September 2017

Name : Handini Indah Rahmawati
NIM : 131611133122
Class : A3 2016
NANDA Nursing Diagnosis
Diagnosis: Risk for electrolyte imbalance ( Domain: 2, Class: 5, Code: 00195)
Definition: Vulnerable to changes in serum electrolyte levels, which may compromise health.
Risk factors: Excessive fluid volume

NOC Outcome Label (s) and Indicators
Fluide Balance 0601
Objectives: After given nursing care for 2 x 24 hours expected to fluid and electrolyte client balance with yield criteria:
1. Blood pressure
2. Radial pulse rate
3. Stable body weight
4. Skin turgor
Rational for NOC Chosen and Indictor Score
1. Patient can know the normal blood pressure
2. Patients can know sudden radial pulse changes
3. Patients can know a stable weight
4. Patient can distinguish the good and bad skin turgor

NIC Intervention Label (s) and Nursing Activities
Fluid Management 4120
1. Monitor hydration status (e.g., moist mucous membranes, adequacy of pulses, and orthostatic blood pressure), as appropriate.
2. Monitor food/fluid ingested and calculate daily caloric intake, as appropriate.
3. Offer snacks (e.g., frequent drinks and fresh fruits/fruit juice), as appropriate.
4. Consult physician if signs and symptoms of fluid volume excess persist or worsen
Rational for NIC Chosen
1. In order for patient to know the moisture of the mucous membranes, the pulse, and the orthostatic blood pressure that is adequate.
2. To balance the fluids or nutrients present in the body as well as those issued.
3. Snacks can help balance the body and prevent patients from malnutrition.
4. In order a get to inhibit and prevent the severity caused by fluid input errors

Ainul Fidiatun Nofa15 September 2017

NAMA : AINUL FIDIATUN NOFA
NIM: 131611133123
KELAS : A3 (2016)

Interference Adjustment Individual
Reduction ability to support positive patterns of response to dangerous situations or crises.
Individual Adjustment Disorders Associated With Psychological Disorder Factors (00210)
Domain 9. Koping / Tolerance Stress
Class 2. Koping response

Individual adjustment disorders are caused by (E) the patient's psychological disorders on self-esteem and social involvement.
Symptoms (S) shown by the patient:
• Impaired confidence level
• Impaired self-assessment
• Can not accept criticism
• Less interaction with friends, family and community

NOC
After the nursing action within 6x24 hours, it is expected that the patient's adjustment response to psychological disorders can be adequate with the results:
Self-Esteem (1205)
• The patient's confidence level is consistently positive
Rational: build and improve the positive aspects of the client
• Feelings about the patient's self-worth are consistently positive
Rational: to let the client understand her own feelings
• Receive constructive criticism with a consistent positive scale
Rational: convince clients to accept constructive criticism
• Fulfilling a significant role personally is done consistently positive
Rational: meet the needs of client service.

NIC
Self-Improvement (5326)
• Determine the patient's self-confidence in self-assessment
Rational: Confidence can only be judged from within oneself
• Helps patients to deal with bullying or ridicule
Rational: Disorders of self-confidence and self-assessment can be caused by pembullyan both verbal and non verbal
• Support the patient to evaluate his own thoughts
Rational: Encourage the coping mechanism from within the patient itself to be done independently
• Monitor the level of self-esteem from time to time, appropriately
Rational: To determine the success rate of nursing care

Desti Nayunda Lulu15 September 2017

Nama : Desti Nayunda Lulu
NIM : 131611133137
Kelas : A3
Nanda Nursing Diagnosis :
Fatigue (00093) Domain 4, Class 3
Definition :An overwhelming sustained sense of exhaustion and decreased capacity for phisical and mental work at the usual level.
Related Factors :
• Anxiety
• Depression
• Environmental barrier (e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting)
• Increase in physical exertion
• Malnutrition
• Negative life event
• Nonstimulating lifestyle
• Occupational demands (e.g., shift work, high level of activity, stress)
• Physical deconditioning
• Physiological condition (e.g., anemia, pregnancy, disease)
• Sleep deprivation
• Stressors
NOC Outcome Label(s) and Indicators :
Fatigue Level (0007) Domain I, Class A
Definition : Severity of observed or reported prolonged generalized fatigue
Outcome Overall Rating :
1. 000701 Exhaustion 1 2 3 4 5
2. 000708 Headaches 1 2 3 4 5
3. 000720 Sleep quality 1 2 3 4 5
4. 000726 Immune function 1 2 3 4 5
Rationale for NOC chosen and Indicator score :
1. Measure how much fatigue is felt by the patient.
2. Measuring how much headache the patient feels because of the defeat.
3. Measuring the sleep quality of the patient can be one of the patient's natural fatigue factors.
4. Ensuring the patient's immune level is not disturbed due to fatigue.
NIC Intervention Label(s) and Nursing Activities :
Sleep Enhancement (1850)
Definition : Facilitation of regular sleep/wake cycles
Activities :
1. Explain the importance of adequate sleep during pregnancy, illness, psychosocial, etc.
2. Adjust environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep.
3. Encourage patient to establish a bedtime routine to facilitate transition from wakefulness to sleep.
4. Adjust medications patient is taking.
Rationale for NIC chosen :
1. To educate patients about the importance of quality sleep for health and also to overcome fatigue.
2. To improve sleep quality in the bed environment can be one of the supporting factors (eg, light, noise, temperature, room and bed).
3. To improve the sleep patterns of patients who initially bad to be good in order to eliminate the exercise experienced by patients.
4. To help patients who have trouble sleeping.

MUHAMMAD DZAKIYYUL FIKRI WACHID15 September 2017

NAME: Muhammad Dzakiyyul Fikri Wachid
NIM: 131611133115
CLASS: A3/2016

NURSING DIAGNOSIS (NANDA)
Insomnia associated with stressor. (Domain 4. Activity / break, class 1. Sleep / rest, code 00095)

NOC
Nursing actions for 1x24 hours
1. Helps normal client hours of sleep (000401 / I)
2. Fixed for normal sleep patterns (000403 / I)
3. Helping to satisfy the client's sleep quality (000404 / I)
4. Encourage clients to establish routine sleep patterns (000407 / I)
NOC RATIONAL
1. Nurses help to remind each client's sleep time in accordance with the correct procedure.
2. Nurses and patient families help patients to start sleeping and wake up on time.
3. making the sleep environment as comfortable as possible for the patient.
4. Helps the patient in determining good sleep time.

NIC
Relaxation therapy
1. Determine sleep patterns / patient activities
2. Estimate the sleep / wake cycle of the patient in planning care
3. Monitor / record patient sleep patterns and number of hours of sleep
4. Monitor the sleep patterns of patients, and note the physical and / or psychological conditions of circumstances that interfere with sleep
5. Facilitation to maintain the usual routine patient time routine, pre-bed / props signs, and commonly used items that are appropriate
6. Advise to take a nap during the day, if indicated, to meet the needs of sleep.
NIC RATIONAL
1. Knowing the consciousness, and the condition of the body under normal circumstances or not.
2. To know the ease of sleep.
3. To know the level of anxiety.
4. To identify the actual cause of the sleep disorder.
5. To monitor how far can be calm and rilex.
6. To help relaxation during sleep.
9. Reality in the patient's body related to personal hygiene and wear.
10. Ease in getting the optimal sleep.
11. To calm the mind of anxiety and reduce muscle tension.

Adji Yudho Pangaksomo15 September 2017

Name : Adji Yudho Pangksomo
NIM : 131611133133
Class : A3/A2016

NANDA Nursing Dignoses: Sexual dysfunction associated with Psychosocial abuse (e.g., controlling, manipulation, verbal abuse).
(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.

NOC Outcome Label(s) and Indicators
Sexual Functioning (0119)
- Uses assistive device as needed (011904) 1 | 2 | 3 | 4 | 5
- Uses hormone replacement therapy as needed (011927) 1 | 2 | 3 | 4 | 5
- Expresses ability to perform sexually despite physical imperfections (011907) 1 | 2 | 3 | 4 | 5

Rationale for NOC chosen and Indicator Score
Sexual Functioning
- Using sex aids in accordance with the need to restore function to the genitals (indicator score: 3)
- Hormone replacement therapy is given in accordance with the need for comfort and increase the circulation of estrogen and progesterone hormones (indicator score: 3)
- Displays the ability of sexual activity well regardless of physical imperfection (indicator score: 3)

NIC Intervention Label(s) and Nursing Activities
Teaching: Sexuality
- Explore the meaning of sexual roles
- Support parents’ role as the primary sexuality educator of their children
- Discuss sexual behavior and appropriate ways to express one’s feelings and needs

Rationale for NIC Chosen
Teaching: Sexuality
- Sexual education has a role in providing knowledge about how sexually healthy it is
- Provide means of sex education according to the age of parents early in order to avoid dysfunction
- Provide guidance and understanding that sexual behavior is vital

Afita Nur Dwiyanti15 September 2017

NAMA : Afita Nur Dwiyanti
NIM : 131611133114

Nanda Nursing Diagnosis : Post-trauma syndrome related with serious threat to self characterized by hopelessness.

