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.Actualdiagnosis:describeshealthconditions
thatexistandsupportedbydefiningcharacteristics
2.Riskdiagnosis:thosewhichdescribedisease
orotherconditionsthatmaydevelopandare
supportedbyriskfactors
3.Wellnessdiagnosis:describelevelsof
wellnessandpotentialforenhancementtoahigher
leveloffunctioning
(NANDA,2009)and(Denehy&Poulton,1999)

Components of a Nursing Diagnosis

1.LabelorNameanddefinition
2.RelatedFactorsORRiskFactors
3. DefiningCharacteristics

Case Study
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

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 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

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,extreme
warmthordrainage(q4hours)
Inspectconditionofsurgicalincision(centrallineinsertion
siteq4hours)
Obtaincultures,asneeded(BloodculturesprnT>38.3Cq
24hours)(Drainage@Centrallinesite)
PromoteNutritionalintake(1500kcalperday,Pt.likes
cereal)

Infection Protection (cont.)

Activities(cont.)
Encouragefluidintake(1225ccperday,Ptlikesorange
Gatorade)
Encouragerest(napseveryafternoonfrom1-3PM,bedtime
at2030)
Monitorforchangeinenergylevel/malaise
Instructpatienttotakeanti-infectiveasprescribed
(BactrimBID,po,MTWandNystatin5cc,s&s,TID)
TeachFamilyabouts&sxofinfectionandwhentoreport
themtoHCP
(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)