[Book Review] NANDA International Nursing Diagnoses 2015-2017 : Buku wajib perawat

Diagnosa keperawatan adalah hal yang essensial dalam Nursing Care Plan atau Asuhan Keperawatan. Sebagai mahasiswa Keperawatan maupun Perawat klinis pasti tak asing lagi dengan cara menegakkan diagnosa.  

Banyak jalan menuju ke Roma, adalah istilh tepat menggambarkan penegakkan diagnosa keperawatan. Semasa belajar seringkali mahasiswa mengalami kesalahan adalah hal yang wajar. Asal tidak melupakannya dalam pelaksanaan praktek kepeawatan yang sesungguhnya.

PERAWAT, boleh mendiagnosa dan WAJIB menegakkan diagnosa, yaitu DIAGNOSA KEPERAWATAN sesuai profesi dan keilmuannya .

Berbagai buku diagnosa keperawatan yang beredar dan populer diantaranya Diagnosa Keperawatan yang disusun oleh Marilyn . E. Doengoes, Lynda Juall Carpenitto dan NANDA. 

Buku diagnosa terbitan Doengoes memberikan kemudahan pembelajaran karena disusun berdasarkan diagnosa keperawatan yang sudah dirumuskan. Sementara Carpenitto mendeskripsikan buku yang disusunnya lebih kompleks berdasarkan keluhan (tanda dan gejala) pasien. NANDA International saat ini menjadi acuan yang lebih populer sebagai kesepakatan bersama.

NANDA sendiri sebenarnya singkatan dari 'The North American Nursing Diagnosis Association'. Sebuah organisasi di Amerika Utara sebelum tahun 2002. Kemudian NANDA berkembang menjadi NANDA Internasional. Nama NANDA bukan lagi mengacu pada organisasi di Amerika Utara tetapi sudah mendunia (Internasional). Pemilihan nama NANDA tidak diubah karena mudah dikenal dan merupakan 'Branding' yang tidak dapat dipisahkan dari kegiatan Diagnosa Keperawatan dan berubah menjadi nama menjadi 'NANDA-I'.

'NURSING DIAGNOSE IS OUR WORD'

Diagnosa Keperawatan adalah penilaian profesional perawat mengenai pasiennya. Diagnosa keperawatan menggambarkan apa yang kita ketahui mengenai orang yang kita rawat. NANDA-I memiliki tujuan mengembangkan, memperbaiki dan mempromosikan terminologi yang secara akurat mencerminkan penilaian klinis perawat. Hal ini bisa dilihat dari proses refisi yang berkala pada beberapa tahun setiap edisinya. Edisi ke 10 memiliki rentang waktu penggunaan 2015-2017. 

Proses renewal  merupakan komitmen NANDA-I untuk meningkatkan kualitas asuhan keperawatan dan peningkatan keselamatan pasien melalui praktek berbasis bukti (Evidence Base). Edisi terbaru dari NANDA International Nursing Diagnoses 2015-2017 memiliki 235 diagnosa, termasuk 25 diagnosa baru dan 13 revisi. Berikut adalah daftar domain, kelas dan diagnosa yang ada di dalam NANDA-I

