STANDARDIZED

NURSING LANGUAGE
Nengah Runiari.,M.Kep.,Sp.Mat

COMPONENTS OF NURSING
LANGUAGE

NANDA: Nursing Diagnosis: Definitions and

Classification : 235 diagnosis, 13 domain and
47 classes (NANDA 2015-2017)

NIC: Nursing Interventions Classification

NOC: Nursing Outcomes Classification

A nursing diagnosis typically contains two parts

:
Descriptor or modifier : ineffective, Risk for,
Readiness for enhanced, impaired.
Focus

of the diagnosis or the key concept of

the diagnosis : airway clearence, overweight,
knowledge, memory, coping

Exception

: fatigue, constipation, anxiety

COMPONENTS OF A NURSING
DIAGNOSIS
1.
2.
3.
4.

Label or Name
Definition
Defining characteristic
Related Factors OR Risk Factors

 VARIATIONS OF NURSING DIAGNOSIS

1. Problem-Focused diagnosis : a clinical judgment
concerning and undesirable human response to a
health condition/life process that exists in an
individual, family, group or community.
To use the PES format, start with the diagnosis
itself, followed by the etiological factors (related
factors in a problem-focused diagnosis). Finally,
identify the mayor signs/symptoms (defining
characteristic)
Ex :
anxiety related to situational crises and stress
(related factors) as evidanced by restlessness,
insomnia, anguish and anorexia

2. Risk diagnosis : a clinical judgment

concerning the vulnerability of an individual,
family, group or community. For developing an
undesirable human response to a health
condition/life process.
for risk diagnosis, there are no related factors
Ex :
Risk for infection as evidenced by inadequate
vaccination and imunossuppression

3. Health promotion diagnosis : a clinical

judgment concerning motivation and desire to
increase well being and actualize human health
potential. These response are express by a
readiness to enhance specific health behaviors
and can be used in any health state. Health
promotion diagnosis exists in an individual,
family, group or community.
Ex :
Readiness for enhanced self care as evidenced
by expressed desire to enhance self care

A Syndrome : is a clinical judgment

concerning a specific cluster of nursing
diagnosis that occur together and are best
addressed together and through similar
interventions.

Ex : chronic pain syndrome

DOMAIN AND CLASSESS NANDA

2015-2017
DOMAIN 1 : HEALTH PROMOTION
Class 1: Health awareness : 2 diagnosis
Class 2 : Health Management : 10 diagnosis
DOMAIN 2 : NUTRITION
Class 1: ingestion: 11 diagnosis
Class 2: Digestion
Class 3: Absorption
Class 4: metabolism : 4 diagnosis
Class 5 : Hydration: 6 diagnosis

DOMAIN 3 : ELIMINATION AND EXCHANGE

Class 1: Urinary function: 9 diagnosis
Class 2: Gastrointestinal function : 9 diagnosis
Class 3: Integumentary function
Class 4 : Respiratory function : 1 diagnosis
DOMAIN 4 ACTIVITY/REST
Class 1: Sleep/rest: 4 diagnosis
Class 2: Activity/exercise: 8 diagnosis
Class 3: Energy balance: 2 diagnosis
Class 4: Cardiovascular/pulmonary response: 14
diagnosis
Class 5: Self Care: 7 diagnosis

DOMAIN 5 PERCEPTION/COGNITION
Class 1: Attention: 1 diagnosis
Class 2: Orientation
Class 3: Sensation/perception
Class 4: Cognition: 4 diagnosis
Class 5: Communication: 2 diagnosis
DOMAIN 6 SELF PERCEPTION
Class 1: self concept: 6 diagnosis
Class 2: self esteem : 4 diagnosis
Class 3: body image: 1 diagnosis

DOMAIN 7 ROLE RELATIONSHIPS

Class 1: Caregiving roles : 5 diagnosis
Class 2: family relationship : 4 diagnosis
Class 3: Role performance : 6 diagnosis
DOMAIN 8 SEXUALITY
Class 1: Sexual identity
Class 2: Sexual function: 2 diagnosis
Class 3: Reproduction : 4 diagnosis

DOMAIN 9 COPING/STRESS TOLERANCE

Class 1: Post Trauma Response : 5 diagnosis
Class 2: Coping response: 26 diagnosis
Class 3: Neurobehavioral stress : 6 diagnosis
DOMAIN 10 LIFE PRINCIPLES
Class 1: Value
Class 2: Beliefs: 1 diagnosis
Class 3: Value/belief/action congruence : 11
diagnosis

DOMAIN 11 SAFETY/PROTECTION
Class 1:Infection : 1 diagnosis
Class 2: Physical injury: 26 diagnosis
Class 3: Violence: 5 diagnosis
Class 4 : Environmental hazards : 3 diagnosis
Class 5 : Defensive processes: 4 diagnosis
Class 6: Thermoregulation: 6 diagnosis
DOMAIN 12 COMFORT
Class 1:Physical comfort : 7 diagnosis
Class 2: environmental comfort: 2 diagnosis
Class 3: Social comfort : 4 diagnosis

