Standardized Nursing language

Applications in A Nursing Practicum CourseCopyright

Kelly J. Smith RN, MSNUniversity of IowaCollege of Nursing

Components of Nursing Language

NANDA: Nursing Diagnosis: Definitions and ClassificationNIC: Nursing Interventions ClassificationNOC: 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 ALLAdmitted one week after chemo with a fever of 102.5FWBC is 0.3,absolute neutrophil count is zeroNew central line placed 10 days agoC/O nausea & vomitingCries 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 outcomesNOC 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 statusA 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 problemEach 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 1Substantially compromised 2Moderately compromised 3Mildly compromised 4Not compromised 5

_____________________________________________________Severe 1Substantial 2Moderate 3Mild 4None 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 labelA definitionA 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 problemInterventions and activities should be chosen to meet the individual clients needsActivities can be further individualized by adding client specific informationAdditional activities may be added if appropriate

NIC Examples: Linked with “Risk for Infection”

6550 infection protection1100 nutrition management3590 skin surveillance6650 surveillance3660 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 StudyNANDA 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 compromisedAbsolute WBC values WNL(within normal limits)1 2 3 4 5Differential WBC values WNL(within normal limits)1 2 3 4 5Skin integrity1 2 3 4 5Mucosa integrity1 2 3 4 5Body temperature IER( in expected range)1 2 3 4 5Gastrointestinal function1 2 3 4 5Respiratory Function1 2 3 4 5Genitourinary Function1 2 3 4 51= severe thru 5= NoneRecurrent Infections1 2 3 4 5Weight Loss1 2 3 4 5Tumors (Immature WBC’s)1 2 3 4 5(NOC, 2008 p.399)

6550 infection protectionDefinition: Prevention and early detection of infection in a patient at riskActivities: 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

Nanda Nursing Diagnosis NOC Outcome Label(s) and indicators

Rationale for NOC chosenand 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

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:

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)