Indonesian Nursing Outcome Standard (SLKI)

 

 

Airway Clearance L.01001

 

Definition

Ability to clear secretions or airway obstruction to maintain a patent airway.

 

Expectations Rise

 

Result Criteria

Effective cough

Sputum production

Wheezing

Wheezing

Meconium (in neonates)

Dyspnea

Orthopnea

Difficult to talk

Cyanosis

Nervous

Respiratory rate

Breathing pattern

 

Weaning Ventilator L.01002

Definition

Adaptability to reduced mechanical ventilator assistance

 

Expectations: Increase

 

Synchronized ventilator assistance

Use of accessory muscles for breathing

Shortness of breath (gasping)

Shallow breath

Agitation

Tired

The feeling of worrying the machine is broken

Focus on breathing

Abdominal paradox breath

Diaphoresis

Respiratory rate

Arterial blood gas values

Breath effort

Auscultation of inspirational sounds

Skin color

 

Gas Exchange L.01003

 

Definition

Oxygenation and/or elimination of carbon dioxide at the alveolus-

capillaries within normal limits.

 

Expectations Rise |

 

Result Criteria

Level of consciousness

Dyspnea

Additional breath sounds

Dizzy

Blurred vision

Diaphoresis

Nervous

Nostril breath

PCO,

PO,

Tachycardia

arterial pH

Cyanosis

Breathing pattern

Skin color

 

Breath Pattern L.01004

 

Definition

inspiration and/or expiration that provides adequate ventilation.

 

Expectations Improve

 

Result Criteria

Minute ventilation

vital capacity

Anterior-posteilor thoracic diameter

Expiratory pressure

Inspiratory pressure

Dyspnea

Use of accessory muscles

breath

Expiratory phase prolongation

Orthopnea

Pursed-tip breathing

Nostril breathing

Respiratory rate

Breath depth

Chest excursion

 

Ventilation ResponseMechanical L.01005

 

Definition

Effective alveolar exchange and tissue perfusion supported by mechanical ventilation

 

Expectations Rise

 

Result Criteria

FIO, meet the needs

Level of consciousness

One oxygen constellation

Symmetry of chest wall movement

Increasing genus Going Decreasing

airway secretion

Additional breath sounds

Lung infection

Difficulty breathing with

ventilator

Atelectasis

Anxiety

Lack of rest

Difficulty expressing | 2 3 4 3

need

Sedation dose

It's getting worse we're on Getting better

airway secretion

Additional breath sounds

Lung infection

Difficulty breathing with

ventilator

Atelectasis

Anxiety

Lack of rest

Difficulty expressing

need

Sedation dose

airway secretion

Additional breath sounds

 

Aspiration Rate L.01006

 

Definition

Condition of entry of liquid or solid particles into the lungs.

 

Expectations Drop

 

Result Criteria

Level of consciousness

Ability to learn

Oral hygiene

Increasing bint Moderate cae

Dyspnea

Muscle weakness

Accumulation of secretions

Wheezing

Cough

Use of accessory muscles

Cyanosis

Nervous

Respiratory rate

 

Spontaneous Ventilation L.01007

 

Definition

adequate energy reserves to support the individual being able to breathe

adequately.

 

Expectations Rise

 

Result Criteria

Tidal volume

Dyspnea

Use of accessory muscles for breathing

Nervous

PCO

PO

Tachycardia

 

Cardiac Output L.02008

 

Definition

Adequate heart pumping blood to meet the body's metabolic needs.

 

Expectations Rise

 

Result Criteria

Peripheral pulse strength

Fractional Ejection (EF)

Cardiec todex (Cl)

Left ventricular stroke work

index (LVSWI)

Stroke volume index (SV1)

Palpitations

Bradycardia

Tachykardla

ECG arrhythmia picture

Tired

Edema

Jugular venous distention

Dyspnea

Oligurla

Pale/cyanosis

Paroxysmal nocturnal dyspnea (PND)

Orthopnea

Cough

S3 heart sound

S4 heart sound

Heart murmur

Weight

Hepatomegaly

Pulmonary vascular resistance (PVR)

Systernic vascular resistance

Capillary refill time (CPT)

Pulmonary artery wedge

pressure (PAWP)

Central venous pressure

 

Gastrointestinal Perfusion | L.02010

 

Adequate blood flow to the gastrointestinal tract to maintain organ function.

 

Expectations Rise

 

Result Criteria

Appetite

Load

Gag

Abdominal pain

ascites

Constipation

Diarrhea

Bowel noise

 

Myocardial Perfusion 1.02011

 

Definition:

Adequate coronary artery blood flow to maintain function

 

Expectation = Increase

 

Result Criteria

ECG arrhythmia picture

Chest pain

Diaphoresis

Nauseous

Gag

Apical artery

Average arterial pressure

Tachycardia

Bradycardia

Radial pulse

Blood pressure 1 2 2 4 S

Ejection fraction

Pulmonary artery wedge pressure

Cardiac index (Cl)

 

Perfusion perifier L.02011

 

Adequate blood flow of distal vessels to support tissue function.

 

Expectation = Increase

 

Peripheral pulse

Wound healing

Sensation

Pale skin color

Peripheral edema

Extremity pain

Parasthesia

Muscle weakness

Muscle cramp

Bruit fernoralis

Necrosis

Capillary refill

Akral

skin turgor

Systolic blood pressure

Diastolic blood pressure

Average arterial pressure

ankle-brachial index

 

Renal Perfusion L.02013

 

Definition

Adequate renal artery blood flow to support kidney function.

 

Expectations Rise

 

Result Criteria

Amount of urine

Abdominal pain

Nauseous

Gag

Abdominal distension

Average arterial pressure

Blood urea nitrogen level

Plasma creatinine level

Systolic blood pressure

Diastolic blood pressure

Electrolyte level

Acid base balance

Bowel noise

Liver function

 

 

 

Cerebral Perfusion L.02014

 

Definition

Adequate cerebral blood flow to support brain function

 

Expectations Rise

 

Result Criteria

Level of consciousness

Cognitive

Increasing vetas Moderate ooo Decreasing

intracranial pressure

Headache

Nervous

Worry

Agitation

Fever

Average value of blood pressure

Awareness

Systolic blood pressure

Diastolic blood pressure

Nerve reflex

 

 

Spontaneous Circulation L.02015

 

Definition

Ability to maintain adequate circulation to support life.

 

Expectations Rise

 

Result Criteria

Level of consciousness

pulse rate

Blood pressure

Respiratory rate

Body temperature

Oxygen saturation

ECG arrhythmia picture

ETCO,

Urine production

 

Circulation Status L.02016

 

Definition

The circulation of various substances that are needed throughout the body and the taking of substances that are not needed to be excreted from the body.

 

Expectations Improve

 

Result Criteria

Pulse power

Urine output

Oxygen saturation

PaO,

Pale

Cold

PaCo,

Pitting edema

Peripheral edema

Orloslastic hypotension

Additional breath sounds

Bruit blood vessels

Jugular venous distention

ascites

Fatigue

Intermittent claudication

paresthesia

syncope

Extremity ulcer

Systolic blood pressure

Diastolic blood pressure

Pulse pressure

Mean arterial pressure

Capillary refill

Central venous pressure

Weight

 

Bleeding Rate L.02017

 

Definition

Blood loss is either internal (occurs inside the body) or external (occurs outside the body).

 

Expectations Drop

 

Result Criteria

Mucous membrane moisture

Skin moisture

Cognitive

Increasing mecca Moderate Ee Decreasing

hemoptysis

Hematemesis

Hematuria

Anal bleeding

Abdominal distension

Vaginal bleeding

Postoperative bleeding

Hemoglobin

Hematocrit

Blood pressure

Apical pulse

Body temperature

 

 

Weight L.03018

 

Definition

Accumulation of body weight according to age and gender.

 

Expectations Improve

 

Result Criteria

Weight

Skin fold thickness

body mass index

 

 

Gastrointestinal Function L.03019

 

Definition

The ability of the gastrointestinal tract to enter and digest as well as absorb nutrients and remove wastes; :

 

Expectations Improve

 

Result Criteria

Tolerance to food

Appetite

Increase

Nauseous

Gag

Dyspepsia

Abdominal pain

Abdominal distension

Regurgitation

Residual amount of gastric fluid

moment of aspiration

Blood in feces

Hematemesis

getting worse

CHAPTER FREQUENCY

Stool consistency

Intestinal peristalsis

Amount of feces

Stool color

 

Liquid Balance L.03020

 

Definition

Equilibrium between the volume of fluid in the intracellular and extracellular spaces of the body.

 

Expectations Rise

 

Result Criteria

Fluid intake

urine output

Membrane humidity

mucosa

Food supply

Edema

Dehydration

ascites

Confucius

Blood pressure

Radial pulse

Average arterial pressure

Mucous membrane

Sunken eyes

skin turgor

Weight

 

 

Electrolyte Balance L.03021

 

Definition

Serum electrolyte levels are within normal limits.

 

Expectations Rise

 

Result Criteria

Serum sodium

Serum potassium

Serum chloride

Calcium Serum

Serum magnesium

Phosphorus Serum

 

 

Stability of Blood Glucose Levels L.03022

 

Definition

Blood glucose levels are in the normal range.

 

Expectations Rise

 

Result Criteria

Coordination

Awareness

Sleepy

Dizzy

Tired / lethargic

Hungry Complaints

Shaky

Sweating

dry mouth

thirst

Weird behavior

Difficulty speaking

Glucose levels in the blood

Glucose level in urine

Palpitations

Behavior

Amount of urine

 

Gastrointestinal Motility L.03023

 

Definition

Gastrointestinal peristaltic activity

 

Expectations Improve

 

Result Criteria

Painful

Abdominal cramps

Nauseous

Gag

Regurgitation

Abdominal distension

Diarrhea

Peristaltic sound

Gastric emptying

Hundred

 

Appetite L.03024

 

Definition

Desire to eat.

 

Expectations Improve

 

Result Criteria

Desire to eat

Food supply

Fluid intake

Energy to eat

Ability to taste food

Ability to enjoy food

Nutritional intake

Stimulus to eat

Starving

 

Behavior of Maintaining Weight L.03025

 

Definition

Measures taken to maintain optimal body weight.

 

Expectations Rise

 

Result Criteria

Decreasing or Moderately Increasing

Monitor weight

Maintain daily calorie intake as needed

Balancing exercise with calorie intake

Choose nutritious food

Drink water according to the body's needs

Maintain fluid balance

Expressing a realistic body image

Maintaining adequate sleep

 

 

Behavior Increase Weight _L.03026

 

Definition

Measures taken to gain weight.

 

Expectations Rise

 

Result Criteriat

Identifying the causes of weight loss

Set a healthy weight target

Identify calorie needs

Identify likes and dislikes

Choose foods and drinks that are high in protein and calories

Maintain intake of nutritious food and drink

Monitor BMI

Monitor weight

Get help from a healthcare professional

Get proper dental care

Obtaining financial assistance to buy food

Identify foods that cause allergies

Drink water according to the body's needs

Taking nutritional supplements

Eat nutritious snacks and drinks between meals

Maintaining adequate sleep

Provide a feeding tube as recommended

Provide parenteral nutrition as recommended

 

Weight Loss Behavior L.03027

 

Definition

Measures taken to reduce weight.

 

Expectations Rise

 

Result Criteria

Setting a target weight within the normal range

Have a commitment to a healthy eating plan

Avoid high-calorie foods and drinks

Choose nutritious food and drinks

Control the portion of food

Establish an exercise routine

Monitor weight

Monitor BMI

Get information about strategies to lose weight from health experts

Identify emotional conditions that can affect food and drink intake

Using behavior modification strategies

Motivate yourself

Drink water according to the body's needs

Use medication as directed (if any)


 

 

Fluid Status _ | L.03028

 

Definition

Condition of intravascular, interstitial, and/or intracellular fluid volume.

 

Expectations Improve

 

Result Criteria

Pulse power

skin turgor

Urine output

Venous filling

Orthopnea

Dyspnea

Paroxysmal nocturnal dyspnea (PND)

Ederna anasarka i

Peripheral edema

Weight

Jugular venous distention

Additional breath sounds

Lung congestion

Feeling weak

thirst complaint

urine concentration

pulse rate

Blood pressure

Pulse pressure

Mucous membrane

Jugular Venous Pressure (JVP)

Hb . level

Ht level

Central Venous Pressure

Hepatojugular reflux

Weight

Hepatomegaly

Oliguria

Fluid intake

mental state

Body temperature

 

 

Breastfeeding Status L.03029

 

Definition |

The ability to provide breast milk directly from the breast to infants and children to meet nutritional needs.

 

Expectations Improve

 

Result Criteria

Baby's attachment to mother's breast

Mother's ability to position baby correctly

Baby micturition more than 8 times/ 24 hours

baby weight

Milk drips/spouts

Adequate breast milk supply

Nipples don't blister after a week of giving birth

Mother's confidence

Baby sleeping after feeding

Mother's breasts are empty after breastfeeding

baby intake

baby sucking

Blisters on the nipples

Maternal fatigue

Maternal anxiety

Fussy baby 1 Zz 3 4 2

Baby crying after feeding

 

 

Nutritional Status L.03030

 

Definition

Adequate nutritional intake to meet metabolic needs.

 

Expectations Improve

 

Result Criteria

Food portion spent

masticatory muscle strength

Swallowing muscle strength Serum albumin

Verbalize the desire to improve nutrition

Knowledge of healthy food choices

Knowledge of healthy drink choices

Knowledge of proper nutritional intake standards

Preparation of safe food storage

Safe preparation and storage of beverages

Attitude towards food/drink in accordance with health goals

Feeling full quickly

Abdominal pain

Sprue

Hair loss

Diarrhea

Weight

Body Mass Index (BMI)

Frequency of eating

Appetite

Bowel noise

Triceps skin fold thickness

Mucous membrane

 

 

Baby Nutrition Status L.03031

 

Definition

adequacy of nutritional intake to meet the needs, metabolism in infants.

 

Expectations Improve

 

Result Criteria

Weight

body length

yellow skin

Yellow sclera

Yellow mucous membrane

Prematurity

Cry baby

Pale

Difficulty eating

food allergy

Dietary habit

Skin fold thickness

Growth process

Fat layer

 

Shock Level L.03032

 

Definition

Insufficient blood flow to body tissues, which can result in life-threatening cellular dysfunction.

