Advances in nursing process by Ejeh S

1. ADVANCES IN NURSING
PROCESS: NANDA-I, NIC,NOC
Presented by:
Ejeh, Sandra N.

2. 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.

3. 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.

4. 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).

5. 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the nursing process is outdated and misrepresents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)

6. STEPS IN NURSING PROCESS
THE MODIFIED NURSING PROCESS: FROM HERDMAN T.H. 2013
Theory/ nursing
science/
underlying
nursing concepts
Assessment/
patient history
PLANNING
Nursing diagnoses
Nursing outcomes
Nursing
interventions.
Implementation
Continual
re-evaluation

7. 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.

8. 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)

9. TYPES OF NURSING DIAGNOSES
Actual / Problem focused
diagnoses
Risk diagnoses
Wellness diagnoses
Syndrome diagnosis

10. Components of nursing Diagnoses: PES or PE
Actual Diagnoses:
Problem statement/label/definition =P
Etiology /related factors/causes=E
Defining characteristics/ Signs &Symptoms =S
Risk diagnoses:
Problem statement/label/definition =P
Etiology /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.

11. ACTUAL DIAGNOSIS 3 PART
P E
Diagnostic Label Related factor
acute pain related to surgery
S
Defining characteristics
evidenced by verbalization, facial expression

12. RISK DIAGNOSIS 2PART
P E
Diagnostic label Etiologic risk factors
Risk for shock related to hypovolaemia
WELLNESS DIAGNOSIS 1 PART
One part statement beginning with “readiness for enhanced”
‘
P
Diagnostic label
Readiness for enhanced parenting

13. 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

14. 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.

15. 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

16. 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

17. 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.

18. 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) #

19. FUNCTIONAL HEALTH
DOMAIN I
A – ENERGY
BALANCE
B - GROWTH AND
DEVELOPMENT C - MOBILITY D – SELF CARE
0301 self care:
Bathing
0302 Self care:
Dressing
030201 – selects
clothes
030203 – picks up
clothing
030206 – buttons
clothing

20.  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.

21. 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

22. 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.

23. 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.

24.  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.

26. CLUSTERS/DIAGNOSIS
Tenderness++ Chronic pain NANDA(00133)
Verbalized pain of 10/12related to pressure on
Swelling nerve endings secondary
Grimacing to tumor infiltration
Rubbing affected area evidenced by verbalization,
Chest pain rubbing of affected area.
Worried about change Disturbed body image NANDA
In body. (00118) related to change
Swelling 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 body
Sleep disturbances .

27. POST OP. CLUSTERS/DIAGNOSIS
Temp 38-39 C hyperthermia(00007)
Body warm to touch related to ineffective
thermo -regulation `
evidenced by
T-39, Body warm to touch.
R-48c/m ineffective breathing
Tachypnae pattern(00032) related to
Chest pain lung congestion secondary
Use of accessory muscle to tumor infiltration
Nasal flarring evidenced by tachypnae,
use of accessory muscle.
Pain/discomfort activity intolerance(00092)
Intolerance of mild activity related to imbalance between
Fatigue oxygen supply/demand
evidenced by fatigue, exertional
discomfort.

28. 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 4
Within 48hrs
of nursing
intervention.
Pain management
NIC 1400
•Place limb in
comfortable
position.
•Provide
diversional
therapy e.g tv,
chats from
relatives.
•Monitor vital
signs.
•Administer
prescribed tab.
Tramadol 100mg.
Pain level
NOC 2102
Reported
pain(210201) :
3-moderate.
Facial
expression(210206)
:4-mild
Rubbing affected
area (210221): 3-
moderate.

29. 2 Impaired
physical
mobility
related to
musculo
skeletal
impairmen
t
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
interventio
n.
Exercise
therapy
NIC 0221
• encourage
patient to
partake in
treatment
regimen
(medical,
physiotherap
y, nursing)
• encourage
passive
exercise.
Ambulation
NOC 0200
Walks at fast
pace(020005)
: 3-
moderately
compromise
d.

30. POST OP CARE PLAN.
Nursing
diagnosis
Objective Order evaluation
1
.
Hyperthe
mia(0000
7) related
to
ineffective
thermoreg
ulation
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(08
0019) 4-mild.
•Reported
thermal comfort
(080015) 4-mild.

31. 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:venti
lation NOC
0403.
•Accessory
muscle use
(040309) 3-
moderate.
•Respirator
y rate
(040301) 2-
substantial.

32. 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.

33. 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.

34. THANKS