Outcome Label(s) and Indicators :
Suicide Self-Restraint :
1. Expresses feelings will be often demonstrated
2. Expresses sense of hope will be sometimes demonstrated
3. Refrains from attempting suicide will be often demonstrated
4. Uses social support group will be consistently demonstrated
5. Plans for future will be consistently demonstrated

Rationale for NOC Chosen and Indicator Score :
1. Client will be less doing suicidal attempt if they can expressing their feeling more often
2. If the client sometimes demonstrated sense of hope they will hope for a better life and listing strengths provides reinforcement of positive self-regard.
3. Client refrains from attempting suicide can be used as an accurate indicator that they are have sense of hope
4. Experiencing warmth, empathy, genuineness and unconditional positive regard from social group support can inspire hope
5. The more client can planning for the future the more awareness of reasons for living and may decrease hopelessness and also risk for suicide

Intervention Label(s) Nursing Activities :
Suicide Prevention :
1. Determining presence and degree of suicidal risk
2. Observing, recording, and reporting any change in mood or behavior that may signify increasing suicidal risk and document results of regular surveillance checks
3. Limit access to window, unless locked and shatterproff as appropriate
4. Facilitate support of patient by family and friends
5. Assisting patient to identify network of supportive persons and resources (e.g., clergy, family, providers)

Rationale for NIC Chosen :
1. The nurse’s priority is to protect the client from suicidal thoughts during post-trauma syndrome
2. With observing, recording and reporting any change in mood or behavior, it could be decreasing suicidal risk,
3. Limiting access to window, unless locked and shatterproff will be prevent client to do suicidal attempt.
4. Facilitating support of patient by family and friens will builds trust, allows the client to vent and decreases feelings of isolation.
5. Assisting patient to identify network of supportive person and resources will gives the client an opportunity to gain some influence over the traumatic event and decreases apprehension about intrusive recollection.

RIZKY TRY KURNIAWATI15 September 2017

Name: Rizky Try Kurniawati
NIM: 131611133142
Diagnosis:
Risk of allergic response: susceptible to response or immune reaction to a substance which is exacerbated, which can harm the healthikmm
NOC:
Allergic response; local: the severity of localized hypersensitive immune response against a specific antigen outside
After intervention during 3x24 hours expected to be adequat client engagement mechanism with outcomes:
Allergic response: local
1. Headache
2. Sneeze
3. The local itching
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: 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

Muhammad Rezza Romadlon15 September 2017

Name : MUHAMMAD REZZA ROMADLON
NIM : 131611133126

Nanda Nursing diagnosis

RISK OF HYPOTHERMIA : Vulnerable to a failure of thermoregulation that may result in a core
body temperature below the normal diurnal range, which may compromise
health.( Domain :11, Class :6, Code :00253 )

Risk Factor
- Alcohol consumption
- Damage to hypothalamus
- Economically disadvantaged
- Extremes of age
- Extremes of weight
- Heat transfer (e.g., conduction, convection, evaporation, radiation)
- Inactivity
- Insufficient caregiver
- knowledge of hypothermia prevention
- Insufficient clothing
- Insufficient supply of subcutaneous fat
- Low environmental temperature
- Malnutrition
- Pharmaceutical agent
- Radiation
- Trauma

NOC

1. Identifies risk factors for hypothermia (192320) (1|2|3|4|5)
2. Identifies health condition that accelerate heat loss (192305) (1|2|3|4|5)
3. Performs self-protective action to control body temperature (192313) (1|2|3|4|5)
Rationale for NOC

1. To know the risk factor of hypothermia, if we know what risk factors cause hypothermia, the patient can avoid hypothermia (indicator score: 4)
2. To find out what health conditions are accelerating the loss of body heat, if we know what are the conditions of the body that can accelerate the loss of body heat, we can keep the patient's body temperature remains normal (indicator score: 4)
3. To know how to self-protect about controlling body temperature , educate patients about protecting themselves in order to control body temperature to stay normal (indicator score: 4)

NIC

1. Identify medical, environmental, and other factors that may precipitate hypothermia (e.g., cold water immersion, illness, traumatic injury, shock states, immobilization, weather, extremes of age, medications, alcohol intoxication, malnutrition, hypothyroidism, diabetes, and malnutrition)
2. Remove patient from cold environment
3. Apply passive rewarming (e.g., blanket, head covering, and warm clothing)

Rationale for NIC

1. with the identification of the medical action to be performed, the environment, and the trigger factors of hypothermia for the patient's temperature to return to normal.
2. By removing the patient from the cold environment, the patient is protected from body heat loss.
3. by applying passive rewarming such as warm clothes can prevent the patient from losing body heat

Endah Desfindasari15 September 2017

Nama : Endah Desfindasari
NIM : 131611133119
Kelas : A3 A16
Discovery Learning :
Nursing diagnoses : Nutrition less than body requirements related to inadequate nutrient input.
Definition: The client complained that no appetite, the client looks pale and weight decreased.

NOC :
Aim :To achieve a balance of a patient's nutritional status
Expected outcomes:
1. Being able to identify the needs of the nutritional intake of patients (100 401 / II)
2. Able to achieve a ratio of weight / height were normal (calculation Brocha: women's weight normal = (height - 100) - (15% x (height-100)), men's weight normal = (height-100) - (10% x (height-100)). (100 405 / II)
RATIONAL :
1. Patients are able to meet the nutritional needs required.
2. Patients know to reach the number of normal weight.
NIC :
1. Identification of any allergies or food intolerance owned patients
2. Determine the number of calories and types of nutrients needed to meet nutrient requirements
3. Monitor the calories and food intake
4. Instruct patients about nutritional needs
5. Monitor the tendency of a decrease and increase in weight
RATIONAL :
1. To determine the presence of food allergy in the client
2. To help meet the nutritional needs required by the patient.
3. To find out the calories and food intake in patients.
4. The information provided can motivate patients to improve nutritional intake
5. To determine the adequacy of nutrition to clients.

Rezkisa D Prambudia15 September 2017

Name : Rezkisa Dwi Prambudia
NIM : 131611133117
Class : A3

Nanda Nursing Diagnosis:
Disturbed Sleep Pattern related with feeling unrested. (Domain: 4, Class: 1, Code: 000198)
Definition: Time-limited interruptions of sleep amount and quality due to external factors.

NOC Outcome Label(s) and Indicators:
Depression Level (1208):
- 120801 Depressed mood – 5 (none)
- 120802 Loss of interest in activities – 3 (moderate)
- 120803 Lack of pleasure in activities – 4 (mild)
- 120814 Sadness – 5 (none)
Rationale for NOC chosen and Indicator score:
1. The patient does not feel depressed.
2. The patient has enough interest to do the activity.
3. The patient often feels happy in doing activities.
4. The patient does not feel the sadness so the patient can avoids the sleep pattern disorder.


NIC Intervention Label(s) and Nursing Activities:
Music Therapy (4400):
1. Define the specific change in behavior and/or physiology that is desired (e.g., relaxation, stimulation, concentration, pain reduction).
2. Determine the individual’s interest in music.
3. Identify the individual’s musical preferences.
4. Limit extraneous stimuli (e.g., lights, sounds, visitors, telephonecalls) during the listening experience.
Rationale for NIC chosen:
1. To explain the specific changes in behavior and physiology after therapy so the patient can overcomes depression.
2. To know the patient’s interest to music so the patient can overcomes depression and can sleeps as usual.
3. To know the music liked by the patient so the patient can improves mood in doing daily activities so the patient does not feel depressed.
4. To limit the interference from outside so patients can express their feelings so they can avoid the depressed feeling and can sleep well.

