Professional Documents
Culture Documents
Case Study
4 year old boy with ALL Admitted one week after chemo with a fever of 102.5F WBC is 0.3,absolute neutrophil count is zero New central line placed 10 days ago C/O nausea & vomiting Cries and hides behind mother when approach by nursing staff
Examples
1. Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter),chronic disease (ALL)and developmental level.
(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
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
Complete NANDA Nursing Dx Statement including related or risk factors and defining characteristics
NOC label and appropriate indicators and rating on scale with date (s)
Describe your rationale for choosing this NOC label and the indicator ratings that you chose for this patient.
References
Denehy,J. & Poulton,S. (1999) Journal of School Nursing, 15 (1), 38-45. Iowa Intervention Project (2008). Nursing interventions and Classification (NIC). (4th ed.) St. Louis: Mosby, Inc. Iowa Outcomes Project (2008). Nursing outcomes classification (NOC). (3rd ed.) St. Louis: Mosby, Inc. NANDA Nursing Diagnosis: Definitions and Classifications 2009-2011. (2009). Indianapolis, IN: Wiley-Blackwell.
References (cont.)
Pesut, D. & Herman, J. (1999) Clinical Reasoning: The Art & Science of Critical and Creative Thinking. Albany, NY: Delmar Publishers. Schoenfelder, Deborah (2004). Nursing outcomes classification (NOC). Appendix F. (2004) St. Louis: Mosby, Inc. Van De Castle, B. (2003) Comparisons of Nanda/NIC/NOC linkages between experts and nursing students. International Journal of Terminologies and Classifications 14(4)