Domain 1: Health Promotion

Class 1. Health awareness

Deficient diversional activity – 00097

Sedentary lifestyle – 00168

Class 2. Health management

Frail elderly syndrome – 00257

Risk for frail elderly syndrome – 00231

Deficient community health – 00215

Risk-prone health behavior – 00188

Ineffective health maintenance – 00099

Ineffective health management – 00078

Readiness for enhanced health management – 00162

Ineffective family health management – 00080

Noncompliance – 00079

Ineffective protection – 00043

Domain 2: Nutrition

Class 1. Ingestion

Insufficient breast milk – 00216

Ineffective breastfeeding – 00104

Interrupted breastfeeding – 00105

Readiness for enhanced breastfeeding – 00106

Ineffective infant feeding pattern – 00107

Imbalanced nutrition: less than body

requirements – 00002

Readiness for enhanced nutrition – 00163

Obesity – 00232

Overweight – 00233

Risk for overweight – 00234

Impaired swallowing – 00103

Class 2. Digestion

None at present time

Class 3. Absorption

None at present time

Class 4. Metabolism

Risk for unstable blood glucose level – 00179

Neonatal jaundice – 00194

Risk for neonatal jaundice – 00230

Risk for impaired liver function – 00178

Class 5. Hydration

Risk for electrolyte imbalance – 00195

Readiness for enhanced fluid balance – 00160

Deficient fluid volume – 00027

Risk for deficient fluid volume – 00028

Excess fluid volume – 00026

Risk for imbalanced fluid volume – 00025 

Domain 3: Elimination and Exchange

Class 1. Urinary function

Impaired urinary elimination – 00016

Readiness for enhanced urinary

elimination – 00166

Functional urinary incontinence – 00020

Overflow urinary incontinence – 00176

Reflex urinary incontinence – 00018

Stress urinary incontinence – 00017

Urge urinary incontinence – 00019

Risk for urge urinary incontinence – 00022

Urinary retention – 00023

Class 2. Gastrointestinal function

Constipation – 00011

Risk for constipation – 00015

Chronic functional constipation – 00235

Risk for chronic functional constipation – 00236

Perceived constipation – 00012

Diarrhea – 00013

Dysfunctional gastrointestinal motility – 00196

Risk for dysfunctional gastrointestinal

motility – 00197

Bowel incontinence – 00014

Class 3. Integumentary function

None at this time

Class 4. Respiratory function

Impaired gas exchange – 00030

Domain 4: Activity/Rest

Class 1. Sleep/rest

Insomnia – 00095

Sleep deprivation – 00096

Readiness for enhanced sleep – 00165

Disturbed sleep pattern – 00198

Class 2. Activity/exercise

Risk for disuse syndrome – 00040

Impaired bed mobility – 00091

Impaired physical mobility – 00085

Impaired wheelchair mobility – 00089

Impaired sitting – 00237

Impaired standing – 00238

Impaired transfer ability – 00090

Impaired walking – 00088

Class 3. Energy balance

Fatigue – 00093

Wandering – 00154

Class 4. Cardiovascular/pulmonary responses

Activity intolerance – 00092

Risk for activity intolerance – 00094

Ineffective breathing pattern – 00032

Decreased cardiac output – 00029

Risk for decreased cardiac output – 00240

Risk for impaired cardiovascular function – 00239

Risk for ineffective gastrointestinal

perfusion – 00202

Risk for ineffective renal perfusion – 00203

Impaired spontaneous ventilation – 00033

Risk for decreased cardiac tissue perfusion – 00200

Risk for ineffective cerebral tissue

perfusion – 00201

Ineffective peripheral tissue perfusion – 00204

Risk for ineffective peripheral tissue

perfusion – 00228

Dysfunctional ventilatory weaning

response – 00034

Class 5. Self-care

Impaired home maintenance – 00098

Bathing self-care deficit – 00108

Dressing self-care deficit – 00109

Feeding self-care deficit – 00102

Toileting self-care deficit – 00110

Readiness for enhanced self-care – 00182

Self-neglect – 00193

Domain 5: Perception/Cognition

Class 1. Attention

Unilateral neglect – 00123

Class 2. Orientation

None at this time

Class 3. Sensation/perception

None at this time

Class 4. Cognition

Acute confusion – 00128

Risk for acute confusion – 00173

Chronic confusion – 00129

Labile emotional control – 00251

Ineffective impulse control – 00222

Deficient knowledge – 00126

Readiness for enhanced knowledge – 00161

Impaired memory – 00131

Class 5. Communication

Readiness for enhanced communication – 00157

Impaired verbal communication – 00051

Domain 6: Self-Perception

Class 1. Self-concept

Readiness for enhanced hope – 00185

Hopelessness – 00124

Risk for compromised human dignity – 00174

Disturbed personal identity – 00121

Risk for disturbed personal identity – 00225

Readiness for enhanced self-concept – 00167

Class 2. Self-esteem

Chronic low self-esteem – 00119

Risk for chronic low self-esteem – 00224

Situational low self-esteem – 00120

Risk for situational low self-esteem – 00153

Class 3. Body image

Disturbed body image – 00118

Domain 7: Role Relationships

Class 1. Caregiving roles

Caregiver role strain – 00061

Risk for caregiver role strain – 00062

Impaired parenting – 00056

Readiness for enhanced parenting – 00164

Risk for impaired parenting – 00057

Class 2. Family relationships

Risk for impaired attachment – 00058

Dysfunctional family processes – 00063

Interrupted family processes – 00060

Readiness for enhanced family processes – 00159

Class 3. Role performance

Ineffective relationship – 00223

Readiness for enhanced relationship – 00207

Risk for ineffective relationship – 00229

Parental role conflict – 00064

