daftar triple n

8/10/2019 Daftar Triple N

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ANSIETAS

NOC Label:

1. Anxiety Self-Control2. Coping

3. Anxiety level

4.

Acceptance : Health status5.

NIC Label:

1. Anxiety Reduction2. Coping Enhancement

3. Teaching : preoperative

4.

Emotional Support5. Crisis Intervention

6. Grief Work Facilitation

7.

DEFISIENSI PENGETAHUAN

NOC Label:

1. Knowledge: Disease Process

2. Knowledge : Health Behaviour

3. Knowledge : Disease Process4. Knowledge: Medication

5. Knowledge: Diet

6.

Pre procedure readiness7. Knowledge: health promotion

8. Knowledge: Parenting

9. Knowledge: Illness Care10.Knowledge : Personal Safety

NIC Label:

1. Teaching : Disease Process

2. Health Education

3. Teaching Prescribed Medication4. Behaviour Medication

5. Surgical preparation

6.

Learning Facilitation7.

DEFISIT PERAWATAN DIRI: MANDI, BERPAKAIAN, ELIMINASI, MAKAN,

NOC Label:

1. selfcare :bathing

2. self-care : hygiene3. Self-care :dressing

4. Self- care : toileting

5.

Self-care : Eating

NIC Label:

1. Bathing

2. Oral health maintenance3. Nail care

4. Self-care Assistance: Dressing/

Grooming5. Self-care Assistance: Toileting

6. Self-care Assistance: Feeding

DEPRIVASI TIDUR

NOC Label:

1. Sleep

2.

NIC Label:

1. Sleep Enhancement

DIARE

NOC Label:

1. Bowel Elimination

2. Fluid Balance

NIC Label:

1. Diarrhea Management

2.

DISFUNGSI SEKSUAL

NOC Label:

1. Sexual Functioning

NIC Label:

1. Sexual Counseling

GANGGUAN ELIMINASI URIN

NOC Label:1. Urinary Elimination

2. Kidney Function

NIC Label:1. Urinary elimination management

2. Hemodyalisis Therapi


2/10

3. Urinary Continence

4.

3. Urinary Retention Care

4. Urinary Catheterization

5. Pelvic Muscle Exercise

6. Medication Management7.

GANGGUAN CITRA TUBUHNOC Label:

1. Body image

2. Adaptation to Physical Disability

3. Self Esteem4.

NIC Label:1. Body Image Enhancement

2. Self Esteem Enhancement

3. Emotional Support4.

RESIKO/GANGGUAN KESEIMBANGAN ELEKTROLIT

NOC Label:

1. Electrolyte & Acid/ Base Balance2.

NIC Label:

1. Electrolyte Management: Hyperkalemia2. electrolyte management: Hyponatremia

3. Electrolyte Management:

GANGGUAN MENELANNOC Label:

1. Swallowing Status

2. Swallowing Status: Oral Phase

3. Swallowing Status: Esophageal Status

4. Aspiration prevention5. Swallowing status : Pharyngeal phase

6. Nutritional Status : Food & Fluid

Intake7.

NIC Label:1. Swallowing Theraphy

2. Aspiration precautions

3. Nutrition Management

GANGGUAN PERTUKARAN GAS

NOC Label:1. Respiratory status2. Respiratory Status : Gas Exchange

3. Vital Sign

4. respiratory status : airway patency5. respiratory status : ventilation

6. Tissue perfusion : peripheral

7.

NIC Label:1. Oxygen Therapy2. Airway Management

3. Energy Management

4. respiratory monitoring5. Airway suctioning

6. Chest Physiotherapy

7. Acid Base Management8. Vital sign monitoring

9. Acid base management: Respiratory

Acidosis

10.

GANGGUAN POLA TIDUR

NOC Label:

1. Sleep

2. Energy Conservation3.

NIC Label:

1. Sleep enhancement

2. Enviromental management: comfort3. Relaxation therapy

4.

GANGGUAN RASA NYAMAN


3/10

NOC Label:

1. Pain Level

2. Comfort Status: Physical

3. Comfort status: psychospiritual4. Discomfort level

5.

symptom control6. Comfort Status : Environment7.

NIC Label:

1. Pain Management

2. Environmental Management: Comfort

3. Pruritus Management4. Anxiety Reduction

5.