 

Expectations Drop

 

Result Criteria:

Pulse power

Urine output

Level of consciousness

Oxygen saturation

Cold

Pale

Thirsty

Confucius

lethargy

Metabolic Asiaosis

Mean arterial pressure

Systolic blood pressure

Diastolic blood pressure

Pulse pressure

Capillary refill

pulse rate

Respiratory rate

 

Fecal Elimination L.04033

 

Definition

The normal process of defecation is accompanied by easy expulsion of feces and the consistency, frequency and shape of the stool is normal.

 

Expectations Improve

 

Result Criteria

Control the expulsion of feces

Complaints of long and difficult defecation

Straining during defecation

Abdominal distension

Feel the mass in the rectal

Urgency

Abdominal pain

Abdominal cramps

Stool consistency

Defecation frequency

Intestinal peristalsis

 

Urine Elimination - L.04034

Definition

Complete bladder emptying.

Expectations Improve

 

 

 

 

Result Criteria

 

Decreasing Fs Medium but Increasing

Urinating sensation | Z 3 4 5

Increasing igri Moderate Praia Decreasing

Urge to urinate

(urgency)

Bladder distension

urine

Urination is not complete

(hesitancy)

residual urine volume

Urine dripping

(dribbling)

nocturia

bedwetting

Enuresis

Dysuria

Anuna

Worsening wees Moderately improving

BAK frequency

Characteristics of urinal

 

EEE

24 Indonesian Nursing Outcome Standards |


 

 

 

Acid Base Balance L.04034

 

Definition |

_Equilibrium between hydrogen ions in the intracellular and extracellular spaces of the body

 

 

 

 

 

 

 

 

 

 

 

Result Criteria

Decreasing gn Moderately Increasing

 

Level of consciousness

Rest

 

Increasing eos Moderate ee Decreasing

Nauseous

Muscle cramp

Muscle weakness

 

Worsening aon k Moderate — a Improving

Respiratory rate

breath rhythm 1 a 3 a 5

pH

CO2 . level

Bicarbonate content

Phosphate level

Sodium level

Chloride level

Protein content

Hemoglobin levels

 

40 Indonesian Nursing Outcome Standards

 

 

Fecal continence L.04035

See ea EOS

Definition

Normal pattern of bowel habits.

 

 

 

Lowering the oven Medium a Increasing

Expenditure control

feces

Enough ;

Worsening AMarcisursile Is Getting Better

Defecation 1 - 3 4 5

Frequency of bowel movements

Perianal skin condition

a ee SS SS

ee: | Indonesian Nursing Outcome Standards |

ty


 

 

Urine Continence L.04036

 

 

Definition

Pattern of urination

 

 

 

Expectations Improve |

 

 

 

CriteriaResult

Decreased oe = Moderately increased

Ability to urinate

Increasing ee Moderate ss Decreasing

nocturia

Residual urine volume after

urinate

Bladder distension

Dribbling

Hesitancy

Enuresis

Verbalization of urine output

not finished

Worsening ae x Moderate ee Better

Urinary frequency

Urinary sensation

 

53

 


 

 

Disability Adaptation L.05037

Definition

The process of functional adjustment to the challenges of physical limitations.

Expectations Rise

 

 

 

 

Result Criteria

 

Decreasing ne, "1 Is increasing iacietancs

Verbalization customize

self with disability

Verbalization of reconciliation

with disability

Adaptation with

physical limitations

Modify the appropriate lifestyle

disability condition

Job modification accordingly

disability condition

Strategies to overcome

stress due to diabetes

Use of assistive devices

according to the needs

Increasing ete Moderate a Decreasing

Negative feelings

Low self esteem

eee

14 Indonesian Nursing Outcome Standards


 

 

Ambulation | L.05038

Definition

The activity of walking from one place to another independently is good

with or without tools.

 

 

 

 

Expectations Rise

Result Criteria

 

 

Decreasing i Moderate Pc Increasing

Support weight

Walk with steps

effective

Walk with steps

slow

Walk with steps

currently

Walk with steps

fast

Walk uphill

Walking downhill

Walking short distances 1 ie 3 4 5

Walking distance seditng

Long distance walking | 2 3 4 S

Walk around the room

Bwijaluri through

obstacle

Increasing Wena Moderate eo Decreasing

Pain when walking

Stiff in joints

Reluctance to walk

Feelings of worry when

walk

16 Indonesian Nursing Outcome Standards


 

Balance | £05039

 

 

My definition

Ability to maintain body equilibrium

Expectations Rise

 

 

 

 

Result Criteria

Decreased oo Moderate (Increased nest

Ability to sit without

backup

Ability to rise from

sitting position

Balance while standing 4 2 3 a 5

Balance while walking

Balance while standing

with one leg

Increase aoe Moderate oo Decrease

Dizzy

Shaking feeling

Stumble

Worsening se. While eon ne is getting better

Posture

 

39


 

 

Definition

Ability to use energy effectively and efficiently.

 

 

 

 

 

_Expectations Rise

 

_Result Criteria

 

Enough

Enough

Decreasing acura: Moderately Increasing Increasing

Physical activity that

recommended

The right activity

Strategy for

balancing

activity and rest

Energy conservation technique

Breathing technique that

effective

Energy restriction

Proper body mechanics

Simplifying technique

profession

Use of assistive devices

correct

Increasing ota Moderate oe Decreasing

Activity restrictions 1 2 2 4 :

The factors that

increase expenses

energy

51


 

 

'Perge rergeral's coordination will be L.05041

Definition

The ability of the circadian muscles to cooperate with appropriate body movements

and directed.

 

Expectation = Increase _

Result Criteria

Decreasing — Moderately eae Increasing

muscle strength

Gesture control

Movement balance

Stability of movement

Motion thirst

Movement in the direction

want a

Movement with time 1 2 2 4 S

wanted

Movement with speed

which is desired

Movement with precision

which is desired

Increased tie bag Medium ——— A Decreased

Muscle tension 1 Z a 5

Muscle cramp

Enough ;

Worsening Worsening Getting Better

muscle shape

Movement speed

61


 

Physical Mobility | ___b,05042

Definition

Ability to physically move one or more extremities

independent.

 

 

Expectations Rise

Result Criteria

Enough

Declining Retuean Is Increasing Increasing

Extremity movement

muscle strength

Range of motion (ROM)

Increase ae Medium — Decrease

Painful

Worry

Stiff joints

Uncoordinated movement

Limited movement

Physical weakness

65


 

 

Organizational Behavior Ba 1.05043,

 

 

Definition

Ability to integrate physiological and neurobehavioral responses of infants to

environment.

 

 

 

 

 

 

 

'Expectations_ Rising

Result Criteria _

Decreasing a Moderately senna a Increasing

Movement in the extremities

Finger ability

holding

Coordinated movement

Normal response to

sensory stimulus

Cry

Able to respond to shock

Irritability

Reflex

Motor tone

Saturation

Increasing color Moderate a Decreasing

Nervous

Tremor

jerk

Arrhythmia

Bradycardia

Tachycardia

Worsening ees Moderate oak Better

Breastfeeding ability

skin color

70 Indonesian Nursing Outcome Standards


 

 

Joint Movement —L.05044

Definition |

The ability to perform joint movements in all joints of the body simultaneously

independent_

 

 

 

 

Expectations Rise

 

 

Result Criteria

 

Enough

Decreased Atorin Moderately Increasing Increasing

Jaw

Neck

Back

Finger (right)

Finger (left)

Thumb (right)

Thumb (left)

Wrist (right)

Wrist (left)

Elbow (right)

Elbow (left) 1 2 2 a

Shoulder (right) 1 2 3 o

Shoulder (left)

Ankle (right)

Ankle (left)

Knee (right)

Knee (left)

Pelvis (right)

Pelvis (left)

87 ;


 

 

Sleep Pattern _ £05045

Definition

Adequate quality and quantity of sleep.

 

 

 

 

Expectations Improve

 

 

Result Criteria

 

Decreasing Pm Moderately Increasing

Complaints of sleeplessness

Complaints are often awake

Complaints of not being satisfied with sleep

Complaints about changing sleep patterns

Complaints of rest no

enough

Increasing wanna Moderate aoe Decreasing

Activity ability

eee

96 Indonesian Nursing Outcome Standards


 

"eee

Fatigue Level L.05046

Definition

Physical and mental work capacity that does not recover with rest.

Expectations Improve

 

 

 

 

Result Criteria

 

Enough

Decreasing Decreasing Increasing Increasing

Verbalization of energy recovery

Power

Ability to do

routine activities

Motivation | Zz 3 4 6

Increasing Se Moderate eee Decreasing

Verbalization tired 1 = 3 4 6

Sluggish

Concentration disorders

Headache

Sore throat

Wheezing 1 = 3 4 Ss

Cyanosis

Nervous

Breathing Frequency

Guilt

Worsening oe Moderate Bo Getting better

Appetite

Breath polo

Libido

Rest pattern

SS eee

| 141


 

 

-Frequency — : Se 3 4 5

~ Oxygen saturation -4 i 3 4 5

_ Ease of doing fe 3 4 5

-—_Daily activities Se |

_ Running rate 1 2 3 4 <=

_walking distance q- =2 3 Sg =8

_ Upper body strength sad ee a= 4 5

body check — bottom 1 <2 SZ “4 Ss

 


 

 

'Sensory Function

 

Definition

The ability to perceive sound stimulation, taste. touch, smell and

visual image

Expectations Improve

 

 

 

Result Criteria

 

Decreasing ed Medium Mane Increasing

Hearing acuity

Visual acuity

Perception of skin stimulation

Perception of Dose1 head

Perception of body position

Smell difference

Taste difference

 

28 Indonesian Nursing Outcome Standards


 

 

Definition

The stability of the intracranial dynamic mechanism in compensating

 

to stimuli that reduce intracranial capacity.

Expectations Rise

SS eee

 

Result Criteria

 

Level of consciousness

Cognitive function

Headache

Nervous

Agitation

Gag

Decerebrate posture

(extension)

Papilledema

Blood pressure

Pulse pressure (pulse

pressure)

Bradycardia

Breathing pattern

Pupil response

Neurological reflex

Intracranial pressure

Decrease

1

1

Increase

—_— —_' —-2 2 —

getting worse

—_— = oe = =

 

Enough

Decrease

2

Za

Enough

Increase

MO NM DM BD PO

2

Enough

getting worse

2

2

NINN BD Ph

Enough

On The Rise

3 4

3 4

Enough

On Decline

3 4

3 4

3 4

3 4

3 4

3 4

Enough

Moderate — good

3 4

3 4

3 4

3 4

3 4

3 4

3 4

Increase

5

5

Decrease

aAnnn

on

getting better

ann nn

 


 

 

Seizure Control L.06050

 

 

Definition

~Ability to; control or reduce episodes

.

_convulsions

 

 

“Result Criteria

 

Enough

Enough

Descending Declining Increasing Increasing

Ability

identify factors

seizure risk/trigger

Ability to prevent

risk factors/triggers

seizure

Ability to report

drug side effects

Compliance with taking medication

Positive attitude 2 aa 5

Use of 1 2 3 * 5 . reduction technique

stress

Role appearance

Social relations

Sleep pattern

Appropriate exercise program

Increasing enc Moderate a Decreasing

Get the medicine

needed

Report seizure frequency

56 Indonesian Nursing Outcome Standards


 

Eee aaa Teeter ieee peepee eects Sinteass is

 

Peripheral Neurovascular L.06051

 

Definition

Circulation and sensation of movement of the extremities are adequate.

 

Expectations Rise

 

Result Criteria

Enough

Decreasing Decreasing Increasing Increasing

Arterial circulation

Venous circulation

Joint movement

Extremity movement

' Enough

Increasing Increasing Moderately Descending Mer

Painful

Bleeding

Deteriorating Net he Pte is getting better

Pulse

Body temperature

Skin color

Blood pressure

Pressure ulcer

69

 


 

Swallowing Status ——-L,06052

Definition

The passage of food from the mouth to the stomach is adequate.

Expectations Improve

 

 

 

_Result Criteria

Decreasing A i Moderate Sorunens Increasing

Preserving food

.. dimutut

Swallowing reflex

Ability to empty

mouth

Chewing ability

Swallowing effort

Bolus formation

Increasing anes Medium 'eo Decrease

Choking frequency

Cough

Gag

Gastric reflux

Nervous

regurgitation

Worsening ,, ENOUGH = Moderate oe getting better

Salivary production

Food reception

Sound quality

ice

118 Indonesian Nursing Outcome Standards


 

 

Neurological Status L.06053

Definition

The ability of the peripheral and central nervous systems to receive, process, and

respond to internal and external stimuli

 

 

Expectations Improve

 

Result Criteria

 

Enough

Descending Sanur Increasing Increasing

Level of consciousness

Pupil reaction

Cognitive orientation

Cognitive status

Central motor control

Cranial sensory function

Spinal sensory function

Cranial motor function | 2 = 4 5

Spinal motor function 1 2 aa 5

Autonomous function

Communication

Increasing ianetak Medium Pees Decreasing

Headache

Seizure frequency

Hyperthermia

Diaphoresis 1 2 2 4 s

Pale

Conjunctival congestion

Nasal congestion

Parasthesia

Metallic sensation in the mouth

Horner's syndrome

Blurred field

Penile erection

Worsening oes Moderately getting better

Systolic blood pressure

pulse rate

Pupil size

eye movement

Breathing pattern

Sleep rest pattern

Respiratory rate

Apical heart rate

Naai radialis pulse

Pilomotor reflex

120

re)

e

=

EC

-

5

> 

5


 

 

Confusion Level L.06054

 

Definition

Disturbed awareness, attention, cognition and perception.