Restu Windi15 September 2017

CHRONIC PAIN
Nanda Nursing Diagnosis NOC Outcome Label(s) and indicators Rationale for NOC chosen
and indictor score NIC Intervention label(s) and nursing activities Rationale for NIC Chosen
CHRONIC PAIN
Definition: a sudden or intense attack of mild to severe, constant or recurrent endless that can be anticipated / credited and the duration of time is greater than 6 months.
Limitations of characteristics:
• Changes in weight
• Verbal and non-verbal reports or facts from
DS:
• observations of protective behavior, vigilance, masking, ritability, self-focus, anxiety, depression
DO:
• Atrophy involving multiplemuscle
• Changes in sleep patterns
• Fear of back injury
• Reduced interaction with people
• Inability to resume previous activity
• Mediating sympathetic responses (eg cold temperature, body position change, hypersensitivity)
• Anorexia
Related factors: Chronic physical / psychological disability After nursing action during ...... x24 hours patient can control pain with indicator:
• Identify the underlying factors
• Recognizes the onset (duration of pain)
• Use prevention methods
• Using nonanalgetic methods to reduce pain
• Use analgesics as needed
• Seeking the help of health workers
• Report symptoms to health personnel
• Use the available resources
• Recognize the symptoms of pain
• Recording previous pain experiences
• Reporting pain is controlled
After nursing action during ...... x24 hours patient can know level of pain with indicator:
• reported the presence of pain
• the area of the affected body
• frequency of pain
• the length of the episode of pain
• statement of pain
• expression of pain on the face
• Protective body position
• lack of rest
• muscle tension
• changes in respiratory rate
• change of pulse
• changes in blood pressure
• changes in pupil size
• excessive sweating
• loss of appetite Chronic pain is a constant or intermittent pain that persists throughout a certain period, lasts longer, and usually lasts more than six months. This pain is a major cause of physical and psychological disability. The unpredictable nature of chronic pain makes the client frustrated and often leads to psychological depression. Individuals who experience chronic pain will feel unsafe feeling, because he never know what will be felt from day to day. Data from Comfort level, Pain control and Pain level pasie included into the scale and indicator of severe pain. MANAGEMENT OF PAIN
Definition: reduce pain and decrease pain level felt by patient.
Intervention:
• perform comprehensive pain assessment including location, characteristics, duration, frequency, quality and precipitation factors
• observation of non-verbal reactions from discomfort
• use therapeutic communication techniques to find out the patient's pain experience
• examine the culture that affects the pain response
• evaluation of past pain experiences
• joint evaluation of patients and other health teams about the ineffectiveness of past pain controls
• help patients and families to seek and find support
• environmental controls that can affect pain such as room temperature, lighting and noise
• reduce precipitation factors
• select and do pain management (pharmacology, non pharmacology and inter personal)
• examine the type and source of pain to determine interventions
• teach about non-pharmacological techniques
• Give analgesics to reduce pain
• evaluation of the effectiveness of pain control
• Increase rest
• collaborate with the doctor if pain complaints and actions fail
ANALGETIC ADMINISTRATION
Definition: use of pharmacological agents to stop or reduce pain
Intervention:
• determine the location, characteristics, quality, and degree of pain prior to administration of the drug
• check doctor's instructions on drug type, dose and frequency
• check allergy history
• select necessary analgesics or combinations of analgesics when administering more than one
• Specify analgetic options depending on the type and severity of pain
• Specify selected analgesic, route of administration and optimal dosage
• select IV delivery route, IM for pain treatment on a regular basis
• monitor vital signs before and after first analgesic
• Give analgesics on time especially when the pain is great
• evaluation of analgesic effectiveness, signs and symptoms (side effects) In chronic pain, health workers are not as aggressive in acute pain. Clients with chronic pain will experience a remission period (symptoms of partial or complete loss) and exacerbations (increased severity). For remission (symptom of partial or complete loss) using analgesic drugs in accordance with SPO will have a positive impact on the patient.


Restu Windi15 September 2017

NAME: RESTU WINDI
NIM:131611133144
CLASS: A3
CHRONIC PAIN
Nanda Nursing Diagnosis NOC Outcome Label(s) and indicators Rationale for NOC chosen
and indictor score NIC Intervention label(s) and nursing activities Rationale for NIC Chosen
CHRONIC PAIN
Definition: a sudden or intense attack of mild to severe, constant or recurrent endless that can be anticipated / credited and the duration of time is greater than 6 months.
Limitations of characteristics:
• Changes in weight
• Verbal and non-verbal reports or facts from
DS:
• observations of protective behavior, vigilance, masking, ritability, self-focus, anxiety, depression
DO:
• Atrophy involving multiplemuscle
• Changes in sleep patterns
• Fear of back injury
• Reduced interaction with people
• Inability to resume previous activity
• Mediating sympathetic responses (eg cold temperature, body position change, hypersensitivity)
• Anorexia
Related factors: Chronic physical / psychological disability After nursing action during ...... x24 hours patient can control pain with indicator:
• Identify the underlying factors
• Recognizes the onset (duration of pain)
• Use prevention methods
• Using nonanalgetic methods to reduce pain
• Use analgesics as needed
• Seeking the help of health workers
• Report symptoms to health personnel
• Use the available resources
• Recognize the symptoms of pain
• Recording previous pain experiences
• Reporting pain is controlled
After nursing action during ...... x24 hours patient can know level of pain with indicator:
• reported the presence of pain
• the area of the affected body
• frequency of pain
• the length of the episode of pain
• statement of pain
• expression of pain on the face
• Protective body position
• lack of rest
• muscle tension
• changes in respiratory rate
• change of pulse
• changes in blood pressure
• changes in pupil size
• excessive sweating
• loss of appetite Chronic pain is a constant or intermittent pain that persists throughout a certain period, lasts longer, and usually lasts more than six months. This pain is a major cause of physical and psychological disability. The unpredictable nature of chronic pain makes the client frustrated and often leads to psychological depression. Individuals who experience chronic pain will feel unsafe feeling, because he never know what will be felt from day to day. Data from Comfort level, Pain control and Pain level pasie included into the scale and indicator of severe pain. MANAGEMENT OF PAIN
Definition: reduce pain and decrease pain level felt by patient.
Intervention:
• perform comprehensive pain assessment including location, characteristics, duration, frequency, quality and precipitation factors
• observation of non-verbal reactions from discomfort
• use therapeutic communication techniques to find out the patient's pain experience
• examine the culture that affects the pain response
• evaluation of past pain experiences
• joint evaluation of patients and other health teams about the ineffectiveness of past pain controls
• help patients and families to seek and find support
• environmental controls that can affect pain such as room temperature, lighting and noise
• reduce precipitation factors
• select and do pain management (pharmacology, non pharmacology and inter personal)
• examine the type and source of pain to determine interventions
• teach about non-pharmacological techniques
• Give analgesics to reduce pain
• evaluation of the effectiveness of pain control
• Increase rest
• collaborate with the doctor if pain complaints and actions fail
ANALGETIC ADMINISTRATION
Definition: use of pharmacological agents to stop or reduce pain
Intervention:
• determine the location, characteristics, quality, and degree of pain prior to administration of the drug
• check doctor's instructions on drug type, dose and frequency
• check allergy history
• select necessary analgesics or combinations of analgesics when administering more than one
• Specify analgetic options depending on the type and severity of pain
• Specify selected analgesic, route of administration and optimal dosage
• select IV delivery route, IM for pain treatment on a regular basis
• monitor vital signs before and after first analgesic
• Give analgesics on time especially when the pain is great
• evaluation of analgesic effectiveness, signs and symptoms (side effects) In chronic pain, health workers are not as aggressive in acute pain. Clients with chronic pain will experience a remission period (symptoms of partial or complete loss) and exacerbations (increased severity). For remission (symptom of partial or complete loss) using analgesic drugs in accordance with SPO will have a positive impact on the patient.


Cici Kurniatil Farhanah15 September 2017

Nama : Cici Kurniatil Farhanah
NIM : 131611133124
Kelas : A3

Intervention with Sleep Deprivation Patient

Diagnosis : Sleep deprivation related with heightened sensitivity to pain (Domain : 4, Class : 1, Code : 00096)

Definition : Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)

NOC :
After nursing during 3 x 24 hours, hopefully the patient can rest and not feel the pain, with the criteria of the results
Anxiety Level (1211) :
1. Inability to rest lightly (121101)
1 2 3 (4) 5
2. The face strained in patients starting decreases( (121107)
1 2 3 (4) 5
3. Patients experienced mild disorders sleep (121129)
1 2 3 (4) 5

Pain Control (1605) :
1. Often explain the causes of pain (160501)
1 2 3 (4) 5
2. Often use the diary to monitor symptoms from time to time (160510)
1 2 3 (4) 5
3. Often report pain symptoms change to health professionals (160507)
1 2 3 (4) 5


NIC :
Anxiety Reduction (5820) :
1. Stay with patient to promote safety and reduce fear
2. Identify when level of anxiety changes
3. Instruct patient on the use of relaxation techniques

Rationale :
1. To make the patient feel safe
2. To know the changes of anxiety patients
3. In order that the patient is able to apply relaxation techniques, thus reducing anxiety

Pain Management (1400) :
1. Perform a comprehensive assesment of pain include location, characteristics, onset/duration, frequency, quality, intensity or severity
2. Utilize a developmentally appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors (e.g., flow chart, daily diary)
3. Reduce or eliminate factors that precipitate or increase the pain experience
4. Colaborate with the patient, significant other health professionals to select and implement nonpharmacological pain relief measures, as appropriate.

