1. Standardized Nursing language
Applications in A Nursing Practicum Course
Copyright
Kelly J. Smith RN, MSN
University of Iowa
College of Nursing

2. Why introduce standardized language at the undergraduate level?
Creates an awareness of Nursing Language
Supports the learning of the nursing process
Provides consistency between practicum
Develops critical thinking skills
Improves Communication
Research Based
*This is the time when student are learning the nursing process and “planning and implementing nursing care are central components of any undergraduate nursing practicum course” (Schoenfelder, NOC, 2004,p.814) It also decrease the students confusion concerning the difference between an outcome and an intervention.
**Standardized language improves consistency through out the undergraduate program, leading to less confusion for the student.
*The use of standardized language should be implemented before the students learn other ways of developing plans of care. Therefore, “old ways” do not need to be un-taught.
*Use of Standardized Language when developing plans of care can develop critical thinking skills (Van De Castle, 2003) Student swill need to prioritize their nursing Diagnosis’ and identify relevant nursing activities and outcome indicators. Students will also need to consider the needs of the patient and family when individualizing care.
*The use of standardize language improves communication among nursing and other healthcare disciplines. It also assist faculty in understanding the students’ perception of the patient’s problem(s).
*The use of NANDA, NIC & NOC frameworks are desirable because they are research based, therefore faculty will be utilizing evidence based practice.

3. Components of Nursing Language
NANDA: Nursing Diagnosis: Definitions and Classification
NIC: Nursing Interventions Classification
NOC: Nursing Outcomes Classification

4. NANDA: Nursing Diagnosis
    A nursing diagnosis is defined as “ a clinical judgment about an individual, family or community responses to actual and potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”(NANDA, 2009)
A Nursing Diagnosis is critical component in the nursing process. This is the first step in identifying how we should plan nursing care for our patients’ to improve patient outcomes for which nurses are held accountable. It also helps us to identify what are the priorities in caring for this patient.

5. Variations of Nursing Diagnosis’:
1.      Actual diagnosis: describes health conditions that exist and supported by defining characteristics
2.      Risk diagnosis: those which describe disease or other conditions that may develop and are supported by risk factors
3.      Wellness diagnosis: describe levels of wellness and potential for enhancement to a higher level of functioning
(NANDA, 2009) and (Denehy & Poulton, 1999) 

6. Components of a Nursing Diagnosis
1.   Label or Name and definition
2.  Related Factors OR Risk Factors
3. Defining Characteristics
1. A label or name and definition: the label is selected base upon a) matching the related factors or defining characteristics and the definition of the label validates your decision.
2.      Related factor(s) which describe conditions antecedent to or associated with the diagnosis OR
Risk factor(s) which describe the environmental factors and physiologic ,genetic or chemical elements that increase the vulnerability of a (client) to an unhealthful event ( NANDA, 2009)
3. Defining characteristics, which are observable signs and symptoms that are manifestations of the diagnosis (Denehy & Poulton. 1999)
a definition does not need to be written in the care plan. It is there to help you decide if this Nursing Diagnosis is appropriate for this patient.
Related factors are elements that have an effect on the person, family or community, either internal or external, that contribute to the problem
Defining Characteristics are subjective or objective s&s indicating the presence of a condition
“Risk for” Nursing Diagnosis’ do not need to include defining characteristics, because at this time there is no evidence that the condition exists. There is only a possibility the condition could exist.

7. Case Study 4 year old boy with ALL
Admitted one week after chemo with a fever of 102.5F
WBC is 0.3,absolute neutrophil count is zero
New central line placed 10 days ago
C/O nausea & vomiting
Cries and hides behind mother when approach by nursing staff
Nursing diagnoses are chosen by using this subjective and objective data.

8. Examples
1.      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 increase risk for being invaded by pathogenic organisms ( NANDA,2009)

9. Was our choice correct?
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)
There are no defining characteristics for this diagnosis since it is a “Risk for” Nursing Diagnosis. More on that later.