DOMAIN 13 GROWTH/DEVELOPMENT
Class 1: Growth : 1 diagnosis
Class 2: development: 1 diagnosis

AXIS DIAGNOSIS CONCEPTS

Axis
Axis
Axis
Axis
Axis
Axis
Axis

1. the focus of diagnosis

2 : subject of diagnosis
3 : judgment
4 : location
5 : age
6 : time
7 : status diagnosis

NOC

The nursing outcomes classification (NOC) is

a system that can be used to select outcome
measures related nursing diagnosis.
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.

COMPONENTS

Definition outcome : a nursing-sensitive

patient outcome is an individual, family or
community state, behavior or perception
that measured along a continuum in response
to nursing intervention.
measurement scale : A five point scale to
rate patients status for each of the
indicators
A list of associated indicators for the concept
Supporting references

Kriteria Hasil:
Blood loss severity (NOC: 0413)
Definisi: keparahan perdarahan internal/eksternal
Rating target hasil:
dipelihara pada....... meningkat menjadi.....
Perkiraan jumlah kehilangan darah....ml.
Rating kehilangan darah
Berat
1

Menda
sar
2

Mod
erat
3

Ringan
4

Tidak
ada
5

Indikator
041301

Kehilangan darah yang dapat dilihat

NA

041302

Hematuria

NA

041303

Adanya darah dari anus

NA

041304

Hemoptysis

NA

041305

Hematemesis

NA

041306

Distensi abdomen

NA

041307

Perdarahan dari vagina

NA

041308

Perdarahan paska operasi

NA

041309

Penurunan tekanan darah sistolik

NA

041310

Penurunan tekanan darah diastolik

NA

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

SELECTING OUTCOMES

The type of health problem

The nursing or medical diagnoses
Patient characteristic
Available resources
Patient preferences
Treatment potential

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

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)

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

NOC TAXONOMY

7 DOMAINS, 32 CLASSES, 490 OUTCOMES

Domain I : Functional health
Classes : energy maintenance, growth &
development, mobility, self care
Domain II :Physiologic health
Classes : cardiopulmonary, elimination, fluid
& electrolytes, immune response, metabolic
regulation, neurocognitive, digestion &
nutrition, therapeutic response, tissue
integrity, sensory function

Domain III : Psychosocial health

Classes : Psychological well-being,
Psychological adaptation, self control, social
interaction
Domain IV : Health knowledge and behavior
classes : health behavior, health beliefs,
health knowledge, health management, risk
control & safety

Domain V : Perceived health

Classes : health & life quality, satisfaction
with care, symptom status
Domain VI : Family health
Classes : family caregiver performance,
family member health status, family wellbeing, parenting
Domain VII : Community health
Classes : community health protection,
community well-being

NIC

The nursing interventions classification

(NIC) is a comprehensive, standardized
classification of interventions that nurse
perform

INTERVENTIONS

Definition: any treatment based upon

clinical judgment and knowledge, that a
nurse performs to enhance patient/client
outcomes.

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

CHOOSING AN INTERVENTION

Desired patient outcomes

Characteristic of the nursing diagnoses
Research base for intervention
Feasibility for doing the intervention
Acceptability to the patient
Capability of the nurse

NIC TAXONOMY

DOMAIN I : PHYSIOLOGICAL BASIC

Classes : Activity and exercise, elimination
management, immobility management, nutrition
support, physical comfort promotion, self care
facilitation

DOMAIN II : PHYSIOLOGICAL COMPLEX

Classes : electrolyte and acid-base
management, drug management, neurologic
management, perioperative care, respiratory
management, skin/wound management,
thermoregulation, tissue perfusion management

NIC TAXONOMY

DOMAIN III : BEHAVIORAL

Classes : behavior therapy, cognitive therapy,
communication enhancement, coping
assistance, patient education, psychological
comfort promotion

DOMAIN IV : SAFETY
Classes : Crisis management, risk
management

NIC TAXONOMY

DOMAIN V :FAMILY
Classes :Childbearing care. Childrearing care,
lifespan care

DOMAIN VI :HEALTH SYSTEM

Classes : health system mediation, health
system management, information
management

NIC TAXONOMY

DOMAIN VII :COMMUNITY

Classes :community health promotion,
community risk management

NIC : 7 DOMAIN, 30 CLASSES

NIC EXAMPLES: LINKED WITH

RISK FOR INFECTION

6550
1100
3590
6650
3660

infection protection
nutrition management
skin surveillance
surveillance
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
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 13 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

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

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

SAMPLE 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