Saterdag, 27 April 2013

STANDAR ASUHAN KEPERAWATAN BERBASIS NANDA, NOC, NIC


NURSING DIAGNOSIS NANDA-1 

List of complete all Nursing Diagnoses
Activity Intolerance
Activity Intolerance, Risk for
Airway Clearance, Ineffective
Anxiety
Anxiety, Death
Aspiration, Risk for
Attachment, Parent/Infant/Child, Risk for
Impaired
Autonomic Dysreflexia
Autonomic Dysreflexia, Risk for
Blood Glucose, Risk for Unstable
Body Image, Disturbed
Body Temperature: Imbalanced, Risk for
Bowel Incontinence
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Caregiver Role Strain
Caregiver Role Strain, Risk for
Comfort, Readiness for Enhanced
Communication: Impaired, Verbal
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Acute, Risk for
Confusion, Chronic
Constipation
Constipation, Perceived
Constipation, Risk for
Contamination
Contamination, Risk for
Coping: Community, Ineffective
Coping: Community, Readiness for Enhanced
Coping, Defensive
Coping: Family, Compromised
Coping: Family, Disabled
Coping: Family, Readiness for Enhanced
Coping (Individual), Readiness for Enhanced
Coping, Ineffective
Decisional Conflict
Decision Making, Readiness for Enhanced
Denial, Ineffective
Dentition, Impaired
Development: Delayed, Risk for
Diarrhea
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Energy Field, Disturbed
Environmental Interpretation Syndrome, Impaired
Failure to Thrive, Adult
Falls, Risk for
Family Processes, Dysfunctional: Alcoholism
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
Fatigue
Fear
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient
Fluid Volume, Deficient, Risk for
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Gas Exchange, Impaired
Grieving
Grieving, Complicated
Grieving, Risk for Complicated
Growth, Disproportionate, Risk for
Growth and Development, Delayed
Health Behavior, Risk-Prone
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Home Maintenance, Impaired
Hope, Readiness for Enhanced
Hopelessness
Human Dignity, Risk for Compromised
Hyperthermia
Hypothermia
Immunization Status, Readiness for Enhanced
Infant Behavior, Disorganized
Infant Behavior: Disorganized, Risk for
Infant Behavior: Organized, Readiness for
Enhanced
Infant Feeding Pattern, Ineffective
Infection, Risk for
Injury, Risk for
Insomnia
Intracranial Adaptive Capacity, Decreased
Knowledge, Deficient (Specify)
Knowledge (Specify), Readiness for Enhanced
Latex Allergy Response
Latex Allergy Response, Risk for
Liver Function, Impaired, Risk for
Loneliness, Risk for
Memory, Impaired
Mobility: Bed, Impaired
Mobility: Physical, Impaired
Mobility: Wheelchair, Impaired
Moral Distress
Nausea
Neurovascular Dysfunction: Peripheral, Risk for
Noncompliance (Specify)
Nutrition, Imbalanced: Less than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements, Risk for
Nutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired
Pain, Acute
Pain, Chronic
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Perioperative Positioning Injury, Risk for
Personal Identity, Disturbed
Poisoning, Risk for
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Power, Readiness for Enhanced
Powerlessness
Powerlessness, Risk for
Protection, Ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: Compound Reaction
Rape-Trauma Syndrome: Silent Reaction
Religiosity, Impaired
Religiosity, Readiness for Enhanced
Religiosity, Risk for Impaired
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Conflict, Parental
Role Performance, Ineffective
Sedentary Lifestyle
Self-Care, Readiness for Enhanced
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing/Grooming
Self-Care Deficit: Feeding
Self-Care Deficit: Toileting
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
Self-Mutilation
Self-Mutilation, Risk for
Sensory Perception, Disturbed (Specify: Auditory,
Gustatory, Kinesthetic, Olfactory Tactile,
Visual)
Sexual Dysfunction
Sexuality Pattern, Ineffective
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Sleep Deprivation
Sleep, Readiness for Enhanced
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Spontaneous Ventilation, Impaired
Stress, Overload
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
Suicide, Risk for
Surgical Recovery, Delayed
Swallowing, Impaired
Therapeutic Regimen Management: Community,
Ineffective
Therapeutic Regimen Management, Effective
Therapeutic Regimen Management: Family,
Ineffective
Therapeutic Regimen Management, Ineffective
Therapeutic Regimen Management, Readiness for
Enhanced
Thermoregulation, Ineffective
Thought Processes, Disturbed
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify: Cerebral, Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, Peripheral
Transfer Ability, Impaired
Trauma, Risk for
Unilateral Neglect
Urinary Elimination, Impaired
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence, Functional
Urinary Incontinence, Overflow
Urinary Incontinence, Reflex
Urinary Incontinence, Stress
Urinary Incontinence, Total
Urinary Incontinence, Urge
Urinary Incontinence, Risk for Urge
Urinary Retention
Ventilatory Weaning Response, Dysfunctional
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
Walking, Impaired
Wandering

