Standardized Nursing language

Applications in A Nursing Practicum

Course
Copyright
Kelly J. Smith RN, MSN
University of Iowa
College of Nursing
 Components of Nursing Language

NANDA: Nursing Diagnosis: Definitions and

Classification
NIC: Nursing Interventions Classification
NOC: Nursing Outcomes Classification
 Variations of Nursing Diagnosis:

1.Actualdiagnosis:describeshealthconditions
thatexistandsupportedbydefiningcharacteristics
2.Riskdiagnosis:thosewhichdescribedisease
orotherconditionsthatmaydevelopandare
supportedbyriskfactors
3.Wellnessdiagnosis:describelevelsof
wellnessandpotentialforenhancementtoahigher
leveloffunctioning
(NANDA,2009)and(Denehy&Poulton,1999)
 Components of a Nursing Diagnosis

1.LabelorNameanddefinition
2.RelatedFactorsORRiskFactors
3. DefiningCharacteristics
 Case Study
4yearoldboywithALL
Admittedoneweekafter
chemowithafeverof
102.5F
WBCis0.3,absolute
neutrophilcountiszero
Newcentrallineplaced10
daysago
C/Onausea&vomiting
Criesandhidesbehind
motherwhenapproachby
nursingstaff
 Examples

1. Risk for infection related to

immunosuppression secondary to
chemotherapy, inadequate primary defenses
(central venous catheter),chronic disease
(ALL)and developmental level.
 Was our choice correct?

Definitionofthelabel: At increased risk for being

invaded by pathogenic organisms
RiskFactors:
Insufficient knowledge to avoid exposure to pathogens
(developmental level)
Inadequate secondary defenses (leukopenia)
Inadequate primary defenses (broken skin from newly placed
central line)
Pharmaceutical Agents (immunosuppressant, i.e.
chemotherapy)
(NANDA,2009)
 Examples

2. Nausea related to chemotherapy as

evidenced by vomiting, patient c/o tummy ache
and aversion toward food.
 Examples

3. Fear related to unfamiliarity with

environmental experiences as evidenced by
avoidance behaviors (hides behind mother) and
crying.
 NOC

The nursing outcomes classification (NOC) is a

classification of nurse sensitive outcomes
NOC outcomes and indicators allow for
measurement of the patient, family, or community
outcome at any point on a continuum from most
negative to most positive and at different points
in time. ( Iowa Outcome Project, 2008)
 Components

A neutral label or name used to characterize the

behavior or patient status
A list of indicators that describe client behavior
or patient status.
A five point scale to rate the patients status for
each of the indicators
 NANDA/NOC Linkage

Each nursing Diagnosis is followed by a list of

suggested outcomes to measure whether the
chosen interventions are helping the identified
problem
Each outcome can be individualized to the
patient or family by choosing the appropriate
indicators or adding additional indicators as
necessary
 NOC examples: Linked with Risk for
Infection

Immune Status (0702)

Infection Severity (0703)
Knowledge: Infection Control (1807)
Nutritional Status (1004)
Tissue Integrity: Skin & Mucous membranes
(1101)
Wound Healing: Primary Intention (1102)
Location of wound (#4, Front of Neck)
 Immune Status (0702)

Definition: Natural and acquired appropriately targeted

resistance to internal and external antigens.
1=severely compromised thru 5= not compromised
Absolute WBC values WNL
Differential WBC values WNL
Skin integrity
Mucosa integrity
Body temperature IER
Gastrointestinal function
 Immune Status (Continued)

1= severe thru 5= None

Recurrent Infections
Weight Loss
Tumors (Immature WBCs)
(NOC, 2004 p.322)
 Scale
Extremely compromised 1
Substantially compromised 2
Moderately compromised 3
Mildly compromised 4
Not compromised 5
_____________________________________________________
Severe 1
Substantial 2
Moderate 3
Mild 4
None 5
 NIC

The nursing interventions classification (NIC) is

a comprehensive, standardized language
describing treatments that nurses perform in all
settings and in all specialties. (Iowa
Intervention Project, 2008)
 Interventions

Definition: any treatment based upon clinical

judgment and knowledge, that a nurse performs
to enhance patient/client outcomes. (Iowa
Intervention Project, 2000,p.3)
 Components

Name or label
A definition
A set of activities the nurse does to carry out the
intervention
 NANDA/NIC Linkage

Each NANDA diagnosis is followed by a list of

suggested interventions for resolving the
identified problem
Interventions and activities should be chosen to
meet the individual clients needs
Activities can be further individualized by adding
client specific information
Additional activities may be added if appropriate
 NIC Examples: Linked with Risk for
Infection

6550 infection protection

1100 nutrition management
3590 skin surveillance
6650 surveillance
3660 wound care
 Infection Protection 6550