 

Expectations Drop

an en nN naar Sissons ies ancl

Outcome Criteria — 3 |

ENE ereenemeene aan SRS ON See SS Se

 

 

Decrease a. On the rise

Cognitive function

Level of consciousness

Psychomotor activity

Motivation 1 2 + 4 5

start/finish

directed behavior

Short term memory

Long term memory

Increasing Poe Medium Rae Decreasing

Hallucinatory behavior

Nervous

Worsening aruee ae While Ree is getting better

Interpretation

Social function

Response to stimulus

Perception

The function of brain

 


 

Sens

 

Sexual Function L.07055

 

Definition

Integration of physical and socioemotional aspects related to sexual distribution and performance

 

Expectations Improve

 

Result Criteria

Descending gone " While Nerina is increasing

Sexual satisfaction

Looking for information to achieve sexual satisfaction

Increasing ieee Moderate a Decreasing

Verbalization of sexual activity changes

Verbalization of sexual excitation changes

Sexual role verbalization changes

Verbalization of sexual function changes

Complaints of pain during sexual intercourse (dyspareunia)

Complaints of limited sexual intercourse

Complaints of difficulty performing sexual activity

Verbalization of sexual activity changes

Verbalization of sexual behavior changes

Value conflict

Worsening ee Moderate ee Getting better

Sexual desire

Sexual orientation

Interest in partner

 

27


 

 

-Pregnancy Acceptance

Definition

Efforts to reconcile changes to the situation/problem of pregnancy. _

Expectations Rise

Result Criteria

Decreasing oe Moderately deme “i Increasing

Verbalization of acceptance

pregnancy

Verbalization of feelings

experienced

Care seeking behavior

pregnancy

Making plans

pregnancy

Ability to appreciate yourself

alone

Positive relationship

Customizability

self with pregnancy

Verbalize feelings of calm

Efforts to find information

pregnancy

Increases eats Moderately Since Decreasing

Angry

Withdraw 1 Za 3 4 >

Feeling lonely

Worsening PP satay 'fk is getting better

Affect

 

76 Indonesian Nursing Outcome Standards


 

Antepartum Status

 

Definition

Conditions in the period of pregnancy calculated from the first day of the last menstruation until the start of labor.

 

Expectations Improve

 

Result Criteria

 

Decreasing cast nl Medium Meramec Increasing

Emotional attachment to the fetus

Coping with pregnancy discomfort

Increase ie mone Moderate ae Decrease

Nausea 1

Vomiting 1 2 3 4.5

Edema

Abdominal pain 1 4 3 4 5

Epigastric pain

Vaginal bleeding

Constipation

Headache

Seizures

unstable mood

Urine protein

urine glucose

Blood glucose

Getting worse Get Moderate Peo is getting better

Weight

Blood pressure

Hemoglobin

Neurological reflexes 1 Z 3 4 >

pulse rate

Respiratory rate 1 z 3 4 o

Body temperature

liver enzymes

Complete blood count

Cognitive status

 

 

 

 

Decrease = decrease 5°48nd saoriespat Increase —

Coping with 1 Z 3 4 >

inconvenience '

labor :, ;

Utilizing techniques for 1 2 3 Ss

facilitate ag delivery

Cervical dilatation 1 2 2 a

: Enough ; ohne

Oni Christmas Oni is Increasing Sedang

Vaginal bleeding 1 2

Headache

Pain with contractions

Seizures

Back pain

a 2 on

NM MN NY

WOW WWW W

Enough

Worsening Redurtile Moderate

—_

Frequency of uterine contractions

uterine contraction period

Intensity of uterine contractions

Blood pressure

pulse rate

Temperature

Blood glucose

Urine output

Neurological reflex

Cognitive status

BENG mos GEN) oak! EXOS

MNNMNMNNMNNN N NH

WOWWWWWWWWW Ww

 


 

 

 

Postpartum Comfort Status _L.07061_

 

Definition of oe

Feelings of comfort related to the condition after childbirth. _

 

Expectations Rise

 

Result Criteria

Amniotic sac is uncomfortable

grimace

Episiotomy wound

uterine contractions

Sweating

Cry

Moaning

hemorrhoids

uterine contractions

Swollen breasts

Blood pressure

pulse rate

 

Postpartum Status L.07062

 

Definition —s

The condition from the time the baby is born until the next six weeks is accompanied by the recovery of the organs related to the womb that have undergone changes.

 

Expectations Improve

 

Result Criteria

 

Decreasing ees Medium ecu Increasing

Peripheral circulation

Full tits

Perineal restoration

Incision Recovery

Intake of food and fluids

Physical activity

Resistance 1 Z = 4 5

Increased bet Cckai Medium . Decrease

Convenience

Infection

Incision pain

Vaginal bleeding

Laceration

Fatigue

Depression

It's getting worse ee Acres is getting better

Number of lochia a

lochla color

Blood pressure

pulse rate 1 ic 3 4 5

Body temperature

Urinary elimination

Fecal elimination

liver enzymes

Hemoglobin

White blood cell

Blood glucose

Mood

Pain Control L.08063

 

Definition

Actions to relieve unpleasant sensory or emotional experiences

unpleasant due to tissue damage.

 

Expectations Rise

 

Result Criteria

Report pain controlled

Ability to recognize pain onset

Ability to recognize the cause of pain

Ability to use non-pharmacological techniques

Closest support

Complaints of pain

Analgesic use

 

Comfort Status

 

Definition

Overall feeling of comfort and security physically, psychologically, spiritually, socially, culturally and environmentally.

 

Expectations Rise

 

Result Criteria

Physical well-being

Psychological well-being

Social support from family

Social support from friends

Treatment according to cultural beliefs

Treatment as needed

Freedom of Worship 1 Z 5 4 Zs

relax

Complaints of discomfort

Nervous

Noise

Complaints of difficulty sleeping 1 2 o 4 5

Complaints of cold

Complaints of heat

Gata!

Nauseous

Tired

Moaning

Cry

irritability

Blame yourself

Confucius

Alcohol consumption

Substance use

Suicide attempt

Memories of the past

Room temperature 1 2 Ss 4 5

Elimination pattern

Body posture

Vigilance

Lifestyle

Sleep pattern

 

Nausea Level L.08065

 

Definition

Discomfort in the back of the throat or stomach

which can cause vomiting.

 

Expectations Drop

 

Result Criteria

Appetite

Increased ilcrin eat Moderate a Decreased

Complaints of nausea

Feeling like throwing up

Sour feeling in the mouth

Hot sensation

Cold sensation

Swallowing frequency

Diaphoresis

Amount of saliva

Worsening ae Moderate o = Better

Pale

Tachycardia

Pupillary dilation

 


 

Pain Level L.08066

 

Definition

Sensory or emotional experience associated with actual or functional tissue damage, of sudden or late onset and of mild to severe and constant intensity.

 

Result Criteria

Ability to complete

activity

Complaints of pain - 1 2 3 5

grimace —

Protective attitude

Nervous

Trouble sleeping

Withdraw

Focus on yourself

Diaphoresis {

Feelings of depression (stress)

Feeling afraid to experience

repeated injury

Anorexia

Perineum feels depressed

Uterus feels rounded

muscle tension

Dilated pupils

Gag

Nauseous

Worsening poe Moderate ee Getting better

pulse rate

Breathing pattern

Blood pressure

thought process

Focus

Urinary function

Behavior

Appetite

Sleep pattern

 

Community Resilience L.08075

 

Definition

The capacity of the community to adapt and function positively after experiencing difficulties or crises.

 

Expectations Rise

 

Result Criteria

Service continuity

community routine

Service availability

health

Availability of resources

to meet

basic needs

Community readiness for

crisis response

Community adaptation

to change

Community collaboration for

face the challenge at

future

Community preparation for

face challenges in

future

Plan updates

crisis response

Key leaders monitor

socioeconomic environment

Key leaders monitor

physical environment

Key leader

coordinate response

crisis

Identify strategy

conflict resolution

Network usage

communication

Collaborating with

agency/government

Access to resources

external

 

Sexual identity 7 at

Definition

Emphasis and self-acceptance of the sexual aspect.

 

 

 

Expectations Improve

Result Criteria

Decreasing enn Medium since “ Increasing

Show stance

clear sexual

Integration of sexual orientation

into life

daily

Setting boundaries

according to gender

Social support search

Relationship verbalization

harmonious

Verbalization of sexual intercourse

healthy

ee a eS Ee

32

Indonesian Nursing Outcome Standard


 

 

Body Image ~~ L.09067

 

 

Definition

Perceptions of an individual's physical appearance, structure and function

 

Expectations Rise

 

Result Criteria

 

It's getting worse, it's getting better

Seeing body parts

Touching body parts

Verbalization of disability

parts of body

Verbalization of loss

parts of body

Increase eas Medium ——, Decrease

Verbalize negative feelings

about body changes

Verbalization of worries

on rejection/reaction

others

Style change verbalization

life

Hide section

excessive body

Show body parts

excessive

Focus on body parts

Focus on appearance

past

Focus on the power of time

then

Worsening ree Moderate oo Better

Nonverbal response to

body change

Social relations

oo

19


 

 

 

 

 

Definition

 

Availability of alternative solutions to the problems at hand. __

 

 

 

 

 

 

 

 

 

 

 

Expectations Rise

We Result Criteria

Decreased Bats Moderate uetiens “i Increase

Involvement in activities

maintenance

Appetite

Initiative

Interest in verbal communication

k

Increasing hence Medium oe Decreasing

Verbalization of despair

Passive behavior

Flat affect 4 Z 3 4 5

Shrugging when talking

Worsening ice Moderately getting better

Sleep pattern

29 |

 

 

 

Self-Esteem -L,09069

Definition

Positive feelings about oneself or abilities in response

to the current situation.

 

 

 

Expectations Rise a

Result Criteria

Enough

Decreasing Decreasing Increasing Increasing

Positive self-assessment

The feeling of having

excess or

positive ability

Appraisal acceptance

positive about yourself

alone

Interested in trying new hi 1 Zz 3 4

Walk show

face

Posture showing

face

Concentration

Sleep

Eye contact

Activity passion

Active

Confidently speak

Assertive behavior

Ability to make

decision

Increasing ee Moderate =. Decrease

Feelings of shame

Guilt

Feeling unable

do anything

Underestimating ability

solving problem

Dependence on

strengthening

excessive

Search reinforcement by

excessive

30 Indonesian Nursing Outcome Standards


 

SS

self identity | L.09070

 

 

 

Definition |

The ability to maintain the integrity of the perception of self

 

Expectations Improve

 

Result Criteria

Enough

Decreasing itenirurs Increasingly Increasing

Consistent behavior

Effective relationship

Effective coping strategies

Effective role appearance 1 z 3 4 2

Increase oe Moderate oe Decrease

Fluctuating feelings

to self

Confusion with

with values

culture

Confusion with purpose

life

Confusion with type

sex

Confusion with value-

ideal value

It's getting worse as it's getting better

Self perception

 

: 31


 

ving

Empowerment L.09071

Definition

Perception that a person's actions are capable of directly influencing outcomes

_significant. eee at

in ola aa a ee

Expectation

 

 

Increase

 

 

Result Criteria , .

cee ee ee eee

Enough

Descending Merniran Increasing Increasing

Capable statement

doing

activity

Statement of belief

about role performance

Participate in

maintenance

Increasing eee Medium nc Decreasing

Statements of frustration 1 ie 3 4 5

Dependence on

others

Feeling alienated

less statement

control

Shame statement

Feeling depressed

(depression)

Exile

37


 

 

Self Awareness —-L.09072

 

Definition

The ability to assess a person's strengths, weaknesses, thoughts, attitudes, beliefs, emotions, motivations related to self, environment and others.

 

Expectations Rise

 

Result Criteria

 Recognizing physical abilities

Recognizing mental abilities

Recognizing emotional abilities

Recognizing physical limitations

Recognizing mental limitations

Recognizing emotional limitations

Recognizing habit patterns

About personal values

Recognizing the subjective responses of others

Recognizing subjective responses 1 zZ 3 4, 5to situations

Maintaining awareness of thinking

Maintain awareness of feelings

Verbalization of feelings in others Interaction with people Sair.

Verbalization of needs

Accept your own feelings

Accept your own behavior

Differentiate yourself and others

Distinguishing oneself from the environment

 

Personal Resistance L.09073

 

Definition

Capacity to adapt» and function positively after experiencing difficulties or crises.

 

Expectations Rise

 

Result Criteria

Enough

down we. On The Rise Increasing

Verbalization of positive expectations

Using effective coping strategies

Verbalization of feelings Shows positive self-esteem

Taking responsibility

Looking for emotional support

Take adversity as a challenge

Using strategies to increase security

Using strategy to avoid danger

Avoid drug abuse

Avoid substance abuse

Refrain from hurting others

Identifying role models

Identifying resources in the community

Leveraging the resources in the q community

Verbalization of readiness for

 

Family Resistance : L.09074

 

Definition

The capacity of the family to adapt and function positively after experiencing difficulties or crises. _

 

Expectations Rise

 

CriteriaResult

Discuss the meaning of crisis

Maintaining family routines

Support for independence among family members

Positive verbalization of expectations between family members

Using effective coping strategies

Verbalization of feelings between family members

Seek emotional support from other family members

Take adversity as a challenge

Separation tolerance

Identifying resources in the community

Leveraging the resources in the community

Leveraging community groups for emotional support

Utilize health workers to: get information

Using health workers to get help

Verbalization of readiness forstudy

 

 

Self Concept L.09076

 

Definition

Perception patterns that are sufficient to feel well.

 

Expectations Improve

 

Result Criteria

Verbalization of self-satisfaction

Verbalization of satisfaction with self-esteem

Verbalization of satisfaction with role performance

Verbalization of satisfaction with body image

Verbalization of satisfaction with self-identity

Verbalization of desire to improve self-concept

Verbalize self-confidence

Verbalization of acceptance of one's strengths

Verbalization of acceptance of one's limitations

Action according to feeling

 

Self Control L.09076

 

Definition

The ability to, control or regulate emotions, thoughts, and behavior in the face of problems.

 

Expectations Rise

 

Result Criteria

Decrease aa. Geel is Increasing

Verbalize threats to others

Swearing verbalization

Attacking behavior 2 3 4 6

Behavior that injures self/others

Behavior that destroys the surrounding environment

Aggressive/angry behavior

Loud noise

Talk curtly

Verbalization of suicidal ideation

Verbalization of suicidal cues.

Verbalization of suicide threats

Verbalize a suicide plan

Verbalization misses an important connection

Suicide planning behavior

Euphoria

Natural feeling of depression

 

Thought Control L.09078

 

Definition

A person's ability to control himself from disturbances in sensory perception, thought processes and thought content.

 

Expectations Rise

 

Result Criteria

Ability to recognize hallucinations and delusions

Ability to refrain from following hallucinations and delusions

Ability to monitor the frequency of hallucinations and delusions

Ability to explain the contents of hallucinations and delusions

Reports decreased hallucinations and delusions

Validation

Ability to interact

Ability to understand other people's ideas

Affective compatibility

Looking at the environment

accurately

Shows thinking patterns

logical

Shows good thoughts

based on reality

Show positive thinking content

 

Memory | | So = ee

 

 

Definition

The ability to remember some information or

Expectations Rise |

Result Criteria

 

 

 

 

Enough

Decreasing Decreasing Increasing Increasing

Ability verbalization

learn new things

Ability verbalization

remember information

factual

Ability verbalization

remember behavior

certain ever

conducted

Ability verbalization

remember events

Doing the ability

studied

Increases steadily at Moderate — as Decreases

Verbalization of forgotten experience

Verbalization forgot schedule

Verbalization is easy to forget

Motivation ) LS

 

 

Definition

The individual's internal desire to take action/behavior.

