DIAGNOSIS KEPERAWATAN NANDA-I 2009-2011
Domain 1 Promosi Kesehatan..............................................................................................................
1.
Ketidakefektifan Pemeliharaan Kesehatan (00099) ..................................................... 67
2.
Ketidakefektifan Manajemen Kesehatan Diri (00078) ................................................. 68
3.
Hambatan Pemeliharaan Rumah (00098) ..................................................................... 72
4.
Kesiapan Meningkatkan Status Imunisasi (00186) ...................................................... 73
5.
Pengabaian Diri (00193) .............................................................................................. 75
6.
Kesiapan Meningkatkan Nutrisi (00163) ..................................................................... 79
7.
Ketidakefektifan Manajemen Regimen Terapeutik Keluarga (00080) ......................... 80
8.
Kesiapan Meningkatkan Manajemen Kesehatan Diri (00162) ........................................... 81
Domain 2 Nutrisi .................................................................................................................... 83
9.
Ketidakefektifan Pola Makan Bayi (00107) ................................................................. 85
10.
Ketidakseimbangan Nutrisi: Kurang dari Kebutuhan Tubuh (00002) .......................... 86
11.
Ketidakseimbangan Nutrisi: Lebih dari Kebutuhan Tubuh (00001) ............................ 87
12.
Risiko Ketidakseimbangan Nutrisi: Lebih dari Kebutuhan Tubuh (00002) ................. 88
13.
Gangguan Menelan (00103) ......................................................................................... 89
14.
Risiko Ketidakstabilan Kadar Glukosa Darah (00179) ................................................ 91
15.
Ikterik Neonatus (00194) - ........................................................................................... 92
16.
Risiko Gangguan Fungsi Hati (00178) ......................................................................... 94
17.
Risiko Ketidakseimbangan Elektrolit (00195) ............................................................. 95
18.
Kesiapan Meningkatkan Keseimbangan Cairan (00160) ............................................. 96
19.
Kekurangan Volume Cairan (00027) ........................................................................... 97
20.
Kelebihan Volume Cairan (00026) .............................................................................. 98
21.
Risiko Kekurangan Volume Cairan (00028) ................................................................ 99
22.
Risiko Ketidakseimbangan Volume Cairan (00025) .................................................. 100
Domain 3 Eliminasi dan Pertukaran .................................................................................. 103
23.
Inkontinensia Urinarius Fungsional (00020) .............................................................. 105
24.
Inkontinensia urinarus aliran berlebih ....................................................................... 106
25.
Inkontinensia urinarus reflex ...................................................................................... 108
26.
Inkontinensia urinarus stress ...................................................................................... 109
27.
Inkontinensia urinarus dorongan ................................................................................ 111
28.
Risiko Inkontinensia urinarus dorongan ..................................................................... 113
29.
Gangguan eliminasi urinarus ..................................................................................... 114
30.
Kesiapan meningkatkan eliminasi urinarus ................................................................ 115
31.
Retsnsi urinarius ......................................................................................................... 116
32.
Inkontinensia defekasi ................................................................................................ 117
33.
Konstipasi................................................................................................................... 118
34.
Persepsi konstipasi ..................................................................................................... 120
35.
Resiko konstipasi ....................................................................................................... 121
36.
Diare ........................................................................................................................... 123
37.
Disfungsi motilitas gastrointestinal ............................................................................ 124
38.
Resiko Disfungsi motilitas gastrointestinal ................................................................ 126
39.
Gangguan pertukaran gas ........................................................................................... 128
Domain 4 aktivitas / istirahat ............................................................................................. 129
40.
Insomnia ..................................................................................................................... 131
41.
Deprivasin tidur .......................................................................................................... 134
42.
Kesiapan meningkatkan tidur ..................................................................................... 135
43.
Resiko sinrome disuse ................................................................................................ 137
44.
Defisiensi aktivitas pengalih ...................................................................................... 138
45.
Gaya hidup kurang gerak ........................................................................................... 139
46.
Hambatan mobilitas ditempat tidur ............................................................................ 140
47.
Hambatan mobilitas fisik ........................................................................................... 141
48.
Hambatan mobilitas berkursi roda ............................................................................ 143
49.
Kelamabatan pemulihan pasca bedah ......................................................................... 145
50.
Hambatan kemampuan berpindah .............................................................................. 147
51.
Hambatan berjalan ..................................................................................................... 152
52.
Gangguan medan energy ..................................................................................................
53.
Keletihan ..........................................................................................................................
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54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
Intoleransi aktivitas ..........................................................................................................
Resiko Intoleransi aktivitas ..............................................................................................
Resiko perdarahan ............................................................................................................
Ketidak efektifan pola nafas .............................................................................................
