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 .................................................................................................................................................................................................................
54.
Intoleransi aktivitas ..................................................................................................................................................................................................
55.
Resiko Intoleransi aktivitas ......................................................................................................................................................................................
56.
Resiko perdarahan ..................................................................................................................................................................................................
57.
Ketidak efektifan pola nafas ....................................................................................................................................................................................
58.
Penurunan Curah Jantung (00029) ................................................................................................................................................................... 162
59.
Ketidakefektifan Perfusi Jaringan Perifer (00204) ............................................................................................................................................. 164
60.
Risiko Penurunan Perfusi Jaringan Jantung* (00200) ....................................................................................................................................... 166
61.
Risiko Ketidakefektifan Perfusi Jaringan Otak* (00201) .................................................................................................................................... 168
62.
Risiko Ketidakefektifan Perfusi Gastrointestinal* (00202) .................................................................................................................................. 170
63.
Risiko Ketidakefektifan Perfusi Ginjal* (00203) ................................................................................................................................................. 172
64.
Risiko Syok (00205) .......................................................................................................................................................................................... 173
65.
Gangguan Ventilasi Spontan (00033) ................................................................................................................................................................ 174
66.
Disfungsi Respons Penyapihan Ventilator (00034) ............................................................................................................................................ 175
67.
Kesiapan Meningkatkan Perawatan Diri (00182) ............................................................................................................................................... 177
68.
Defisit Perawatan Diri: Mandi* (00108) .............................................................................................................................................................. 179
69.
Defisit Perawatan Diri: Berpakaian* (00109) ..................................................................................................................................................... 180
70.
Defisit Perawatan Diri: Makan (00102) .............................................................................................................................................................. 182
71.
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

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99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.

Resiko Ketegangan peran pemberi asuhan ....................................................................................................................................................... 238

Ketidakmampuan menjadi orang tua ................................................................................................................................................................. 240
Resiko Ketidakmampuan menjadi orang tua ..................................................................................................................................................... 243
Resiko gangguan perlekatan ............................................................................................................................................................................. 244
Disfungsi proses keluarga ................................................................................................................................................................................. 246
Gangguan proses keluarga ............................................................................................................................................................................... 247
Kesiapan meningkatkan proses keluarga .......................................................................................................................................................... 250
Keefektifan pemberian ASI ................................................................................................................................................................................ 252
Konflik peran menjadi orang tua ........................................................................................................................................................................ 253
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 .........................................................................................................................................................................................................
162.
Resiko jatuh .............................................................................................................................................................................................................
163.
Resiko cidera ...........................................................................................................................................................................................................
164.
Resiko cidera akibat kondisi perioperatif .................................................................................................................................................................
165.
Kerusakan membrane mukosa oral .........................................................................................................................................................................
166.
Resiko disfungsi neurovascular perifer ....................................................................................................................................................................
167.
Ketidakefektifan perlindungan .................................................................................................................................................................................
168.
Kerusakan integritas kulit ........................................................................................................................................................................................
169.
Resiko Kerusakan integritas kulit ............................................................................................................................................................................
170.
Resiko asfiksia ........................................................................................................................................................................................................
171.
Kerusakan integritas jaringan ..................................................................................................................................................................................
172.
Resiko trauma .........................................................................................................................................................................................................
173.
Resiko trauma vascular ...........................................................................................................................................................................................
174.
Menciderai diri .........................................................................................................................................................................................................
175.
Resiko Menciderai diri .............................................................................................................................................................................................
176.
Resiko bunuh diri .....................................................................................................................................................................................................
177.
Resiko perilaku kekerasan terhadap orang lain .......................................................................................................................................................
178.
Resiko perilaku kekerasan terhadap diri sendiri ......................................................................................................................................................
179.
Kontaminasi (00181) ......................................................................................................................................................................................... 387
180.
Risiko Kontaminasi (00180). .............................................................................................................................................................................. 392
181.
Risiko Keracunan (00037) ................................................................................................................................................................................. 395
182.
Respons Alergi Lateks (00041) ......................................................................................................................................................................... 396
183.
Risiko Respons Alergi Lateks (00042) ............................................................................................................................................................... 398
184.
Risiko Ketidakseimbangan Suhu Tubuh (OOQ05) ............................................................................................................................................. 399
185.
Hipertermia (00007) ........................................................................................................................................................................................... 400
186.
Hipotermia (00006) ............................................................................................................................................................................................ 401
187.
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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