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NANDA NIC & NOC A3

Silakan kumpulkan discovery learningnya di sini.


1. Ramadhani Wahyuningtyas

pada : 14 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."


2. Shavira

pada : 15 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."


3. Hayu Ulfaningrum

pada : 15 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.











"


4. Endah Desfindasari

pada : 15 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
"


5. ARDINA NADYA WAHYUHERMANTO

pada : 15 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
"


6. RENDHY RIAN KOESMA BACHTIAR

pada : 15 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.








"


7. INDAH AZHARI

pada : 15 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"


8. EKA APRILLIA DIYAH SANTI K

pada : 15 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



"


9. EKA APRILLIA DIYAH SANTI K

pada : 15 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



"


10. Hilmy Ghozi Alsyafrud

pada : 15 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
"


11. Alfia Dwi Sunarto

pada : 15 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

"


12. Nafiul ikroma wijayanti

pada : 15 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
"


13. MITHA MULIA VIRDIANTY

pada : 15 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"


14. Siti Nur Aisa

pada : 15 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

"


15. Ramadhani Wahyuningtyas

pada : 15 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."


16. Sanidya Nisita Pratiwimba

pada : 15 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


"


17. Nabiila Rahma Ulinnuha

pada : 15 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 "


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