Ne 35 4 2010 04 16 Smith 200117 SDC1
Ne 35 4 2010 04 16 Smith 200117 SDC1
Ne 35 4 2010 04 16 Smith 200117 SDC1
Case Study
4yearoldboywithALL
Admittedoneweekafter
chemowithafeverof
102.5F
WBCis0.3,absolute
neutrophilcountiszero
Newcentrallineplaced10
daysago
C/Onausea&vomiting
Criesandhidesbehind
motherwhenapproachby
nursingstaff
Examples
1. Risk for infection related to
immunosuppression secondary to
chemotherapy, inadequate primary defenses
(central venous catheter),chronic disease
(ALL)and developmental level.
(NANDA,2009)
Examples
2. Nausea related to chemotherapy as
evidenced by vomiting, patient c/o tummy ache
and aversion toward food.
Examples
3. Fear related to unfamiliarity with
environmental experiences as evidenced by
avoidance behaviors (hides behind mother) and
crying.
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)
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 patients status for
each of the indicators
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
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
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)
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)
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
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
(NOC, 2008 p.399)
References
Denehy,J.&Poulton,S.(1999)Journal of School Nursing,
15 (1), 38-45.
IowaInterventionProject(2008).Nursing interventions and
Classification (NIC). (4th ed.) St.Louis:Mosby,Inc.
IowaOutcomesProject(2008). Nursing outcomes
classification (NOC). (3rd ed.) St.Louis:Mosby,Inc.
NANDANursingDiagnosis:Definitions and Classifications
2009-2011.(2009).Indianapolis,IN:Wiley-Blackwell.
References (cont.)
Pesut,D.&Herman,J.(1999)ClinicalReasoning:TheArt&
ScienceofCriticalandCreativeThinking.Albany,NY:
DelmarPublishers.
Schoenfelder,Deborah(2004).Nursing outcomes
classification (NOC). Appendix F. (2004) St.Louis:Mosby,
Inc.
VanDeCastle,B.(2003)Comparisons of Nanda/NIC/NOC
linkages between experts and nursing students.
InternationalJournalofTerminologiesandClassifications
14(4)