Bahasa Baku dalam Keperawatan

NANDA, NIC, & NOC

PERLUNYA BAHASA BAKU DALAM

KEPERAWATAN
MENGETAHUI DAMPAK ASUHAN KEPERAWATAN TERHADAP
PENCAPAIAN PASIEN
DI KLINIK
PENGELOLAAN STAF DAN VARIABEL ADMINISTRATIF LAINNYA

MENYEDIAKAN STRUKTUR UNTUK PENGKAJIAN KLINIS YANG

BERFOKUS PADA PASIEN
MEREKAM AKTIVITAS SURVEILANS YANG DIGUNAKAN UNTUK
MENCEGAH KOMPLIKASI
MENGAJARKAN KEPADA MAMHASISWA KEPERAWATAN BAHASA
PELAYANAN KLINIK DAN KEPERAWATAN
DISIPLIN ILMU YANG SPESIFIK
KOLABORASI MULTIDISIPLIN

NILAI NILAI YANG TERDAPAT DALAM

BAHASA BAKU YANG TERSTRUKTUR
LANDASAN UNTUK MENDAPATKAN:
INTEGRASI PENGETAHUAN YANG DIARAHKAN
OLEH FAKTA-FAKTA
DOKUMENTASI YANG FLEKSIBEL
KOORDINASI ASUHAN
MENGUKUR KUALITAS
KEJELASAN KEPERAWATAN
PENEMUAN PENGETAHUAN

Taxonomy dalam Keperawatan

Taxonomi: suatu klasifikasi khususnya dalam
pengelompokan hewan dan tanaman sesuai
dengan hubungan alamiahnya
Taxonomi diaplikasikan untuk sistem pemberian
nama (nomenklatur) yang formal
Inti dari taxonomi adalah pemberian nama untuk
sekelompok karakter yang memiliki
kesamaan/hubungan secara alamiah

Lanjutan
Pengelompokan nama dalam bahasa baku
keperawatan: domain, kelas, dan
diagnosis/outcome/intervensi
Domain: pengelompokan pengetahuan,
pengaruh atau pengamatan
Kelas: sekelompok, satu set, atau sesuatu yang
memiliki ciri yang umum

Lanjutan.
Bahasa baku untuk diagnosis keperawatan memiliki 7 unsur
(axis)
1. Fokus (nyeri, nutrisi, dll)
2. Subjek diagnosis (individu, keluarga, kelompok, komunitas)
3. Penilaian (kerusakan, tidak efektif, defisiensi, gangguan,
dll)
4. Lokasi (bladder, auditory, dll)
5. Kelompok umur (bayi, anak-anak, dewasa, lansia)
6. Waktu (kronik, akut, hilang timbul, terus menerus)
7. Status diagnosis (aktual, risiko, promosi kesehatan)

Komponen-komponen bahasa baku

dalam keperawatan
NANDA-I
NIC: Nursing Interventions Classification
NOC: Nursing Outcomes Classification

Variasi Diagnosis Keperawatan

1.DiagnosisAktual:menjelaskankondisi
kesehatanyangadadandidukungolehbatasan
karakteristik(P+E+S)
2.DiagnosisRisiko:menjelaskanpenyakitatau
kondisilainyangdapatberkembangdandidukung
olehfaktorrisiko(P+E)
3.Diagnosissehat/sejahtera:menjelaskan
tingkatkesehatandanpotensiuntukmeningkatkan
ketingkatfungsiyanglebihtinggi
(NANDA,2009)and(Denehy&Poulton,1999)

Komponen Diagnosis Keperawatan

1.Labelataunamadandefinisi
2.faktoryangberhubunganataufakorrisiko
(Relatedfactor)
3.batasankarakteristik(defining
characteritics)..tandadangejala

Taxonomi Diagnosis Keperawatan (NANDA-I)