Expectations Rise |

Result Criteria

 

 

 

 

 

down o.e. Standing a“ Increasing

Time focused mind

front

Efforts to plan 1 2 é 4 5

action

Attempt to source 1 2 J 4 5

according to the needs

Attempt to find support 1 z 2 & 5

according to the needs

Purposeful behavior i

Initiative

Positive self esteem

Positive belief

Dare to seek experience

new

Task completion z 3 4 a

Taking a chance Zz 2 4 5

Responsible 2 3 4 a

67

 


 

 

 

Setentasl Cognitive

 

 

 

Result Criteria |

 

Decrease

Self-identification

identify the closest person

Current place identification

Identify the day

Identify the month

Identification year

Identify important events

 

1

— ef = —-2 = —

Enough

Decrease

2

2

2

2

2

2

2

Medium M

WWW WW WW

Enough

increase

&-PpPbRD SA

Increase

aAnnananan

n


 

aay

Admission __L.09082

 

 

Definition —

Efforts to consciously accept the understanding or meaning of an event

or unconsciously to reduce anxiety/fear as a process

"It's normal to grieve.

 

 

 

 

 

 

Expectations Rise

Result Criteria

Decreasing Ra Moderate Seraaiical Increasing

Verbalization of acceptance

Verbalization of feelings

experienced

Seeking behavior

treatment/treatment

Making plans

future

Behavior according to feelings

experienced

Ability to appreciate yourself | 2 3 A 5

alone

Positive relationship

Customizability

self

Verbalization of feelings of calm 12 2 4 5

Resilience

Efforts to find information

situation/problem

Coping

Decision making

Task completion

Increasing ania at Moderate ao Decreasing

Angry

Thoughts about losing

Dependence on people

other

Withdraw

Feeling lonely

Worsening ee Moderate a. . getting better

Affect

 


 

 

Sensory Perception

 

 

Definition

Reality-perception of both internal and external stimuli

Expectations Improved os

 

 

 

 

 

Result Criteria

 

Enough

Declining Meiviirin Is Increasingly Increasing

Verbalization of hearing

whisper

Verbalization view

shadow

Verbalization feel

something through Indra

touch

Verbalization feel

something through the senses

smell

Verbalization feel

something through Indra

touch

Verbalization feel

something through the senses

tasting

Sensory distortion

Hallucinatory behavior

Withdraw

Daydream

Suspect

Back and forth

Worsening ic a Moderate Pies: Getting better

Response according to stimulus

Concentration

Orientation

 

93


 

 

Psychospiritual L.09084

 

Definition

Psychosocial comfort is related to self-concept, emotional well-being, sources of inspiration, and the meaning and purpose of one's life.

 

Expectations Improve

 

Result Criteria

Confidence

Hope

Self concept

Self image

Calm felling

Verbalization of optimism

Goal setting

Ability to make sense of life

Anxiety

Depression

Fear

Feelings of spiritual abandon

Suicidal thoughts

 

Grief Resolution L.09085

 

Definition

Psychosocial response shown due to loss of object function, status, body part or relationship)

 

Expectations Improve

 

Result Criteria

Verbalization of accepting loss

Verbalization of hope

Verbalization of useful feelings

Concentration

Immunity

Verbalization of sad feelings

Verbalize feelings of guilt

Verbal'sasi blames others

Nightmare verbalization

Crying | 2 3 4 a

phobia

Angry

Panic

Sleep pattern

 

 

Coping Status L.09086

Definition

The ability to assess and respond to stressors and/or the ability to use existing resources to deal with problems.

 

Expectations Improve

 

Result Criteria

Ability to fulfill age-appropriate roles

Adaptive coping behavior

Verbalization of problem solving skills

Verbalization of problem acknowledgment

Verbalization of self-weakness

Assertive behavior

Social participation

Self responsibility

Reality Orientation

Interest in following treatment/treatment

Ability to build relationships

Verbalization of blaming others

Verbalization of rationalization of failure

Hypersensitivity to criticism

Substance abuse behavior

Manipulation Behavior

Hostile behavior

Superior behavior

 

Cognitive Status L.09086

 

Definition

Ability to perform complex mental processes.

 

Expectations Rise

 

Result Criteria

 

Enough

Age-appropriate communication

Understanding the meaning of the situation 1

Decision making ability

Attention

Concentration

Cognitive orientation

Fresh Memory

Current memory

Long term memory

Process information

Consider alternatives when deciding

Counting ability

 

Family Coping Status L.09088

 

Definition

The behavior of dateftv family members supports, provides comfort, helps and motivates other sick family members towards the ability to adapt, manage and overcome health problems.

 

Expectations Improve

 

Result Criteria

Satisfaction with behavior

help other family members

Information exposure

Feeling neglected

Concerns about family members

Behavior of ignoring family members

Ability to meet the needs of family members

Commitment to care/treatment

Communication between family members

Feeling depressed (depression)

Attacking behavior (aggression)

Instigating behavior

Psychosomatic symptoms

Behavior refusing treatment

Hostile behavior

Individualist behavior

Dependence on other family members

Overprotective behavior

Tolerance

Purposeful behavior

Healthy behavior

 

Community Coping Status | L.09089

 

Definition

Patterns of adaptation of community activities and satisfactory problem solving to meet the demands of community needs.

 

Expectations Improve

 

Result Criteria

Community Empowerment

Community planning

Community troubleshooting

Community resources

Society participation

Community activities meet the expectations of their members

Positive communication

Recreation program

Relaxation/relax program

Community responsibility

on stress management

Incidence of health problems in the community

Community vulnerability

Conflict in the community

Disease incidence rate

Stress level

 

Orientation Status L.09090

 

Definition

Beliefs that match reality

 

Expectations Improve

 

Result Criteria

Productivity

Verbalization of delusions

delusional behavior

Worried

Suspect

Hostility

Tense

Withdraw

Behavior according to reality

lsi think according to reality

Talks

Concentration

Sleep pattern

Ability to take

decision

thought process

Self care


 

Spiritual Status L.09091

 

Definition

Beliefs or value systems in the form of the ability to feel the meaning and purpose of life through relationships with oneself, others, the environment or God.

 

Expectations Improve

 

Result Criteria

Verbalization of the meaning and purpose of life

Verbalization of satisfaction with the meaning of life

Verbalize feelings of empowerment

Verbalize feelings of calm

Verbalization of acceptance

Verbalization of believing in others

Angry behavior towards God

Verbalize feelings of guilt

Verbalization of foreign feelings

Verbalization of feelings of being ignored

Verbalization of self-blame

Nightmares Feelings of fear

Avoidance of BS activities, places, people related to trauma

Excessive vigilance

Self-destructive behavior

Ability to worship

Interaction with closest people/spiritual leaders

Coping

memory

Reality interpretation

 

Agitation Level L.09092

 

Definition

Physiological and behavioral manifestations of stress or biochemical triggers.

 

Expectations Drop

 

Result Criteria

Anxiety

Frustration

Irritability

Unable to hold back

Back and forth

Repeated movement

Inability to remain seated

Refuse help

Hit

Kick

Throw

Spit

Bite

cursing

Improper expression

Inappropriate gesture

Emotion

Hydration status

Blood pressure

Radial pulse

Sleep


 

 

Anxiety Level | L.09093 |

 

Definition

Emotional conditions and subjective experiences of objects that are not clear and specific due to the anticipation of danger, which allows individuals to take action to deal with threats.

 

Expectations Drop

 

Result Criteria

Verbalization of confusion

Verbalization is worried about the consequences

the conditions faced

Restless behavior 1 Zz 3 a 5

Tense behavior

Complaints of dizziness

Anorexia

Palpitations

Breathing frequency

pulse rate

Blood pressure

Diaphoresis

Tremor

Pale

Concentration

Sleep pattern

Feelings of empowerment

Eye contact

Urinary pattern

Orientation

 

Grieving Level L.09094

 

Definition

Psychosocial responses exhibited by loss (person, object, function, status, body part or relationship)

 

Expectations Improve

 

 

 

 

 

CriteriaResult =

Increased antique t Medium a - Decreased

Verbalization receive

lost

Verbalization of hope

Verbalization of useful feelings

Increasing coneat Moderate Si Descending

Verbalization of sad feelings

Verbalization of feelings

guilty or

blame others

Crying 1 Zz = a 5

Nightmare verbalization

Phobia 4

Angry 1 2 3 oh 5

Panic

Worsening en On rec Getting better

Sleep pattern

Concentration

Immunity

134 Indonesian Nursing Outcome Standards |


 

 

Delirium Level L.09095

Definition

Impaired level of consciousness and cognition for short periods of time and

reversible

 

 

 

 

 

 

Expectations Drop

Result Criteria

Decreasing Sn Medium montane Increasing

Level of consciousness

Ability to follow

order

Psychomotor activity

Interpretation Ability

environmental stimulus

Increases ject eat Medium Eanes Decreases

Nervous

Agitation

hallucination

delusion

Pi Sae getting worse ee getting better

Time orientation

Place orientation

People orientation

focus attention {

Conversation skills

Signal interpretation 1 2 a 4 s

Abstract thinking

Sleep pattern

Mood

 

136 Indonesian Nursing Outcome Standards.


 

 

Dementia Grade L.09096

Definition

Impaired consciousness and cognition leading to loss of function

irreversible mental, physical and social

 

 

 

 

 

 

Expectations Drop

Result Criteria

Decreasing oo Medium ean Increasing

Ability to follow

order

Ability to remember

current events

Ability to remember

name

Ability to recognize

family members

Ability to remember

familiar object

Ability to find

familiar place

Ability to defend

conversation

Interpretation of physical symptoms

Process information

Completion ability

problem

Need express

problem

Purposeful behavior o

Increasing ee Moderate oo Decreasing

Depression

Agitation

Nervous

Aggression

Suspect

Worsening a Moderate —— Getting better

Time, place and 1 ea orientation 4 5

person

Sleep pattern

Social activity

Social interaction 1 2 3 4. 5

Fecal continence

Urinary continence

1 37 :


 

 

Depression Level L.09097

Definition

Sad feelings that have a negative impact on thoughts, actions, feelings

and health.

 

 

 

Expectation = Decrease

 

 

 

Result Criteria

Decreasing oe Moderate Genes Increasing

Interest in activities

Daily activities

Concentration

Pride

personal hygiene

Increase ines Moderate Siena Zh Decrease

Feeling worthless

Sad

Hopeless

Negative events 1 2 3 4. 5

Guilt

Fatigue

Thoughts of self-injury

Suicidal thoughts

worried

Cry

Angry

Substance abuse

Alcohol abuse

Worse wo. Moderate —— Getting better

Weight

Appetite

Sleep pattern

Libido

138 Indonesian Nursing Outcome Standards


 

 

Neonate Adaptation

 

Definition of ne

The process of functional adjustment of the neonate from intra-uterine to extra-uterine life

uterus.

 

 

 

 

Expectations Improve

 

 

 

 

Result Criteria

 

Enough

Descending Marit Is Increasing Increasing

Weight

Increasing wanes Moderate oe Decreasing

Mucous membrane

yellow

yellow skin

Yellow sclera

Prematurity

Lateness

faecal discharge

: Enough .

Worsening Worsening Worsening Getting Better

Extremity activity

Response to

sensory stimulus

 

= 5


 

Nausea/Vomiting Control L.10099

Definition

The ability to control or reduce feelings of discomfort

in the back of the throat or stomach which can cause

gag

Bo ee a

Result Criteria

Enough

Declining Senet Is Rising Increasing

Ability to recognize 1 2 3 45

symptom

Ability to recognize 1 2 3 45

cause/trigger

Ability to do

action for

control nausea/vomiting

Report nausea and

controlled vomiting

Avoid factor | 2 3 a 5

cause/trigger

Record monitoring of symptoms

Avoid bad smell 4

Increased ice Medium ae: Decreased

Use of antiemetic drugs

Report failure

antiemetic treatment

Report drug side effects

Reporting symptoms that do not

controlled

 

57

 


 

 

Process Information _ ae L.10100

 

 

Definition

_Ability to search, organize and use information

_Expectations Improved

 

 

 

Result Criteria

 

Enough

Decreased ienurin Moderately Increased Increasing

Understanding sentences

Understanding paragraphs 1 o 3 4 2

Understanding the story

Understanding symbols

general

Deliver a message that

coherent

Coherent verbal messages 1 Z 3 4 >

Regular thought process

Logical thought process

Explain the similarities between

two items

Explain the difference

between two items

o

97


 

 

 

Expectations | getting better

 

 

 

Result Criteria —

Decreasing ae Moderately aselnee - Increasing

Skills/behavior

age appropriate

Ability to do

self care

Social response

Eye contact

Increases 'ne Medium Pie a4 " Decreases

Anger

Regression

Worsening ae Moderately a Bettering

Affect

Sleep pattern

4I4 Indonesian Nursing Outcome Standard


 

 

 

 

 

-Definition

-Ability to grow according to age group.

 

Expectations |

 

Result Criteria

Decrease

Weight according to age

Suitable length/height

age

head circumference

Weight gain speed

body

accretion speed

length/height

body mass index

Nutritional intake

eh —

 

Growth Status

improving __

Enough

Decrease

2

2

2

Nh

NO BN

 

Currently

Www

Enough

Increase

4

4

4

4

> tb

'1.10102,

 

 

 

Increase

an

an


 

 

Self care_

 

£11103

 

 

 

 

 

 

 

 

 

Definition

Ability to perform or complete p activities

Expectations Rise

_Result Criteria

Decreased Bass Moderate tient “i Increase

Bathing ability

Ability to wear

clothes

Feeding ability Z 3 4 5

Ability to toilet

(CHAPTER/BAK)

Verbalization of wishes

do self care

Interest in doing treatment

self

Maintaining cleanliness

self

Maintaining cleanliness

mouth

 

81


 

'Health Management L.12104

 

Definition

Ability to organize and integrate problem solving

health in daily life to achieve health status

Optimal.

Expectations Rise

Result Criteria

Enough

Decreasing emia Moderately Increasing Increasing

Take action for

reduce risk factors

Implementing the program

maintenance

Activities of daily living

effectively meet the goals

health

Increasing wea Medium Pages Decreasing

Verbalization of difficulties in

go through the program

treatment/treatment

 

62 Indonesian Nursing Outcome Standards


 

 

Family Health Management _—L.12105

 

 

Definition

Ability to handle family health problems optimally for

restore the health condition of family members.