Nursing Outcomes Classification (NOC)
The Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses. An outcome is a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions. The outcomes are developed for use in all settings and with all patient populations. Clinical sites used to test the NOC included tertiary care hospitals, community hospitals, community agencies, nursing centers, and a nursing home. The outcomes are developed for use in all settings and can be used across the care continuum to follow patient outcomes throughout an illness episode or over an extended period of care. Since the outcomes describe patient/client status, other disciplines may find them useful for the evaluation of their interventions. 

The 330 NOC outcomes in Nursing Outcomes Classification (NOC) (3rd ed.) are listed in alphabetical order. Each outcome has a definition, a list of indicators that can be used to evaluate patient status in relation to the outcome, a target outcome rating, place to identify the source of data, a five-point Likert scale to measure patient status, and a short list of references used in the development of the outcome. For 76 of the outcomes an additional measurement scale was added to the outcome based on feedback from our research in 10 clinical sites. Examples of scales used with the outcomes are: 1=Extremely compromised to 5= Not compromised and 1=Never demonstrated to 5=Consistently demonstrated. The NOC (3rd ed.) includes 311 individual level outcomes, 10 family and 9 community level outcomes. The NOC outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual framework to facilitate locating an outcome. The 330 outcomes are grouped into thirty-one classes and seven domains for ease of use. The seven domains are: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge & Behavior, Perceived Health, Family Health, and Community Health. Each outcome has a unique code number that facilitates its use in computerized clinical information systems and allows manipulation of data to answer questions about nursing care quality and effectiveness. The classification is continually updated to include new outcomes and to revise older outcomes based on new research or user feedback and is published on a 4 year cycle.
 

The research to develop NOC began with the formation of the outcomes research team in 1991 and has progressed through the following phases.
Phase I - Pilot Work to Test Methodology (1992-1993) 
Phase II - Construction of the Outcomes (1993-1996)
 
Phase III - Construction of the Taxonomy and Clinical Testing (1996-1997)
 
Phase IV - Evaluation of Measurement Scales (1998-2002)
 
Phase V - Refinement and Clinical Use (1997 - Present)
Funding for Phase I was received from Sigma Theta Tau International and funding for Phases II through V from the National Institutes of Health, National Institute of Nursing. Multiple research methods have been used in the development of NOC. An inductive approach was used to develop the outcomes based on current practice and research. Concept analysis and research team review were used in the construction of the outcomes. Questionnaire surveys of expert nurses were used to assess the content validity and nursing sensitivity of the outcomes. The taxonomy was constructed using similarity/dis-similarity analysis and hierarchical clustering techniques. Feedback from clinical test sites and other sites implementing NOC have been used to identify new outcomes for development and refine current outcomes. Currently, inter-rater reliability, criterion measures and other methods are being used to evaluate the reliability, validity, and sensitivity of the outcome measures in clinical sites. This data is included in the third edition. 

The outcomes have been linked to NANDA International diagnoses, to Gordon's functional patterns, to the Taxonomy of Nursing Practice, to Omaha System problems, to resident admission protocols (RAPs) used in nursing homes, to the OASIS System used in home care and to NIC interventions. A more in depth look at the linkage between NANDA, NIC and NOC is available in a separate book Nursing diagnoses, outcomes, & interventions: NANDA, NOC, and NIC Linkages. This publication is also available in a CD-ROM.
 