Rationale :
1. To find out the assessment of pain patients with comprehensive
2. To monitor the development and changes of pain
3. To eliminate the factors that trigger pain
4. To obtain comprehensive care

Adhelia Putri Prastiwi15 September 2017

Nama : ADHELIA PUTRI PRASTIWI
NIM : 131611133109
Kelas : A3

Anxiety

Diagnosis : Anxiety related with situational crisis (Domain : 9, Class : 2, code : 00146)
Definition : Vague, uneasy feeling of discomfort or dread accompanied by an autogonomic response (the source is often or unknown to the individual) ; a feeling of apprehension caused by anticipation of danger. It is a alerting sign that warns of impending danger and enables the individual to take measure to deal with that threat

NOC
After done action nursing for 5 x 24 hours, hopefully the ability to afford to experience the meaning of life through relationships themselves, or the power of harnessing higher criteria results
Koping (1302)
1. Reports decrease in stress (4) (130204)
2. Verbalizes acceptance of situation (4) (130205)
3. Reports decrease in physical symptons of stress (3) (130216)

NIC
Emotional Support (5270)
1. Refer to counseling, as appropriate
2. Assist patient in recognizing feelings, such as anxiety, anger, or sadness
3. Encourage talking or crying as means to decrease te emotional response
Rationale :
1. With routine counseling it will be known level of stress reduction client
2. If the patient is more expressing his feelings then it will be easier to help overcome them
3. The nurse encourages the client to talk so the nurse can report how to decrease emotion



ARDINA NADYA WAHYUHERMANTO15 September 2017

NAMA: ARDINA NADYA WAHYUHERMANTO
NIM: 131611133120
KELAS: A3 2016
Nursing Diagnoses : Spiritual distress (Domain 10. Life Principles, Class 3. Value/Belief/Action Congruence. Code00067)
Definition: A state of suffering related to the impaired ability to experience meaning in life trough connections with self, others, the world, or a superior being.
May be related to:
ilness
Possibly evidenced by:
- inability to participate in religious activities
- inability to pray
- inability to experience the transcendent
NOC:
1. Spiritual Health (2001)
- Quality of hope (200102) : 5 (not compromised)
- Ability to pray (200109) : 5 (not compromised)
- Ability to worship (200110) : 5 (not compromised)
2. Outcome Overall Rating (1300)
- Recognizes reality of health situation (130008) : 5 (consistently demonstrated)
- Adjusts to change in health status (130017) : 5 (consistently demonstrated)
- Pursues information about health (130009) : 5 (consistently demonstrated)
Rationale for NOC choosen:
1. Spiritual Health (2001)
- Patients have a high hope to out from spiritual distress
- Patients can pray as usually, so can controll stress
- Patients can worship as usually, so can get motivated
2. Outcome Overall Rating (1300)
- Patient can receive and accept his/her current health condition
- Patient is accuistomed to his/her current health condition
- Patient has a high curiosity about his/her health and can analyze his current condition
NIC:
1. Spiritual Growth Facilitation (5426)
- Encourage conversation that assists the patient in sorting out spiritual concerns
- Encourage participation in devotional services, retreats, and special prayer/study programs
- Encourage patient’s examination of his/her spiritual commitment based on beliefs and values
2. Hope Inspiration (5310)
- Help the patient expand spiritual self
- Develop a plan of care that involves degree of goal attainment, moving from simple to more complex goals
- Encourage therapeutic relationships with significant others
Rationale for NIC choosen:
1. Spiritual Growth Facilitation (5426)
- To know what kind of things the patients are concern
- To make patients not feels lonely, then he/she are motivated to pray
- To know the levels commitment of patients spirituality, then can provide the appropriate support
2. Hope Inspiration (5310)
- The patient will feel peacefully and can focus on how to resolve their spiritual distress
- To make the nursing plan same with the health goal of patients, so the patient will be able to accept their change of health
- Therapeutic support from nearest person effectively motivate patients and accelerate healing

Alfiana Permatasari15 September 2017

NAME : Alfiana Permatasari
NIM : 131611133130
CLASS : A3

Nanda Nursing Diagnosis :
Diagnosis: Impaired swallowing (Domain: 2, Class: 1, Code: 00103)
Definition : Abnormal function of the swallowing mechanism associated with deficits in oral, pharyngeal structure or function
Related Factor: Neuromuscular impairment
Outcome Lable(s) and Indicators :
Aspirations prevention (1918)
1. 191803 Position self upright for eating and dringking
2. 191806 Select food and fluid of proper consistency
3. 191810 Remains upright for 30 minutes after eating
Rationale for NOC Chosen and Indicator Score :
1. Patient can know position to avoid increases the risk of aspiration
2. Patient can know their nutritional needs and dietary modification
3. Patient can know position after eating which reduces the risk of aspiration
Intervention Label(s) Nursing Activities:
Swallowing therapy (1860)
1. Assist patient to sit in an errect position (as close to 90 degrees as possible) for feeding/exercise
2. Assist patient maintain sitting position for 30 minutes after completing meal
3. Provide/monitor consistency of food/liquid based on findings of swallowing study
Rational for NIC Chosen:
1. This position allows the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration
2. An upright position guarantees that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals
3. To avoid ignoring diet restrictions and inappropriate feeding to patient who predispose to aspiration

SULPINCE WEYA15 September 2017


Aspiration Risk
Nanda :
- Increased pressure
in the stomach
- upper body elevation
- decrease level
awareness
- increase in residuals
stomach
- decreased function
esophageal sphincter
- Swallowing disorders
- NGT
- Cough reflex suppression
and reflux disorders
- Decreased motility
gastrointestinal

NOC:
 Respiratory Status:
Ventilation
 Aspiration control
 Swallowing Status
After the action is done
nursing for ...
patients do not experience
aspirations with criteria:
 Client
can breathe with
easy, no rhythm,
frequency of breathing
normal
 Patients
capable of swallowing,
chewing without
aspirations, and
can oral
hygiene
 Road
patent breath, easy
breathe, not feel
suffocated and absent
abnormal breath sounds

NIC:
 Monitor awareness level, cough reflex
and swallowing ability
 Monitor lung status
 Maintain airway
 Do suction if necessary
 Nasogastric checks before meals
 Avoid eating if the residue is still
many
 Cut a small snack
 Puree the drug before giving
 Raise the head 30-45 degrees after
eat

Arsika Windy Hardiyanti15 September 2017

NAME: Ariska Windy Hardiyanti
NIM: 131611133131
CLASS: A3 2016
Nursing Diagnoses : Risk for unstable blood glucose level (Domain 2. Nutrition Class 4. Metabolism Code 00179).
Definition : Vulnerable to variation in blood glucose/sugar levels from the normal range, which may compromise health.
My be related to:
excessive weight gain
NOC Outcome Label(s) and Indicartors :
Depression Level (1208)
• Increased appetite (120811): 5 (not compromised)
• Weight gain (120810): 5 (not compromised)
• Weight loss (120831): 5 (not compromised)
Rationale for NOC chosen and indictor score:
• Increased appetite in patients after done to meet the nutritional needs of various foods so that client appetite and nutritional clients can be fulfilled.
• The patient's weight improves after the client's education about food intake to increase the client's appetite.
• The patient's weight will decrease after a collaboration with the nutrition team determines the composition of a good diet for the patient.
NIC Interuction Label(s) and Nursingn Activities:
Nutritional Counseling (5246)
• Facilitate indefication of eating behaviors to be changed.
• Determine patient’s food intake and eating habits.
• Discuss the meaning of food to patient.
Rationale for NIC Chosen
• To know the appetite of the patient so the nurse can assess and change the appetite of the patient better.
• To help patients in reducing excess fat and to teach patients to adjust their diet.
• To discuss with the patient about the food intake for the body so the patient can increase the intake of enough food for the body..

Retno Galuh Kusumawardhani15 September 2017

Nama: Retno Galuh Kusumawardhani
NIM: 131611133145
(Impaired Bed Mobility Patient)

Diagnosis :Impaired bed mobility related with physical deconditioning (Domain : 4, Class : 2, Kode : 00091)
Definition : Limitation of independent movement from one bed position to another.

NOC :
After 3x24 hours of nursing action, it is expected that the patient's ability to move actively on the bed without a hitch with the criteria of result:
Physical Fitness (2004):
Definition: Performance of Physical activities with vigor
1. the flexibility of the joints a little distracted (200403)
1 2 3 (4) 5
2. the performance of physical activity of the patient is not interrupted (200404)
1 2 3 (4) 5
3. the performance of routine exercise of the patient not interrupted (200405)
1 2 3 (4) 5
4. the index patient's body undisturbed period (200409)
1 2 3 (4) 5
NIC :
Exercise Therapy : Joint Mobility :
Definition : Use of active or passive body movement to maintain or restore joint flexibility.
1. Collaborate with physical therapy in developing and executing an exercise program
2. Initiate pain control measures before beginning joint exercise
3. Encourage active range-of-motion (ROM) exercise, according to regular, planned schedule
4. Determine progress toward goal achievement
RATIONALE:
• Allow the success of implementing a program of exercise for the patient with an experienced physical therapist or expert in this field.
• Patients can controlling the pain independently before starting the exercise.
• Patients willing to follow regular active exercise as scheduled with a passion because of the high motivation to be able to move freely.
• The patient's goal to be able to move freely over the success of the program of physical exercise that is already given.

