ADVANCES IN NURSING PROCESS: NANDA-I, NIC,NOCPresented by:

Ejeh, Sandra N.

INTRODUCTION The quest to satisfy the ever changing needs of

consumers of nursing care has led to the struggle for nursing to assume its place as an independent profession.

Nurses aimed at helping people to care for themselves. The nursing process has been adopted as the frame of

reference for nursing practice.

The integration of nursing diagnoses into the care plan and the recent introduction of the use of standardized nursing languages (SNL): NANDA I, NIC and NOC has brought a lot of intellectual challenges to nurses, the young and the old alike.

Nurses are thus expected to update their knowledge and use the SNL for the documentation of patients problems and interventions given.

OBJECTIVES

At the end of this presentation, students will be able to:

Define Nursing process , NANDA I, NIC and NOC

State the types and components of nursing diagnoses

Make a good nursing diagnoses Integrate NANDA I, NIC and NOC in the

nursing care plan. 

DEFINITION OF NURSING PROCESS According to NANDA (1990), nursing process

is a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health.

Nursing process can be said to be a systematic and goal directed set of activities which are interrelated and dynamic, used by the nurse to determine, plan and implement individualized nursing care, which is aimed at helping the patient to achieve integration of his whole being or optimal level of wellness(Nwonu 2002).

STEPS IN NURSING PROCESS Assessment Diagnoses Planning Implementation Rationale Evaluation.

According to some theorists, this six-steps description of the nursing process is outdated and misrepresents nursing as linear and atomic (Kozier, Barbara, et al., 2004)

STEPS IN NURSING PROCESSTHE MODIFIED NURSING PROCESS: FROM HERDMAN T.H. 2013

Theory/ nursing science/

underlying nursing

concepts

Assessment/ patient history

PLANNINGNursing diagnosesNursing outcomes

Nursing interventions.

Implementation

Continual re-

evaluation

CHARACTERISTICS OF NURSING PROCESS The nursing process is a cyclical and ongoing

process that can end at any stage if the problem is solved.

The nursing process exists for every problem that the individual/family/community has.

The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.

The entire process is recorded or documented in order to inform all members of the health care team.

NANDA INTERNATIONAL The primary organization for defining, dissemination and

integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis Association.

The new 2015-2017 edition NANDA I has been rigorously updated and revised throughout.

It contains 235 nursing diagnoses grouped into 13 domains and

47 classes. It also has 25 new nursing diagnoses and 13 revised diagnoses.

It contains Standardized diagnostic indicator terms (characteristics, related factors, risk factors) to aid clarity.

A domain is a “sphere of knowledge (Merriam-Webster, 2009). Examples of domains in the NANDA-I taxonomy include: Nutrition, Elimination/Exchange, Activity/Rest, or Coping/Stress Tolerance. Domains are divided into classes (groupings that share common attributes)

TYPES OF NURSING DIAGNOSESActual / Problem focused diagnoses

Risk diagnoses

Wellness diagnoses

Syndrome diagnosis

Components of nursing Diagnoses: PES or PEActual Diagnoses: Problem statement/label/definition =P Etiology /related factors/causes=E Defining characteristics/ Signs &Symptoms =S

Risk diagnoses:Problem statement/label/definition =PEtiology /related factors/causes=E

Wellness diagnoses: Problem statement/label = P Syndrome diagnoses comprises of a cluster of problems. It is

a statement. E.g. rape trauma syndrome.

Qualifiers – are words added to the diagnostic label or problem statement to gain additional meaning. Examples are impaired, deficient, decreased, ineffective.

ACTUAL DIAGNOSIS 3 PART

P EDiagnostic Label Related factor

acute pain related to surgery

S Defining characteristicsevidenced by verbalization, facial

expression

RISK DIAGNOSIS 2PART

P EDiagnostic label Etiologic risk factorsRisk for shock related to hypovolaemia

WELLNESS DIAGNOSIS 1 PART

One part statement beginning with “readiness for enhanced”‘

PDiagnostic labelReadiness for enhanced parenting

STEPS TO FORMULATING A GOOD NURSING DIAGNOSIS

Conduct a nursing assessment

Cluster and interpret cues/patterns

Generate Hypotheses/ possible alternatives

Validation & Prioritization of Nursing Diagnoses

RULES FOR WRITING A NURSING DIAGNOSES State human response not a clients need. Start the diagnostic statement with the human response. Connect the human response to the etiology with the phrase

“related to” not “due to”. Be sure the first two parts are not restatements of each

other. E.g “impaired skin integrity related to ulceration”. Do not mention a medical diagnosis in either of the first two

parts. Several factors may be involved in the etiology of the human

response, include them. Select an etiology that can be changed by nursing

intervention. Avoid judging the client as bad in any part of the diagnostic

statement. Avoid suggesting that some members of the health care

team is not doing his/her job. Put the cues that led to the diagnosis in the third part

(defining characteristics.