Ineffective role performance – 00055

Impaired social interaction – 00052

Domain 8: Sexuality

Class 1. Sexual identity

None at present time

Class 2. Sexual function

Sexual dysfunction – 00059

Ineffective sexuality pattern – 00065

Class 3. Reproduction

Ineffective childbearing process – 00221

Readiness for enhanced childbearing process – 00208

Risk for ineffective childbearing process – 00227

Risk for disturbed maternal–fetal dyad – 00209

Domain 9: Coping/Stress Tolerance

Class 1. Post-trauma responses

Post-trauma syndrome – 00141

Risk for post-trauma syndrome – 00145

Rape-trauma syndrome – 00142

Relocation stress syndrome – 00114

Risk for relocation stress syndrome – 00149

Class 2. Coping responses

Ineffective activity planning – 00199

Risk for ineffective activity planning – 00226

Anxiety – 00146

Defensive coping – 00071

Ineffective coping – 00069

Readiness for enhanced coping – 00158

Ineffective community coping – 00077

Readiness for enhanced community coping – 00076

Compromised family coping – 00074

Disabled family coping – 00073

Readiness for enhanced family coping – 00075

Death anxiety – 00147

Ineffective denial – 00072

Fear – 00148

Grieving – 00136

Complicated grieving – 00135

Risk for complicated grieving – 00172

Impaired mood regulation – 00241

Readiness for enhanced power – 00187

Powerlessness – 00125

Risk for powerlessness – 00152

Impaired resilience – 00210

Readiness for enhanced resilience – 00212

Risk for impaired resilience – 00211

Chronic sorrow – 00137

Stress overload – 00177

Class 3. Neurobehavioral stress

Decreased intracranial adaptive capacity – 00049

Autonomic dysreflexia – 00009

Risk for autonomic dysreflexia – 00010

Disorganized infant behavior – 00116

Readiness for enhanced organized infant behavior – 00117

Risk for disorganized infant behavior – 00115

Domain 10: Life Principles

Class 1. Values

None at this time

Class 2. Beliefs

Readiness for enhanced spiritual well-being – 00068

Class 3. Value/belief/action congruence

Readiness for enhanced decision-making – 00184

Decisional conflict – 00083

Impaired emancipated decision-making – 00242

Readiness for enhanced emancipated decision-making – 00243

Risk for impaired emancipated decision-making – 00244

Moral distress – 00175

Impaired religiosity – 00169

Readiness for enhanced religiosity – 00171

Risk for impaired religiosity – 00170

Spiritual distress – 00066

Risk for spiritual distress – 00067

Domain 11: Safety/Protection

Class 1. Infection

Risk for infection – 00004

Class 2. Physical injury

Ineffective airway clearance – 00031

Risk for aspiration – 00039

Risk for bleeding – 00206

Risk for dry eye – 00219

Risk for falls – 00155

Risk for injury – 00035

Risk for corneal injury – 00245

Risk for perioperative positioning injury – 00087

Risk for thermal injury – 00220

Risk for urinary tract injury – 00250

Impaired dentition – 00048

Impaired oral mucous membrane – 00045

Risk for impaired oral mucous membrane – 00247

Risk for peripheral neurovascular

dysfunction – 00086

Risk for pressure ulcer – 00249

Risk for shock – 00205

Impaired skin integrity – 00046

Risk for impaired skin integrity – 00047

Risk for sudden infant death syndrome – 00156

Risk for suffocation – 00036

Delayed surgical recovery – 00100

Risk for delayed surgical recovery – 00246

Impaired tissue integrity – 00044

Risk for impaired tissue integrity – 00248

Risk for trauma – 00038

Risk for vascular trauma – 00213

Class 3. Violence

Risk for other-directed violence – 00138

Risk for self-directed violence – 00140

Self-mutilation – 00151

Risk for self-mutilation – 00139

Risk for suicide – 00150

Class 4. Environmental hazards

Contamination – 00181

Risk for contamination – 00180

Risk for poisoning – 00037

Class 5. Defensive processes

Risk for adverse reaction to iodinated

contrast media – 00218

Risk for allergy response – 00217

Latex allergy response – 00041

Risk for latex allergy response – 00042

Class 6. Thermoregulation

Risk for imbalanced body temperature – 00005

Hyperthermia – 00007

Hypothermia – 00006

Risk for hypothermia – 00253

Risk for perioperative hypothermia – 00254

Ineffective thermoregulation – 00008

Domain 12: Comfort

Class 1. Physical comfort

Impaired comfort – 00214

Readiness for enhanced comfort – 00183

Nausea – 00134

Acute pain – 00132

Chronic pain – 00133

Labor pain – 00256

Chronic pain syndrome – 00255

Class 2. Environmental comfort

Impaired comfort – 00214

Readiness for enhanced comfort – 00183

Class 3. Social comfort

Impaired comfort – 00214

Readiness for enhanced comfort – 00183

Risk for loneliness – 00054

Social isolation – 00053

Domain 13: Growth/Development

Class 1. Growth

Risk for disproportionate growth – 00113

Class 2. Development

Risk for delayed development – 00112 

Penggunaan NANDA-I sangat maudah dengan merunut dari Domain, kelas dan diagnosa. Tentu saja penggunaannya mutlak membutuhkan latihan ketrampilan. Terutama dalam memahami keterkaitan data temuan dengan definisi dan mengaitkannya pada faktor resiko dari sebuah diagnosa.

Kode taksonomy pada tiap diagnosa bukan hanya untuk kerapian semata, namun dapat digunakan sebagai koding entry otomatis dalam komputerisasi asuhan keperawatan. Kemudahan ini akan mengurangi jumlah waktu yang dihabiskan perawat untuk mencatat sehingga lebih fokus memberikan Asuhan Keperawatan. 

Jadi, sudahkah anda menggunakan NANDA International Nursing Diagnoses 2015-2017 saat ini?