 

 

Expectations Increase _

 

Result Criteria

Descending gene Moderate sented Increasing

Ability to explain

health problems that

experienced

Coping family activities

proper health problem

Actions to reduce

risk factors

Increased mone Moderate Rie: Decreased

Difficulty verbalization

carry out maintenance

set

Symptoms of member's disease

family

 

63


 

 

‘Health Maintenance _ 3 eas:

Definition

Ability to identify, manage, and/or find help

to maintain health.

 

Increased Expectations:

Result Criteria

Decreasing oo Moderately Increasing

Show behavior

adaptive

Show understanding

healthy behavior

Ability to run

healthy behavior

Help seeking behavior

Show interest

improve behavior

healthy

Have a support system

 

72 Indonesian Nursing Outcome Standards


 

Health Behavior | L.12107

 

-Definition

Ability to change lifestyle/behavior to improve

health status.

 

Expectations Improve

 

Result Criteria

Decreasing anette Medium wasnt Increasing

Acceptance of changes in health status

Ability to take action to prevent health problems

Health enhancing ability

Health control achievement


 

Definition

The condition of the family's physical, mental and social well-being

 

 

 

 

 

 

Expectations Rise |

 

 

 

Result Criteria

Decreasing go, Medium ganna at Increasing

Members' physical health

family

Mental health of members 1 2 2 a 5

family

Physical activity of members 1 2 3 4 :

family

Immunization of family members

Psychosocial development

family members

Adjustment to

disability

Child care supervision

Maintenance supervision

adult health

Access to health facilities

Member health screening

age-appropriate family

Family member visit

to school

Member school achievements

family

Parents' job

Suitable housing 1 2 3 - 2

Nutritious food supply

Source of finance

Health care resources 1 ie 3 4 5

Sources of social services

Increase in color Medium Praise Decrease

Member infection incidence

family

Domestic violence i

Physical abuse

Psychological abuse

Substance abuse

Smoking abuse

Gambling addiction

112 Indonesian Nursing Outcome Standards


 

 

Community Health Status L.12109

 

 

Definition = ee =

Conditions of physical, mental and social well-being of the community —

Increased Expectations:

Result Criteria

 

 

 

Enough

Decreasing Decreasing Increasing Increasing

Promotional program availability

health

Availability of protection program

health

Participation in the program

community health

Opt-in

insurance/health insurance

Compliance with standards

environmental Health

Health surveillance system

Standard monitoring

community health

Increasing genre Medium Pe Descending

Mortality rate

Morbidity rate

Number of health problems

mental

Disease prevalence

Substance abuse rate 2 3 al 5

Abuse rate 2 3 4 .

alcohol

Number of smoking habits

Infectious disease rate

sexual

Preterm birth rate

Birth weight

low

Incidence of injuries 2 3 4 9

Crime rate

113


 

 

Compliance Level L.12110

Definition

Behavior of the individual and/or caregiver in following the plan

agreed care/treatment with health workers,

so that the results of treatment / treatment are effective.

 

 

 

 

_Increased Expectations

 

 

Enough

Descending Manx Is Rising Up

Verbalization of will

comply with the program

treatment or

treatment

Verbalization follows

suggestion

Increasing ete Medium Sees Decreasing

Risk of complications 1 2 Z 4 5

illness/health problem

Yuku gets worse, Moderate = ENOUGH — Improves

Behavior following the program

treatment/treatment

Running behavior

suggestion

Signs and symptoms of disease 1 2 2 4 3


 

 

Knowledge Level L.12111

Definition

Adequacy of cognitive information related to a particular topic.

Expectations Improve

 

 

 

 

 

 

Result Criteria

 

Enough

Decreasing Aces Increasing Increasing

Behavior as recommended

Verbalization of interest in 1 z S 4 5

study

Ability to explain

knowledge about

a topic

Ability

describe

previous experience

appropriate to the topic

Behavior according to

knowledge

Increase ot Moderate eee Decrease

Questions about problems

faced

Wrong perception

to problems

Undergo an inspection

not exactly

Worsening jy ENOUGH | Currently Mem, _Improvement

Behavior

ee Se

 

146


 

 

Family support

 

 

Definition

Availability of support from family members to meet needs |

individuals undergoing treatment.

 

Expectations Rise

 

 

Result Criteria

 

Decreased B jeacr Moderately increasing

Family members Verbalization

desire to

support members

sick family

Asking the patient's condition 1 2 s 4 2

Seek social support for 1 2 3 6 5

sick family member

Looking for spiritual support for

sick family member

Collaborate with members

sick family

determine treatment

Cooperating with providers

health services in

determine treatment

Participate in planning = 1 2. a 4 5

go home

 

21


 

 

Social Support | | L.13113

Definition

Availability of support from others to meet individual needs

who, undergoing treatment

 

 

Expectations Rise

Result Criteria

Decrease ta Moderate moment = Increase

Ability to ask for rock

on other people

Help offered by

others

Emotional support

provided by others

Helpful social network

22

 


 

 

Family Function L.13114

 

Definition

The ability of the family to meet the needs of family members during the development process

 

Expectations Improved

 

Result Criteria

Decreasing Culaip While Conte is Increasing

Decrease Increase

Meeting the needs of family members

Family members support each other

Family members perform expected roles

Adaptation to problems

Adaptation to developmental transitions

Distribution of responsibilities to each family member

The environment supports family members expressing feelings

Involvement of family members in problem solving

Verbalize commitment to family

Family members are involved in community activities

Maintaining family traditions

 

L.13415

Sa ee nents ey aeeneeneenon

social interaction

Definition —

Sufficient quantity and/or quality of social relations.

 

Expectations Rise

 

 

Result Criteria

 

Feeling comfortable with

social situation

Feeling easy to accept

or communicate

feeling

Responsive to others

Feeling attracted to people

other

Interested in making contact

emotion

Interest in physical contact

Verbalizer of affection

Eye contact

Responsive facial expressions

Cooperative in play

with peers

Cooperative with

friends of the same age

Age-appropriate behavior

Symptoms of anxiety

Decrease

1

1

Increase

1

Enough

Decrease

2

Z

NO PO

RO

Nh MN DN PD

2

Z

Enough

Increase

2

Currently

3

3

WOW WOW

WOWWW WW

Currently

3

Enough

Increase

4

4

= >

ARK DBS

4

4

Enough

Decrease

4

Increase

5

5

an

anon oo on

oO

Decrease

5

 

Indonesian Nursing Outcome Standard

 


 

 

Social Engagement L.13116

 

Definition

Ability to develop close, warm, open and independent relationships with others.

 

Expectations Rise

 

Result Criteria

Interaction interest

Verbalization of clear goals

Interest in activities

Isolation verbalization

Verbalization of insecurity in public places

Withdrawal behavior

Verbalize feelings differently from other people

Pre-occupational verbalization with one's own mind

Mood/sad affect

Hostile behavior

getting worse

Behavior in accordance with the expectations of others

Purposeful behavior

Eye contact

Age-appropriate developmental tasks

 

Parenting Performance L.13117

 

Definition

The pattern of providing an environment for children or family members to support and build physical, emotional and social aspects.

 

ExpectationsIncrease

 

Result Criteria

Enough

Decreasing ienurrs Increasing Increasing

Fulfillment of children's physical needs

Meeting children's emotional needs

Fulfillment of children's social needs

Meeting children's special needs

Provision of age-appropriate nutrition

Child health care

Stimulation of cognitive development

Stimulation of social development

Stimulation of emotional development

Spiritual development stimulation

Interaction according to the child's temperament

Use of age-appropriate discipline

Interact with children

Empathy for children

Open communication with children

Positive verbalization in children

Mutual love

Realistic expectations of the role of parents

Expression of parental satisfaction

Increase by one Moderate i. Decrease

Environmental hazards

Closed communication with children

Negative self-esteem Ekspresi

 


 

Verbal Communication L118

 

Definition

Ability to receive, process, send, and/or use the symbol system

 

Expectations Rise

 

Result Criteria

Enough

Decreasing Fallows Increasingly Increasing

Speaking ability

Hearing ability

Expression suitability

face/body

Eye contact

Aphasia

Dysphasia

Apraxia

dyslexia

knight

Afonia

Dislalia

Pelo

stutter

Behavioral response

Communication understanding

 

'Role Appearance

 

 

Result Criteria

 

Decreasing ote Moderate Monday a Increasing

Verbalization of expectations fulfilled

Role satisfaction verbalization

Verbalization of expectations fulfilled

Role satisfaction verbalization

Role adaptation

Effective coping strategies

Social support

Role responsibilities

Verbalization of feeling confused about playing the role

Role conflict

Verbalize feelings of anxiety

Anxious behavior

Depression affect

 

 

The Role of Being a Parent 1.43420

 

Definition

the ability of parents to provide an environment for children or family members that is sufficient, to facilitate growth and |

 

Expectations | getting better

 

Result Criteria

Bouding attachment

Positive behavior in parenting baby care interactions

Verbalize the satisfaction of having a baby

Giving understanding to children/family members

Physical needs of children/family members are met

Emotional needs of children/family members are met

Desire to increase the role of being a parent

Verbalization of satisfaction with the home environment

Child or family Verbalize realistic expectations

Visual stimulation

Tactile stimulation

auditory stimulation

 

 

Lagat's Caregiver Role

 

Definition

Ability to play a role in providing care in the family.

 

Expectations Improve

 

Result Criteria

Ability to provide care

Ability to treat patients

Ability to complete patient care tasks

Worried about being treated again

Continuation of care concerns

 

Attachment , | <<. Bteige

 

Definition

The ability to interact between parents or the closest person to the baby/child which can affect the process of honing, caring and nurturing.

 

Expectations Rise

 

Result Criteria

Decreasing ete Moderate Mociatce Increasing

Practicing healthy behavior during pregnancy

Prepare baby equipment before birth

Verbalize positive feelings towards baby

Kissing baby

Smiling to baby

Make eye contact with baby

Talking to baby

Play with baby

Responds to baby cues

Entertaining baby

Carrying baby for breastfeeding / feeding

Keep baby clean and warm

Baby looking at parents

Worries about carrying out parental roles

Conflict between parent and baby/child relationship

Worries due to hospitalization

Physical barrier

Substance abuse

 

 

 

Family Process | L.13123

 

Definition

Ability to change in family relationships or functioning.

 

Expectations Improve

 

Result Criteria

Adaptation of the family to the situation

Family ability to communicate effectively

open among family members

The ability of the family to meet the physical needs of family members

The ability of the family to meet the emotional needs of family members

Ability of the family to seek help appropriately

Activities to support the safety of members, families

Activities support the growth of family members

Accuracy of the role of the family at the stage of development

Respect among family members

Family interest in positive activities

Family's ability to recover from difficult conditions

The balance of autonomy and togetherness

Death at the limits of family members

Relations with the community

Family adaptation to change

 

 

Parenting Process L.13124

 

Definition

Ability to accept the process of pregnancy, childbirth and after delivery, including care for newborns in accordance with the context of norms and expectations.

 

Expectations Improve

 

Result Criteria

emia cn ae a lg a

Decreasing — Moderately Nena a Increasing

Exposure to information about the birth/care process

Adequate management of discomfort during labor is adequate

Access to health services is easy to reach

Conformity of the baby's condition with expectations

Baby environmental safety

Domestic violence

Psychological stress

Unwanted/planned pregnancy

Maternal powerlessness

Drug abuse

Lack of interest in the birth process

Less proactive in the labor process

 

Skin and Tissue Integrity L.14125

 

Definition

Intact skin (dermis and/or epidermis) or mucous membrane tissue, cornea, fascia, muscle, tendon, bone, cartilage, joint capsule and/or ligament).

 

Expectations Rise

 

Elasticity

Hydration

tissue perfusion

Network damage

Damage to the skin layer

Painful

Bleeding

redness

Hematoma

Abnormal pigmentation

Scar tissue

Necrosis

Corneal abrasion

Worsening ews Moderate oe Getting better

skin temperature

Sensation

Texture

hair growth

 

Environmental SafetyHome L.14126

 

Definition

Arrangement of space and furniture to prevent physical injury at home

 

Expectations Rise

 

Result Criteria

home maintenance

Exterior lighting

Interior lighting

Availability of clean water

Storage cleanliness

Kebeisihun food ready

Residential cleanliness

Security lock on door

The death of the lock on the window

Handrail installation

Carbon monoxide detector maintenance

Emergency response system

Availability of telephone access

Easy access to the bathroom

Drug storage safety

Availability of assistive devices

Home appliance maintenance

Availability of fire alarm

Disposal of hazardous materials

Children's play area safety

Electrical outlet protector

Room temperature setting

Mushroom risk

Risk of toxic fumes

Tobacco smoke risk

Lead hazard

Dangerous sound risk

 

Symptom Control L.14127

 

Definition

The ability to control aneurysms reduces changes in physical and emotional function that are felt due to the emergence of health problems

 

Expectations Rise

 

Result Criteria

Ability to monitor the appearance of symptoms independently

Ability to monitor duration of symptoms

Ability to monitor symptom severity

Ability to monitor symptom frequency

Ability to monitor symptom variations

Ability to take preventive action

Ability to take action to reduce symptoms

Get health care when symptoms of danger appear

Ability to use available resources

Record the results of symptom monitoring

Ability to report symptoms

 

 

Risk Control L.14128

 

Definition

Ability to understand, prevent, eliminate or reduce modifiable health threats.

 

Expectations Rise

 

Result Criteria

Ability to find information about risk factors

Ability to identify risk factors

Ability to carry out risk control strategies

Ability to change behavior

Commitment to strategy

Lifestyle modification ability

Ability to avoid risk factors

Ability to recognize changes in health status

Ability to participate in risk screening

Use of health facilities

Use of support system

Monitoring changes in health status Immunization

 

 

Postoperative Recovery L.14129

 

Definition

Healing process after undergoing surgery to start and perform daily activities.

 

Expectations Rise

 

Result Criteria

Convenience

Appetite

Mobility

Ability to continue work

Ability to work

Self-care ability

Healing time

Decreasing eruican Medium Increasing Increasing

skin union

The unification of the edges

Granulation tissue

Scar tissue formation

Increases “oe a Moderate Brakes # Decreases

Edema on the wound side

Wound inflammation

Painful

Purulent drainage

Sorous drainage

Sanguinis drainage

Serosanguinous drainage

Enthema on surrounding skin

Increased skin temperature

Bad smell in the wound

Necrosis

Infection

 


 

 

 

Local Allergy Response 44131

 

Definition

Changes in the body's local reaction power due to exposure to allergens and experiencing excessive stimulation of the immune response. :

 

Expectations Drop

 

Result Criteria

Painful

Local itching

Mucus secretion

Sneeze

Local erythema

conjunctivitis

lacrimation

Rhinitis

Local edema

 

Systemic Allergic Response |

 

 

Definition | ae

Systemic changes in the body's reaction power due to exposure to allergens and

overstimulation of the immune response.

