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Taxonomy of Nursing Diagnoses

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 :

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Taxonomy of Nursing Diagnoses

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

  2. 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 (belajardaripengalaman)

  3. 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

  4. 5 THING about NURSING DIAGNOSE

  5. DiagNoSaKeperawatanTERSTANDAR KALIMATNYA BAKU

  6. DiagNoSaKeperawatanTERTENTU ADA SYARAT DAN BATASAN KARAKTERISTIK MASING-MASING DIAGNOSA

  7. DiagNoSaKeperawatanTIDAK NGAWUR TIDAK BERDASAR “FEELING” / “KAYAKNYA”

  8. DiagNoSaKeperawatanTIDAK DIBUAT SENDIRI SESUAI DENGAN DAFTAR DIAGNOSA NANDA

  9. DiagNoSaKeperawatanIDENTITAS TIDAK BISA mendiagnosa ?? Anda BUKAN PERAWAT

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

  11. Data Pengkajian : Puzzle: What is the Diagnosis?

  12. Solving the Puzzle

  13. 1998 – Gordon’s Functional Health Patterns were adapted to create Taxonomy II NANDA-I Taxonomy II: 2008

  14. The Diagnoses • NANDA : North American for Nursing Diagnosis Association • Diagnosis versi NANDA ygsekarangdisusunsesuaidenganTaksonomi/urutan • Kodediagnosa (5 digit) dan multi axial (axis 1- axis 7). • Tujuan : mudahdigunakan, mudahdipahamidanfleksibelutkdirubahdandimodifikasi

  15. Structure of Taxonomy II

  16. NANDA-I Axes Required Optional

  17. 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

  18. Components of a Nursing Diagnosis • 1.   Label or Name and definition • 2.  Related Factors OR Risk Factors • 3. Defining Characteristics

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

  20. 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).

  21. Diagnostic Process Assessment Cluster cues / defining characteristics Generatelist of potential diagnoses Collect additional data to narrow list of potential diagnoses Determine diagnosis/diagnoses to be treated Implement plan of care based on identified diagnoses Evaluate success of plan of care

  22. Deteksi Cepat

  23. 1st step : Look domain

  24. Domain : 12

  25. 2nd step : Look KELAS

  26. Kelas: 1

  27. 3rd step : SPESIFIK ke batasan KARAKTERISTIK Semua diagnosa di kelas tersebut.

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

  29. Deteksi DEtaiL

  30. 1st step : Look axis

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

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

  33. Axis 7 NYERI : aktual

  34. 2nd step : Look DEFINISI dan batasan karakteristik

  35. Lihat data pengkajian; obyektif dan subyektif

  36. Penulisan Diagnosa : Nyeri Akut berhubungan dengan agen cedera

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

  38. 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).

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