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. Actual diagnosis: describes health conditions

that exist and supported by defining characteristics
2. Risk diagnosis: those which describe disease
or other conditions that may develop and are
supported by risk factors
3. Wellness diagnosis: describe levels of
wellness and potential for enhancement to a higher
level of functioning
(NANDA, 2009) and (Denehy & Poulton, 1999)
 Components of a Nursing Diagnosis

1. Label or Name and definition

2. Related Factors OR Risk Factors
3. Defining Characteristics
 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.
 Was our choice correct?
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, 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 patient‘s 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 WBC’s)
(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: Prevention and early detection of

infection in a patient at risk
Activities:
– Monitor for systemic and localized s & sx of infection
(central line site check every 4 hours.)
– Monitor WBC, and differential results (qd or qod)
– Follow neutropenic precautions
– Provide a private room
– Limit number of visitors
 Infection Protection (Cont.)
Activities (Cont.)
– 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)
 Infection Protection (cont.)
Activities (cont.)
– Encourage fluid intake (1225 cc per day, Pt likes orange
Gatorade)
– Encourage rest (naps every afternoon from 1-3 PM,
bedtime at 2030)
– Monitor for change in energy level/malaise
– Instruct patient to take anti-infective as prescribed
(Bactrim BID, po, MTW and Nystatin 5cc,s & s, TID)
– Teach Family about s & sx of infection and when to
report them to HCP
(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
Absolute WBC values WNL(within normal limits) (central 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
WBC’s) (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 Rationale for NIC Chosen
and indicators and indictor score nursing 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.
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)