Taxonomy of Nursing Diagnoses The NANDA International Taxonomy Dewi Baririet Baroroh Departement Keperawatan Dasar : Proses Dokumentasi Keperawatan PSIK FIKES UMM

Nurse are diagnosticians As foundation of nursing care. 2 basics development need of competencies to diagnose : Requires intelectual, interpersonal, technical Personal strength of tolerance for ambiguity (flexibel) and reflective practice (belajar dari pengalaman)

Critical Thinking (CT) Thinking (CT) processes can be improved Stimulate to use Expect use Validate appropriate use Demonstrate support & confidence in abilities CT abilities -essential for accuracy of diagnoses & use of NOC & NIC The Good News, also based on research findings from educational psychology and other disciplines, is that thinking processes can be improved. Currently, in nursing, we equate thinking with critical thinking, so, from now on, I will use the term critical thinking. Many nursing studies have shown that critical thinking abilities in nursing vary widely and that CT can be improved with education and effort. The way we can do this is by: Stimulating students to use thinking processes, not just receive knowledge Expecting students to think, not just to memorize knowledge Validating students’ thinking processes, tell them it is good Demonstrating support & confidence in students’ abilities to think I am proposing that CT abilities are essential to achieve accurate interpretations of patient data and appropriate selection of the concepts in NOC and NIC, so helping students with their thinking needs to be a high priority.

5 THING about NURSING DIAGNOSE

DiagNoSa Keperawatan TERSTANDAR Menggunakan NANDA KALIMATNYA BAKU

DiagNoSa Keperawatan TERTENTU Berdasarkan definisi karakteristik dan label diagnosis ADA SYARAT DAN BATASAN KARAKTERISTIK MASING-MASING DIAGNOSA

DiagNoSa Keperawatan TIDAK NGAWUR Tidak dikaranf berdasar perasaan TIDAK BERDASAR “FEELING” / “KAYAKNYA”

DiagNoSa Keperawatan TIDAK DIBUAT SENDIRI Ada saat berpikir kritis..tapi bukan dengan membuat aturan baru SESUAI DENGAN DAFTAR DIAGNOSA NANDA

DiagNoSa Keperawatan IDENTITAS Inilah profesi anda!!!! NDX : respon manusia, KDM, berubah sesuai keadaan klien, mengarah pada tindakan mandiri perawat, saling melengkapi dg Dx dokter TIDAK BISA mendiagnosa ?? Anda BUKAN PERAWAT

PRINSIP diagnosa ∞ pengkajian TIDAK ADA pengkajian  TIDAK ADA diagnosa Pengkajian TIDAK LENGKAP  diagnosa SALAH Pengkajian LENGKAP  BELUM TENTU diagnosa BENAR

Puzzle: What is the Diagnosis? Data Pengkajian : So, needless to say, identifying the best diagnosis of human responses is a puzzle. It is a much more difficult puzzle to solve than nurses and teachers presently realize. We like to believe that if we say a patient is anxious they are anxious, rather than thinking that the data we are noticing can have other possible meanings, for which different interventions would be needed. For example, if the best diagnosis is fear, the interventions would be different than if it is anxiety or ineffective coping, or ineffective breathing pattern. Puzzle: What is the Diagnosis?

Solving the Puzzle Is it this? Or this? To achieve the best use of NNN, nurses should be asking themselves about patient data: Is it this? Or this? Or this? Note here how the same puzzle pieces can go into 3 different shapes. The same is true in respect to patient data.

NANDA-I Taxonomy II: 2008 13 Domains 47 Classes Nursing Diagnoses 206 1998 – Gordon’s Functional Health Patterns were adapted to create Taxonomy II

The Diagnoses NANDA : North American for Nursing Diagnosis Association Diagnosis versi NANDA yg sekarang disusun sesuai dengan Taksonomi/urutan Kode diagnosa (5 digit) dan multi axial (axis 1- axis 7). Tujuan : mudah digunakan, mudah dipahami dan fleksibel utk dirubah dan di modifikasi

Structure of Taxonomy II Domains Class NDx

NANDA-I Axes Required Optional The Diagnostic Concept Page. 446-447 Axis 1 (Individual, Family, Group, Community) Subject of the Diagnosis Axis 2 (Decreased, Effective, Impaired, Situational, etc.) page. 448 Judgment Axis 3 (GI, Oral, Skin, etc.) page 449-450 Location Axis 4 (Infant, Preschool Child, Adolescent, Adult, etc.) Age Axis 5 (Acute, Intermittent, Chronic, Continuous) Time Axis 6 (Actual, Health Promotion, Risk, Wellness) Status of the diagnosis Axis 7 Required Optional

Axis 1  Konsep Diagnosa : 136 Axis 2  Subyek yang sakit : individu, klg, klmpk, komnts Axis 3  Penilaian : terganggu, tdk efektif dll Axis 4  Lokasi : jantung, pulmo, ekstremitas dll Axis 5  Usia : janin, bayi ,dewasa, lansia dll Axis 6  Waktu : kronis, akut, intermitten, kontinyu Axis 7  Status Diagnosa : aktual, promosi, resiko, potensial