 

 

Expectations Rise

 

 

Result Criteria

 

Increasing itohindie Medium ee. Decrease

Ectma of the larynx

Dtspnea

Wheezing

Stridor

Additional breath sounds

Tachycardia

BP drop

dysrhythmia

pulmonary edema

Loss of consciousness

Mucus secretion

Itching all over the body

red spots

Petechie

Erythema

Increased skin temperature

Fever

Nauseous

Gag

Diarrhea

Abdominal cramps

Hemolysis of red blood cells

Bilirubin levels

Joint pain

Muscle ache

Anaphylactic shock

ee

 

 

'Ince Immune Status Aaa

 

Definition

_Immune to internal and external antigens

 

 

 

 

 

 

 

 

 

 

 

ktasi Improve

 

 

 

 

 

-Result Criteria

 

Decreasing o Medium waa Increasing

skin integrity

Mucosal integrity

Antibody titer

Immunization

T4 . cell levels

T8 . cell levels

 

Increasing Binant Moderate a Decreasing

recurrent infection

Tumor

Weight loss

Chronic fatigue

 

Worsening we Moderate — Improving

Body temperature 1 ye 3 4 5

White blood cell

 

 

 

108

 

 

 

 

neater citi tee

 

Thermoregulation | L.14134

 

Definition

Regulating body temperature to stay in the normal range.

 

Expectations Improve |

 

Result Criteria

Shivering

red skin

Seizures

Acrocyanosis

Oxygen consumption

Piloerection

Peripheral vasoconstriction

Kutis memorata

Pale

Tachycardia

Tachypnea

Bradycardia

Cyanolic nail base

Hypoxia

Body temperature

skin temperature

Blood glucose level

Capillary Filling

Ventilation

Blood pressure

 

 

Neonate Thermoregulation L.14135

 

Definition

Regulating the neonate's body temperature to keep it in the normal range. _

 

Expectations Improve

 

Result Criteria

Decreased avon " Moderate ears Increased

Shivering

Acroslanosis

Piloerection

Oxygen consumption

Kutis memorata

Cyanotic nail bed

Increasing sieciietai Moderate ee Decreasing

Body temperature

skin temperature

pulse rate

Land glucose level

Capillary refill

Piloerection

Ventilation

 

Injury Rate L.14136

 

Definition

Observed or reported severity and injury.

 

Expectations Drop

 

Result Criteria

Activity tolerance

Appetite

Food tolerance

Injury incident

Wounds/blisters

muscle tension

Fracture

Bleeding

Painful facial expression

Agitation

irritability

Mobility disorders

Cognitive impairment

Blood pressure

pulse rate

Respiratory rate

Apical heart rate

Radial heart rate

Rest/sleep pattern

 

Infection Rate L.14137

 

Definition

Degree of infection based on observations or sources of information.

 

Expectations Drop

 

Result Criteria

Hand hygiene

Body hygiene

Appetite

Fever

redness

Painful

Swollen

Vesicle

Foul-smelling liquid

Sputum is green

Purulent drainage

Piuna

period of malaise

Shivering period

Lelargy

Cognitive impairment

White blood cell levels

blood culture

urine culture

Sputum culture

Wound area culture

Stool culture

White blood cell levels

 

Fall Rate L.14138

 

Definition

Degree of fall based on observations or sources of information.

 

Expectations Drop

 

Result Criteria

Fall out of bed

Fall while standing

Fall while sitting

Fall while walking

Falls when moved

Fall while climbing stairs

Fall while in the bathroom

Falls while bending _


 

Airway Clearance L.01001

 

Definition

Ability to clear secretions or airway obstruction to maintain a patent airway.

 

Expectations Rise

 

Result Criteria

Effective cough

Sputum production

Wheezing

Wheezing

Meconium (in neonates)

Dyspnea

Orthopnea

Difficult to talk

Cyanosis

Nervous

Respiratory rate

Breathing pattern

 

 

 

Help sync

ventilator

Increase

Use of accessory muscles

breath

Gasping breath

(gasping)

Shallow breath

Agitation

Tired

The feeling of worrying the machine is broken

Focus on breathing

Abdominal paradox breath

Diaphoresis

getting worse

Respiratory rate

Arterial blood gas values

Breath effort

Auscultation of inspirational sounds

Skin color


 

Gas Exchange L.01003

 

Definition

Oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane was within normal limits.

 

Expectations Rise |

 

Result Criteria

Decreasing ee Medium lyseli Increasing

Level of consciousness

Increase weed Moderate a 7 Decrease

Dyspnea

Additional breath sounds

Dizzy

Blurred vision

Diaphoresis

Nervous

Nostril breath 1 2 3 a 2

Deteriorating Pin Moderate ae Better

PCO,

PO,

Tachycardia

arterial pH

Cyanosis

Breathing pattern

Skin color

 


 

—,

Breath Pattern L.01004

Definition of Xe

inspiration and/or expiration that provides adequate ventilation.

 

 

 

 

 

Improved Expectations __

Result Criteria a

Descending ane - Moderate spate of Increasing

Minute ventilation

vital capacity

Anterior thoracic diameter

posteilor

Expiratory pressure

Inspiratory pressure

3 Enough Enough

Increasing Increasing Medium Meccwiil Decreasing

Dyspnea

Use of accessory muscles

breath

Expiratory phase prolongation

Orthopnea

Pursed-tip breathing

Nostril breathing

Worsening CuKee Moderately Better

Worse Better

Respiratory rate

Breath depth

Chest excursion

TE nnn ne LIES SSIInISS SISSIES

 


 

Ventilation ResponseMechanical ———_—iL.01005

 

 

Definition

Effective alveolar exchange and tissue perfusion supported by

_mechanical ventilation

 

 

Expectations Rise

 

 

Result Criteria

 

Enough

Decreased Decreased Increasing Increasing

FIO, meet the needs

Level of consciousness

One oxygen constellation

Symmetry of wall movement

chest

Increasing genus Going Decreasing

airway secretion

Additional breath sounds

Lung infection

Difficulty breathing with

ventilator

Atelectasis 1 z 3 “ >

Anxiety

Lack of rest

Difficulty expressing | 2 3 4 3

need

Sedation dose

It's getting worse we're on Getting better

airway secretion

Additional breath sounds

Lung infection

Difficulty breathing with

ventilator

Atelectasis

Anxiety

Lack of rest

Difficulty expressing

need

Sedation dose

airway secretion

Additional breath sounds

eee

104 Indonesian Nursing Outcome Standards


 

 

Aspiration Rate L.01006

 

Definition

Condition of entry of liquid or solid particles into the lungs.

 

Expectations Drop

 

Result Criteria

Level of consciousness

Ability to learn

Oral hygiene

Dyspnea

Muscle weakness

Accumulation of secretions

Wheezing

Cough

Use of accessory muscles

Cyanosis

Nervous

Respiratory rate

 

 

Spontaneous Ventilation L.01007

 

Definition

adequate energy reserves to support the individual being able to breathe

adequately.

 

Expectations Rise

 

Result Criteria

 

Enough

Tidal volume

Dyspnea

Use of accessory muscles

breath

Nervous

PCO,

PO,

PO,

Tachycardia

 

Cardiac Output L.02008

 

Definition

Adequate heart pumping blood to meet the body's metabolic needs.

 

Expectations Rise

 

Result Criteria

Peripheral pulse strength

Fractional Ejection (EF)

Cardiec todex (Cl)

Left ventricular stroke work

index (LVSWI)

Stroke volume index (SV1)

Palpitations

Bradycardia

Tachykardla

ECG arrhythmia picture

Tired

Edema

Jugular venous distention

Dyspnea

Oligurla

Pale/cyanosis

Paroxysmal nocturnal dyspnea (PND)

Orthopnea

Cough

S3 heart sound

S4 heart sound

Heart murmur

Weight

Hepatomegaly

Pulmonary vascular resistance (PVR)

Systernic vascular resistance

Worsening ee Moderate oe Getting better

Blood pressure

Capillary refill time (CPT)

Pulmonary artery wedge

pressure (PAWP)

Central venous pressure

 

Gastrointestinal Perfusion | L.02010

 

Mastiekuten blood flow to the gastrointestinal tract to maintain

organ function.

 

Expectations ——_ Increase

 

Result Criteria

decreased co. Medium Eyes at Increasing

Appetite

Increasing Fi ee Moderate oe 1 Decreasing

Load

Gag

Abdominal pain

ascites

Constipation

Diarrhea

Enough :

Worsening Worsening Getting Better

Bowel noise

 

Myocardial Perfusion 1.02011

 

Definition:

_ Adequate coronary artery blood flow to maintain function

“AMUN.

 

Expectation = Increase

 

Result Criteria

Decreasing wane Medium sennas Increasing

ECG arrhythmia picture

Chest pain

Diaphoresis

Nauseous

Gag

Apical artery

Average arterial pressure

Tachycardia

Bradycardia

Radial pulse

Blood pressure 1 2 2 4 S

Ejection fraction

Pulmonary artery wedge pressure

Cardiac index (Cl)

 

Peripheral pulse

Wound healing

Sensation

Pale skin color

Peripheral edema

Extremity pain

Parasthesia

Muscle weakness

Muscle cramp

Bruit fernoralis

Necrosis

Capillary refill

Akral

skin turgor

Systolic blood pressure

Diastolic blood pressure

Average arterial pressure

ankle-brachial index

 

annem

 

SE Renal Perfusion ee

 

 

Definition

Adequate renal artery blood flow to support kidney function.

Expectations Rise

 

 

 

Result Criteria

 

Enough

Decreasing Manuran Is Increasing Increasing

Amount of urine

Increasing ante Moderate aa Decreasing

Abdominal pain

Nauseous

Gag

Abdominal distension

Worsening Oectoon Moderate ice Better

Average arterial pressure

Blood urea nitrogen level

Plasma creatinine level

Systolic blood pressure

Diastolic blood pressure 1 2 2 4 >

Electrolyte level

Acid base balance

Bowel sounds 1 Z 3 4 2

Heart function 1 2 3 oh °

85

 


 

 

Cerebral Perfusion L.02014

 

Definition

Adequate cerebral blood flow to support brain function

Expectations Rise

Result Criteria

 

 

Decreasing cee A Moderate Ps Increasing

Level of consciousness

Cognitive

Increasing vetas Moderate ooo Decreasing

intracranial pressure

Headache

Nervous

Worry

Agitation

Fever

Worsening jycurUP | Medium = UNUF. = Improve

Average value of blood pressure

Awareness

Systolic blood pressure

Diastolic blood pressure

Nerve reflex

86 Indonesian Nursing Outcome Standard =

 


 

 

£02015 Spontaneous Circulation.

Definition

Ability to maintain adequate circulation

support life.

 

 

 

 

Expectations Increase by 2

Result Criteria

 

 

Decreasing wee Moderate conieins Increasing

Level of consciousness

Increased seeder Medium ae = Decreased

pulse rate

Blood pressure

Respiratory rate

Body temperature

Oxygen saturation

ECG arrhythmia picture

ETCO,

Urine production

———

| 105


 

 

Circulation Status | us See

 

 

Definition

Circulation of various necessary substances throughout the body and

the uptake of substances that are not needed to be excreted from the body.

 

Expectations Improve

——

 

 

 

Result Criteria

 

 

Decreasing nt Medium niomos Increasing

Pulse power

Urine output

Oxygen saturation

PaO,

Increasing ice Moderately Decreasing

Increase Decrease

Pale

Cold

PaCo,

Pitting edema

Peripheral edema

Orloslastic hypotension

Additional breath sounds

Bruit blood vessels

Jugular venous distention

ascites

Fatigue

Intermittent claudication

paresthesia

syncope

Extremity Uicus

Worsening wares: Moderate ee Better

Systolic blood pressure

Diastolic blood pressure

Pulse pressure

Mean arterial pressure

Capillary refill

Central venous pressure

Weight

 

1 27


 

———

Bleeding Rate L.02017

Definition

Blood loss, both internal (occurs inside the body) and external

(happens to exit the body).

 

 

 

 

Expectations Drop

 

 

Result Criteria

 

Enough

Declining Mararus Is Rising Increasing

Membrane humidity

mucosa

Skin moisture

Cognitive

Increasing mecca Moderate Ee Decreasing

hemoptysis

Hematemesis

Hematuria

Anal bleeding 1 rs 3 4 5

Abdominal distension

Vaginal bleeding 1 = 3 4 S

Postoperative bleeding

Worsening oo Moderately improving

Hemoglobin

Hematocrit

Blood pressure

Apical pulse

Body temperature


 

 

 

Weight | ___L.03018

Definition , eee

Accumulation of body weight according to age and gender.

 

 

Result Criteria

Enough

Worsening serabusrult Getting Better Better

Weight

Skin fold thickness

body mass index

 

ee

 


 

 

Gastrointestinal Function

 

 

Definition _

The ability of the digestive tract to enter and digest

and absorb nutrients and get rid of waste _ ; :

 

Expectations Improve

 

 

Result Criteria

 

Decrease

Tolerance to food

Appetite

Increase

Nauseous

Gag

Dyspepsia

Abdominal pain

Abdominal distension

Regurgitation

Residual amount of gastric fluid

moment of aspiration

Blood in feces

Hematemesis

getting worse

CHAPTER FREQUENCY

Stool consistency

Intestinal peristalsis

Amount of feces

Stool color

 

1

1

—_— — — —

Enough

Decrease

2

2

Enough

Increase

2

MMM NY NH PN

Nh ho

Enough

getting worse

2

NO NM ND PN

Currently

3

3

Currently

3

WWWWW WWW

Www Ww

Currently

a

WOW W Ww

Enough

Increase

4

4

Enough

Decrease

4

BHA HRA AA

> 

Enough

getting better

4

&ARH HL

5

Increase

S

Decrease

oO

nog oo oO

on-on

aw o vl

getting better

25


 

Liquid Balance L.03020

Definition

Equilibrium between the volume of fluid in the intracellular and extracellular spaces

body.

