Abstract

Nursalam Nursalam , Haris widodo, Erna Dwi wahyuni, Ferry Efendi

Standard nursing language is now a global trend in the nursing profession with the aim of uniting the terminology used in nursing practice. This study aimed to compile the development an Indonesian Standard of Nursing diagnostic, outcomes and intervention-based perioperative nursing care instrument. Research and Development study of 106 medical records with sample size 21 participants for FGD and 33 respondents in model trial were selected using purposive sampling. The variable in this study was the development of perioperative nursing care instruments and collected using observation sheet and questionnaire, data analysis used descriptive approach. Preoperative nursing care instruments developed were: anxiety, acute pain, risk of infection, knowledge deficit, and risk of perioperative hypothermia. Intraoperative nursing care instruments developed were: ineffective airway clearance, risk of perioperative hypothermia, risk of aspiration, risk of bleeding, anxiety, risk of infection, acute pain, risk of fluid imbalance, and risk of falls. The postoperative nursing care instruments developed were: ineffective airway clearance, risk of infection, acute pain, risk of falls, risk of perioperative hypothermia, and risk of aspiration. Preoperative nursing care instruments developed were 10 instruments consisting of preoperative, intraoperative, and postoperative. The trial results of the instrument showed good results and positive opinions expressed by nurses at the hospital