Fitrinia Puspita Sari15 September 2017

NAMA : Fitrinia Puspita Sari
NIM : 131611133139
CLASS : A3

Diagnosis : Stress overload related with repeated stressors (Domain : 9, Class : 2, Code : 0077
Definiton : Excessive amounts and types of demands that require action

NOC
After done action nursing for 4 x 24 hours, hopefully the ability to afford to experience the meaning of life through relationships themselves, or the power of harnessing higher criteria results
Anxiety Self Control (1402)
1. Eliminates precursors of anxiety (4) (14020)
2. Decreases enviromental stimuli when anxious (4) (140203)
3. Seeks information to reduce anxiety (4) (14004
4. Control anxiety response (4) (140217)

NIC
Anxiety Reduction (5820)
1. Use a calm, reassuring approach
2. Stay with patient to promote safety and reduce fear
3. Provide factual information concering diagnosis, treatment, and prognosis
4. Identify when level of anxiety changes
Rationale:
1. Approaching patients, making patients more confident and confident about the information provided
2. If the patient feels safe will reduce stress
3. Providing accurate information about the patient and accompanied by motivation to reduce the patient's stress level
4. Monitor the client's anxiety level so the nurse knows how to reduce the stress level on the client

Agustina Lia Fitriani15 September 2017

Nama : Agustina Lia Fitriani
NIM :131611133103
Kelas : A3_2016


Intervention with Risk for shock Patient

Diagnosis : Risk for shock related with Infection (Domain : 11, Kelas : 2, Kode : 00205)
Definition : Vulnerable to an inadequade blood flow to the body’s tissues that may lead to life-threatening cellular dysfunction, which may compromise health.

NOC :
After a nursing action for 1x24 hours, the expected shock on the client is reduced by the outcome criteria
infection severity (0703) :
Definition : the severity of signs and symptoms of infection
1. there was a slight fever in the patient (070307)
1 2 3 (4)
2. mild gastrointestinal symptoms occur in the patient (070309)
1 2 3 (4)
3. loss of appetite to the client is reduced (070332)
1 2 3 (4)
NIC :
Infection Control (6540) :
Definition : Minimizing the acquisition and transmission of infectious agents
1. Administer antibiotic therapy, as appropriate
Rasional : To help reduce the pain caused by infection.

2. Ensure aseptic handling of all IV lines
Rasional : Prevent further infection due to wrong action.

3. Promote appropriate nutritional intake
Rasional : Helping the fulfillment of the need for nutritional intake in patients

4. Encourage rest
Rasional : Helps meet the patient's rest needs so as to speed up the healing process due to shock

Nurrochma Alyadra15 September 2017

Nama : Nurrochma Alyadira
NIM : 131611133152
Kelas : A3

Intervention of Impaired Social Interaction

Diagnosis : Impaired social interaction related with environtmental barrier (Domain : 7, Class : 3, Code : 00052)
Definition : Insufficient or excessive quantity or ineffective quality of social exchange.

NOC :
After nursing during 3 x 24 hours, hopefully the mechanism of patient involvement becomes adequate, with the criteria of the results
Social Involvement (1503) :
1. Interacts with close friends (150301)
1 2 3 (4) 5
2. Interacts wit neighbors (150302)
1 2 3 (4) 5
3. Interacts with members of work group(s) (150304)
1 2 3 (4) 5

NIC :
Social Enhancement (5100) :
1. Encourage social and community activities
2. Encourage honesty in presenting oneself to other
3. Encourage participation in group and/or individual reminiscence activities

Rationale :
1. Patients can interct socially with society in order to improve self-skill.
2. Patients can measure the value pf self-righteousness by acting in accordance with the behavior of the patient.
3. Have the same discussion in interaction to improve interpersonal self.

ismi shonatul chofifah15 September 2017

NAME: ISMI SHON’ATUL CHOFIFAH
NIM: 131611133118
CLASS: A3
Nursing Diagnosis:
Fear (Domain 9. Coping/stress Tolerance, Class 2. Coping Responses. Code 200148)
Definition: Response to perceived threat that is consciously recognized as a danger
Posibility evidenced by:
- apprehensiveeness
- feeling of fear
May be related to: unfamiliar setting
NOC:
1. Fear Level(1210)
- Tendency to blame others(121002): 5 (none)
- Difficulty concentrating(121008): 5 (none)
- Perceived inadequacy in interpersonal relationships(121012): 5 (none)
2. Anxiety Level(1211)
- Hand wringing(121103): 5 (none)
- Facial tension(121107): 5 (none)
- Panic attack(121115): 5 (none)
Rationale for NOC choosen:
1.Fear Level(1210)
- patient is act to reduce or decrease feelings of inadequacy due to fear, tension or anxiety that comes from a recognized source
- Using relaxation techniques to reduce fear to concentrate
- Improve the patient's inability to build patient interpersonal relationships
2. Anxiety Level(1211)
- Patients do not feel tense when they get scared
- the patient's face looks happy, not feel a sense of fear
- letting the patient out of panic because of the strange environment
NIC:
Environmental Management (6480)
1. Provide family/significant other with information about making home environment safe for patient
2. Create a safe environment for the patient
3. Provide music of choice
Rationale for NIC choosen:
1.provide constant support to the patients, so he/she not experiencing excessive fear
2.a safe environment can prevent the patient's fear
3. music can help patients more relaxed and anxious

Achmad Ubaidillah Mughni15 September 2017

Nama : Achmad Ubaidillah Mughni
NIM : 131611133128
Kelas: A3 A6
Discovery Learning:
DIAGNOSES:
Disturbed body image related to Alteration in body function (disease)
NOC:
Body Image
Purpose: Can recover the client’s physical condition, with criteria results:
1. Satisfaction with body function (120006): Sometimes positive (3)
2. Adjustment to changes in health status (120009): Sometimes positive (3)
Rational :
1. Patient can accept current body condition
2. Patients can adjust to his health at this time so that the patient can develop themselves optimally through positive behavior
NIC:
1. Anxiety Reduction
- Explain all procedures, including sensations likely to be experienced during the procedure
- Help patient identify situations that precipitate anxiety
- Support the use of appropriate defense mechanisms
2. Counseling
- Provide factual information as necessary and appropriate
- Assist patient to list and prioritize all possible alternatives to a problem
Rational :
1. In order for the patient to know the procedures and the sensation will do.
2. To minimize disturbances self-destructive emotional as fear, guilt, guilt, anxiety, feeling anxious, angry.
3. So that clients know the current state so that the client can develop themselves optimally in performing daily activities
4. encourage clients to use their ability to eliminate emotional disturbances through alternatives.

Esti Ristanti15 September 2017

Name : Esti Ristanti
Class : A3
Number : 131611133129

Diagnosis : Obesity related with sleep disturbed (Domain : 2, Class : 1, Code : 00232)
Definition : A conditionin which an individual accumulates abnormal or excessive fat for age and gender that exceeds overweight

Nanda Nursing Diagnosis:
Obesity related with sleep disturbed
NOC :
After done action nursing for 4x24 jam, expected obesity in the patient disappeared with the outcome criteria
Depression level :
1. feelings of depression are greatly increased (5) ( 120801 )
2. the patient has severe fatigue (5) (120806 )
3. patients are overweight (5) ( 120810 )
NIC :
Environtmental Management:
1. Create a safe environtment for the patient
2. reduce environmental stimuli, as appropriate
3. provide attractively arranged meals and snacks
Rationale for NIC chosen
1. To prevent patients from crowds of people who can lead to overeating
2. To prevent patients wanting to buy too much food
3. To avoid the portion of excessive and unhealthy eating that leads to obesity

Yohana Rahmawati Santoso15 September 2017

Nama : Yohana Rahmawati Santoso
NIM : 131611133111
Kelas : A-3 2016
Urinary retention
Diagnosis : urinary retention related with dysuria (Domain 3. Class 1. Code 00023)
Definition : incomplete emptying of the bladder
NOC Outcome Label(s) and Indicators:
after the nurse provides care for 1x24 hours, the client is expected to remove the urine with the appropriate number and criteria, as follows:
Urinary Elimination :
1. Fluid intake
2. Urinary frekuesi
3. Urinary uncontinance
Rational for NOC chosen and Indicator score :
1. infusion is useful to meet the needs of fluids
2. often experience pain while urinating and urinating slightly
3. clients often wet the bed and unnoticed urine
NIC Intervention Label(s) and Nursing Activies :
Urinary elimination management :
1. Monitor for signs and symtoms of urinary retention
2. Instruct patient/family to record urinary output, as appropriate
3. Restrict fluids, as needed

