NUEL 316

NANDA: Nursing Diagnosis: Definitions and Classification

NOC: Nursing Outcomes Classification

NIC: Nursing Interventions Classification

Actual diagnosis: describes health conditions that exist and are supported by defining characteristics

At Risk diagnosis: those which describe disease or other conditions that may develop and are supported by risk factors

Health Promotion diagnosis: describe levels of wellness and potential for enhancement to a higher level of functioning

(Johnson, et. al., 2012) 

   Label or Name and definition

Defining Characteristics

Related Factors

15 month old girl with ALL (Acute Lymphocytic Leukemia)

Admitted one week after chemo with a fever of 103F

WBC is 0.3,absolute neutrophil count is zero

New central line placed 10 days ago

C/O nausea & vomiting Cries when approached

by staff and pulls blanket over head.

Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter),chronic disease (ALL)and developmental level.

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)

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” (Johnson, et. al., 2012).

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

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

Immune Status

Infection Severity

Knowledge: Infection Control

Nutritional Status

Tissue Integrity: Skin & Mucous membranes

Wound Healing: Primary Intention

Location of wound (Front of Neck)

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

1= severe thru 5= None

• Recurrent Infections• Weight Loss• Tumors (Immature WBCs)

(NOC, 2004 p.322)

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

“The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties” (Johnson, et. al., 2012)).

Definition: “any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes” (Johnson, et. al., 2012).

Name or label A definition A set of nursing activities (aka nursing

interventions) the nurse does to carry out the intervention

Each NANDA diagnosis is linked to a variety of NIC Labels which indicate what nursing interventions should be done to treat the nursing diagnosis.

Once a nurse has identified the NIC Labels associated with the selected NANDA Diagnoses, s/he must use nursing knowledge, clinical judgment, and any nursing resources to identify the actual nursing interventions/activities that should be performed to meet individual client’s needs.

Nursing interventions can be further individualized by adding client specific information

infection protection

nutrition management

skin surveillance

surveillance

wound care

Definition: Prevention and early detection of infection in a patient at risk

Nursing Interventions: ◦ 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

Nursing Interventions (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)

Nursing Interventions (cont.)o Encourage fluid intake (1225 cc per day, Pt likes

orange Gatorade)o Encourage rest (naps every afternoon from 1-3

PM, bedtime at 2030)o Monitor for change in energy level/malaiseo Instruct patient to take anti-infective as

prescribed (Bactrim BID, po, MTW and Nystatin 5cc,s & s, TID)

o Teach Family about s & sx of infection and when to report them to HCP

(NIC, 2008)

Describe your patient scenario briefly

NANDA Nursing Diagnosis

NOC Outcome Labels & Indicators

Rationale for NOC chosen and indicator

score

NIC Intervention Label and Nursing Interventions

Complete NANDA Nursing Dx Statement including related or risk factors and defining characteristics

NOC label, definition, appropriate indicators, rating scale being used, and rating on that scale.

Describe your rationale for choosing this NOC label and the indicator ratings that you chose for this patient.

NIC label, definition, and appropriate nursing interventions with individualized information added.

Sample Blank Care Plan

15 month old girl with ALL (Acute Lymphocytic Leukemia) was dmitted one week after chemo with a fever of 103F. The patients WBC is 0.3,absolute neutrophil count is zero. A new central line was placed 10 days ago. The child now presents with c/o nausea & vomiting and cries when approached by staff and pulls the blanket over head.

NANDA Nursing Diagnosis

NOC Outcome Labels & Indicators

Rationale for NOC chosen and indicator

score

NIC Intervention Label and Nursing Interventions

Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter), chronic disease (ALL) and developmental level.

Immune 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)Differential WBC values WNL(within normal limits)1 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

Patient has compromised immune status due to low WBC count – making the ranking a 1 (severely compromised).

Patient has a temperature of 103 – making the ranking a 1 (severely compromised).

(You are given 2 examples here but there are many more NOC indicators for this case study patient).

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)