Domain
Class

1
HealthPromotion

2
Nutritions

3
Elimination/Exch
ange

4
Activity/Rest

5
Perception/Cogni
tion

6
SelfPerceptions

Health
awareness

Ingestion

UrinaryFunction

Sleep/Rest

attention

Self-Concept

Health
management

Digestion

Gastrointestinal
Function

Activity/Exercise

Orientation

Self-Esteem

Absorption

Integumentary
Function

EnergyBalance

Sensation/Perce
ption

BodyImage

Metabolism

Respiratory
Function

Cardiovascular/P
ulmonary
Responses

Cognition

hydration

Self-Care

Communication

Domain
Class

7
Role
Relationship

8
Sexuality

9
Coping/stres
sTolerance

10
Life
Principles

11
Safety/Prote
ction

12
Comfort

13
Growth

Development

Caregiving
Roles

Sexual
Identity

Post-Trauma
Response

Values

Infection

Physical
Comfort

Growth

Family
Rrelationship

Sexual
Function

Coping
Response

Beliefs

Physical
Injury

Environmenta
l Comport

Development

Role
Performance

Reproduction

NeuroBehavioural
Stress

Value/Beliefs/
Action
Congruence

Violence

Social
Comfort

Environmenta
l Hazards

Defensive
Processes

Thermoregula
tion

Domain, class, Nsg. Dx. yang sering

digunakan di klinik untuk memenuhi
kebutuhan dasar

Domain2:Nutrition
class1

class2

class3

class4

class5

Ingestion

Digestion

Absorption

Metabolism

Hydration

Insufisiensi menyusui

Saat ini belum

ada

Saat ini belum

ada

Risiko ketidakstabilan
kadar glukose

Risiko
ketidakseimbangan
elektrolit

Tidak efektif pola makan

bayi
Ketidakseimbangan
nutrisi: kurang dari yang
dibutuhkan tubuh
Ketidakseimbangan
nutrisi: lebih dari yang
dibutuhkan tubuh

Kuning pada neonatal

Risiko kuning pada
neonatal
Risiko kerusakan fungsi
liver

Kesiapan untuk
meningkatkan
keseimbangan cairan
Defisiensi volume cairan
Kelebihan volume
cairan
Risiko kekurangan
cairan
Aaaarisiko
ketidakseimbangan
volume cairan

Domain3:EliminationandExchange
Class1: urinary
function

Class2:
Gastrointestinal
Function

Class3:
Integumentary
Function

Class4: Respiratory
function

Inkontinensia urin fungsional

Konstipasi

Saat ini belum ada

Kerusakan pertukaran gas

Incontinensia urin overflow

Konstipasi yang dipersepsikan

Inkontinensia urin stress

Risiko konstipasi

Risk for urge urinary

incontinence

Diare

Kerusakan eliminasi urin

Kesiapan untuk meningkatkan
eliminasi urin

Disfungsi motilitas
gastrointestinal
Risiko Disfungsi motilitas
gastrointestinal

Retensi urin
Bowel incontinence

Domain4:Activity/Rest
Class1:
Sleep/Rest

Class2:
Class3: energy
Activity/Exercice balance

Class4:
Cardiovascular/
Pulmonary
Response

Class5: selfcare

Insomnia

Risk for dysuse

syndrome

Intoleransi aktivitas
Risiko Intoleransi
aktivitas
Tidak efektif pola napas
Penurunan curah
jantung
Risiko tidak efektif
perfusi gastrointestinal
Risiko tidak efektif
perfusi ginjal
Kerusakan ventilasi
spontan
Tidak efektif perfusi
jaringan perifer
Risiko penurunan
perfusi jaringan cardiac
Risiko tidak efektif
perfusi jaringan
serebral
Risiko tidak efektif
perfusi jaringan perifer
Disfungsi respons
penyapihan ventilator

Kerusakan
pemeliharaan rumah

Sleep deprivasion
Readiness for enhance
sleep
Gaangguan pola tidur

Disturbed energy field

Kelelahan

Kerusakan mobilitas di
tempat tidur
Kerusakan mobilitas
fisik
Kerusakan mobilitas
kursi roda
Kerusakan kemampuan
berpindah tempat
Kerusakan berjalan

Wandering

Kesiapan untuk
meningkatkan
perawatan diri
Defisit perrawatan diri
mandi
Defisit perrawatan diri
berpakaian
Defisit perrawatan diri
makan
Defisit perrawatan diri
toileting
Melalaikan diri sendiri