BIOFOCAL MODEL….COLLABORATIVE PROBLEMS Collaborative problems are certain physiologic complications that

nurses monitor to detect onset or changes in status (Carpenito 2007).

They usually occur in association with a specific pathology treatment and they require nursing and medical interventions hence the title “collaborative”.

Certain physiologic problems are nursing diagnoses and so nurses monitor to detect onset or change in status

All collaborative problems begin with the label POTENTIAL COMPLICATION (PC). For example:

Situation 1: Man is admitted after a myocardial infarction with a normal blood pressure.

Diagnosis: PC: Hypertension Nurses focus: to monitor for a change in BP or onset of

hypertension

NURSING INTERVENTION CLASSIFICATION (NIC) Nursing intervention classification is a standardized

list of nursing interventions to achieve a specific outcome (Bulecheek, Butcher and Dochterman, 2008).

The current 5th edition of NIC has 7 domains, 30 classes and 542 interventions and more than 12,000 activities (Bulecheek, Butcher and Dochterman, 2008).

Each interventions includes a label name with a definition and a unique numeric code example Airway Management NIC3140, Ventilation assistance NIC3390.

NIC is used in implementation phase

NURSING OUTCOME CLASSIFICATION (NOC).

A nursing sensitive patient outcome is an individual, family or community state, behavior or perception that is measured along a continuum in response to nursing intervention(s) (Moorhead, Johnson, Maas and Swanson, 2013)

The first edition of NOC was published in 1997 with 190 outcomes. The current 5th edition of NOC was published in 2013 and has 490 outcomes, 32 classes and 7 domains.

NOC is used in planning and evaluation phase.

CODING STRUCTURE OF NOC Domains are represented with numbers (1-9) #

Class are represented with alphabets (A-Z) or (AA-ZZ) ##

Outcome are represented with 4numbers ####

Indicators are represented with numbers (01-99) ##

Scale are representes with numbers (01-99) ##

Scale value are represented with numbers (1-5) #

FUNCTIONAL HEALTH DOMAIN I

A – ENERGY BALANCE

B - GROWTH AND

DEVELOPMENT

C - MOBILITY

D – SELF CARE

0301 self

care: Bathin

g

0302 Self

care: Dressi

ng

Some scale used in measuring outcome include: severely compromised (1), substantially compromised (2), moderately compromised (3), midly compromised (4), not compromised (5).

Numbers in bracket are the scale value.

NANDA – I, NIC AND NOC (NNN) LINKAGES. NNN linkages shows the association between the three

standardized languages recognized by the American Nurses Association: NANDA – I, NIC and NOC (Hye, 2010).

Step to using NNN Form clusters of similar patients signs and symptoms. Using NANDA –I, determine the best nursing diagnosis that

explains your patients problem. Go to NOC and determine which NOC outcome is appropriate to

help set an objective and evaluation. In NOC, select appropriate scale and scale rating value for

clients present problem Choose NIC interventions that are most likely to achieve the

desired outcome. Itemize list of activities for each NIC interventions Make evaluation by comparing patients NOC scale value before

and after your intervention

ADVANTAGES OF STANDARDIZED NURSING LANGUAGE : NNN It provides a unified language for

communication amongst nurses as well as the public.

It allows for provision of uniform nursing interventions of patients nursing diagnoses

Supports development of electronic clinical information systems and health records.

It supports nursing informatics It facilitates the evaluation and

improvement of a nursing care through evaluation.

USE OF NNN IN MANAGEMENT OF MR E.U. Mr E.U a 24years old male patient who was admitted into MWD4 of

the NOHE on 17/9/15 with a diagnosis of tumor right proximal tibia ??osteosarcoma. He noticed swelling 10/12ago following mild trauma while playing football after the ball hit his leg. Visited TBS before presenting to NOHE 6/12ago. He was booked for incisional biopsy but patient disappeared only to return 5months later.

On examination, there was pain of 10/12 ago, reduced appetite, swelling around tibia, pale+, tenderness++, tumor warm to touch. Patient is worried about change in body structure and change in life, fear of unknown.

Patient had incisional biopsy done on 21/9/15 and received 2 unit of blood after biopsy. Also had above knee amputation on 28/9/15. about 1week post surgery, he started complaining of increase in chest pain, abdominal pain/discomfort, loss of appetite, anxiety, intolerance of mild activity, fatigue and tense look.

periodic examination of patient revealed hyperthermia with temperature ranging from 38-39 c and body warm to touch, tachypnea(40-52c/m), tachycardia(140-160), BP 130/80-140/80 mmHg., nasal flaring and use of accessory muscle of respiration.