Distraction

GANGGUAN VENTILASI SPONTAN

NOC Label:1. Respiratory Status

2. Vital Signs

3. Respiratory status: ventilation

4. Respiratory status: gas exchange5.

NIC Label:1. Respiratory monitoring

2. Vital sign monitoring

3. Acid-Base Management: Respiratory

Acidosis4. Acid-Base Management

5. Mechanical Ventilation

6.

Infection Control7. Airway Suctioning8.

HAMBATAN INTERAKSI SOSIAL

NOC Label:1. Hearing Compensation Behavior

2. Agitation level

3.

NIC label:1. Communication Enhancement: Hearing

Deficit

2. Anxiety Reduction

3.

HAMBATAN KOMUNIKASI VERBAL

NOC Label:

1.

Communication: expressive

NIC Label:

1.

Communication enhancement: hearingdeficit

HAMBATAN MOBILITAS FISIK

NOC Label:

1. Mobility2. Body Positioning : Self-Initiated

3. Body positioning : Mobility

4. Ambulation5. Balance

6. Body Mechanics Performance

7.

NIC Label:

1. Exercise Therapy: Muscle Control2. Exercise promotion

3. Exercise Therapy: Join mobility

4. Exercise Therapy: balance5. Exercise therapy : ambulation

6.

HARGA DIRI RENDAH KRONIKNOC Label:

1. MotivationNIC Label:

1. Emotional Support

2. Coping Enhancement

3.

HARGA DIRI RENDAH SITUASIONAL

NOC Label: NIC Label:


4/10

1. Self-esteem

2. Abuse recovery : emotional

3. Stress level

4.

1. Self-esteem enhancement

2. Emotional support

3.

HYPERTHERMIA

NOC Label:1. Thermoregulation2. Vital sign

3. Hydration

NIC Label:1. Temperature Regulation2. Fever Treatment

3. Vital Sign Monitoring

4. NUTRITION MANAGEMENT5. INFECTION CONTROL

INKONTENSIA URINE REFLEKS

NOC Label:

1. Urinary elimination2.

NIC Label:

1. urinary elimination management2.

INTOLERANSI AKTIVITAS

NOC Label:1. Activity tolerance2. Fatigue Level

3. Energy Conservation

4. Respiratory status : ventilation

5. respiratory status : airway patency6.

NIC label:1. Activity therapy2. Energy Management

3. Teaching : Prescribe Activity/Exercise

4. Exercise Therapy : Strength Training

5.

KEKURANGAN VOLUME CAIRAN

NOC Label:1. Fluid Balance

2.

NIC Label:1. Fluid Management

2. Fluid Monitoring

3.

Hypovolemia Management4.

KELEBIHAN VOLUME CAIRAN

NOC Label:

1. Fluid Balance2.

Fluid overload severity

3. Weight: Body Mass

4. Hemodialisis Access

5. Electrolyte & Acid/Base Balance

6.

NIC Label:

1. Fluid management2.

Fluid Monitoring

3. Hemodialisis Therapy

4.

KELETIHAN

NOC Label:

1. Energy conservation2. Fatigue Level

3.

NIC Label:

1. energy management2. Sleep Enhancement

KERUSAKAN INTEGRITAS KULIT

NOC Label:

1. Tissue Integrity: Skin & Mucous

NIC Label:

1. Skin Care: Topical Treatment


5/10

Membrane

2. Infection Severity

3. Infection Severity: Newborn

4. Allergic Respond : Localized5. Wound Healing: Secondary intention

6.

Risk control7. Hemodialysis Access

2. Skin Surveillance

3. Medication Administration: Eye

4. Perineal Care

5. Pressure management6. Medication Management

7.

Foot Care8. Wound Care9. Wound Irrigation

10.Risk Identification

11.Self-Care Assistance : Bathing/Hygiene

KERUSAKAN MEMBRAN MUKOSA ORAL

NOC Label:

1. Oral hygiene

2. Tissue Integrity: Skin & mucousmembrane

3.

