Unit 14

Neurologic Function

Case Study: Applying Concepts from NANDA, NIC, and NOC

A Patient With Brain Injury And A History of Alcohol Abuse
Mr. Williams is a 56-year-old man with a history of alcohol abuse. On the evening before his admission to the hospital, Mr.
Williams fell down a flight of stairs while intoxicated, hitting the front and left side of his head. He was admitted to the
neurologic intensive care unit (NICU) and diagnosed with a traumatic brain injury. After several days in the NICU, Mr. Williams
developed increased intracranial pressure (ICP) and is being treated for alcohol withdrawal. When family members come to
visit, they admit to a significant history of alcoholism in the family.

Turn to Appendix C to see a concept map that illustrates the

relationships that exist between the nursing diagnoses,
interventions, and outcomes for the patient's clinical
problems.

Nursing Classifications and Languages

NANDA NIC NOC

Nursing Diagnoses Nursing Interventions Nursing Outcomes
Return to
functional
baseline status,
stabilization of, or
improvement in:

Decreased Intracranial Adaptive Neurologic Neurological

Capacity—Intracranial fluid dynamic Monitoring Status—Ability
mechanisms that normally compensate for —Collection and of the peripheral
increases in intracranial volumes are analysis of patient data and central
compromised, resulting in repeated to prevent or minimize nervous system to
disproportionate increases in increased neurologic receive, process,
intracranial pressure (ICP) in response to a complications and respond to
variety of noxious stimuli internal and
external stimuli

Risk for Injury—At risk of injury as a Cerebral Edema Seizure

result of environmental conditions Management Control
interacting with the individual's adaptive and —Limitation of —Personal
defensive resources secondary cerebral actions to reduce
injury resulting from or minimize the
swelling of brain tissue occurrence of

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 seizure episodes

Dysfunctional Family Processes: Medication Physical Injury

Alcoholism—Psychosocial, spiritual, and Administrationy Severity
physiological functions of the family unit are —Preparing, giving, —Severity of
chronically disorganized, which leads to and evaluating the injuries from
conflict, denial of problems, resistance to effectiveness of trauma
change, ineffective problem solving, and a prescription and
series of self-perpetuating crises nonprescription drugs

Surveillance: Family Coping

Safety—Purposeful —Family actions
and ongoing collection to manage
and analysis of stressors that tax
information about the family resources
patient and the
environment for use in
promoting and
maintaining patient
safety

Family support
—Promotion of family
values, interests and
goals

NANDA International (2005). Nursing diagnoses: Definitions and classification 2005–2006. Philadelphia: North American
Nursing Diagnosis Association.
Dochterman, J.M. & Bulechek, G. M. (2004). Nursing interventions classification (NIC) (4th ed.). St. Louis: Mosby.
Iowa Outcomes Project (2004). In Moorhead, S., Johnson, M. & Maas, M. (2004). Nursing outcomes classification (NOC) (3rd
ed.). St. Louis: Mosby.
Dochterman, J. M. & Jones, D. A. (2003). Unifying nursing languages: The harmonization of NANDA, NIC, and NOC.
Washington, D.C.: American Nurses Association.

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