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NUEL 316

NANDA: Nursing Diagnosis: Definitions and
Classification

NOC: Nursing Outcomes Classification

NIC: Nursing Interventions Classification

al. et. Actual diagnosis: describes health conditions that exist and are supported by defining characteristics  At Risk diagnosis: those which describe disease or other conditions that may develop and are supported by risk factors  Health Promotion diagnosis: describe levels of wellness and potential for enhancement to a higher level of functioning (Johnson. 2012)  ..

    Label or Name and definition  Defining Characteristics  Related Factors .

3.      15 month old girl with ALL (Acute Lymphocytic Leukemia) Admitted one week after chemo with a fever of 103F WBC is 0.absolute neutrophil count is zero New central line placed 10 days ago C/O nausea & vomiting Cries when approached by staff and pulls blanket over head. .

. inadequate primary defenses (central venous catheter). Risk for infection related to immunosuppression secondary to chemotherapy.chronic disease (ALL)and developmental level.

 Definition of the label: At increased risk for being invaded by pathogenic organisms  Risk Factors: ◦ 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.e. chemotherapy) (NANDA.2009) . i.

family. . 2012). or community outcome at any point on a continuum from most negative to most positive and at different points in time” (Johnson.. The nursing outcomes classification (NOC) is a classification of nurse sensitive outcomes  NOC outcomes and indicators “allow for measurement of the patient. al. et.

 A five point scale to rate the patient‘s status for each of the indicators . A neutral label or name used to characterize the behavior or patient status  A list of indicators that describe client behavior or patient status.

 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 .

 Immune Status  Infection Severity  Knowledge: Infection Control  Nutritional Status  Tissue Integrity: Skin & Mucous membranes  Wound Healing: Primary Intention  Location of wound (Front of Neck) .

1=severely compromised thru 5= not compromised • • • • • • Absolute WBC values WNL Differential WBC values WNL Skin integrity Mucosa integrity Body temperature IER Gastrointestinal function .Definition: Natural and acquired appropriately targeted resistance to internal and external antigens.

1= severe thru 5= None • • • Recurrent Infections Weight Loss Tumors (Immature WBCs) (NOC. 2004 p.322) .

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  .

. al. “The nursing interventions classification (NIC) is a comprehensive. 2012)). standardized language describing treatments that nurses perform in all settings and in all specialties” (Johnson. et..

.. Definition: “any treatment based upon clinical judgment and knowledge. et. that a nurse performs to enhance patient/client outcomes” (Johnson. 2012). al.

Name or label  A definition  A set of nursing activities (aka nursing interventions) the nurse does to carry out the intervention  .

clinical judgment.  Once a nurse has identified the NIC Labels associated with the selected NANDA Diagnoses.  Nursing interventions can be further individualized by adding client specific information . Each NANDA diagnosis is linked to a variety of NIC Labels which indicate what nursing interventions should be done to treat the nursing diagnosis. s/he must use nursing knowledge. and any nursing resources to identify the actual nursing interventions/activities that should be performed to meet individual client’s needs.

 infection protection  nutrition management  skin surveillance  surveillance  wound care .

) ◦ Monitor WBC. and differential results (qd or qod) ◦ Follow neutropenic precautions ◦ Provide a private room ◦ Limit number of visitors . Definition: Prevention and early detection of infection in a patient at risk  Nursing Interventions: ◦ Monitor for systemic and localized s & sx of infection (central line site check every 4 hours.

as needed (Blood cultures prn T>38.) ◦ 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. likes cereal) . Nursing Interventions (Cont. Pt.3 C q 24 hours) (Drainage @ Central line site) ◦ Promote Nutritional intake (1500 kcal per day.

 Nursing Interventions (cont. po. TID) o Teach Family about s & sx of infection and when to report them to HCP (NIC. MTW and Nystatin 5cc. 2008) . bedtime at 2030) o Monitor for change in energy level/malaise o Instruct patient to take anti-infective as prescribed (Bactrim BID.s & s. Pt likes orange Gatorade) o Encourage rest (naps every afternoon from 1-3 PM.) o Encourage fluid intake (1225 cc per day.

definition. NIC Intervention Label and Nursing Interventions NIC label. .Sample Blank Care Plan Describe your patient scenario briefly NANDA Nursing Diagnosis Complete NANDA Nursing Dx Statement including related or risk factors and defining characteristics NOC Outcome Labels & Indicators NOC label. rating scale being used. Rationale for NOC chosen and indicator score Describe your rationale for choosing this NOC label and the indicator ratings that you chose for this patient. and appropriate nursing interventions with individualized information added. definition. appropriate indicators. and rating on that scale.

absolute neutrophil count is zero. as needed (Blood cultures prn T>38.3. 2008) . Nystatin 5cc. NOC Outcome Labels & Indicators Immune Status Definition: Natural and acquired appropriately targeted resistance to internal and external antigens. Patient has a temperature of 103 – making the ranking a 1 (severely compromised).swish & swallow. NANDA Nursing Diagnosis Risk for infection related to immunosuppression secondary to chemotherapy. 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. Pt likes orange Gatorade) Encourage rest (naps daily 1-3 PM. A new central line was placed 10 days ago. TID) Teach Family about s & symptoms of infection and when to report them to HCP -Teach patient and family how to avoid infections (NIC.) Monitor WBC. 1=severely compromised thru 5= not compromised Absolute WBC values WNL(within normal limits) Differential WBC values WNL(within normal limits) 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 WBC’s) 1 2 3 4 5 Rationale for NOC NIC Intervention chosen and indicator Label and Nursing score Interventions Patient has compromised immune status due to low WBC count – making the ranking a 1 (severely compromised). chronic disease (ALL) and developmental level.15 month old girl with ALL (Acute Lymphocytic Leukemia) was dmitted one week after chemo with a fever of 103F. The child now presents with c/o nausea & vomiting and cries when approached by staff and pulls the blanket over head. 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. (You are given 2 examples here but there are many more NOC indicators for this case study patient). bedtime t 8:30 PM) Monitor for change in energy level/malaise Instruct patient to take anti-infective as prescribed (Bactrim po BID. inadequate primary defenses (central venous catheter). The patients WBC is 0. extreme warmth or drainage (q4 hours) Inspect condition of surgical incision (central line insertion site q 4 hours) Obtain cultures. Pt likes cereal) Encourage fluid intake (1225 cc per day.3 C q 24 hours) (Drainage @ Central line site) Promote Nutritional intake (1500 kcal per day.