Definition:Preventionandearlydetectionof
infectioninapatientatrisk
Activities:
Monitorforsystemicandlocalizeds&sxofinfection
(centrallinesitecheckevery4hours.)
MonitorWBC,anddifferentialresults(qdorqod)
Followneutropenicprecautions
Provideaprivateroom
Limitnumberofvisitors
 Infection Protection (Cont.)
Activities(Cont.)
Screenallvisitorsforcommunicabledisease
Maintainasepsis
Inspectskinandmucousmembranesforredness,extreme
warmthordrainage(q4hours)
Inspectconditionofsurgicalincision(centrallineinsertion
siteq4hours)
Obtaincultures,asneeded(BloodculturesprnT>38.3Cq
24hours)(Drainage@Centrallinesite)
PromoteNutritionalintake(1500kcalperday,Pt.likes
cereal)
 Infection Protection (cont.)
Activities(cont.)
Encouragefluidintake(1225ccperday,Ptlikesorange
Gatorade)
Encouragerest(napseveryafternoonfrom1-3PM,bedtime
at2030)
Monitorforchangeinenergylevel/malaise
Instructpatienttotakeanti-infectiveasprescribed
(BactrimBID,po,MTWandNystatin5cc,s&s,TID)
TeachFamilyabouts&sxofinfectionandwhentoreport
themtoHCP
(NIC,2008)
Sample Care Plan using Case Study
NANDA Nursing Diagnoses
Risk for infection related to
immunosuppression
secondary to chemotherapy,
inadequate primary defenses
(central venous catheter),
chronic disease (ALL) and
developmental level.
NOC Outcomes and Indicators NIC Intervention Label and select nursing activities
0702Immune Status 6550 infection protection
Definition: Natural and acquired appropriately targeted Definition: Prevention and early detection of infection in a patient at risk
resistance to internal and external antigens. Activities:
1=severely compromised thru 5= not compromised Monitor for systemic and localized signs & symptoms of infection (central
Absolute WBC values WNL(within normal limits) line site check every 4 hours.)
1 2 3 4 5 Monitor WBC, and differential results (qod)
Differential WBC values WNL(within normal limits) Follow neutropenic precautions
1 2 3 4 5 Provide a private room
Skin integrity Limit number of visitors
1 2 3 4 5 Screen all visitors for communicable disease
Mucosa integrity Maintain asepsis
1 2 3 4 5 Inspect skin and mucous membranes for redness, extreme warmth or
Body temperature IER( in expected range) drainage (q4 hours)
1 2 3 4 5 Inspect condition of surgical incision
Gastrointestinal function (central line insertion site q 4 hours)
1 2 3 4 5 Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours)
Respiratory Function (Drainage @ Central line site)
1 2 3 4 5 Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Genitourinary Function Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
1 2 3 4 5 Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
1= severe thru 5= None Monitor for change in energy level/malaise
Recurrent Infections Instruct patient to take anti-infective as prescribed
1 2 3 4 5 (Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
Weight Loss Teach Family about s & symptoms of infection and when to report them
1 2 3 4 5 to HCP
Tumors (Immature -Teach patient and family how to avoid infections
WBCs) (NIC, 2008)
1 2 3 4 5
(NOC, 2008 p.399)
 Sample Blank Careplan
Nursing Diagnosis and Interventions: Choose the highest priority Nursing Diagnosis as indicated on the clinical reasoning web.
Include problem statement (NANDA), related to or risk factors (etiology), and defining characteristics (as evidenced by or AEB) as appropriate.
List all of the appropriate NOC Outcome labels and indicators and NIC intervention labels and nursing activities which will best help your client achieve those outcomes.
List the rationale for each and determine where your client falls on the outcome indicator scale (1-5) at the specified time intervals.
In the final column summarize why you gave your client the indicator scores that were given and any changes in your care plan that should be made.
Briefly describe how the plan of care is helping the patient meet the desired outcomes and any changes that need to be made:
Nanda Nursing Diagnosis NOC Outcome Label(s) Rationale for NOC chosen NIC Intervention label(s) and nursing Rationale for NIC Chosen
and indicators and indictor score activities

Complete NANDA Nursing NOC label and Describe your rationale for NIC label and appropriate activities Describe your rationale for choosing this
Dx Statement including appropriate indicators choosing this NOC label and with individualized information added. NIC label
related or risk factors and and rating on scale with the indicator ratings that you
defining characteristics date (s) chose for this patient.
 References

Denehy,J.&Poulton,S.(1999)Journal of School Nursing,

15 (1), 38-45.
IowaInterventionProject(2008).Nursing interventions and
Classification (NIC). (4th ed.) St.Louis:Mosby,Inc.
IowaOutcomesProject(2008). Nursing outcomes
classification (NOC). (3rd ed.) St.Louis:Mosby,Inc.
NANDANursingDiagnosis:Definitions and Classifications
2009-2011.(2009).Indianapolis,IN:Wiley-Blackwell.
 References (cont.)
Pesut,D.&Herman,J.(1999)ClinicalReasoning:TheArt&
ScienceofCriticalandCreativeThinking.Albany,NY:
DelmarPublishers.
Schoenfelder,Deborah(2004).Nursing outcomes
classification (NOC). Appendix F. (2004) St.Louis:Mosby,
Inc.
VanDeCastle,B.(2003)Comparisons of Nanda/NIC/NOC
linkages between experts and nursing students.
InternationalJournalofTerminologiesandClassifications
14(4)