Rational for NIC chosen and indicator score:
1. that the urine frequency is regular.
2. in order that knows the development of urine frequency
3. liquids that do not cause improved dysuria are limited so as not to cause disease

Shintia Ekawati15 September 2017

Name : shintia ekawati
Class : A3
NIM : 131611133141


Nursing Diagnosis :
Ineffective peripheral tissue perfusion r/t diabetes mellitus
(code 00204; domain; class 4)

NOC (Nursing Outcome Classification)
After treatment for 2x24 expected results:
1. Self-Management: Diabetes(1619)
outcomes
• Seeks information about methods to prevent complications. Rational : so that patients understand how to prevent blood sugar is not high. 5(none)
• Monitors blood glucose. Rational : patients can know their own sugar levels so that patients can anticipate or do things that can lower sugar levels when high.5(none)
• Reports symptoms of complications. Rational : so the patient can know the sugar content and report to the nurse 5(none)


NIC (Nursing Interventions Classification)
1. fluid management (4120)
• Weigh daily and monitor trends. Rational : because weight gain risks raising diabetes 5(none)
• Distribute the fluid intake over 24 hours, as appropriate. Rational : diabetes mellitus 5(none)
• Monitor nutrition status. Rational : Diabetes mellitus will worsen if the nutrients present in the body are too much and will decrease the immune system if insufficient nutrients in the body. 5(none)
2. Vital Signs Monitoring (6680)
• Monitor blood pressure, pulse, temperature, and respiratory status, as appropriate. Rational : because the vital signs of diabetes patients should be stable. 5(none)


KHILYATUD DINIYAH15 September 2017

Nama : Khilyatud Diniyah
NIM : 131611133107
Kelas : A3 2016

NANDA NURSING DIAGNOSIS
Vulnerable to an increased risk of falling, can cause physical harm and health problems.

OUTCOME KABEL(S) AND INDICATORS
1. Knowledge of fall prevention with the correct use of safety devices (182802, 5)
2. Fall prevention behavior with Using the handle rod as required (190915, 5)
3. Fall prevention behavior with Puts overhead to prevent falling (190903, 5)

RATIONALE FOR NOC CHOSEN AND INDICATOR SCORE
1. Knowing how to properly use the client's self-safety tools so that they are optimally protected against falling risks
2. Can know the necessary self-security needs for clients
3. Increase the barrier to sustain the client's body well so avoid the risk of falling

INTERVENTION LABEL(S) NURSING ACTIVITIES
1) Make sure the restriction action starts (if the level is low, make sure that this is not effective before rising on the limit to a higher level)
2) Limit to the right area
3) Use protective equipment and actions (eg detection of movements, alarms, fences, doors, bedside bars, gloves, seats that can be closed, locked doors, restraints)

RATIONALE FOR NIC CHOSEN
1. With the act of initiating restrictions early on the client can reduce the risk of falling
2. Adapted fit within the client can avoid the risk of falling
3. the use of client self-protection tools in accordance with what is needed and can protect all elements of the client's body entirely so that all elements of the body can be protected from the risk of falling

PUTRI HISAANAH15 September 2017

NAME: PUTRI HISAANAH
NIM: 131511133015
Domain 3. Elimination and Exchange
Class 2. Gastrointestinal Function
00013 Diarrhea (1975, 1998)

NANDA Nursing Diagnosis:
Definition Passage of loose, unformed stools.
Characteristics:
■ Abdominal pain
■ Bowel urgency
■ Cramping
■ Hyperactive bowel sounds
■ Loose liquid stools > 3 in 24 hours
Related Factors:
Physiological
■ Gastrointestinal inflammation
■ Gastrointestinal irritation
■ Infection
■ Malabsorption
■ Parasite
Psychological
■ Anxiety
■ Increase in stress level
Situational
■ Enteral feedings
■ Exposure to contaminant
■ Exposure to toxin
■ Laxative abuse
■ Substance abuse
■ Travel
■ Treatment regimen


NOC:
Outcomes to Measure Resolution of Diagnosis:
• Bowel Continence
• Bowel Elimination
Additional Outcomes to Measure Defining Characteristics:
• Discomfort Level
• Pain Level
• Symptom Severity
Outcomes Associated with Related Factors or Intermediate Outcomes:
• Adherence Behavior: Healthy Diet
• Alcohol Abuse Cessation Behavior
• Anxiety Level
• Anxiety Self-Control
• Compliance Behavior: Prescribed Diet Electrolyte & Acid/Base Balance
• Fluid Balance
• Gastrointestinal Function
• Hydration
• Infection Severity
• Infection Severity: Newborn
• Knowledge: Disease Process
• Knowledge: Healthy Diet
• Knowledge: Inflammatory Bowel Disease Management
• Knowledge: Medication Knowledge: Prescribed Diet
• Medication Response
• Nutritional Status: Biochemical Measures
• Nutritional Status: Food & Fluid Intake
• Ostomy Self-Care
• Self-Care: Non-Parenteral Medication
• Self-Management: Acute Illness
• Self-Management: Chronic Disease
• Stress Level
• Symptom Control
Rationale for NOC:
• The patient will report less diarrhea within 36 hours.
• The patient stool with look like Type 4 of the Bristol stool chart within 48 hours.
• The patient will consume at least 1500-2000 cc of clear liquids within 24 hours period.
• The patient will verbalize 4 ways on how to treat diarrhea when it presents.
• The patient will verbalize understanding about the contributing factor that is causing her diarrhea.

NIC:
Suggested Nursing Interventions for Problem Resolution:
• Bowel Management
• Diarrhea Management
Electrolyte Monitoring
Fluid/Electrolyte Management
Fluid Management
Fluid Monitoring
• Medication Management
Medication Prescribing
Nutrition Management
Ostomy Care
Perineal Care
Skin Surveillance
Additional Optional Interventions:
• Anxiety Reduction
• Chemotherapy Management
• Enteral Tube Feeding
• Environmental Management
• Infection Control
• Intravenous (IV) Insertion
• Intravenous (IV) Therapy
• Peripherally Inserted Central Catheter (PICC) Care
• Radiation Therapy Management
• Self-Care Assistance: Toileting
• Skin Care: Topical Treatment
• Substance Use Treatment
• Total Parenteral Nutrition (TPN) Administration
• Tube Care: Gastrointestinal
• Weight Management
Rationale for NIC:
• The nurse will assess the patient report of diarrhea every shift.
• The nurse will assess the patients stool consistency daily according to the Bristol stool chart.
• The nurse will keep track of how many bowel movements the patient has daily.
• The nurse will encourage and provide the patient with clear liquids every two hours while awake.
• The nurse will educate the patient on what clear liquids to consume and avoid.
• The nurse will educate the patient on 4 ways on how to treat diarrhea when it presents.
• The nurse will educate the patient about the contributing factor that is causing her diarrhea.

HAPPY PUSPITA RISNA15 September 2017

NAMA : Happy Puspita Risna
NIM : 131611133127
KELAS : A3
Intervention with Constipation Patients
Diagnosis : Constipation related with dehydration (Domain : 3, Class : 2, Code : 00011)
Definition : Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
NOC :
After done action nursing for 1x24 hours, constipation is expected in patients to disappear with the outcome criteria :
Hydration (0602) :
1. Patient fluid intake is not disturbed (060215)
1 2 3 4 (5)
2. Patient's urine output is not disturbed (060211)
1 2 3 4 (5)
3. Patients have mild thirst (060205)
1 2 3 (4) 5
NIC :
Fluid Management (4120) :
1. Weight daily and monitor trends
2. Maintain accurate intake and output record
3. Monitor hydration status (e.g., moist mocus membranes, adequacy of pulses, and orthostatic blood pressure), as appropriate

Rationale :
1. To know the condition and development of patients related weight
2. To keep the fluid intake and output right so the patient is not deprived fluid
3. To know patient's hydration status

KHILYATUD DINIYAH15 September 2017

Nama : Khilyatud
NIM : 131611133107
Kelas: A3 2016

NANDA NURSING DIAGNOSIS
Vulnerable to an increased risk of falling, can cause physical harm and health problems.

