JENIS DAN KOMPONEN DIAGNOSIS KEPERAWATAN

Didalam buku Standar Diagnosis Keperawatan Indonesia (SDKI) jenis diagnosis dibagi menjadi dua yaitu diagnosis negatif dan diagnosis positif. Diagnosa negatif menunjukan bahwa klien dalam kondisi sakit atau berisiko mengalami sakit sehingga penegakan diagnosis ini akan mengarah kepada pemberian intervensi keperawatan yang bersifat penyembuhan, pemulihan dan pencegahan. Diagnosis ini terdiri dari diagnosis aktual dan risiko tinggi. Diagnosis positif menunjukan bahwa klien dalam kondisi sehat dan dapat mencapai kondisi yang lebih sehat dan optimal. Diagnosis ini disbeut dengan diagnosis promosi kesehatan. Jenis jenis diagnosis tersebut adalah :

https://mindfullners.com/jenis-dan-komponen-diagnosis-keperawatan/

1. Diagnosis Aktual

    Menunjukan respons klien terhadap kondisi kesehatanya atau proses kehidupanya yang menyebabkan klien mengalami masalah kesehatanya. Memiliki tanda dan gejala baik mayor maupun minor dan dapat divalidasi pada klien.

    2. Diagnosis Risiko

    Menunjukan respons klien terhadap kondisi kesehatan atau proses kehidupanya yang dapat menyebabkan klien berisiko mengalami masalah kesehatan. Klien memiliki factor risiko, tanpa memiliki tanda dan gejala mayor dan minor.

    3. Diagnosis Promosi Kesehatan

    Mengggambarkan adanya keinginan dan motivasi klien untuk mengingkatkan kondisi kesehatanya ke tingkat yang lebih baik.

    https://mindfullners.com/jenis-dan-komponen-diagnosis-keperawatan/

    Komponen Diagnosis Keperawatan Terdiri Dari Dua Komponen Utama Yaitu Problem (Masalah) Atau Label Diagnosis Dan Indikator Dignostik.

    1. Masalah (Problem)

    Masalah merupakan label dignostik keperawatan yang menggambarkan inti dari respons klien terhadap kondisi kesehatan atau proses kehidupanya. Label dignostik ini terdiri dari desktiptor (penjelas) dan fokus dignostik.

    Contoh deskriptor dan fokus dignostik pada diagnosis keperawatan :

    NODeskriptorFokus Diagnostik
    1Tidak EfektifBersihan jalan napas
    2GangguanPertukaran gas
    3PenurunanCurah jantung
    4IntoleransiAktivitas
    5DefisitPengetahuan

    Beberapa descriptor yang digunakan dalam diagnosis keperawatan.

    NODeskriptorFokus Diagnostik
    1DefisitTidak cukup, tidak adekuat
    2DisfungsiTidak berfungsi secara normal
    3EfektifMenimbulka efek yang diinginkan
    4GangguanMengalami hambatan atau kerusakan
    5LebihBerada diatas nilai normal atau yang diperlukan
    6PenurunanBerkurang baik dalam ukuran, jumlah atau derajat
    7RendahBerada dibawah nilai normal atau yang diperlukan
    8Tidak efektifTidak menimbulkan efek yang diinginkan
    9Tidak proporsionalTerlalu besar/kecil bila dibandingkan dengan yang normal

    2. Indikator Dignostik

    Terdiri dari penyebab dan tanda dan gejala

    a. Penyebab (Etiologi)

    Adalah factor yang mempengarhui perubahan status kesehatan klien. Secara umum dapat dikelompokan menjadi empat kategori yaitu :

    1. Patofisiologis, biologis atau psikologis
    2. Efek terapi/tindakan
    3. Situasional (lingkungan atau personal)
    4. Maturasional

    b. Tanda Dan Gejala

    Tanda adalah data objektif yang didapatkan dari hasil pemeriksaan fisik, laboratorium dan prosedur dignostik. Gejala adalah data subjektif yang diperoleh dari hasil anamnesa atau wawancara klien. Tanda dan gejala dikategorikan menjadi dua, yaitu :

    • Mayor : tanda/gejala ditemukan sekitar 80% -100% untuk validasi diagnosis.
    • Minor : tanda/gejala tidak harus ditemukan, namun jika ditemukan dapat mendukung penegakan diagnosis.
    https://mindfullners.com/jenis-dan-komponen-diagnosis-keperawatan/

    Pada diagnosis risiko tidak memiliki etiologi dan tanda/gejala, namun memiliki factor risiko. Factor risiko merupakan kondisi atau situasi yang dapat meningkatkan kerentanan klien mengalami masalah kesehatan. Sedangkan pada diagnosis promosi kesehatan hanya memiliki tanda/gejala yang menunjukan kesiapan klien untuk mencapai kondisi yang lebih optimal.

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