Domain11:Safety/Protection
Class1: Infection

Class2:Physical Injury

Risiko infeksi

Tidak efektif bersihan jalan

napas

Class6:
Thermoregulation
Kerusakan integritas kulit

Risiko ketidakseimbangan
suhu tubuh

Risiko aspirasi

Risiko sindrom kematian

mendadak pada bayi

Hipertermi

Risiko perdarahan

Risiko tersedak

Hipotermi

Kerusakan gigi

Pemulihan pembedahan
tertunda

Tidak efektif pengaturan panas

Risiko mata kering

Risiko perlukaan panas
Risiko jatuh
Kerusakan integritas kulit
Risiko perlukaan
Risiko trauma
Kerusakan membran mukosa
mulut
Risiko perlukaan posisi
perioperatif
Risiko disfungsi neurovaskular
Risiko syok

Risiko trauma vaskular

Domain12:Comfort
Class1: Physical comfort

Class2: Environmental
comfort

Class3: Social Comfort

Kerusakan kenyamanan

Kerusakan kenyamanan

Kerusakan kenyamanan

Kesiapan untuk
meningkatkan kenyamanan

Kesiapan untuk
meningkatkan kenyamanan

Kesiapan untuk
meningkatkan kenyamanan

Mual
Nyeri akut
Nyeri kronis

Isolasi Sosial

Cara-cara menemukan diagnosis

keperawatan
Identifikasi tanda dan gejala yang menonjol pada klien
Identifikasi pola yang terganggu
NANDA-I penulisannya disusun berdasarkan pola (domain)
bukan huruf awal diagnosis
Cari kelas (class)
Perhatikan pengklasifikasian berdasarkan pengetahuan
mengenai respons sistem tubuh manusia
Buat kata kunci untuk memudahkan menghubungkan dengan
NANDA
Mual, nyeri, berhubungan dengan kenyamanan (sesuatu sensasi
yang dirasakan secara subjektif)

Contoh:
Ketidakseimbangan nutrisi: kurang dari yang
diperlukan tubuh (00002)
Domain 2: Nutrisi
Kelas 1: ingestion
Definisi: asupan nutrien kurang untuk memenuhi
kebutuhan metabolik

Contoh
Domain2: Nutrisi
Class1: Ingestion
Nsg Dx.:
Insufficient breast milk (00216)
Ineffective Infant Feeding Pattern (00107)
Imbalance Nutrition: less than body requirements (00002)
Imbalance Nutrition: more than body requirements (00001)
Readiness for enhance nutritions(00163)
Risk for imbalance nutrition: more than body requirement
(00003)

Batasan karakteristik:
Kram perut
Nyeri perut
Tidak ada nafsu makan
Berat badan dibawah 20% atau lebih rendah dari BB rata-rata
Kapiler rapuh
Diare
Rambut rontok berlebihan
..

Faktor yang berhubungan

Biologis
Ketidakmampuan menyerap nutrien
Ketidakmampuan mencerna makanan
Ketidakmampuan memasukkan makanan
Kekurangan finansial
Faktor psikologis

Contoh kasus
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

NOCDomainsintheTaxonomy

FunctionalHealth
PhysiologicalHealth
PsychologicalHealth
HealthKnowledgeBehavior
PerceivedHealth
FamilyHealth
CommunityHealth

Taxonomi NOC
Domain
(level1)

1
FunctionalHealth

2
Physiologic
Health

3
Psychosocial
Health

4
Health
Knowledgeand
Behavior

5
PerceivedHealth

6
FamilyHealth

7
Community
Health

Level2

A
EnergyMaintenance

E
Cardiopulmonary

M
Psychological
Well-Being

Q
Health Behavior

U
Health&Life
Quality

W
FamilyCaregiver
Performance

b
CommunityWellBeing

B
Growth&
Development

F
Elimination

N
Psychosocial
Adaptation

R
Haelth Beliefs

V
SymptomStatus

Z
FamilyMember
HealthStatus

c
Community
HealthProtection

C
Mobility

G
Fluid&
electrolytes

O
Self-Control

S
Health Knowledge

e
Satisfactionwith
Care

X
FamilyWell-Being

D
Self-Care

H
Immune
Response

P
SocialInteraction

T
RiskControl&
Safety

I
Metabolic
Regulation
J
Neurocgnitive
K
Digestion&
Nutrition
e
Therapeutic
Response
L
TissueIntegrity
Y
SensoryFunction

d
Parenting

Afive-pointLikerttypescalethatquantifiesa
patientoutcomeorindicatorstatusona
continuumfromleasttomostdesirableand
providesaratingatapointintime
1=LeastDesirableState
5=MostDesirableState

