NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions

NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions

Book Description

This book unifies the languages of nursing

Product Description

Based on years of research at the University of Iowa, this one-of-a-kind reference provides linkages between three standardized languages recognized by the American Nurses Organization: NANDA, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). A perfect companion to Dochterman: NIC, 4th Edition and Moorhead: NOC, 3rd Edition, this book is a useful tool for nurses in developing care plans for patients, and for institutions in tracking and quantifying nursing care.

  • Links all of the NANDA-approved nursing diagnoses to outcome labels and three levels of suggested interventions
    • Major
    • Suggested
    • Optional
  • Uses easy-access, user-friendly tables to show terminology and criteria.
  • Presents case studies along with nursing care plans to demonstrate the application of linkages.
  • Defines all NANDA, NOC, and NIC labels.
  • Makes an excellent companion to the new editions of NIC and NOC.

Complete with the most up-to-date NIC, NOC, and NANDA-I approved lists.

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ReadmoreNANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions

Ineffective Breathing Pattern NANDA NIC NOC

Nursing Diagnosis :

Ineffective breathing pattern

Definition: The exchange of air inspired and / or inadequate expiratory

Defining characteristics:
  • The pressure drop of inspiration / expiration
  • Decreased air exchange per minute
  • Using the additional respiratory muscles
  • Nasal flaring
  • Dyspnea
  • Orthopnea
  • Changes in breast irregularities
  • Shortness of breath
  • Assumption of the 3-point position
  • Respiratory pursed-lip
  • Expiratory phase lasts very long
  • Increased anterior-posterior diameter
  • Respiratory rata-rata/minimal
    • Infants: less than 25 or more than 60
    • Ages 1-4: less than 20 or more than 30
    • Age 5-14: less than 14 or more than 25
    • Age over 14: less than 11 or more than 24
  • The depth of breathing
    • Adult 500 ml tidal volume at rest
    • Baby tidal volume 6-8 ml / kg
  • Timing ratio
  • Decrease in vital capacity

Related factors:
  • Hyperventilation
  • Bone deformities
  • Chest wall deformity
  • Reduction of energy / fatigue
  • Destruction / musculoskeletal impairment
  • Obesity
  • The position of the body
  • Fatigue of respiratory muscles
  • Hypoventilation syndrome
  • Pain
  • Anxiety
  • Neuromuscular Dysfunction
  • Damage to perceptual / cognitive
  • Injury to the spinal cord
  • Immaturity of Neurological

  • Respiratory status: Ventilation
  • Respiratory status: Airway patency
  • Vital sign Status

Criteria Results:
  • Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspneu (capable of removing sputum, able to breathe easily, no pursed lips)
  • Indicates a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
  • Vital signs are within normal range (blood pressure, pulse, respiration)

Airway Management
  • Open the airway, using chin lift technique or jaw thrust if necessary
  • Position the patient to maximize ventilation
  • Identify the patient's need for the installation of an artificial airway devices
  • Place the mayo if needed
  • Perform chest physiotherapy if necessary
  • Remove secretions by coughing or suction
  • Auscultation of breath sounds, record the presence of additional noise
  • Perform suction on the mayo
  • Give bronchodilators if necessary
  • Adjust intake to optimize fluid balance.
  • Monitor respiration and oxygenation status

Oxygen therapy
  • Clean the mouth, nose and trachea secret
  • Maintain a patent airway
  • Set oxygenation equipment
  • Monitor the flow of oxygen
  • Maintain the position of the patient
  • Observe for signs of hypoventilation
  • Monitor the patient's anxiety to oxygenation

Vital sign monitoring
  • Monitor blood pressure, pulse, temperature, and respiratory rate
  • Note the presence of fluctuations in blood pressure
  • Monitor vital signs while the patient is lying down, sitting, or standing
  • Auscultation of blood pressure in both arms and compare
  • Monitor blood pressure, pulse, respiratory rate, before, during, and after activity
  • Monitor the quality of the pulse
  • Monitor respiratory rate and rhythm
  • Monitor lung sounds
  • Monitor abnormal breathing pattern
  • Monitor the temperature, color, and skin moisture
  • Monitor peripheral cyanosis
  • Monitor the existence of Cushing's triad (a widened pulse pressure, bradycardia, increased systolic)
  • Identify the causes of changes in vital signs
ReadmoreIneffective Breathing Pattern NANDA NIC NOC