Penurunan Curah Jantung (00029) ............................................................................. 162
Ketidakefektifan Perfusi Jaringan Perifer (00204) ..................................................... 164
Risiko Penurunan Perfusi Jaringan Jantung* (00200) ................................................ 166
Risiko Ketidakefektifan Perfusi Jaringan Otak* (00201) ........................................... 168
Risiko Ketidakefektifan Perfusi Gastrointestinal* (00202) ........................................ 170
Risiko Ketidakefektifan Perfusi Ginjal* (00203) ....................................................... 172
Risiko Syok (00205) .................................................................................................. 173
Gangguan Ventilasi Spontan (00033) ........................................................................ 174
Disfungsi Respons Penyapihan Ventilator (00034) .................................................... 175
Kesiapan Meningkatkan Perawatan Diri (00182) ....................................................... 177
Defisit Perawatan Diri: Mandi* (00108) .................................................................... 179
Defisit Perawatan Diri: Berpakaian* (00109) ............................................................ 180
Defisit Perawatan Diri: Makan (00102) ..................................................................... 182
Defisit Perawatan Diri: Eliminasi* (00110) ............................................................... 183
Domain 5 Persepsi/Kognisi ................................................................................................. 185
72.
Kealpaan Tubuh Unilateral (00123) ........................................................................... 187
73.
Sindrom Gangguan Interpretasi Lingkungan (00127) ................................................ 190
74.
Keluyuran (00154) ..................................................................................................... 191
75.
Gangguan Sensori Persepsi (Tipe: Penglihatan, Pendengaran, Kinestetik, GustatQri,
Taktil, Olfaktori) (00122) ........................................................................................... 193
76.
Konfusi Akut (00128) ................................................................................................ 194
77.
Konfusi Kronik (00129) ............................................................................................. 198
78.
Risiko Konfusi Akut (00173) ..................................................................................... 199
79.
Defisiensi Pengetahuan (00126) ................................................................................. 203
80.
Kesiapan Meningkatkan Pengetahuan (00161) .......................................................... 204
81.
Kerusakan Memori (00131) .......................................................................................'205
82.
Kesiapan Meningkatkan Pembuatan Keputusan (00184) ........................................... 206
83.
Ketidakefektifan Perencanaan Aktivitas (00199) ....................................................... 208
84.
Hambatan Komunikasi Verbal (00051) ...................................................................... 210
85.
Kesiapan Meningkatkan Komunikasi (00157) ........................................................... 212
Domain 6 Persepsi Diri ........................................................................................................ 213
86.
Risiko Pelemahan Martabat (00174) .......................................................................... 215
87.
Keputusasaan.............................................................................................................. 126
88.
Ganggaun identifikasi personil ................................................................................... 217
89.
Resiko kesepian .......................................................................................................... 219
90.
Kesiapan meningkatnya daya ..................................................................................... 220
91.
Ketidakberdayaan ....................................................................................................... 222
92.
Resiko Ketidakberdayaan ........................................................................................... 224
93.
Kesiapan meningkatkan konsep diri ........................................................................... 225
94.
Harga diri rendah situasional...................................................................................... 226
95.
Harga diri rendah kronik ............................................................................................ 227
96.
Resiko harga diri rendah situasioal ............................................................................ 230
97.
Gangguan citra tubuh ................................................................................................. 231
Domain 7 hubungan peran.................................................................................................. 233
98.
Ketegangan peran pemberi asuhan ............................................................................. 235
99.
Resiko Ketegangan peran pemberi asuhan ................................................................. 238
100. Ketidakmampuan menjadi orang tua .......................................................................... 240
101. Resiko Ketidakmampuan menjadi orang tua .............................................................. 243
102. Resiko gangguan perlekatan ....................................................................................... 244
103. Disfungsi proses keluarga .......................................................................................... 246
104. Gangguan proses keluarga ......................................................................................... 247
105. Kesiapan meningkatkan proses keluarga .................................................................... 250
106. Keefektifan pemberian ASI ........................................................................................ 252
107. Konflik peran menjadi orang tua ................................................................................ 253
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108.
109.
110.
Kesiapan meningkatkan hubungan ............................................................................. 254
Ketidak efektifan performa peran ............................................................................... 256
Hambatan interaksi social .......................................................................................... 257
Domain 8 seksualitas
111. Disfungsi seksual .............................................................................................................
112. Ketidakefektifan pola seksualitas .....................................................................................
113. Kesiapan meningkatkan proses kehamilan persalinan .....................................................
114. Resiko gangguan hubungan ibu/Janin ..............................................................................
Domain 9 Koping/Toleransi Stres 273
115. Sindrom Pascatrauma (00141) .................................................................................. 275
116. Risiko Sindrom Pascatrauma (00145) ....................................................................... 277
117. Sindrom Trauma Perkosaan (00142) ......................................................................... 278
118. Sindrom Stres Akibat Perpindahan (00.114) ............................................................. 279
119. Risiko Sindrom Stres Akibat Perpindahan (00149) ................................................. 280
120. Ansietas (00146) ....................................................................................................... 281
121. Ansietas Kematian (00147) ....................................................................................... 284
122. Perilaku Kesehatan Berisiko* (00188) : .................................................................... 287
123. Penurunan Koping Keluarga (00074) ........................................................................ 290
124. Koping Defensif (00071) .......................................................................................... 292
125. Ketidakmampuan Koping Keluarga (00073) ............................................................. 295
126. Ketidakefektifan Koping (00069) ............................................................................. 297
127. Ketidakefektifan Koping Komunitas (00077) ........................................................... 299
128. Kesiapan Meningkatkan Koping (00158) .................................................................. 300
129. Kesiapan Meningkatkan Koping Komunitas (00076) ............................................... 301
130. Kesiapan Meningkatkan Koping Keluarga (00075) .................................................. 302
131. Penyangkalan Tidak Efektif (00072) ........................................................................ 303
132. Ketakutan (00148) ............................................................................................................