OUTCOME KABEL(S) AND INDICATORS
1. Knowledge of fall prevention with the correct use of safety devices (182802, 5)
2. Fall prevention behavior with Using the handle rod as required (190915, 5)
3. Fall prevention behavior with Puts overhead to prevent falling (190903, 5)

RATIONALE FOR NOC CHOSEN AND INDICATOR SCORE
1. Knowing how to properly use the client's self-safety tools so that they are optimally protected against falling risks
2. Can know the necessary self-security needs for clients
3. Increase the barrier to sustain the client's body well so avoid the risk of falling

INTERVENTION LABEL(S) NURSING ACTIVITIES
1) Make sure the restriction action starts (if the level is low, make sure that this is not effective before rising on the limit to a higher level)
2) Limit to the right area
3) Use protective equipment and actions (eg detection of movements, alarms, fences, doors, bedside bars, gloves, seats that can be closed, locked doors, restraints)

RATIONALE FOR NIC CHOSEN
1. With the act of initiating restrictions early on the client can reduce the risk of falling
2. Adapted fit within the client can avoid the risk of falling
3. the use of client self-protection tools in accordance with what is needed and can protect all elements of the client's body entirely so that all elements of the body can be protected from the risk of falling

INDAH AZHARI15 September 2017

NAME : INDAH AZHARI
STUDENT ID NUMBER : 131611133146
CLASS : A3
Risk for Constipation ( 00015)
Definition : Vulnerable to decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool, which may compromise health
Domain : 3
Class : 2
NANDA Nursing Diagnosis
Risk for Constipation related to Habitually ignores urge to defecate
NOC
After discusses activity recommendations with health professional :
a. it is hoped the client can eliminate the habit of holding back defecation (5)
b. the client be able to Identifies expected benefits of physical activity (5)
Rationale for NOC
a. by fixing the bad habits of clients holding back defecation will avoid the risk for constipation
b. by knowing the benefits of changing these bad habits, clients will try to eliminate his bad habits
NIC
Bowel Management :
a. Monitor bowel movements including frequency, consistency,
shape, volume, and color, as appropriate
b. Teach patient about specific foods that are assistive in promoting
bowel regularity
Rational for NIC
a. 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
b. because the regularity of intestinal activity can provide comfort defecation in patients

EKA APRILLIA DIYAH SANTI K15 September 2017

Name : EKA APRILLIA DIYAH SANTI K
NIM: 13161133125
CLASS :A3
Nursing diagnoses : Wheeled mobility barriers (activity / rest) (activity / sport)
Definition : Limited ability to use wheelchair independently in the environment
May be related to : Pain
Possibly evidenced by :
1. Barriers to the ability to operate a manual wheelchair on the uphill road
2. Obstacles ability to operate the wheelchair on uneven surface
NOC
1. Pain Level
- Pain reported (210201): 5 (not compromised)
- Expression of facial pain (210206): 5 (not compromised)
- Muscle tension (210209): 5 (not compromised)
Rationale for NOC choosen :
- No patient pain is expected
- The face looks happy no pain in the patient
- Expected muscle weakness in patients
NIC
1. Positioning (0846)
- Facilitate minimal weight loss
- Give modifications or equipment to the wheelchair to correct the patient's problem or muscle weakness
- - Provide bearings and other enhancements (eg back pads, limb pads, troughs, coated mats) for patients with special needs
Rationale for NIC choosen :
- Patients who have more weight will feel tired and have a higher risk of falling
- So that the muscles in the patient's body does not feel tense and stiff
- In order for patients more comfortable and not easily tired when having to sit too long in a wheelchair



EKA APRILLIA DIYAH SANTI K15 September 2017

Name : EKA APRILLIA DIYAH SANTI K
NIM: 13161133125
CLASS :A3
Nursing diagnoses : Wheeled mobility barriers (activity / rest) (activity / sport)
Definition : Limited ability to use wheelchair independently in the environment
May be related to : Pain
Possibly evidenced by :
1. Barriers to the ability to operate a manual wheelchair on the uphill road
2. Obstacles ability to operate the wheelchair on uneven surface
NOC
1. Pain Level
- Pain reported (210201): 5 (not compromised)
- Expression of facial pain (210206): 5 (not compromised)
- Muscle tension (210209): 5 (not compromised)
Rationale for NOC choosen :
- No patient pain is expected
- The face looks happy no pain in the patient
- Expected muscle weakness in patients
NIC
1. Positioning (0846)
- Facilitate minimal weight loss
- Give modifications or equipment to the wheelchair to correct the patient's problem or muscle weakness
- - Provide bearings and other enhancements (eg back pads, limb pads, troughs, coated mats) for patients with special needs
Rationale for NIC choosen :
- Patients who have more weight will feel tired and have a higher risk of falling
- So that the muscles in the patient's body does not feel tense and stiff
- In order for patients more comfortable and not easily tired when having to sit too long in a wheelchair



Hilmy Ghozi Alsyafrud15 September 2017

Name :Hilmy ghozi alsyafrud
NIM :131611133108

NANDA Nursing Diagnosis: Latex allergy response associated with hypersensitivity to natural latex rubber protein (domain 11, class 5, code 00041)
Definition: A hypersensitive reaction to natural latex rubber products
NOC outcome lebel(s) and indicators
Allergic response: localized (0705)
• Sinus pain (070501) 1,2,3,4,5
• Headache (070502) 1,2,3,4,5
• Conjunctivitis (070503) 1,2,3,4,5
Rasional for NOC chosen and indicator score
• common sinus disease that infects all ages, breathing latek can also cause sinus disease
• People who mostly breathe in latex can cause more headaches with people who have allergies to latex
• Not only cause latex allergy can also cause conjunctivitis
NIC
• Place allergy bad on patient
• Survey environment and remove latex products
• Instruct patient and family about risk factors for developing a letex allergy
Rasional for NIC chosen and indicator score
• in order to recover the patient tersebuat have allergic to latex signs given allergy signs bracelet
• cleaning the environment of all latex ingredients to avoid increasing people who are allergic to latex
• advocating patients and families how important latex allergy risk factors are

Alfia Dwi Sunarto15 September 2017

Name : Alfia Dwi Sunarto
NIM : 131611133105
Class : A3 2016

Nursing Diagnosis : Ineffective airway clearance ( Domain 11. Safety/ Protection Class 2. Physical Injury 00031)

Definition : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Possibly evidenced by: Alteration in respiratory rate

May be related to : Exudate in the alveoli

NOC Outcome Label(s) and Indicators:
Respiratory status; Airway Patency (0410):
o 041004 Respiratory rate - 5 (No deviation from normal range)
o 041005 Respiratory rhythm - 5 (No deviation from normal range)
o 041012 Ability to clear secretions - 3 (Moderate deviation from normal range)

Rationale for NOC chosen and Indicator score:
o The patient has normal range respiratory rate
o The patient has normal range respiratory rhythm
o The patient can clear the secret, so the airway is in good condition

NIC Intervention Label(s) and Nursing Activities:
Airway management (3140):
o Position patient to maximize ventilation potential
o Monitor respiratory and oxygenation status, as appropriate
o Instruct how to cough effectively

Rationale for NIC chosen:
o The semifowler position helps the chest expansion, so this position can maintain comfort and facilitate the patient's respiratory function.
o To Know the level of disturbance that occurs and help in determining the interventionthat will be given.
o Back massage can help clear the secret on the airway

Nafiul ikroma wijayanti15 September 2017

NAME: NAFIUL IKROMA WIJAYANTI
NIM: 131611133149
Risk for perioperative positioning injury
Definition
Vulnerable to inadvertent anatomical and physical changes as a result of
posture or equipment used during an invasive/surgical procedure, which
may compromise health.
NANDA:
•Disorientation
•Edema
•Emaciation
•Immobilization
•Muscle weakness
•Obesity Sensoriperceptual disturbance from anesthesia
NOC:
•Weight: Body Mass
•Aspiration Prevention
RATIONALE:
•patients experience weight gain exceeding normal limits
•with overweight patients having respiratory distress
NIC:
•Nutrition Therapy
RATIONALE:
•because with nutritional therapy, the patient can adjust the diet so as not to experience obesity

MITHA MULIA VIRDIANTY15 September 2017

Nama : Mitha Mulia Virdianty
NIM : 131611133135
Kelas : A3

NANDA
Deficient fluid volume (00027)
Deficient fluid volume related to active fluid volume loss
Domain 2. Nutrition
Class 5. Hydration
Definition: decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

NOC
Fluid balance (0601)
Definition: water balance in the intracellular and extracellular compartments of the body
Indicators:
1. 24-hour intake and output balance (060107) – 5 (none)
2. Skin turgor (060116) – 5 (none)
3. Moist mucus membranes (060117) – 5 (none)

Rationale for NOC Choosen:
1. The balance of intake and output within 24 hours may indicate that the fluid requirement in the patient’s body has been met
2. Skin turgor can indicate the fluid requirement in the patient’s body is met
3. Moist mucus membranes may indicate that fluid requirements in the body are met

NIC
Electrolyte Management
1. Maintain accurate intake and output record
2. Consult physician on administration of electrolyte-sparing medications
3. Teach patient and family about the type, cause, and treatments for electrolyte imbalance
4. Monitor patient response to prescribed electrolyte therapy

Rationale for NIC Choosen:
1. This needs to be done to keep the fluid balance in the patient’s body
2. Consultation needs to be done so that the medication given to the patient more precise and accurate
3. Education to patients and families should be done in order to live healthy and to minimize the incidence of fluid imbalance occurs again
4. Patient electrolyte therapy should always be monitored so that the nurse can immidiately determine the action if there are abnormalities

Siti Nur Aisa15 September 2017

Name : SITI NUR AISA
Nim : 131611133138
Class : A3-2016

Nursing diagnoses : risk for trauma related with slippery floor (Domain : 11, class : 2, code : 00038)

Definition : vulnerable to accidental tissue injury (e.g., wound, burn, fracture), which may compromise health.

