Kasus Nic Noc

8/21/2019 Kasus Nic Noc

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KASUS

Riwayat masuk RS

n Klien Ny. SM ( 43 th) , masuk RS dengan keluhan sulit defekasi dan feses berdarah dan bau

busuk, perut terasa penuh dan mual.

n Dx. Medis: Ca Rectosigmoid Kondisi klien saat ini

n Post laparotomi dan colostomi hari 2

n Luka operasi kering, pus (-)

n Produk stoma lunak,warna kecoklatan, bau khas , perdarahan (-)

n Mengeluh nyeri pd daerah operasi dan tidak tahu cara merawat stoma

n Posisi stoma 2,5 cm dari luka laparotomi

Tanda-tanda vital:

n TD: 120/70 mmHg

n N : 84 x/mnt

n S : 37,2 C

n P : 20 x/mnt Terapi analgetik 3 x 100 mg (IM) antibiotika 2 x 1 gr ( IV )

n Lab: Hb: 9,8 ; Alb: 2,9

n Klien tampak lemah, pucat dan bibir kering

n Terpasang infus D5% : 20 tetes/mntn Skema infus: D5% : RL = 2 : 2

n Klien mengeluh tidak nafsu makan dan hanya menghabiskan 3 sdk makan bubur & sayur

n BB sebelum sakit: 62 kg

n BB saat ini : 50 kg Setelah dilakukan pengkajian keperawatan pada Ny.SM maka dapat ditetapkan

Fuctional Health Patterns yang sesuai dg Ny.SM adalah:

n Nutrition - Metabolic

n Cognitive - Perceptual

n Coping /stress/tolerance

n Elimination


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n SelfPerception/ Self - Concept

n Health PerceptionHealth Management Berdasarkan data yang diperoleh, ditetapkan berbagai

masalah keperawatan yang sesuai dengan kondisi klien.

Masalah Keperawatan NANDA yg sesuai dg Ny.SM adalah:

n DeficientKnowledge : Ostomy Care

n Acute Pain

n Disturbed Body image

n Risk for infection

n Imbalance Nutrition : less than body requirements

n Fatigue

n dll

Penentuan Masalah keperawatan dapat mengalami kesulitan/hambatan dan keragu-raguan perawat

terutama jika data yang diperoleh sangat minimal dan memiliki karakteristik yang sama dengan

diagnosis keperawatan lain, maka Domain pada NANDA dapat digunakan sebagai alat bantu dalam

penentuan Diagnosis Keperawatan.

Diagnosis Keperawatan NANDA, NOC dan NIC pd Ny.SM

Knowledge defisit : Ostomy Care(Kurang pengetahuan tentang perawatan kolostomi )

definisi:mengungkapkan secara verbal masalah yg dihadapi dan menunjukkan ekspresi

ambivalenEtiologi /faktor yg berhubungan:lack of exposure( belum pernah mengalami kolostomi) dan

tidak terbiasa dgn sumber informasi Perawat menentukan NOC yang sesuai dengan kondisi klien ,

dari beberapa NOC yang ada pada diagnosis keperawatan Knowledge defisit : Ostomy Care.

Ditetapkan ada 2 NOC yang sesuai dengan klien yaitu:

NOC :

Knowledge: Treatment Procedure (Colostomy Care)(Pengetahuan : Prosedur perawatan

kolostomi

Pengetahuan : Penanganan penyakit (Knowledge:treatment Regimen)
http://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Acute%20Pain.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Acute%20Pain.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Disturbed%20Body%20image.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Disturbed%20Body%20image.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Disturbed%20Body%20image.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Acute%20Pain.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppthttp://nursing-care-indonesia.com/SIVITAS%20UGM/My%20Documents/Deficient%20Knowledge.ppt


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Dalam penulisan NOC pada rekam asuhan keperawatan hendaknya dituliskan secara lengkap dengan

mencantumkan Subyek, Predikat, dan obyek ,keterangan waktu dan skala indikator.

NOC 1: Pasien mampu mengetahui Prosedur perawatan kolostomi (Treatment Procedure) dalam 3

hari perawatan

Indikator :

pasien mampu :

Menjelaskan langkah2 prosedur perawatan kolostomi

Menjelaskan alat2 yg dibutuhkan

Menjelaskan berbagai tindakan yg dilakukan utk mencegah/mengatasi komplikasi

Mampu melakukan perawatan kolostomiSkala indikator dapat dilihat pada panduan NOC dan

penentuan skala dapat disesuaikan dengan target waktu dan kondisi klien atau berdasarkanevidence /hasil penelitian

NOC 2:

Pengetahuan : Penanganan penyakit (treatment Regimen)Indikator:

Menjelaskan diet yg dianjurkan

- Memilih makanan yg sesuai dgn anjuran diet

- Menjelaskan aktifitas yg dianjurkan

- Mampu mengontrol/monitor diri sendiri

- Menjelaskan cara merawat diri sendiri pd kondisi darurat

Penentuan NIC berdasarkan masing-masing NOC

NIC yang tersedia harus dipilih dan disesuaikan dengan kebutuhan klien dalam mencapai

tujuan/mengatasi masalah. Beberapa sumber menyebutkan bahwa tindakan-tindakan yang ada pada

NIC minimal 5 tindakan (aktivitas) yang dapat digunakan untuk mengatasi masalah keperawatan klien

Untuk mencapai NOC 1:

Pengetahuan : Prosedur perawatan kolostomiDiperlukan NIC :

n Perawatan Kolostomi

n Pemantauan kulit NICOstomy CareActivities (NIC3 pg. 483)

Mark the skin for stoma placement


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Instruct patient/significant other in the use of ileostomy/colostomy equipment

