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

NOC Outcome Labels

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

Rationale for NOC

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

NIC Intervention
Label and Nursing
Interventions
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
WBCs)
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)