Components of a Nursing Diagnosis 1.   Label or Name and definition 2.  Related Factors OR Risk Factors 3. Defining Characteristics 1. A label or name and definition: the label is selected base upon a) matching the related factors or defining characteristics and the definition of the label validates your decision. 2.      Related factor(s) which describe conditions antecedent to or associated with the diagnosis OR Risk factor(s) which describe the environmental factors and physiologic ,genetic or chemical elements that increase the vulnerability of a (client) to an unhealthful event ( NANDA, 2009) 3. Defining characteristics, which are observable signs and symptoms that are manifestations of the diagnosis (Denehy & Poulton. 1999) a definition does not need to be written in the care plan. It is there to help you decide if this Nursing Diagnosis is appropriate for this patient. Related factors are elements that have an effect on the person, family or community, either internal or external, that contribute to the problem Defining Characteristics are subjective or objective s&s indicating the presence of a condition “Risk for” Nursing Diagnosis’ do not need to include defining characteristics, because at this time there is no evidence that the condition exists. There is only a possibility the condition could exist.

Konstruksi Label diagnosa (masalah keperawatan) : Axis 1 – Axis 3 – Axis 2  wajib ada Axis 4, 5, 6, 7  lengkap lebih baik

Contoh : Data pengkajian : Ny. J, 72 tahun mengeluh NYERI luka di kaki. ± 6 tahun yang lalu pasien menderita penyakit DM, dan telah melakukan pengobatan secara rutin, dengan glibenkamid sehari 1 kali. Selama ini jarang melakukan pemeriksaan rutin kadar gula darah. ± 8 hari yang lalu telapak kaki kena paku, sudah diperiksakan ke dokter dan diberi obat tetapi sampai obat habis belum sembuh, bahkan dirasakan semakin berat.Terdapat nanah, dan bertambah nyeri nyeri serta demam.Akhirnya dirujuk ke RSUD Dr. Soetomo Surabaya.Telapak kaki kena paku ± 8 hari yang lalu, terdapat nanah dan bengkak.Nyeri telapak kaki semakin nyeri jika kaki digelantungkan .Pasien batuk pilek (-), nyeri dada (-), ulu hati terasa ampek, dan tadi malam muntah 1 kali.(P). Nyeri dirasa panas, senut-senut seperti disedot, bercampur dengan perih seperti teriris (Q). Nyeri dirasakan di telapak kaki yang terdapat luka gangrene (R). nyeri dirasakan skala 7 (S). Nyeri dirasakan terus menerus (T).

Diagnostic Process Assessment Cluster cues / defining characteristics Collect additional data to narrow list of potential diagnoses Generate list of potential diagnoses Implement plan of care based on identified diagnoses Evaluate success of plan of care Determine diagnosis/diagnoses to be treated Use of case studies can assist students in identifying cues in patient situations that may be defining characteristics of one or more nursing diagnoses Hypothesis generation and differential diagnosis skills can be developed through case studies, clinical conference discussions and in skills lab scenarios

Deteksi Cepat

1st step : Look domain

Domain : 12

2nd step : Look KELAS

Kelas: 1

Semua diagnosa di kelas tersebut. 3rd step : Semua diagnosa di kelas tersebut. SPESIFIK ke batasan KARAKTERISTIK

Kira-kira Di kelas itulah diagnosa pasien That’s All Kira-kira Di kelas itulah diagnosa pasien

Deteksi DEtaiL

1st step : Look axis

Axis 1 NYERI : Axis 2 NYERI : Axis 3 NYERI : nyeri individu situasional

Axis 4 NYERI : ekstremitas Axis 5 NYERI : lansia Axis 6 NYERI : akut

Axis 7 NYERI : aktual

Look DEFINISI dan batasan karakteristik 2nd step : Look DEFINISI dan batasan karakteristik

Lihat data pengkajian; obyektif dan subyektif

DATA ETIOLOGI Masalah keperawatan DS : Ny. J mengeluh nyeri luka di kaki. ± 8 hari yang lalu telapak kaki kena paku, sudah diperiksakan ke dokter dan diberi obat tetapi sampai obat habis belum sembuh, bahkan dirasakan semakin berat. Terdapat nanah, dan bertambah nyeri nyeri serta demam.Akhirnya dirujuk ke RSUD Dr. Soetomo Surabaya.Telapak - ± 6 tahun yang lalu pasien menderita penyakit DM, dan telah melakukan pengobatan secara rutin, dengan glibenkamid sehari 1 kali. DO : - Selama ini jarang melakukan pemeriksaan rutin kadar gula darah. kaki kena paku ± 8 hari yang lalu, terdapat nanah dan bengkak - .Nyeri telapak kaki semakin nyeri jika kaki digelantungkan . - Nyeri dirasa panas, senut-senut seperti disedot, bercampur dengan perih seperti teriris (Q). - Nyeri dirasakan di telapak kaki yang terdapat luka gangrene (R). - nyeri dirasakan skala 7 (S). Nyeri dirasakan terus menerus (T). Ketidakberdayaan fisik Nyeri

Penulisan Diagnosa : Nyeri Akut berhubungan dengan agen cedera

Made a priority Base on basic human need : individu, family, community

Diagnostic Difficulties Significant overlap of cues (Defining Characteristics) to diagnoses Contextual factors such as culture can change the perspective on diagnosis Many studies have verified that interpretations of clinical cases have the potential to be less accurate than indicated by the data (Lunney, 2007).