133. Dukacita* (00136) ............................................................................................................
134. Dukacita Terganggu* (00135) ..........................................................................................
135. Risiko Dukacita Terganggu* (00172) .............................................................................
136. Gangguan Penyesuaian Individu (00210).........................................................................
137. Kesiapan Meningkatkan Penyesuaian (00212) ................................................................
138. Risiko Gangguan Penyesuaian (00211) ............................................................................
139. Kepedihan Kronis (00137) .............................................................................................
140. Stres Berlebihan (00177) .................................................................................................
141. Disrefleksia Autonomik (00009) .....................................................................................
142. Risiko Disrefleksia Autonomik (00010) .........................................................................
143. Disorganisasi Perilaku Bayi (00116). ..............................................................................
144. Risiko Disorganisasi Perilaku Bayi (00115) ...................................................................
145. Kesiapan Meningkatkan Perilaku Bayi (00117) ...............................................................
146. Penurunan Kapasitas Adaptif Intrakranial (00049) ..........................................................
Domain 10: Prinsip-Prinsip Hidup,.................................................................................... 335
147. Kesipana meningkatkan harapan ......................................................................................
148. Kesiapan meingkatkan kesejahteraan spiritual .................................................................
149. Konflik keputusan ............................................................................................................
150. Distress moral ..................................................................................................................
151. Ketidakpatuhan ................................................................................................................
152. Hambatan religiositas .......................................................................................................
153. Kesiapan meingkatkan religiositas ...................................................................................
154. Resiko hambatan religiositas ............................................................................................
155. Distress spiritual ...............................................................................................................
156. Resiko sistress spiritual ....................................................................................................
Domain 11: Keamanan/Perlindungan ......................................................................................
157. Resiko infeksi ...................................................................................................................
158. Ketidakefektifan bersihan jalan nafas ..............................................................................
159. Resiko aspirasi .................................................................................................................
160. Resiko syndrome kematian bayi mendadak .....................................................................
161. Kerusakan gigi .................................................................................................................
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162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
186.
187.
Resiko jatuh......................................................................................................................
Resiko cidera ....................................................................................................................
Resiko cidera akibat kondisi perioperatif .........................................................................
Kerusakan membrane mukosa oral...................................................................................
Resiko disfungsi neurovascular perifer ............................................................................
Ketidakefektifan perlindungan .........................................................................................
Kerusakan integritas kulit ................................................................................................
Resiko Kerusakan integritas kulit ....................................................................................
Resiko asfiksia .................................................................................................................
Kerusakan integritas jaringan ...........................................................................................
Resiko trauma ..................................................................................................................
Resiko trauma vascular ....................................................................................................
Menciderai diri .................................................................................................................
Resiko Menciderai diri .....................................................................................................
Resiko bunuh diri .............................................................................................................
Resiko perilaku kekerasan terhadap orang lain ................................................................
Resiko perilaku kekerasan terhadap diri sendiri ...............................................................
Kontaminasi (00181) .................................................................................................. 387
Risiko Kontaminasi (00180). ..................................................................................... 392
Risiko Keracunan (00037) ......................................................................................... 395
Respons Alergi Lateks (00041) .................................................................................. 396
Risiko Respons Alergi Lateks (00042) ....................................................................... 398
Risiko Ketidakseimbangan Suhu Tubuh (OOQ05) .................................................... 399
Hipertermia (00007) ................................................................................................... 400
Hipotermia (00006) .................................................................................................... 401
Ketidakefektifan Termoregulasi (00008) ................................................................... 402
Domain 12: Kenyamanan .................................................................................................... 403
188. Kesiapan Meningkatkan Rasa Nyaman (00183) ........................................................ 405
189. Gangguan Rasa Nyaman (00214) ............................................................................... 407
190. Mual (00134) .............................................................................................................. 408
191. Nyeri Akut (00132) .................................................................................................... 410
192. Nyeri Kronis (00133) ................................................................................................. 411
193. Isolasi Sosial (00053) ................................................................................................. 412
Domain 13 Pertumbuhan/Perkembangan ......................................................................... 415
194. Kegagalan Orang Dewasa untuk Tumbuh (00101) .................................................... 417
195. Keterlambatan Pertumbuhan dan Perkembangan (00111) ......................................... 419
196. Risiko Pertumbuhan Tidak Proporsional (00113) ...................................................... 420
197. Risiko keterlambatan Perkembangan (00112) ............................................................ 421
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