ARIF RESI: Standar Diagnosa Keperawatan

Standardize Nursing Diagnosis Language

Oleh : Irman Somantri

Saat Janji Kepaniteraan bagi mahasiswa Fakultas Keperawatan angkatan XX, Dekan Fkep Unpad (H. Mamat Lukman, SKM. S.Kp. MSi) menyatakan bahwa : untuk meningkatkan salah satu aspek profesionalisme keperawatan adalah dengan adanya dan penggunaan standar keperawatan yang baku. Saat ini calon perawat dan perawat senior masih merasa ragu dalam menentukan diagnosa keperawata, dikarenakan penggunaan standar yang masih minim. dalam sambutannya pun beliau mengatakan “ke depan mahasiswa keperawatan sebaiknya menyiapkan di dalam kantongnya berupa buku standar diagnosa keperawatan, bukan hanya alat-alat pemeriksaan fisik saja”.

Di bawah ini merupakan standar diagnosa keperawatan berdasar “Nursing Diagnosis and 11 Gordon’s Functional Health Patterns”
Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

11 Gordon’s Functional Health Patterns

Health Perception Health Management Pattern
Nutritional Metabolic Pattern
Elimination Pattern
Activity Exercise Pattern
Sleep Rest Pattern
Cognitive-Perceptual Pattern
Self-Perception-Self-Concept Pattern
Role-Relationship Pattern
Sexuality-Reproductive
Coping-Stress Tolerance Pattern
Value-Belief Pattern

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use.

Contamination
Disturbed energy field
Effective therapeutic regimen management
Health-seeking behaviors (specify)
Ineffective community therapeutic regimen management
Ineffective family therapeutic regimen management
Ineffective health maintenance
Ineffective protection
Ineffective therapeutic regimen management
Noncompliance (ineffective Adherence)
Readiness for enhanced immunization status
Readiness for enhanced therapeutic regimen management
Risk for contamination
Risk for infection
Risk for injury
Risk for perioperative positioning injury
Risk for poisoning
Risk for sudden infant death syndrome
Risk for suffocation
Risk for trauma
Risk-prone health behavior

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

Adult failure to thrive
Deficient fluid volume: [isotonic]
[Deficient fluid volume: hyper/hypotonic]
Effective breastfeeding [Learning Need]
Excess fluid volume
Hyperthermia
Hypothermia
Imbalanced nutrition: more than body requirements
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: risk for more than body requirements
Impaired dentition
Impaired oral mucous membrane
Impaired skin integrity
Impaired swallowing
Impaired tissue integrity
Ineffective breastfeeding
Ineffective infant feeding pattern
Ineffective thermoregulation
Interrupted breastfeeding
Latex allergy response
Nausea
Readiness for enhanced fluid balance
Readiness for enhanced nutrition
Risk for aspiration
Risk for deficient fluid volume
Risk for imbalanced fluid volume
Risk for imbalanced body temperature
Risk for impaired liver function
Risk for impaired skin integrity
Risk for latex allergy response
Risk for unstable blood glucose

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin).

Bowel incontinence
Constipation
Diarrhea
Functional urinary incontinence
Impaired urinary elimination
Overflow urinary incontinence
Perceived constipation
Readiness for enhanced urinary elimination,
Reflex urinary incontinence
Risk for constipation
Risk for urge urinary incontinence
Stress urinary incontinence
Total urinary incontinence
Urge urinary incontinence
[acute/chronic] Urinary retention

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

Activity intolerance
Autonomic dysreflexia
Decreased cardiac output
Decreased intracranial adaptive capacity
Deficient diversonal activity
Delayed growth and development
Delayed surgical recovery
Disorganized infant behavior
Dysfunctional ventilatory weaning response
Fatigue
Impaired spontaneous ventilation
Impaired bed mobility
Impaired gas exchange
Impaired home maintenance
Impaired physical mobility
Impaired transfer ability
Impaired walking
Impaired wheelchair mobility
Ineffective airway clearance
Ineffective breathing pattern
Ineffective tissue perfusion
Readiness for enhanced organized infant behavior
Readiness for enhanced self care
Risk for delayed development
Risk for disorganized infant behavior
Risk for disproportionate growth
Risk for activity intolerance
Risk for autonomic dysreflexia
Risk for disuse syndrome
Sedentary lifestyle
Self-care deficit
Wandering

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input.

Acute confusion
Acute pain
Chronic confusion
Chronic pain
Decisional conflict
Deficient knowledge
Disturbed sensory perception
Disturbed thought processes
Impaired environmental interpretation syndrome
Impaired memory
Readiness for enhanced comfort
Readiness for enhanced decision making
Readiness for enhanced knowledge
Risk for acute confusion
Unilateral neglect

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation.

Insomnia
Readiness for enhanced sleep
Sleep deprivation

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth.

Anxiety
disturbed Body image
Chronic low self-esteem
Death anxiety
Disturbed personal identity
Fear
Hopelessness
Powerlessness
Readiness for enhanced hope
Readiness for enhanced power
Readiness for enhanced self-concept
Risk for compromised human dignity
Risk for loneliness
Risk for powerlessness
Risk for situational low self-esteem
Risk for [/actual] other-directed violence
Risk for [actual/] self-directed violence
Situational low self-esteem

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships.

Caregiver role strain
Chronic sorrow
Complicated grieving
Dysfunctional family processes: alcoholism (substance abuse)
Grieving
Impaired social interaction
Impaired verbal communication
Ineffective role performance
Interrupted family processes
Parental role conflict
Readiness for enhanced communication
Readiness for enhanced family processes
Readiness for enhanced parenting
Relocation stress syndrome
Risk for caregiver role strain
Risk for complicated grieving
Risk for impaired parent/infant/child attachment
Risk for relocation stress syndrome
Social isolation

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

Ineffective sexuality patterns
Rape-trauma syndrome
Sexual dysfunction

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies.