Standardized Nursing Language NANDA NOC NIC - PowerPoint PPT Presentation

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Standardized Nursing Language NANDA NOC NIC

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Title: Standardized Nursing Language NANDA NOC NIC


1
Standardized Nursing LanguageNANDA NOC
NIC
  • Lemuel Dizon, RN

2
Definition
  • NANDA taxonomy of nursing diagnosis
  • North American Nursing Diagnosis Association

NOC nomenclature of nursing outcomes Nursing
Outcomes Classification
NIC nomenclature of nursing interventions Nursin
g Interventions Classification
3
Scope
  • NANDA 172 diagnosis 47 classes 13 domains
  • NOC 385 outcomes 31 classes 7 domains
  • NIC 542 interventions 31 classes 7 domains

4
Organizational Structure
  • Nursing Information and Data Set Evaluation
    Center (NIDSEC)
  • Evaluates information systems along Four
    dimensions
  • 1. Nomenclature (terms used)
  • 2. Clinical content (the linkages among
    terms)
  • 3. Clinical data repository (how the data are
    stored and made accessible for retrieval)
  • 4. General system characteristics (i.e.,
    performance, security, confidentiality, etc.)
  • NANDA International
  • Center for Nursing Classification and Clinical
    Effectiveness (NIC/NOC)

5
Formulation of a Nursing Diagnosis
  • Format Problem related to cause of problem
    evidenced by symptoms of problem.
  • Examples
  • Impaired gas exchange related to excessive
    secretions as evidenced by O2 saturation of 86.
  • Fluid volume deficit related to frequent vomiting
    for three days as manifested by increased pulse
    rate.

6
Format Features of NIC
  • ELECTROLYTE MANAGEMENT 2000Definition
    Promotion of electrolyte balance and prevention
    of complications resulting from abnormal or
    undesired serum electrolyte levelsActivities-
    Monitor for manifestations of electrolyte
    imbalance- Maintain patent IV access Administer
    fluids, as prescribed, if appropriate -
    Maintain intravenous solution containing
    electrolyte(s) at constant flow rate, as
    appropriate- Administer supplemental
    electrolytes (e.g., oral, NG, and IV) as
    prescribed, if appropriate- Consult physician
    on administration of electrolyte-sparing
    medications (e.g., spiranolactone), as
    appropriate- Administer electrolyte-binding or
    -excreting resins (e.g., Kayexalate) as
    prescribed, if appropriate- Obtain ordered
    specimens for laboratory analysis of electrolyte
    levels (e.g., ABG, urine, and serum levels), as
    appropriate- Monitor for loss of
    electrolyte-rich fluids (e.g., nasogastric
    suction, ileostomy drainage, diarrhea, wound
    drainage, and diaphoresis)- Irrigate
    nasogastric tubes with normal saline- Provide
    diet appropriate for patient's electrolyte
    imbalance (e.g., potassium-rich, low-sodium, and
    low-carbohydrate foods)- Teach patient and
    family about the type, cause, and treatments for
    electrolyte imbalance, as appropriate - Consult
    physician if signs and symptoms of fluid and/or
    electrolyte imbalance persist or worsen-
    Monitor patient's response to prescribed
    electrolyte therapy- Place on cardiac monitor,
    as appropriate

7
Components of NOC
  • Fluid Balance 0601
  • Balance of water in the intracellular and
    extracellular compartments of the body
  • Extremely Compromised Substantially Compromised
    Moderately Compromised Mildly Compromised Not
    Comprised
  • 1
    2
    3 4
    5
  • Indicators
  • BP IER
  • 1
    2
    3 4
    5
  • Mean arterial pressure IER
  • 1
    2
    3 4
    5
  • Pulmonary wedge pressure IER
  • 1
    2
    3 4
    5
  • Peripheral pulses palpable
  • 1
    2
    3 4
    5
  • Ascites not present
  • 1
    2
    3 4
    5
  • Neck vein distention not present
  • 1
    2
    3 4
    5
  • Peripheral edema not present
  • 1
    2
    3 4
    5

8
NIC/NOC Inclusion
  • SNOMED multidisciplinary record system
  • National Library of Medicines Metathesaurus for
    a Unified Medical Language
  • Joint Commission
  • Alternative Billing Concepts (ABC) codes
  • Registered in HL7

9
Vendors who have licenses for NIC NOC
  • AtStaff, Inc., Durham, NC, www.atstaff.com   
    NOC integrated within their ClairVia
    outcomes-driven acuity and patient management
    solutions for use by hospitals.
  • Healthland (Formerly Dairyland Healthcare
    Solutions), Louisville, KY, www.healthland.com  
     NIC and NOC integrated with their Clinical
    Documentation software system for care planning.
    System is used by small to midsize hospitals
  • DIPS ASA, www.dips.com    NIC integrated within
    their Electronic Patient Record System for care
    planning. Company located in Norway.
  • DxR Development Group, Carbondale, IL,
    www.dxrgroup.com    Web based system for
    teaching students nursing process. Product called
    DxR Nursing.
  • eClinical Notes, LLC, Centreville, VA,    NIC
    and NOC are being integrated within a nursing
    documentation section of an electronic
    documentation system for hospice providers.
  • Ergo Partners, Lake Quivira, KS,
    www.ergopartners.com    Product is EMRitus
    software
  • McKesson Corporation, Alpharetta, GA,
    www.mckesson.com    NIC and NOC integrated
    within Horizon Expert Plan for use in Care
    planning
  • MedSoftCCS, LLC., Vancouver, WA,
    www.medsoftccs.com    NIC integrated within
    Medtrack CCS job specific Orientation
    e-checklists.
  • Nurse's Aide LLC, Keller, TX, www.nursesaide.net
       Product for School Nurses to assist with
    their care plans for students.
  • Purkinje, Inc., www.purkinje.com    Electronic
    clinical documentation tool. Company located in
    Canada.
  • Sanum AS, www.sanum.no    Sanum system used
    within hospitals and the educational market.
    Company located in Norway.
  • IHTSDO (SNOMED-ownership has transferred),
    Northfield, IL. www.snomed.com    NIC and NOC
    used within mapping tool.
  • Tech-Time, Inc., Billings, MT, www.techtimeinc.com
       Clinical documentation system
  • Typhon Group, LLC, Metairie, LA,
    www.typhongroup.com    NIC and NOC integrated
    within their Registered Nurse Student Tracking
    (RNST) program used by Nursing Schools. Product
    helps student users develop patient care plans.

10
Impact A call for nursing standards
  • Developing standards would improve
    vendor-supplied nursing information systems.
  • Standards from the nursing community would
    significantly reduce the cost and time of
    developing the nursing component of clinical
    systems.
  • Nursing-developed standards would enhance nurses
    efficiency.
  • Automated information systems would help the
    current nursing shortage crisis by supporting the
    work of nurses.

11
Reference
  • www.nanda.org
  • www.nursing.uiowa.edu/excellence/nursing_knowledge
    /clinical_effectiveness
  • Simpson, R. Whats in a name? The taxonomy and
    nomenclature puzzle, part 2. Nursing Management.
    August 2003, p. 12, 14, 16.
  • Simpson, R. Setting the Informatics Standards An
    Overview of NIDSECs Information Systems
    Evaluation Criteria. Nursing Economic.
    September-October 1998, Vol. 16, No. 5,
    pp.279-281.
  • Simpson, R. Finally, a Central Place to Evaluate
    Nursing Systems. Nursing Management. July 1997,
    pp.17-18.
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