PCV of 10/10/15-29%, chest Xray of 9/10/15 showed pulmonary and pleural metastasis of osteosarcoma and right pleural effusion.

A diagnosis of pulmonary metastasis from right proximal tibia osteosarcoma was made on 10/10/15.

Our patient was referred to UNTH, Oncology unit on 16/10/15 for palliative management. Biopsy result to be forwarded when out.

CLUSTERS/DIAGNOSISTenderness++ Chronic pain NANDA(00133)Verbalized pain of 10/12 related to pressure onSwelling nerve endings secondaryGrimacing to tumor infiltrationRubbing affected area evidenced by verbalization,Chest pain rubbing of affected area.

Worried about change Disturbed body image NANDAIn body. (00118) related to changeSwelling of tibia in body structure evidenced

by verbalization.

Fear of unknown Anxiety NANDA(00146) related to unknown outcome of condition evidenced by

Worried about change verbalization.in bodySleep disturbances .

POST OP. CLUSTERS/DIAGNOSISTemp 38-39 Chyperthermia(00007) Body warm to touch related to ineffective thermo -

regulation ` evidenced byT-39, Body warm to touch.

R-48c/m ineffective breathing Tachypnae pattern(00032) related toChest pain lung congestion secondaryUse of accessory muscle to tumor infiltrationNasal flarring evidenced by tachypnae,

use of accessory muscle.

Pain/discomfort activity intolerance(00092)Intolerance of mild activity related to imbalance betweenFatigue oxygen supply/demand

evidenced by fatigue, exertionaldiscomfort.

PRE OP. NURSING CARE PLAN.Nursing diagnosis

objectives orders evaluation

1 Chronic pain(00133) related to pressure on nerve endings secondary to tumor infiltration evidenced by facial expressio verbalization, rubbing affected area.

Patient will verbalize reduction in pain improving his rating (NOC 2102) from 1 to 4Within 48hrs of nursing intervention.

Pain managementNIC 1400•Place limb in comfortable position.•Provide diversional therapy e.g tv, chats from relatives.•Monitor vital signs.•Administer prescribed tab. Tramadol 100mg.

Pain levelNOC 2102

Reported pain(210201) :3-moderate.

Facial expression(210206) :4-mild

Rubbing affected area (210221): 3-moderate.

2 Impaired physical mobility related to musculo skeletal impairment evidenced by slowed movement, difficulty in turning.

Patient will be able to move faster with assistive device improving his rating (NOC 6208) from 2 to 4 within 2-4 weeks of nursing intervention.

Exercise therapyNIC 0221• encourage patient to partake in treatment regimen (medical, physiotherapy, nursing)• encourage passive exercise.

Ambulation NOC 0200

Walks at fast pace(020005): 3-moderately compromised.

POST OP CARE PLAN.Nursing diagnosis

Objective Order evaluation

1.

Hyperthemia(00007) related to ineffective thermoregulation evidenced by body warm to touch, T 39c

Patients body temperature will be maintained at 36-37.2 C improving his rating NOC0800 from 1 to 5 within 30mins of nursing intervention

Fever treatment NIC3740•Tepid sponge patient every 15minuite.•Open nearby windows•Expose patient.•Administer prescribed inj. IM paracetamol 600mg.

Temperature Regulation NIC3900•Monitor vital signs.

Thermoregulation NOC 0800.

•Hyperthermia(080019) 4-mild.

•Reported thermal comfort (080015) 4-mild.

2.

Ineffective breathing pattern (00032) related to lung congestion secondary to tumuor infiltration evidenced by R 48c/m, SPO2-79

Patient breathing will be maintained at 16-24c/m improving his rating NOC 0403 from 1 to 3 within 1-3hr of nursing intervention.

Airway Management NIC3140• nurse in fowlers position•Encourage chest physiotherapy•Administer prescribed syrup broncholyte 10mls

Ventilation assistance NIC3390•Administer prescribed oxygen 5L/m.

Respiratory status:ventilation NOC 0403.

•Accessory muscle use (040309) 3-moderate.•Respiratory rate (040301) 2-substantial.

RECOMMENDATION

The inclusion of Standardized Nursing Language as a core course in the curricula of nursing education.

The Standardized Nursing Language should also be produced and published for various fields of nursing example orthopaedics, plastic, emergency, oncology. This makes it less cumbersome, handy and cheaper.

CONCLUSION The nursing process and standardized nursing

languages has improved the quality of patients care and also the image of the nursing profession.

As nurse professionals, we must identify ourselves with this awesome breakthrough of the nursing profession and begin to utilize standardized nursing language in the care of our patients.

THANKS