NOC is one of the standardized languages recognized by the American Nurses' Association (ANA). As a recognized language it meets the language guideline standards set by ANA's Nursing Information and Data Set Evaluation Center (NIDSEC) for information system vendors. NOC is included in the National Library of Medicine's Metathesaurus for a Unified Medical Language and in The Cumulative Index to Nursing Literature (CINAHL) and has been approved for use by Health Level 7 Terminology (HL7). NOC is currently being mapped into SNOMED (Systemized Nomenclature of Medicine). The use of NOC in practice, nursing education, and research is the most accurate indicator of NOC's usefulness. NOC is being adopted in a number of clinical sites for the evaluation of nursing practice and is being used in educational settings to structure curricula and teach students clinical evaluation. Interest in NOC has been demonstrated in other countries. NOC has been translated into Dutch, Japanese, Korean, French, and Spanish and several other translations are in progress including German and Portuguese.

For further information contact :
Center for Nursing Classification & Clinical Effectiveness 
The University of Iowa, College of Nursing 407 NB
 
Iowa City IA 52242-1121
 
            319-335-7051       Fax: 319-335-6820 
e-mail:
 classification-center@uiowa.edu 



Nursing Interventions Classification (NIC)
OVERVIEW OF NIC

The Nursing Interventions Classification (NIC) is a comprehensive, research-based, standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An intervention is defined as "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes." While an individual nurse will have expertise in only a limited number of interventions reflecting on her or his specialty, the entire classification captures the expertise of all nurses. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice, to primary care) and all specialties (from critical care to ambulatory care and long term care). While the entire classification describes the domain of nursing, some of the interventions in the classification are also done by other providers. NIC can be used by other non-physician providers to describe their treatments.

NIC interventions include both the physiological (e.g. Acid-Base Management) and the psychosocial (e.g. Anxiety Reduction). Interventions are included for illness treatment (e.g. Hyperglycemia Management), illness prevention (e.g. Fall Prevention), and health promotion (e.g. Exercise Promotion). Most of the interventions are for use with individuals but many are for use with families (e.g. Family Integrity Promotion), and some are for use with entire communities (e.g. Environmental Management: Community). Indirect care interventions (e.g. Supply Management) are also included. Each intervention as it appears in the classification is listed with a label name, a definition, a set of activities to carry out the intervention, and background readings.

The 542 interventions in NIC (5th ed.) are grouped into thirty classes and seven domains for ease of use. The 7 domains are: Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, Health System, and Community. Each intervention has a unique number (code). NIC interventions have been linked with NANDA nursing diagnoses, Omaha System problems, and NOC outcomes. The classification is continually updated with an ongoing process for feedback and review. In the back of the book, there are instructions for how users can submit suggestions for modifications to existing interventions or propose a new intervention. All contributors whose changes are included in the next edition are acknowledged in the book. New editions of the classification are planned for approximately every 4 years. The classification was first published in 1992, the second edition in 1996, the third edition in 2000, the fourth edition in 2004, and the fifth edition in 2008. Work that is done between editions and other relevant publications that enhance the use of the classification are available form the Center for Nursing Classification & Clinical Effectiveness at the College of Nursing, The University of Iowa.

NIC is recognized by the American Nurses' Association (ANA) and is included as one data set that will meet the uniform guidelines for information system vendors in the ANA's Nursing Information and Data Set Evaluation Center (NIDSEC). NIC is included in the National Library of Medicine's Metathesaurus for a Unified Medial Language and the cumulative index of nursing Literature (CINAHL). NIC is also included in The Joint Commission as one nursing classification system that can be used to meet the standard on uniform data. The National League for Nursing has made a 40-minute video about NIC to facilitate teaching of NIC to nursing students and practicing nurses. Alternative Link has included NIC in its ABC codes used for reimbursement for alternative providers. NIC is registered in HL7 and is mapped into SNOMED (Systemized Nomenclature of Medicine).

Hundreds of health care agencies have adopted NIC for use in standards, care plans, competency evaluation, and nursing information systems; nursing education programs are using NIC to structure curriculum and identify competencies of graduating nurses; authors of major texts are using NIC to discuss nursing treatments; and researchers are using NIC to study the effectiveness of nursing care. Interest in NIC has been demonstrated in several other countries, notably Brazil, Canada, Denmark, England, France, Germany, Iceland, Japan, Korea, Spain, Switzerland, and The Netherlands. NIC has been translated into Chinese, Dutch, French, German, Icelandic, Japanese, Korean, Portugese, and Spanish; other translations are in progress.

For further information contact :

Center for Nursing Classification & Clinical Effectiveness
The University of Iowa, College of Nursing 407 NB
Iowa City IA 52242-1121
319-335-7051 Fax: 319-335-9990
e-mail: classification-center@uiowa.edu


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