Use of a standard language in nursing for the nursing care documentation is very crucial to the bedside or direct care nurse and the nursing profession. The American Nurses Association currently approves thirteen standardized nursing languages to direct care. Ten of these languages are specifically for the nursing care. In the course of delivering nursing services, all the nurses need to have a common means of expression and communication. They need to agree over a common terminology when describing interventions, outcomes, and interventions related to the specific documentation. By doing this, nurses all over the world are able to apply commonly comprehended terminology to identify intervention or specific problem and the outcome observed. In this paper, I am going to discuss the NANDA, NIC and NOC for a specific patient scenario.
NANDA is a primary organisation for disseminating, defining and integrating standardized nursing diagnoses all over the world. For my case I was dealing with a patient of hypertension. There were five nursing diagnosis and interventions. Hypertension is a general term used to refer to high blood pressure. The measure of the force exerted against the walls of the blood capillaries as blood is pumped by the heart is referred to as blood pressure. For my hypertension patient, I had the following Nursing care plan.
Diagnosis I: decreased Cardiac system Output.
NANDA definition: Insufficient blood supplied by the heart to satisfy the demands of the metabolic system.
The NOC:
- Demonstrate fixed cardiac rate and rhythm within individual’s normal range
- Maintain required blood pressure within acceptable range
- Participate in events that lower blood pressure or and cardiac workload.
Interventions:
- Monitor pressure of blood, measure in thighs/ both arms three times, use accurate technique and correct cuff size. Rationale: Comparison of different pressures provides a clear picture of scope of problem.
- Note general edema/dependent. Rationale: May indicate renal or vascular impairment, heart failure.
- Note the presence, quality of peripheral and central pulses. Rationale: Pulses in feet/legs may diminish, reflects effects of venous congestion and vasoconstriction.
- Observe skin colour, capillary refill time and temperature. Rationale: Pallor presence.
Diagnosis II: Constant Acute Pain
NANDA definition: Pain is what the experiencing individual confirms, exists when the person say complains of it.
NOC:
- Verbal ways that give relief
- Report discomfort/pain is controlled/relieved
- Follow prescribed pharmacological dosage and procedures
Interventions:
- Asses the pains scale. Determine details of pain, e.g. characteristics, location. Rationale: Helps in evaluating the effectiveness of therapy.
- Recommend bed rest during the acute phase. Rationale: Promotes relaxation/minimises stimulation.
- Assist the patient with ambulation as required. Rationale: Patient may experience episodes of postural hypertension, resulting to general weakness when ambulating.
- Limit vasoconstriction activities that may influence headache. Rationale: Activities that raise vasoconstriction influence headache.
Diagnosis III: Tolerance of Activity
NANDA Definition: Inadequate psychological or physiological energy to complete or endure desired or required daily activities.
NOC:
- Demonstrate some decrease in psychological signs of intolerance
- Participate in desired/necessary activities
- Report a substantial improvement in tolerance of activity.
Interventions:
- Advocate for self-care and progressive activity when tolerated. Give assistance as required. Rationale: Activity progression prevents sudden rise in cardiac workload.
- Instruct patient on techniques of energy-conservation, e.g. sitting to comb hair or brush teeth, using a chair when in the shower. Rationale: Energy saving activities reduces energy expenditure, thereby equalizing oxygen demand and supply.
Diagnosis IV: Imbalanced Nutrition.
NANDA definition: Taking in nutrients exceeding metabolic needs.
NOC:
- Initiate and maintain individually recommended exercise program
- Demonstrate change in feeding patterns e.g. quantity of food and food choices.
- Establish the correlation between obesity and hypertension.
Interventions:
- Discuss the necessity for limited intake of salt, sugar and fats and decreased caloric intake. Rationale: Excessive salts expand intravascular fluid volume and hence may damage kidneys.
- Establish patients will to lose weight .Rationale: Weight reduction motivation is individual based. The person of interest must be willing to cut weight.
- Review the usual daily dietary choices and caloric intake. Rationale: Identifies current weaknesses and strength in the dietary program
- Assist and instruct appropriate food selections e.g. meals rich in vegetables, fruits and minimal fat foods. Rationale: Avoiding saturated cholesterol and fat foods prevents progressing atherogenesis.
Diagnosis V: Lack of Knowledge
NANDA definition: Lack of cognitive information relating to a specific area.
NOC:
- Establish drug possible complications and side effects that need medical attention.
- Verbalize the understanding of disease treatment. Maintain blood pressure within acceptable parameters.
Interventions:
- Specify and define the required blood pressure limits: Rationale: Gives a basis for comprehending blood pressure elevation.
- Help patients in establishing the factors of risk that can be modified. Rationale: Risk factors indicated to contribute to cardiovascular, hypertension and renal disease.
This knowledge was very ideal in guiding me through the procedure of handling a hypertension patient. Besides that, it creates better communication between me, other nurses, and different health care providers. Generally, this information increases the visibility on nursing interventions.
References
Cowen, P.S., & Moorhead, S (2011) Current issues in nursing (8th ed.). St. Louis, Mo.: Mosby Elsevier.
Doenges, M.., Moor house, M.F., & Murr, A.C. (2008). Nursing diagnosis manual planning, individualizing, and documenting client care (2nd ed.). Philadelphia, PA: F.A. Davis.
Gulanick, M., & Myers, J. L. (2007). Nursing care plans: nursing diagnosis and intervention (6th ed.). St Louis, MO: Mosby.