10. Examples
2.      Nausea related to chemotherapy as evidenced by vomiting, patient c/o “tummy ache” and aversion toward food.
Other pertinent Nursing Diagnosis’

11. Examples
3.     Fear related to unfamiliarity with environmental experiences as evidenced by avoidance behaviors (hides behind mother) and crying.
A pertinent Growth and Development ND
Note defining characteristics.

12. 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)
“The use of NOC outcomes provides a quantitative measure of the [patient's] progress that is easy for all health care providers to understand and use.“ (Denehy and Poulton)

13. 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 patient‘s status for each of the indicators
The NOC outcome label indicates the behavior or status to be monitored.
When using NOC Outcomes, You must use the label and definition as written, but the outcome can be individualized by selecting only the appropriate indicators or adding additional indicators if needed (Denehy and Poulton)

14. 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

15. 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)

16. 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
The scale applies to each outcome indicator in above example
ie. WBC count would be rated at a “1” since it is <1.0K and the differential cannot be measured

17. Immune Status (Continued)
1= severe thru 5= None
Recurrent Infections
Weight Loss
Tumors (Immature WBC’s)
(NOC, 2004 p.322)
Other NOC outcome labels that may apply are:
Wound healing primary Intention
Knowledge: infection control

18. 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

19. 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)
NIC was developed based on existing practice and research and was designed in an easy to use organizing structure, using language that is familiar and clinically useful.

20. 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)
Note in the language the linkage to patient/client outcomes.

21. Components Name or label A definition
A set of activities the nurse does to carry out the intervention
**Students should include the name/label of the intervention and all of the appropriate individualized activities.

22. 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
** Some interventions and activities are more general than others. Activities can be further individualized by adding pertinent information concerning that individual client. i.e # cc’s of fluid per day required for maintenance listed with “Encourage Fluids”
** When using NIC interventions, you must use the NIC label and definition as written, but care can be individualized by selecting only those activities that are needed, adding more specific information to an activity or by creating additional activities as appropriate.
**Interventions or activities may be direct or indirect. Both are to benefit the patient/ client outcome.

23. NIC Examples: Linked with “Risk for Infection”
6550 infection protection
1100 nutrition management
3590 skin surveillance
6650 surveillance
3660 wound care
Examples

24. 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 (qd or qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors
A detailed example: The details, such as frequency of the activity are determined by institution-specific protocols or by age/weight specific information found in textbooks. Other specific details may be added by gathering input from the patient and/or family. The items in red/orange are those that were added to individualize the nursing activity for this particular patient.

25. 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) Central line site)
Promote Nutritional intake (1500 kcal per day, Pt. likes cereal)

26. Infection Protection (cont.)
Activities (cont.)
Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
Encourage rest (naps every afternoon from 1-3 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
(NIC, 2008)
If there is something that the nurse feels needs to be added, then she should rely on her own clinical decision making skills and add additional activity(ies) as necessary.

27. 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)
Differential WBC values WNL(within normal limits)
Skin integrity
Mucosa integrity
Body temperature IER( in expected range)
Gastrointestinal function
Respiratory Function
Genitourinary Function
1= severe thru 5= None
Recurrent Infections
Weight Loss
Tumors (Immature
WBC’s)
(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) 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)

28. 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

29. References
Denehy,J. & Poulton,S. (1999) Journal of School Nursing, 15 (1),
Iowa Intervention Project (2008). Nursing interventions and Classification (NIC). (4th ed.) St. Louis: Mosby, Inc.
Iowa Outcomes Project (2008). Nursing outcomes classification (NOC). (3rd ed.) St. Louis: Mosby, Inc.
NANDA Nursing Diagnosis: Definitions and Classifications (2009). Indianapolis, IN: Wiley-Blackwell.

30. References (cont.)
Pesut, D. & Herman, J. (1999) Clinical Reasoning: The Art & Science of Critical and Creative Thinking. Albany, NY: Delmar Publishers.
Schoenfelder, Deborah (2004). Nursing outcomes classification (NOC). Appendix F. (2004) St. Louis: Mosby, Inc.
Van De Castle, B. (2003) Comparisons of Nanda/NIC/NOC linkages between experts and nursing students. International Journal of Terminologies and Classifications 14(4)