Hambatan Berjalan dan Resiko Jatuh
A. Diagnosa keperawatan
Prioritas Diagnosa Keperawatan
1 Domain 12 : kenyamanan
Kelas 1 : kenyamanan Fisik
Diagnosa Nyeri Akut (00132)
2 Domain 4 : Aktivitas/Istirahat
Kelas 2 : Aktivitas atau latihan
Diagnosa Hambatan Berjalan (00088)
3 Domain 11 : Keamanan atau perlindungan
Kelas 2 : Cedera Fisik
Diagnosa Resiko Jatuh (00155)
B. Rencana keperawatan
No Diagnosa Keperawatan NOC NIC
1 Domain 12 : kenyamanan
Kelas 1 : kenyamanan Fisik
Diagnosa Nyeri Akut (00132) Setelah dilakukan tindakan keperawatan selama kurang lebih 1 hari masalah nyeri dapat teratasi dengan kriteria hasil :
Domain IV : Pengetahuan
2 Domain 4 : Aktivitas/Istirahat
Kelas 2 : Aktivitas atau latihan
Diagnosa Hambatan Berjalan (00088) Setelah dilakukan tindakan keperawatan selama kurang lebih 15 menit masalah hambatan berjalan dapat teratasi dengan kriteria hasil :
Domain I : Fungsi kesehatan
Kelas C : Mobilitas
- 020003 Berjalan pada kecepatan lambat (2-3)
- 020010 berjalan jarak pendek (2-3)
- 020014 Berjalan disekitar ruangan (2-3) Domain 1 : Psikologi Dasar
Kelas A : Aktivitas dan managemen latihan
- Bantu pasien untuk menggunakakn alas kaki yang memfasilitasi berjalan dan mencegah cidera
- Terapkan atau sediakan alat bantu (tongkat atau kursi roda) untuk ambulasi jika pasien jatuh
3 Domain 11 : Keamanan atau perlindungan
Kelas 2 : Cedera Fisik
Diagnosa Resiko Jatuh (00155) Setelah dilakukan tindakan keperawatan selama kurang lebih 1 hari masalah resiko jatuh dapat teratasi dengan kriteria hasil :
Domain IV : Pengetahuan dan kesehatan
Kelas S : pengetahuan kesehatan
- 182811 Latihan untuk mengurangi resiko jatuh (2-4)
- 182814 Penyakit akut yang meningkatkan resiko jatuh (2-3) Domain 4 : perlindungan
Kelas V : Manajemen Resiko
Perlindungan jatuh (6490)
- Identifikasi factor-faktor yang mempengaruhi resiko jatuh
- Identifikasi lingkungan pasien untuk mencegah terjadinya jatuh
- Identifikasi karakteristik yang dapat meningkatkan potensi untuk jatuh
- Ajarkan pasien bagaiman meminimalkan jatuh atau cidera
- Berikan penkes kepada keluarga pasien tentang factor resiko yang berkonstribuisi untuk jatuh
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