Assist patient in providing ostomy /ileostomy self-care

Have patient/significant other demonstrate use of equipment

Apply appropriately-fitting ostomy appliance, as needed

Monitor for incision/stoma healing

Encourage patient/significantother to express feelings and concerns about changes in body

image

Encourage visitation to client by persons from such support groups as ileostomy/colostomy

clubs

Irrigate colostomy, as appropriate

Assist patient in obtaining ostomy/ileostomy equipment

Instruct patient on mechanisms to reduce odor

Instruct patient/significant other in appropriate diet and expected changes in elimination

function

Provide and assistance, while client develops skill in caring for stoma/surrounding tissue

Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment

Change/empty ostomy bag, as appropriate

Encourage participation in ostomy support groups after hospital discharge

NICSkin Surveillance Activities (NIC 3 pg. 601)

Inspect condition of surgical incision, as appropriate

Observe extremities for color, warmth, swelling, pulses, texture, edema, and ulcerations

Inspect skin and mucous membranes for redness, extreme warmth, or drainage

Monitor skin for areas of redness and breakdown

Monitor for sources of pressure and friction

Monitor for infection, especially of edematous areas

Monitor skin for rashes and abrasions


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Monitor skin for excessive dryness and moistness

Inspect clothing for tightness

Monitor skin color Monitor skin temperature Note skin or mucous membrane changes

Institute measures to prevent further deterioration, as needed

Instruct family member/caregiver about signs f skin breakdown, as appropriate

NOC 2:

Pengetahuan : Penanganan penyakiT(treatment Regimen)

NIC:

n Teaching Prescribed Diet

n Teaching Prescribed Activity /exercise NICTeaching: Prescribed Diet (NIC3 pg., 649)

Appraise the patients current level of knowledge about prescribed diet

Determine the patients/significant others feelings/attitude toward prescribed diet and

expected degree of dietary compliance

Instruct the patient on the proper name of the prescribed diet

Explain the purpose of the diet Inform the patient about how long the diet should be followed

Instruct the patient about how to keep a food diary, as appropriate

Instruct the patient on allowed and prohibited foods

Inform the patient of possible drug/food interactions, as appropriate

Assist the patient to accommodate food preferences into theprescribed diet

Assist the patient in substituting ingredients to conform favorite recipes to the prescribed

diet

Instruct the patient about how to read labels and select appropriate foods

Observe the patients selection of foods appropriate to prescribed diet

Instruct the patient about how to plan appropriate meals

Provide written meal plans, as appropriate

Recommend a cookbook that includes recipes consistent with the diet, as appropriate

Reinforce information provided by other health care team members, as appropriate


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Refer patient to dietitian/nutritionist, as appropriate Include the family/significant others, as

appropriate

NICTeaching: Prescribed Activity/Exercise(NIC 3, pg.648)

Appraise the patients current level of exercise and knowledge ofprescribed activity/exercise

Inform the patient of the purpose for, and the benefits of, the prescribed activity/exercise

Instruct the patient how to perform the prescribed activity/exercise

Instruct the patient how to monitor tolerance of the activity/exercise

Instruct the patient how to keep an exercise diary, as appropriate

Inform the patient what activities are appropriate based on physical condition

Instruct the patient how to safely progress activity/exercise

Caution the patient on the dangers of overestimating capabilities, as appropriate

Warn the patient of the effects of extreme heat and cold, as appropriate

Instruct the patient on methods to conserve energy, as appropriate

Instruct the patient how to warm up and cool down before and after activity/exercise and the

importance of doing so, as appropriate

Instruct the patient on good posture and body mechanics, as appropriate

Observe the patient perform the prescribed activity/exercise

Provide information on available assistive devices that may be used to facilitate performance

of required skill, as appropriate

Instruct the patient on the assembly, use, and maintenance of assistive devices , as

appropriate

Assist the patient to incorporate activity/exercise regimen into daily routine/life style

Assist the patient to properly alternate periods of rest and activity

Refer the patient to physical therapist/occupational therapist/exercise physiologist, as

appropriate

Reinforce information provided by other health care team members, as appropriate


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Include the family/significant others, as appropriate

Provide information on available community resources/support groups to increase the

patients compliance with activity/exercise, as appropriate

Refer the patient to a rehabilitation center, as appropriate

DAFTAR PUSTAKA

1. Black. J.M.; Jacob, E.M. (1993). Luckman & Sorensens : Medical Surgical Nursing: a

Psychophysiologic approach. 3rded. Philadelphia W.B. Saunder Company

2. Earnest, Vicki Vine. (1993). Clinical skills in Nursing Practice. (2 nd). Philadelphia. J.B. Lippincott

Company.

3.Flue, Jenice R., Nowlis, Elizabeth A., Bentz, Patricia M.(1996). Moduls for basic Nursing Skills.

6thed.Philadelphia: Llppincott.

4.Hampton, Beverly G. and Ruth A. Bryant . (1992). Ostomies and Divertions. Nursing

Management. Philadelphia. Mosby - Year Book, Inc.

5. NANDA International.(2005). Nursing Diagnoses: Definitions and Classification 2005

2006.Philadelphia: NANDA International.

6. Nettina, Sandra M. (1996). The Lippincott Manual of Nursing Practice.6th

ed. Philadelphia:

Lippincott.

7. Potter. PA; Perry,A.G. (1993). Fundamental of Nursing : Concepts, Process and Practical. 3rded. St.

Louis: Mosby Year Book

8. Smeltzer, Suzanne C. and Brenda G. Bare.(1996)Brunner and Suddarths Textbook of Medical

Surgical Nursing.LippincotRaven Publishers,Philadelphia.

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