NIC Label:

1. Oral health restoration

2. Oral Health Maintenance3.

KESIAPAN MENINGKATKAN MANAJEMEN KESEHATAN DIRINOC Label:

1. Knowledge : Health BehaviorNIC Label:

1. Health System Guidance

KETAKUTAN

NOC Label:

1. Anxiety level2. Anxiety Self Control

NIC Label:

1. Anxiety reduction2. Coping Enhancement

KETERLAMBATAN PERTUMBUHAN DAN PERKEMBANGAN

NOC Label:1. Growth

2. Child Development : 4 Years

3.

Child Development : 6 Month4. Knowledge Parenting5. Child development : 2 month

6.

NIC Label:1. Nutrition Therapy

2. Development Enhancement : Child

3.

Development Care4. Teaching infant stimulation5. Nutrition Management

6. Teaching : Infant Nutrition

KETIDAKEFEKTIFAN BERSIHAN JALAN NAFAS

NOC Label:

1. Respiratory Status : Airway Patency

2. Allergic Response Localize

3. Mechanical Ventilation Response

(Adult)4. Asthma Self-Management

5.

Respiratory Status: Ventilation6.

NIC Label:

1. Airway Management

2. Oxygen Therapy

3. Chest Physiotherapy

4. Airway Suctioning5. Allergy Management

6.

Ventilation Assistance7. Temperature regulation:8. Vital sign monitoring

9. Asthma Management

10.Respiratory Monitoring11.Cough Enhancement:

12.

KETIDAKEFEKTIFAN MANAGEMENT REGIMENT TERAPEUTIK KELUARGA


6/10

NOC Label:

1. Knowledge: treatment procedure

2. Knowledge: treatment regimen

3. Family Coping4. family support during treatment

5.

Asthma Self-Management6.

NIC Label:

1. Cognitive Restructuring

2. Family Mobilization

3. Family Involvement Promotion4. Teaching : disease process

5.

KETIDAKEFEKTIFAN MANAJEMEN KESEHATAN DIRI

NOC Label:

1. Knowledge : Treatment Regimen2.

NIC Label:

1. Health Education2. Coping Enhancement

3. Anticipatory Guidance

4.

KETIDAKEFEKTIFAN PEMBERIAN ASI

NOC Label:

1. Breastfeeding Establishment : Infant

2.

Breastfeeding Maintenance3. Knowledge Breastfeeding

NIC Label:

1. Lactation counseling

2.

Breastfeeding Assistance3. Teaching : Infant nutrition

KETIDAKEFEKTIFAN PERFORMA PERAN

NOC Label:

1. Knowledge : Infant Care

2. Parenting : Infant/Toddler PhysicalSafety

3.

NIC Label:

1. Teaching : Infant Safety 0-3 Months

KETIDAKEFEKTIFAN PERFUSI JARINGAN PERIFER

NOC Label:

1. Tissue Perfusion : Peripheral

2.

NIC Label:

1. Circulatory Care: Arterial Insufficiency

2.

Circulatory Care: Mechanical AssistDevice

3. Vital Signs Monitoring

4. Hemodynamic Regulation

KETIDAKEFEKTIFAN POLA NAFAS

NOC Label:

1. Respiratory Status : Ventilation

2. Respiratory Status: Airway Patency

3. Vital Signs

4. Discomfort Level5. Aspiration Prevention

NIC Label:

1. Respiratory Monitoring

2. Vital Signs Monitoring

3. Airway Management

4. Pain Management5. Ventilation Assistance

6.

Oxygen Therapy

KETIDAKPATUHAN

NOC Label:

1. Knowledge: treatment regimen

2. Knowledge : disease process

NIC Label:

1. Health education

KETIDAKSEIMBANGAN NUTRISI KURANG DARI KEBUTUHAN TUBUH

NOC Label: NIC Label:


7/10


8/10

14.Fluid Overload Severity

15.Neurological Status: Peripheral

16.Blood Loss Severity

17.Energy conservation18.Fatigue Level

19.

Endurance20.

14.Acid-Base Management

15.Acid Base Monitoring

16.Electrolyte management

17.Electrolyte monitoring18.Fluid Management

19.

Fluid Monitoring20.Neurology Monitoring21.Bleeding reduction

22.Positioning

23.Surveillance24.nutrition management

25.Invasive Hemodynamic Monitoring

26.Cardiac care: Rehabilitative

27.Circulatory Care: Arterial Insufficiency28.Nutrition Management

29.

PERFUSI JARINGAN SEREBRAL TIDAK EFEKTIFNOC Label:

1. Acute Confusion Level

2. Tissue Perfusion: Cerebral

3.