Expectations Increase _

Result Criteria

nem

 

 

 

 

 

 

Enough

Decreasing Men inas is Increasing Increasing

Fluid intake

urine output

Membrane humidity

mucosa

Food supply

Increasing ee Medium Scott Decreasing

Edema

Dehydration

ascites

Confucius

Deteriorating yy vruP | Moderate MnP, getting better

Blood pressure

Radial pulse

Average arterial pressure

Mucous membrane

Sunken eyes

skin turgor

Weight

 

41


 

 

Electrolyte Balance L.03021

 

Definition

Serum electrolyte levels are within normal limits.

Expectations — Increase

Result Criteria |

 

Decreases Medium Tires Sdesiehint Increases

Serum sodium

Serum potassium

Serum chloride

Calcium Serum

Serum magnesium

Phosphorus Serum

 

42 Indonesian Nursing Outcome Standards


 

 

Stability of Blood Glucose Levels L.03022

Definition

Blood glucose levels are in the normal range.

 

 

Expectations Increase _

 

 

Result Criteria

Decreasing —— Moderately Souteariail Increasing

Coordination

Awareness

Increasing ncn Medium ee Decreasing

Sleepy

Dizzy

Tired / lethargic

Hungry Complaints

Shaky

Sweating

dry mouth

thirst

Weird behavior

Difficulty speaking

Enough :

Worsening Worsening Getting Better

Glucose levels in the blood

Glucose level in urine

Palpitations

Behavior

Amount of urine

ee nnn nnn nee SnTEE EES

43

 


 

 

Definition

Gastrointestinal peristaltic activity

Expectations Improve

 

Result Criteria

Descending Baga Moderate Sonnei Increasing

Painful

Abdominal cramps

Nauseous

Gag

Regurgitation

Abdominal distension

Diarrhea

Increasing elena On the way to Decrease

Peristaltic sound

Gastric emptying

Hundred

 

66 Indonesian Nursing Outcome Standards


 

 

Appetite _ £03024

Definition

Desire to eat.

 

 

 

 

 

 

Expectations Improve

 

Result Criteria

Enough

Decrease ee. On The Rise Increasing

Desire to eat

Food supply

Fluid intake

Energy to eat

Ability to feel

food

Ability to enjoy 1 2 3 4. 5

food

Nutritional intake

Stimulus to eat

Starving

68 Indonesian Nursing Outcome Standards _


 

na

L.03025

 

Weight Maintenance Behavior —

 

 

Definition

Measures taken to maintain weight

optimal.

 

 

Expectations Rise

 

 

 

Result Criteria

Decreasing or Moderately Increasing

Monitor weight

Maintain calorie intake 1 2 o 4 5

daily as needed

Balancing workout

with calorie intake

Choose nutritious food

Drink water accordingly

body needs

Maintain

fluid balance

Expressing body image

realistic

Maintaining sufficiency

sleep

 

89


 

 

Behavior Increase Weight _L.03026

Definition

Measures taken to gain weight.

 

 

 

 

 

 

Expectations Rise

 

 

Result Criteria

 

Decreasing Bisco Medium iiaaranet Increasing

Identify causes 1 - 3 4 5

weight loss

Setting a target weight

healthy one

Identifying needs

calories

Identifying food

likes and dislikes

liked

Choose food and

protein drink

and high calorie

Maintain intake

food and Drink

nutritious

Monitor BMI

Monitor weight

Get help from the experts

health

Getting dental care

appropriate

Getting help

finance to buy

food

Identifying food

which causes allergies

Drink water accordingly

body needs

Taking supplements

nutrition

Eat food and

interlude drink

nutritious meal time

Maintaining adequate sleep

Giving feeding tube

according to recommendation

Provide parenteral nutrition

according to recommendation

90 Indonesian Nursing Outcome Standards —


 

Weight Loss Behavior L.03027

 

 

 

Definition

Measures taken to reduce weight.

Expectations Rise

Result Criteria

 

 

 

Decreasing oe Medium iameeaie Increasing

Determine target weight

body in range

normal

Have a commitment to

great meal plan

healthy

Avoid food and

high calorie drink

Choose food and

nutritious drink

Control the portion of food

Establish an exercise routine

Monitor weight

Monitor BMI

Get information

about strategy

lose weight

from health experts

Identify conditions

emotional that can

affect intake

food and Drink

Using strategy

behavior modification

Motivate yourself

Drink water accordingly

body needs

Using the right medicine

instructions (if any)

91


 

 

Fluid Status _ | L.03028

Definition

Condition of intravascular, interstitial, and/or intracellular fluid volume.

 

 

 

Expectations Improve

 

 

 

Result Criteria

Going down, I'm Wade Increasing

Pulse power

skin turgor

Urine output

Venous filling

Increasing Wane Is Pte Decreasing

Orthopnea

Dyspnea

Paroxysmal nocturnal

dyspnea (PND)

Ederna anasarka i

Peripheral edema

Weight

Jugular venous distention

Additional breath sounds

Lung congestion

Feeling weak

thirst complaint

urine concentration

Worsening in vain tk Moderate oo Getting better

pulse rate

Blood pressure

Pulse pressure

Mucous membrane

Jugular Venous Pressure 1 2 3 + °

(JVP)

Hb . level

Ht level

Central Venous Pressure

Hepatojugular reflux

Weight

Hepatomegaly 1 2 o 4 5

Oliguria

Fluid intake

mental state

Body temperature

1 07


 

 

Breastfeeding Status ee ae

Definition |

The ability to give breast milk directly from the breast to the baby

and children to meet nutritional needs.

 

 

 

Expectations Improve

 

 

Result Criteria

 

Enough

Increasing Increasing Moderately Decreasing

Baby's attachment to

boobsmom

Mother's ability

position baby

correctly

Baby micturition more than 8 times/

24 hours

Baby's weight 1 2 3 é 5

Milk drips/spouts | 2 a 4 5

Adequate breast milk supply

Nipples don't blister after 2 1 Z 3 4 y

week of delivery

Mother's confidence

Baby sleeping after feeding

Mother's breasts are empty after

breast-feed

baby intake

baby sucking

Blisters on the nipples

Maternal fatigue

Maternal anxiety

Fussy baby 1 Zz 3 4 2

Baby crying after

breastfeeding

 

119


 

Nutritional Status

Definition

fa

 

L.03030

 

 

Adequate nutritional intake to meet metabolic needs.

 

Expectations Improve

Result Criteria

Food portions

spent

masticatory muscle strength

Swallowing muscle strength

Serum albumin

Verbalization of desire for

improve nutrition

Knowledge of choice

healthy food

Knowledge of choice

healthy drink

Knowledge of standards

proper nutrition

Setup from storage

safe food

Setup and storage

safe drink

Attitude towards

appropriate food/drink

with health goals

Feeling full quickly

Abdominal pain

Sprue

Hair loss

Diarrhea

Weight

Body Mass Index (BMI)

Frequency of eating

Appetite

Bowel noise

Triceps skin fold thickness

Mucous membrane

Decrease

12

1

1

Increase

12

—_ =-— =) —)

getting worse

1

a_i at ot ot = —

 

Enough

Decrease

3

2

2

Enough

Increase

MPN DM Ww

Enough

getting worse

NO NO RN ND PO

 

 

Enough

Saceng Rising

4 5

3 4

3 4

3 4

3 4

3 4

3 4

3 4

3 4

3 4

Enough

Descending Seceng

4 S

a 4

= 4

3 4

2 4

Enough

Meaeng Better

2 4

2 4

3 4

3 4

3 4

3 4

3 4

 

 

 

Increase

an

Decrease

on nn oO

getting better

Aanan»nnn

121


 

 

Ba Nutritional Status

Definition

rig a nutrient intake to meet needs, metabolism in

ayl.

 

 

 

Expectations |§= Improved

 

 

Result Criteria

Decreasing won, Medium marines Increasing

Weight

body length

Increasing ces Medium pee Decreasing

yellow skin

Yellow sclera

Yellow mucous membrane

Prematurity

Cry baby

Pale

Difficulty eating

food allergy

It's getting worse ee While it's getting better

Dietary habit

Skin fold thickness

Growth process

Fat layer

ee ee

122 Indonesian Nursing Outcome Standards


 

Sra ee ee scan sm eerie ease

Shock Level L.03032

Definition

Insufficient blood flow to body tissues, which can result in:

life-threatening cellular dysfunction.

se a ee

Expectations Drop

Sa i nennninicencncnice ae en dn

Result Criteria:

ns ee

Enough

Decreasing Decreasing Increasing Increasing

Pulse power

Urine output

Level of consciousness

Oxygen saturation

Increased veringent Medium Ree Decreased

Cold

Pale 1 = = 4 5

Thirsty

Confucius

lethargy

Metabolic Asiaosis

It's getting worse Poe is getting better

Mean arterial pressure 1 2 2 4 o

Systolic blood pressure

Diastolic blood pressure

Pulse pressure

Capillary refill

pulse rate

Respiratory rate

148 Indonesian Nursing Outcome Standards


 

Fecal Elimination at 4.04033

Definition

The normal process of defecation is accompanied by easy and easy expulsion of feces

The consistency, frequency and shape of the stool are normal.

 

 

 

 

 

Expectations Improve

 

 

 

Result Criteria

Decreasing me Medium waiions a Increasing

Control the expulsion of feces

Increases sce Medium oe " Decreases

Complaints of long defecation and

difficult

Straining during defecation

Abdominal distension

Feel the mass in the rectal

Urgency

Abdominal pain

Abdominal cramps

Worsening in Moderate ee Getting better

Stool consistency

Defecation frequency

Intestinal peristalsis 1 Z 3 4 a

23


 

 

Urine Elimination - L.04034

Definition

Complete bladder emptying.

Expectations Improve

 

 

 

 

Result Criteria

 

Decreasing Fs Medium but Increasing

Urinating sensation | Z 3 4 5

Increasing igri Moderate Praia Decreasing

Urge to urinate

(urgency)

Bladder distension

urine

Urination is not complete

(hesitancy)

residual urine volume

Urine dripping

(dribbling)

nocturia

bedwetting

Enuresis

Dysuria

Anuna

Worsening wees Moderately improving

BAK frequency

Characteristics of urinal

 

EEE

24 Indonesian Nursing Outcome Standards |


 

 

 

Acid Base Balance L.04034

 

Definition |

_Equilibrium between hydrogen ions in the intracellular and extracellular spaces of the body

 

 

 

 

 

 

 

 

 

 

 

Result Criteria

Decreasing gn Moderately Increasing

 

Level of consciousness

Rest

 

Increasing eos Moderate ee Decreasing

Nauseous

Muscle cramp

Muscle weakness

 

Worsening aon k Moderate — a Improving

Respiratory rate

breath rhythm 1 a 3 a 5

pH

CO2 . level

Bicarbonate content

Phosphate level

Sodium level

Chloride level

Protein content

Hemoglobin levels

 

40 Indonesian Nursing Outcome Standards

 

 

Fecal continence L.04035

See ea EOS

Definition

Normal pattern of bowel habits.

 

 

 

Lowering the oven Medium a Increasing

Expenditure control

feces

Enough ;

Worsening AMarcisursile Is Getting Better

Defecation 1 - 3 4 5

Frequency of bowel movements

Perianal skin condition

a ee SS SS

ee: | Indonesian Nursing Outcome Standards |

ty


 

 

Urine Continence L.04036

 

 

Definition

Pattern of urination

 

 

 

Expectations Improve |

 

 

 

CriteriaResult

Decreased oe = Moderately increased

Ability to urinate

Increasing ee Moderate ss Decreasing

nocturia

Residual urine volume after

urinate

Bladder distension

Dribbling

Hesitancy

Enuresis

Verbalization of urine output

not finished

Worsening ae x Moderate ee Better

Urinary frequency

Urinary sensation

 

53

 


 

 

Disability Adaptation L.05037

Definition

The process of functional adjustment to the challenges of physical limitations.

Expectations Rise

 

 

 

 

Result Criteria

 

Decreasing ne, "1 Is increasing iacietancs

Verbalization customize

self with disability

Verbalization of reconciliation

with disability

Adaptation with

physical limitations

Modify the appropriate lifestyle

disability condition

Job modification accordingly

disability condition

Strategies to overcome

stress due to diabetes

Use of assistive devices

according to the needs

Increasing ete Moderate a Decreasing

Negative feelings

Low self esteem

eee

14 Indonesian Nursing Outcome Standards


 

 

Ambulation | L.05038

Definition

The activity of walking from one place to another independently is good

with or without tools.

 

 

 

 

Expectations Rise

Result Criteria

 

 

Decreasing i Moderate Pc Increasing

Support weight

Walk with steps

effective

Walk with steps

slow

Walk with steps

currently

Walk with steps

fast

Walk uphill

Walking downhill

Walking short distances 1 ie 3 4 5

Walking distance seditng

Long distance walking | 2 3 4 S

Walk around the room

Bwijaluri through

obstacle

Increasing Wena Moderate eo Decreasing

Pain when walking

Stiff in joints

Reluctance to walk

Feelings of worry when

walk

16 Indonesian Nursing Outcome Standards


 

Balance | £05039

 

 

My definition

Ability to maintain body equilibrium

Expectations Rise

 

 

 

 

Result Criteria

Decreased oo Moderate (Increased nest

Ability to sit without

backup

Ability to rise from

sitting position

Balance while standing 4 2 3 a 5

Balance while walking

Balance while standing

with one leg

Increase aoe Moderate oo Decrease

Dizzy

Shaking feeling

Stumble

Worsening se. While eon ne is getting better

Posture

 

39


 

 

Definition

Ability to use energy effectively and efficiently.

 

 

 

 

 

_Expectations Rise

 

_Result Criteria

 

Enough

Enough

Decreasing acura: Moderately Increasing Increasing

Physical activity that

recommended

The right activity

Strategy for

balancing

activity and rest

Energy conservation technique

Breathing technique that

effective

Energy restriction

Proper body mechanics

Simplifying technique

profession

Use of assistive devices

correct

Increasing ota Moderate oe Decreasing

Activity restrictions 1 2 2 4 :

The factors that

increase expenses

energy

51


 

 

'Perge rergeral's coordination will be L.05041

Definition

The ability of the circadian muscles to cooperate with appropriate body movements

and directed.

 

Expectation = Increase _

Result Criteria

Decreasing — Moderately eae Increasing

muscle strength

Gesture control

Movement balance

Stability of movement

Motion thirst

Movement in the direction

want a

Movement with time 1 2 2 4 S

wanted

Movement with speed

which is desired

Movement with precision

which is desired

Increased tie bag Medium ——— A Decreased

Muscle tension 1 Z a 5

Muscle cramp

Enough ;

Worsening Worsening Getting Better

muscle shape

Movement speed

61


 

Physical Mobility | ___b,05042

Definition

Ability to physically move one or more extremities

independent.