NOC :
After done action of nursing for 3x24 hours, hopefully the ability to afford to experiencethe meaning of life through relationships themselves, or the powerof harnessinghigher criteria results.
Gait (0222) :
1.the patient has a slightly disturbed balance while walking (4)
2.patient's walking speed is slightly disturbed during walking (4)
3.the patient does not hesitancy while walking (5)

NIC :
fall prevention (6490) :
1.Identify behaviors and factors that effect risk of falls
2.Identify characteristics of environment that may increase potential for falls (e.g., slippery floors and open stairways)
3.Monitor gait, balance, and fatique level with ambulation

Rationale :
1.To inform the nurse if the patient is fell or not
2.To knowing the behaviour and factor of the fell
3.To knowing the changes of speed, balance, and fatigue level

Ramadhani Wahyuningtyas15 September 2017

NAMA: RAMADHANI WAHYUNINGTYAS
NIM: 131611133110

RISK OF BLEEDING

Definition: At risk of experiencing decrease in blood volume that can interfere with health.

Risk factor:
1. Aneurysm
2. Circumcision
3. Knowledge deficiency
4. Disseminated intravascular coagulopathy
5. History dropped
6. Gastrointestinal disorders (eg, gastric ulcer disease, polyps, varicose veins)
7. Impaired liver function (eg, cirrhosis, hepatitis)
8. Inherent coagulopathy (eg, thrombocytopenia)
9. Postpartum complications (eg, uterine atony, placental retention)
10. Complications related to pregnancy (eg, placenta previa, molar pregnancy, placental abruption)
11. Trauma

NOC
1. Blood loss severity
2. Blood coagulation

Results Criteria:
1. No haematuria and hematemesis occur
2.The loss of visible blood
3. Blood pressure within normal systole and diastole
4. There is no vaginal bleeding
5. There is no abdominal distension
6. Hemoglobin and hematrokrit within normal limits
7. Plasma, PT, PTT within normal limits

RATIONAL
1. To find out how severe the bleeding is
2. To determine the action to be given

NIC
Bleeding Precautions
1. Monitor signs of bleeding
2. Monitor lab values (coagulation) which includes PT, PTT, platelets
3. Record Hb and HT values before and after the occurrence of bleeding
4. Monitor orthostatic vital signs
5. Maintain a bed rest during active bleeding
6. Collaboration in the administration of blood products (platelets or fresh frozen plasma)
7. Protect the patient from trauma that can cause bleeding
8. Avoid measuring the temperature through the rectal
9. Avoid aspirin and anticoagulant
10. Instruct patients to increase the intake of foods that contain lots of vitamin K
11. Avoid the occurrence of constipation by suggesting to maintain adequate fluid intake and fecal softeners

Bleeding Reduction
1. Identify the cause of the bleeding
2. Monitor trend of blood pressure and hemodynamic parameters (CVP, pulmonary capillary / artery wedge pressure
3. Monitor fluid status that includes intake and output
4. Monitor determinant of delivery of oxygen to tissue (PaO2, SaO2 and Hb level and cardiac output)
5. Maintain intravenous patency line

Bleeding Reduction: Wound
1. Perform manual pressure (pressure) on the area of bleeding
2. Use the ice pack in the bleeding area
3. Apply pressure dressing on the wound area
4. Elevate the extremity of the bleeding
5. Monitor the size and characteristics of the hematoma
6. Monitor the distal pulse from the wounded area or bleeding
7. Instruct the patient to suppress the wound area during sneezing or coughing
8. Instruct patient to limit activity

Bleeding Reduction: Gastrointestinal
1. Observe the presence of blood in secretion of body fluids: emesis, stool, urine, gastric residue, and wound drainage
2. Monitor complete blood count and leukocyte
3. Collaboration in therapy: lactulose or vasopressin
4. Perform NGT installation to monitor gastric secretion and bleeding
5. Rinse the stomach with cold NaCI
6. Document the color, number and characteristics of the feces
7. Avoid extreme pH with collaborative administration of antacids or histamine blocking agents
8. Reduce stress factors
9. Keep the airway
10. Avoid using anticoagulant
11. Monitor the nutritional status of patients
12. Give Intravenous fluids

RATIONAL
1. Reduce complications.

Sanidya Nisita Pratiwimba15 September 2017

Name : Sanidya Nisita Pratiwimba
NIM : 131611133132 - A3

Functional Urinary Incontinence

Diagnosis : Functional urinary incontinence related with impaired vision (Domain : 3, class : 1, code : 00020)
Definition : Inability of a usually continent person to reach the toilet in time to avoid unintentional loss or urine
NOC:
After done action nursing for 2 x 24 hours, hopefully the ability to afford to experience the meaning of life through relationships themselves, or the power of harnessing higher criteria results
Urinary elimination:
1. The patient's elimination pattern is slightly disturbed (4)
2. The amount of urine in patients a little distracted (4)
3. Fluid intake in patients a little distracted (4)

NIC:
Urinary incontinence care:
1. Identify multifactorial causes of incontinence (e.g., urinary output, voiding pattern, cognitive function, preexistent urinary prolems, post void residual, anda medications)
2. Explain etiology of problem and rationale fot actions
3. Monitor urinary elimination, including frequency, consistency, odor, volume, and color

Rational for NIC:
1. To know the cause of patient incontinence
2. To know the cause of incontinence and to know the rational action
3. To know monitor the patient's elimination


Nabiila Rahma Ulinnuha15 September 2017

NAME: NABIILA RAHMA ULINNUHA
NIM: 131611133136
CLASS: A3 2016
Nanda Nursing Diagnosis
Diagnosis : Insufficient breast milk (Domain 2, Class 1: Ingestion Taking food or nutrients into the body , Code: 00216)
Definition : Low production of maternal breast milk.
Characteristics :
• Infant : Weight gain

Galang Tegar Indrawan15 September 2017

NAME: GALANG TEGAR INDRAWAN
NIM: 131611133106
CLASS: A3

NANDA:
Nursing diagnosis : Imbalanced nutrition: less than body requirements 1975,2000 (Domain 2, Class 1, Code 00002)
Definition : Intake of nutrients insufficient to meet metabolic needs.
NOC :
1.Carbohydrate Intake (100904)
2.Fat Intake (100903)
3.Vitamin Intake (100905)
RATIONAL NOC:
Nutrition status : nutrient intake
1.Meet the nutritional carbohydrates intake as much as 1200 calories (100904)
2.Meet the balance of fat nutrition intake as much as 62 grams/day (100903).
3.Equal vitamin that needed and recommended to consume 5-9 servings of fruits and vegetables everyday . 1 serving of fruits and vvegetables equivalent to 40 calories helps the sleep patterns of patien become more regular that is to have enough time (100905)
NIC :
Nutrition management:
1.Determine patient’s nutritional status and ability to meet nutritional needs.
2.Determine number of calories and type of nutrients needed to meet nutritionalrequirements.
3.Offer nutrient-dense snacks
RATIONAL NIC :
Nutrition managemen:
1.Knowing how the condition of the patient's nutritional status so that in case of problems the patient can fix it.
2.With the fulfillment of the number of calories, fats and types of nutrients the body needs, the body can optimize the potential for body performance.
3.Maintain equality of vitamins and nutritional intake to keep patients balanced, so there is no malnutrition problems, because the fulfillment of vitamins from fruits and vegetables will help patients to maintain adequate sleep patterns.

RIZKY TRY KURNIAWATI15 September 2017

Name: Rizky Try Kurniawati
NIM: 131611133142
Diagnosis:
Risk of allergic response: susceptible to response or immune reaction to a substance which is exacerbated, which can harm the healthikmm
NOC:
Allergic response; local (0705): the severity of localized hypersensitive immune response against a specific antigen outside
After intervention during 3x24 hours expected to be adequat client engagement mechanism with outcomes:
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

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