NIC Label:1. Intracranial Pressure (ICP) Monitoring

2. Neurogical Monitoring

3. Vital Sign Monitoring

PK ANEMIA

NOC Label:

1. Blood Transfusion Reaction

2.

NIC Label:

1. Blood Products Administration

2.

PK HIPERKALEMIA

NOC Label:

1.

Electrolyte And Acid/Base Balance2.

NIC Label:

1.

Electrolyte Management: Hyperkalemia

RISIKO ASPIRASI

NOC Label:

1. Aspiration Prevention2. Swallowing Status

3.

NIC Label:

1. Aspiration Precautions2.

RISIKO CEDERA

NOC Label:

1. Fall Prevention behavior2. neurologic status: consciousness

3.

Risk Control4. Risk Detection5. Personal Safety Behavior

6. Aspiration Prevention

7. Physical Injury Severity8. Sensory function : vision

9. Coordinated Movement

10.Thermoregulation

NIC Label:

1. Environmental Management2. Neurologic monitoring

3.

Fluid management4. Behavior Modification5. Risk Identification

6. Aspiration Precautions

7. Fall Prevention8. Infection Control: Intraoperative

9. Thermoregulation : Intraoperative

10.Positioning : Intraoperative


9/10

11.Tissue perfusion : Peripheral

12.Tissue perfusion: Cellular

13.Circulation Status

14.Mobility15.Balance

16.

NOC Label : Fall Occurence

11.Surgical Precaution

12.circulatory precaution

13.Environmental Management : Safety

14.

RESIKO INFEKSI/PK INFEKSI

NOC Label:

1. Risk control: Infectious Process

2. Risk control3. Tissue Integrity: skin and mucous

membrane

4. Wound Healing : Primary Intension

5. Knowledge: Infection Management6. Risk Detection

7. Infection Severity

8.

Immune Status9.

NIC Label:

1. Infection control

2. Infection Protection3. Wound Care

4. Tube Care : Chest

5. Teaching: Disease Process

6. Medication Prescribing

RESIKO KETIDAKSTABILAN GULA DARAH

NOC Label:

1. Blood Glucose Level2. Nutritional Status

3. Knowledge : diet

4.

NIC Label:

1. Nutritional Management2. Nutritional Monitoring

3. Health education :

RISIKO PERTUMBUHAN TIDAK PROPORSIONAL

NOC Label:

1. Growth

2.

Appetite3.

NIC Label:

1. Lactation Counseling

2.

Bottle Feeding

RISIKO SYOK

NOC Label:

1. Vital Sign2. Circulation status

3.

NIC Label:

1. Shock Prevention2.

SINDROM DISUSE

NOC Label:

1. Coordinated Movement2. Join Movement

NIC Label:

1. Exercise therapy Joint Mobility

RETENSI URINE

NOC Label:1. Urinary elimination

2.

NIC Label:1. Urinary elimination management

2. Urinary Retention Care

RISIKO JATUH

NOC Label:

1. Fall Prevention Behavior

NIC Label:

1. Fall Prevention


10/10

2.

RISIKO KETIDAKEFEKTIFAN PERFUSI JARINGAN OTAK

NOC Label:

1. Tissue Perfusion: Cerebral2.

NIC Label:

1. Cerebral Perfusion Promotion

PK ASIDOSISNOC Label:

1. Electrolyte & Acid/Base Balance

NIC Label:1. Acid Base Monitoring

2. ACID BASE MANAGEMENT

PK/RISIKO PERDARAHAN

NOC Label:

1. Blood coagulation

2. Blood Loss Severity

NIC Label:1. Bleeding Reduction : Nasal

2. Bleeding Precaution

3.

PK UREMIA

NOC Label:

1.

Systemic Toxin Clearance : Dialysis2. Kidney Function

3. Electrolyte and Acid/Base Balance

4.

NIC Label:

1.

Hemodialysis Therapy2. Electrolyte Management :

Hyperkalemia

3. Acid-Base Management Metabolic

Acidosis

4. Peritoneal Dialysis Therapy5.

KONTAMINASI

NOC Label:

1. Risk Control: Infectious process

NIC Label:

1. Communicable disease management2. Infection Control

daftar triple n

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