 

 

Expectations Rise

Result Criteria

Enough

Declining Retuean Is Increasing Increasing

Extremity movement

muscle strength

Range of motion (ROM)

Increase ae Medium — Decrease

Painful

Worry

Stiff joints

Uncoordinated movement

Limited movement

Physical weakness

65


 

 

Organizational Behavior Ba 1.05043,

 

 

Definition

Ability to integrate physiological and neurobehavioral responses of infants to

environment.

 

 

 

 

 

 

 

'Expectations_ Rising

Result Criteria _

Decreasing a Moderately senna a Increasing

Movement in the extremities

Finger ability

holding

Coordinated movement

Normal response to

sensory stimulus

Cry

Able to respond to shock

Irritability

Reflex

Motor tone

Saturation

Increasing color Moderate a Decreasing

Nervous

Tremor

jerk

Arrhythmia

Bradycardia

Tachycardia

Worsening ees Moderate oak Better

Breastfeeding ability

skin color

70 Indonesian Nursing Outcome Standards


 

 

Joint Movement —L.05044

Definition |

The ability to perform joint movements in all joints of the body simultaneously

independent_

 

 

 

 

Expectations Rise

 

 

Result Criteria

 

Enough

Decreased Atorin Moderately Increasing Increasing

Jaw

Neck

Back

Finger (right)

Finger (left)

Thumb (right)

Thumb (left)

Wrist (right)

Wrist (left)

Elbow (right)

Elbow (left) 1 2 2 a

Shoulder (right) 1 2 3 o

Shoulder (left)

Ankle (right)

Ankle (left)

Knee (right)

Knee (left)

Pelvis (right)

Pelvis (left)

87 ;


 

 

Sleep Pattern _ £05045

Definition

Adequate quality and quantity of sleep.

 

 

 

 

Expectations Improve

 

 

Result Criteria

 

Decreasing Pm Moderately Increasing

Complaints of sleeplessness

Complaints are often awake

Complaints of not being satisfied with sleep

Complaints about changing sleep patterns

Complaints of rest no

enough

Increasing wanna Moderate aoe Decreasing

Activity ability

eee

96 Indonesian Nursing Outcome Standards


 

"eee

Fatigue Level L.05046

Definition

Physical and mental work capacity that does not recover with rest.

Expectations Improve

 

 

 

 

Result Criteria

 

Enough

Decreasing Decreasing Increasing Increasing

Verbalization of energy recovery

Power

Ability to do

routine activities

Motivation | Zz 3 4 6

Increasing Se Moderate eee Decreasing

Verbalization tired 1 = 3 4 6

Sluggish

Concentration disorders

Headache

Sore throat

Wheezing 1 = 3 4 Ss

Cyanosis

Nervous

Breathing Frequency

Guilt

Worsening oe Moderate Bo Getting better

Appetite

Breath polo

Libido

Rest pattern

SS eee

| 141


 

 

-Frequency — : Se 3 4 5

~ Oxygen saturation -4 i 3 4 5

_ Ease of doing fe 3 4 5

-—_Daily activities Se |

_ Running rate 1 2 3 4 <=

_walking distance q- =2 3 Sg =8

_ Upper body strength sad ee a= 4 5

body check — bottom 1 <2 SZ “4 Ss

 


 

 

'Sensory Function

 

Definition

The ability to perceive sound stimulation, taste. touch, smell and

visual image

Expectations Improve

 

 

 

Result Criteria

 

Decreasing ed Medium Mane Increasing

Hearing acuity

Visual acuity

Perception of skin stimulation

Perception of Dose1 head

Perception of body position

Smell difference

Taste difference

 

28 Indonesian Nursing Outcome Standards


 

 

Definition

The stability of the intracranial dynamic mechanism in compensating

 

to stimuli that reduce intracranial capacity.

Expectations Rise

SS eee

 

Result Criteria

 

Level of consciousness

Cognitive function

Headache

Nervous

Agitation

Gag

Decerebrate posture

(extension)

Papilledema

Blood pressure

Pulse pressure (pulse

pressure)

Bradycardia

Breathing pattern

Pupil response

Neurological reflex

Intracranial pressure

Decrease

1

1

Increase

—_— —_' —-2 2 —

getting worse

—_— = oe = =

 

Enough

Decrease

2

Za

Enough

Increase

MO NM DM BD PO

2

Enough

getting worse

2

2

NINN BD Ph

Enough

On The Rise

3 4

3 4

Enough

On Decline

3 4

3 4

3 4

3 4

3 4

3 4

Enough

Moderate — good

3 4

3 4

3 4

3 4

3 4

3 4

3 4

Increase

5

5

Decrease

aAnnn

on

getting better

ann nn

 


 

 

Seizure Control L.06050

 

 

Definition

~Ability to; control or reduce episodes

.

_convulsions

 

 

“Result Criteria

 

Enough

Enough

Descending Declining Increasing Increasing

Ability

identify factors

seizure risk/trigger

Ability to prevent

risk factors/triggers

seizure

Ability to report

drug side effects

Compliance with taking medication

Positive attitude 2 aa 5

Use of 1 2 3 * 5 . reduction technique

stress

Role appearance

Social relations

Sleep pattern

Appropriate exercise program

Increasing enc Moderate a Decreasing

Get the medicine

needed

Report seizure frequency

56 Indonesian Nursing Outcome Standards


 

Eee aaa Teeter ieee peepee eects Sinteass is

 

Peripheral Neurovascular __L.06051

Definition

Circulation and sensation of movement of the extremities are adequate. 4

Expectations Rise

 

 

 

Result Criteria

 

Enough

Decreasing Decreasing Increasing Increasing

Arterial circulation

Venous circulation

Joint movement

Extremity movement

' Enough

Increasing Increasing Moderately Descending Mer

Painful

Bleeding

Deteriorating Net he Pte is getting better

Pulse

Body temperature

Skin color

Blood pressure

Pressure ulcer

69

 


 

Swallowing Status ——-L,06052

Definition

The passage of food from the mouth to the stomach is adequate.

Expectations Improve

 

 

 

_Result Criteria

Decreasing A i Moderate Sorunens Increasing

Preserving food

.. dimutut

Swallowing reflex

Ability to empty

mouth

Chewing ability

Swallowing effort

Bolus formation

Increasing anes Medium 'eo Decrease

Choking frequency

Cough

Gag

Gastric reflux

Nervous

regurgitation

Worsening ,, ENOUGH = Moderate oe getting better

Salivary production

Food reception

Sound quality

ice

118 Indonesian Nursing Outcome Standards


 

 

Neurological Status L.06053

Definition

The ability of the peripheral and central nervous systems to receive, process, and

respond to internal and external stimuli

 

 

Expectations Improve

 

Result Criteria

 

Enough

Descending Sanur Increasing Increasing

Level of consciousness

Pupil reaction

Cognitive orientation

Cognitive status

Central motor control

Cranial sensory function

Spinal sensory function

Cranial motor function | 2 = 4 5

Spinal motor function 1 2 aa 5

Autonomous function

Communication

Increasing ianetak Medium Pees Decreasing

Headache

Seizure frequency

Hyperthermia

Diaphoresis 1 2 2 4 s

Pale

Conjunctival congestion

Nasal congestion

Parasthesia

Metallic sensation in the mouth

Horner's syndrome

Blurred field

Penile erection

Worsening oes Moderately getting better

Systolic blood pressure

pulse rate

Pupil size

eye movement

Breathing pattern

Sleep rest pattern

Respiratory rate

Apical heart rate

Naai radialis pulse

Pilomotor reflex

120

re)

e

=

EC

-

5

> 

5


 

 

Confucian Level £06054

Definition

Disturbed awareness, attention, cognition and perception.

 

 

 

 

 

 

Expectations Drop

an en nN naar Sissons ies ancl

Outcome Criteria — 3 |

ENE ereenemeene aan SRS ON See SS Se

 

 

Decrease a. On the rise

Cognitive function

Level of consciousness

Psychomotor activity

Motivation 1 2 + 4 5

start/finish

directed behavior

Short term memory

Long term memory

Increasing Poe Medium Rae Decreasing

Hallucinatory behavior

Nervous

Worsening aruee ae While Ree is getting better

Interpretation

Social function

Response to stimulus

Perception

The function of brain

 


 

Sens

Sexual Function L.07055

Definition

Integration of physical and socio-emotional aspects related to distribution and performance

sexual

 

Expectations Improve

Result Criteria

Descending gone " While Nerina is increasing

Relationship satisfaction 1 I 3 4 5

sexual

Looking for information for

achieve satisfaction

sexual

Increasing ieee Moderate a Decreasing

Activity verbalization

sexual change

Verbalization of sexual excitement

changed

Sexual role verbalization

changed

Verbalization of sexual function

changed

Complaints of pain

have sex

(dyspareunia)

Complaints about sexual intercourse

limited

Complaints are hard to do

sexual activity

Verbalization of sexual activity

changed

Verbalization of sexual behavior

changed

Value conflict

Worsening ee Moderate ee Getting better

Sexual desire

Sexual orientation

Interest in partner

 

27


 

 

-Pregnancy Acceptance

Definition

Efforts to reconcile changes to the situation/problem of pregnancy. _

Expectations Rise

Result Criteria

Decreasing oe Moderately deme “i Increasing

Verbalization of acceptance

pregnancy

Verbalization of feelings

experienced

Care seeking behavior

pregnancy

Making plans

pregnancy

Ability to appreciate yourself

alone

Positive relationship

Customizability

self with pregnancy

Verbalize feelings of calm

Efforts to find information

pregnancy

Increases eats Moderately Since Decreasing

Angry

Withdraw 1 Za 3 4 >

Feeling lonely

Worsening PP satay 'fk is getting better

Affect

 

76 Indonesian Nursing Outcome Standards


 

Antepartum Status

Definition

Conditions in the period of pregnancy calculated from the first day of menstruation

last until the start of labor.

Expectations Improve

 

 

 

Result Criteria

 

Decreasing cast nl Medium Meramec Increasing

Emotional attachment to

fetus

Coping with

inconvenience

pregnancy

Increase ie mone Moderate ae Decrease

Nausea 1

Vomiting 1 2 3 4.5

Edema

Abdominal pain 1 4 3 4 5

Epigastric pain

Vaginal bleeding

Constipation

Headache

Seizures

unstable mood

Urine protein

urine glucose

Blood glucose

Getting worse Get Moderate Peo is getting better

Weight

Blood pressure

Hemoglobin

Neurological reflexes 1 Z 3 4 >

pulse rate

Respiratory rate 1 z 3 4 o

Body temperature

liver enzymes

Complete blood count

Cognitive status

 

106 Indonesian Nursing Outcome Standards


 

 

 

Decrease = decrease 5°48nd saoriespat Increase —

Coping with 1 Z 3 4 >

inconvenience '

labor :, ;

Utilizing techniques for 1 2 3 Ss

facilitate ag delivery

Cervical dilatation 1 2 2 a

: Enough ; ohne

Oni Christmas Oni is Increasing Sedang

Vaginal bleeding 1 2

Headache

Pain with contractions

Seizures

Back pain

a 2 on

NM MN NY

WOW WWW W

Enough

Worsening Redurtile Moderate

—_

Frequency of uterine contractions

uterine contraction period

Intensity of uterine contractions

Blood pressure

pulse rate

Temperature

Blood glucose

Urine output

Neurological reflex

Cognitive status

BENG mos GEN) oak! EXOS

MNNMNMNNMNNN N NH

WOWWWWWWWWW Ww

 


 

 

 

Postpartum Comfort Status _L.07061_

 

 

 

 

 

 

 

Definition of oe

Feelings of comfort related to the condition after childbirth. _

Expectations Rise

Result Criteria

Enough

Decreasing Matiiirur Increasing Increasing

Amniotic discomfort | 2 3 4 3

grimace

Episiotomy wound

uterine contractions

Sweating

Cry

Moaning

hemorrhoids

Increase Culp Medium Cube Decrease

g Increase Decrease

uterine contractions

Swollen breasts

Blood pressure

pulse rate

111

 


 

 

Postpartum Status | __ L.07062

Definition —s

The condition from the time the baby is born until the following six weeks is accompanied by:

with the recovery of organs related to the womb

which has changed.

 

 

 

 

Expectations Improve

 

 

Result Criteria

 

Decreasing ees Medium ecu Increasing

Peripheral circulation

Full tits

Perineal restoration

Incision Recovery

Intake of food and fluids

Physical activity

Resistance 1 Z = 4 5

Increased bet Cckai Medium . Decrease

Convenience

Infection

Incision pain

Vaginal bleeding

Laceration

Fatigue

Depression

It's getting worse ee Acres is getting better

Number of lochia a

lochla color

Blood pressure

pulse rate 1 ic 3 4 5

Body temperature

Urinary elimination

Fecal elimination

liver enzymes

Hemoglobin

White blood cell

Blood glucose

Mood

126 Indonesian Nursing Outcome Standards


 

Pain Control L.08063

 

Definition

Actions to relieve unpleasant sensory or emotional experiences

unpleasant due to tissue damage.

 

Expectations__ Increase

Result Criteria

 

It's decreasing ee "Medium sachet is increasing

Report pain controlled

Ability to recognize

pain onset

Ability to recognize

cause of pain

Ability to use

non-pharmacological techniques

Closest support

Increasing o Medium — Decreasing

Complaints of pain +=

Analgesic use

 

58 Indonesian Nursing Outcome Standards


 

 

 

Comfort Status

 

 

 

 

 

Spec definition

Overall feeling of comfort and security physically, psychologically, spiritually, socially,

culture and environment.

 

 

 

 

 

Expectations Rise

 

 

 

 

 

Result Criteria

SSSR eee ee ee

 

Decrease a. It's always increasing

Physical well-being

Psychological well-being

Social support from family

Social support from friends

Treatment according to faith

culture

Treatment as needed

Freedom of Worship 1 Z 5 4 Zs

relax

Increasing Gana Moderate ee Decreasing

Complaints of discomfort

Nervous

Noise

Complaints of difficulty sleeping 1 2 o 4 5

Complaints of cold

Complaints of heat

Gata!

Nauseous

Tired

Moaning

Cry

irritability

Blame yourself

Confucius

Alcohol consumption

Substance use

Suicide attempt

It's getting worse wees is getting better

Memories of the past

Room temperature 1 2 Ss 4 5