NUEL 316
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NANDA: Nursing Diagnosis: Definitions and
Classification
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NOC: Nursing Outcomes Classification
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NIC: Nursing Interventions Classification
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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)
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Label or Name and definition
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Defining Characteristics
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Related Factors
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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.
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Risk for infection related to immunosuppression
secondary to chemotherapy, inadequate primary
defenses (central venous catheter),chronic disease
(ALL)and developmental level.
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Definition of the label: At increased risk for
being invaded by pathogenic organisms
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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)
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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).
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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
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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
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Immune Status
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Infection Severity
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Knowledge: Infection Control
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Nutritional Status
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Tissue Integrity: Skin & Mucous membranes
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Wound Healing: Primary Intention
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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
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Absolute WBC values WNL
Differential WBC values WNL
Skin integrity
Mucosa integrity
Body temperature IER
Gastrointestinal function
1= severe thru 5= None
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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
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“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)).
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Definition: “any treatment based upon
clinical judgment and knowledge, that a
nurse performs to enhance patient/client
outcomes” (Johnson, et. al., 2012).
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Name or label
A definition
A set of nursing activities (aka nursing
interventions) the nurse does to carry out the
intervention
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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
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infection protection
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nutrition management
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skin surveillance
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surveillance
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wound care
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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
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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)
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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/malaise
o 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)
Sample Blank Care Plan
Describe your patient scenario briefly
NANDA Nursing
Diagnosis
NOC Outcome Labels
& Indicators
NOC label, definition, appropriate
Complete NANDA Nursing Dx
Statement including related or risk indicators, rating scale being used, and
rating on that scale.
factors and defining characteristics
Rationale for NOC
chosen and indicator
score
NIC Intervention Label
and Nursing
Interventions
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.
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
Risk for infection related to
immunosuppression secondary to
chemotherapy, inadequate primary
defenses (central venous catheter),
chronic disease (ALL) and
developmental level.
NOC Outcome Labels
& Indicators
Immune
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)
Differential WBC values WNL(within normal limits)
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
WBC’s)
1 2 3 4 5
Rationale for NOC
NIC Intervention
chosen and indicator Label and Nursing
score
Interventions
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 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)