VeryweaktoVerystrong
NevertoConsistentlyDemonstrated
SeveretoNone
PoortoExcellent
NotatalltoCompletelySatisfied
NoKnowledgetoExtensiveKnowledge

SeverelytoNotCompromised
SeveretoNoDeviationfromNormalRange
NotAdequatetoTotallyAdequate
10andovertoNone
NonetoExtensive
NeverPositivetoConsistentlyPositive

SelectOutcome

Problem/Diagnoses
PatientPreferences
PatientCharacteristics
NursingTreatment

RatePatientStatus

Selectindicators
Evaluatepatientonselectedindicators
Determineoveralloutcomerating
Settargetrating-goal
Determinefocusofeachdisciplineinvolved
incare

TargetOutcomeRating
Allowsforsettinggoalforpatientrelatedtoa
NOCoutcomescoreusing2options:
Maintainat_____
Increaseto_____

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

Menyambungkan NANDA-NOC Contoh

NIC

NOC

Domain

class

Level 1

Level 2

2 nutrition

1 ingestion

2 Physiologic Health

K Nutrition

2 metabolism

2 Physiologic Health

a Therapeutic respons

3 hydration

2 Physiologic Health

G fluid electrolyte

1 urinary

2 Physiologic Health

F Elimination

2 gastrointestinal

2 Physiologic Health

F Elimination

4 respiratory

2 Physiologic Health

E Cardiopumonary

1 sleep rest

1 functional health

A Energy mantenance

2 activity exercise

1 functional health

C Mobility

3 energy balance

1 functional health

A Energy mantenance

4 cardiopulmonary

2 Physiologic Health

E Cardiopumonary

5 self care

1 functional health

D Self care

1 infection

2 Physiologic Health

H immune respons

2 physical injury

2 Physiologic Health

E Cardiopumonary

6 thermoregulation

2 Physiologic Health

I Metabolic regulation

3 eliminasi exchange

4 activity rest

11 safety protection

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

Taxonomi NIC
1

Physiological:Basic
Carethatsupportsphysical
functioning

Activity & Exercise Mgt.:

Interventions to organize or assist with
physical activity and energy conservation
and expenditure

Elimination Mgt.: Interventions to establish

and maintain regular bowel and urinary
elimination patterns and manage
complications due to altered patterns

Physiological:Complex
Carethatsupportshomeostatic

Behavioral
Carethatsupports
psychosocialfunctioningand
facilitateslifestylechanges

Carethatsupportsprotection
againstharm

Electrolyte & Acid-Base Mgt.:

Interventions to regulate electrolyte/acid
base balance and prevent complications

Behavior Therapy: Interventions to

reinforce or promote desirable
behaviors or alter undesirable
behaviors or alter undesirable
behaviors

Crisis Mgt.: Interventions to provide

immediate short-term help in both
psychological and physiological crises

Drug Mgt.: Interventions to facilitate

desired effects of pharmacologic agents

Cognitive Therapy: Interventions to

reinforce or promote desirable
cognitive functioning or alter
undesirable cognitive functioning

Risk Mgt.: Interventions to initiate risk

reduction activities and continue
monitoring risks over time

Immobility Mgt.: Interventions to

manage restricted body movement and
the sequelae

Neurological Mgt.: Interventions to

optimize neurologic function

Communication Enhancement:
Interventions to facilitate delivering
and receiving verbal and nonverbal
messages

Nutrition Support: Interventions to

modify or maintain nutritional status

Perioperative Care: Interventions to

provide care prior to, during, and
immediately after surgery

Coping Assistance: Interventions

to assist another to build on own
strengths, to adapt to a change in
function, or achieve a higher level

regulation

of function

Physical Comfort Promotion:

Interventions to promote comfort using
physical techniques

Self-Care Facilitation:
Interventions to provide or assist with
routine activities of daily living

Respiratory Mgt.: Interventions to

promote airway patency and gas
exchange

Skin/Wound Mgt.: Interventions to

maintain or restore tissue integrity

Patient Education: Interventions to

facilitate learning
Psychological Comfort Promotion:
Interventions to promote comfort
using psychological techniques

Thermoregulation: Interventions to
maintain body temperature within a
normal range

Tissue Perfusion Mgt.: Interventions to

optimize circulation of blood and fluids to
the tissue

Family
Carethatsupportsthefamily

HealthSystem
Carethatsupportseffectiveuseofthe
healthcaredeliverysystem

Community
Carethatsupportsthehealthofthe
community

Childbearing Care: Interventions to assist in the

preparation of childbirth and management of the
psychological and physiological changes before,
during, and immediately following childbirth

Health System Mediation: Interventions to facilitate

the interface between patient / family and the health
care system

Yc

Community Health Promotion: Interventions that

promote the health of the whole community

Childrearing Care: Interventions to assist in raising

children

Ya

Health System Mgt.: Interventions to provide and

enhance support service for the delivery of care

Yd

Community Risk Mgt.: Interventions that assist

in detecting or preventing health risks to the
whole community

Lifespan Care: Interventions to facilitate family unit

functioning and promote the health and welfare of
family members throughout the lifespan

Yb

Information Mgt.: Interventions to facilitate

communication about health care

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,
extremewarmthordrainage(q4hours)
Inspectconditionofsurgicalincision(centralline
insertionsiteq4hours)
Obtaincultures,asneeded(BloodculturesprnT>38.3C
q24hours)(Drainage@Centrallinesite)
PromoteNutritionalintake(1500kcalperday,Pt.likes
cereal)

Infection Protection (cont.)

Activities(cont.)
Encouragefluidintake(1225ccperday,Ptlikesorange
Gatorade)
Encouragerest(napseveryafternoonfrom1-3PM,
bedtimeat2030)
Monitorforchangeinenergylevel/malaise
Instructpatienttotakeanti-infectiveasprescribed
(BactrimBID,po,MTWandNystatin5cc,s&s,TID)
TeachFamilyabouts&sxofinfectionandwhento
reportthemtoHCP
(NIC,2008)

Sample Care Plan using Case Study

NANDA Nursing Diagnoses

NOC Outcomes and Indicators

NIC Intervention Label and select nursing activities

Risk for infection related to

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

0702Immune Status
Definition: Natural and acquired appropriately targeted resistance to
internal and external antigens.
1=severely compromised thru 5= not compromised
Absolute WBC values WNL(within normal limits)
1 2 3 4 5
Differential WBC values WNL(within normal limits)
1 2 3 4 5
Skin integrity
1 2 3 4 5
Mucosa integrity
1 2 3 4 5
Body temperature IER( in expected range)
1 2 3 4 5
Gastrointestinal function
1 2 3 4 5
Respiratory Function
1 2 3 4 5
Genitourinary Function
1 2 3 4 5
1= severe thru 5= None
Recurrent Infections
1 2 3 4 5
Weight Loss
1 2 3 4 5
Tumors (Immature
WBCs)
1 2 3 4 5
(NOC, 2008 p.399)

6550 infection protection

Definition: Prevention and early detection of infection in a patient at risk
Activities:
Monitor for systemic and localized signs & symptoms of infection (central line site check every 4
hours.)
Monitor WBC, and differential results (qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for redness, extreme warmth or drainage (q4 hours)
Inspect condition of surgical incision
(central line insertion site q 4 hours)
Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage @ Central line
site)
Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
Monitor for change in energy level/malaise
Instruct patient to take anti-infective as prescribed
(Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
Teach Family about s & symptoms of infection and when to report them to HCP
-Teach patient and family how to avoid infections
(NIC, 2008)

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)

and indicators

Rationale for NOC chosen

and indictor score

NIC Intervention label(s) and nursing

activities

Rationale for NIC Chosen

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.

NIC label and appropriate activities

with individualized information added.

Describe your rationale for choosing this

NIC label

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)