How To Use

NANDA NIC NOC

Disampaikan oleh:
Agung Waluyo, SKp, MSc, PhD

Nursing Outcomes Classification

(NOC)
The nursing outcomes classification
(NOC) is a classification of nurse
sensitive outcomes
NOC outcomes and indicators allow
for measurement of the patient,
family, or community outcome at any
point on a continuum from most
negative to most positive and at
different points in time. (Iowa
Outcome Project, 2008)

NOC
Before providing an intervention,
nurses use NOC to understand the
patients current problems and nursing
diagnoses and rate the chosen
outcome to obtain a baseline rating.
After providing an intervention, NOC
is used to measure the outcome and
determine a change score.

NANDA/NOC Linkage

Each nursing Diagnosis is followed

by a list of suggested outcomes to
measure
whether
the
chosen
interventions
are
helping
the
identified problem
Each outcome can be individualized
to the patient or family by choosing
the appropriate indicators or adding
additional indicators as necessary

NANDA NIC NOC (NNN) Linkages

The first step in the process to link NNN
is for nurses to determine a nursing
diagnosis using NANDA-I diagnoses.
After determining the nursing diagnosis,
nurses consider which NOC outcomes
are appropriate for the patient situation,
and then
Choose NIC interventions that are most
likely to achieve the desired outcome
(Johnson, 2006).

Taxonomy NOC
Level 1: Domain
Contoh: Functional Health
Level 2: Classes
Contoh: Energy Maintenance
Level 3: Outcomes
Contoh: Fatigue, Disruptive Effects
Indikator:
Malaise
Lethargy
Menurunnya Energi
Gangguan ADL , etc

Immune Status (0702)

Definition: Natural and acquired appropriately
targeted resistance to internal and external
antigens.
1=severely compromised thru 5= not
compromised
Absolute WBC values Within Normal Limit
(WNL)
Differential WBC values WNL
Skin integrity
Mucosa integrity
Body temperature IER
Gastrointestinal function

Immune Status (Continued)

1= severe thru 5= None
Recurrent Infections
Weight Loss
Tumors (Immature WBCs)
(NOC, 2013 p.271-272)

Scale
Extremely compromised
1
Substantially compromised
2
Moderately compromised
3
Mildly compromised
4
Not compromised
5
_______________________________
Severe
1
Substantial
2
Moderate
3
Mild
4
None
5

Nursing Interventions Classification

(NIC)

The nursing interventions

classification (NIC) is a
comprehensive, standardized
language describing treatments that
nurses perform in all settings and in
all specialties. (Iowa Intervention
Project, 2008)

Interventions
Definition: any treatment based
upon clinical judgment and
knowledge, that a nurse performs
to enhance patient/client
outcomes. (Iowa Intervention
Project, 2000,p.3)

INTERVENTION

Nursing Intervention Classification

(NIC)

Nsg intervention standard

comprehensive based on research.
NIC: Nsg intervention direct,
indirect, independent, collaborative
514 interventions (542 interventions)
NIC Project of University of IOWA

NIC TAXONOMY

LEVEL 2 CLASSES

LEVEL 2 CLASSES

Agi_Collections

16

Studi Kasus

Tn Daibi 45 th di rawat
dengan DM type II
Dirawat sejak 1 minggu yg
lalu setelah kakinya luka
yang dia tidak sadari
sebelumnya, yang
kemudian disertai demam
39C
Leukosit 18.000
Ukuran luka 2X8X1
Gula darah 380 mg/dL

Nursing Diagnosis 1:

Risk for infection

(00004) related to
chronic disease: DM,
inadequate primary
defenses: broken skin.

Was our choice correct?

Definition of the label: At increased
risk for being invaded by pathogenic
organisms
Risk Factors:
Insufficient knowledge to avoid exposure
to pathogens (developmental level)
Inadequate secondary defenses (DM)
Inadequate primary defenses (broken
skin from wound)

(NANDA,2009)

Nursing Diagnosis 2:

Impaired skin integrity

(00046) related to
impaired metabolic
state

NOC Gangguan Integritas Kulit

temperatur jaringan dalam rentang yang
diharapkan
elastisitas dalam rentang yang diharapkan
hidrasi dalam rentang yang diharapkan
pigmentasi dalam rentang yang diharapkan
warna dalam rentang yang diharapkan
tektur dalam rentang yang diharapkan
bebas dari lesi
kulit utuh

NIC Manajemen Luka

Ganti balutan lama dengan balutan yang baru

Cukur rambut disekitar luka jika diperlukan
Kaji kondisi luka (pus, warna, ukuran dan bau)
Ukur wound bed
Bersihkan dengan NaCl steril atau larutan
pembersih
Dst

Nursing Diagnosis 3:
Risk for deficient fluid volume
(00028) related to:
Excessive loss through normal routes
(polyuria)
Deficient knowledge (DM
management)
Hyper metabolic state

Dx 4:
Ineffective Self-Health Management (00078)
related to
Deficient knowledge of DM management
Complexity of therapeutic regimen: Inadequate
blood sugar monitoring
Social support deficit

Definition: pattern of regulating into daily living

a therapeutic regimen for the treatment that is
unsatisfactory for meeting specific health
goals

NANDA/NIC Linkage
Each NANDA diagnosis is followed by a
list of suggested interventions for
resolving the identified problem
Interventions and activities should be
chosen to meet the individual clients
needs
Activities can be further individualized
by adding client specific information
Additional activities may be added if
appropriate

NIC Examples: Linked with

Risk for Infection

6550 infection protection

3660 wound care
1100 nutrition management
3590 skin surveillance
6650 surveillance

NOC Examples: Linked with Risk for

Infection
Immune status (0702)
Wound Healing: Primary Intention
(1102) Location of wound
Nutritional Status (1004)
Knowledge: DM management (1820)
Tissue Integrity: Skin & Mucous
membranes (1101)

NOC: Immune status (0702)

0702 Immune Status
Definition: Natural and acquired appropriately targeted resistance to internal and external antigens.
1=severely compromised thru 5= not compromised
Absolute WBC values WNL(within normal limits)
1 2 3 4 5
Differential WBC values WNL(within normal limits)
1 2 3 4 5
Skin integrity
1 2 3 4 5
Mucosa integrity
1 2 3 4 5
Body temperature IER( in expected range)
1 2 3 4 5
Gastrointestinal function
1 2 3 4 5
Respiratory Function
1 2 3 4 5
Genitourinary Function
1 2 3 4 5
1= severe thru 5= None
Recurrent Infections
1 2 3 4 5
Weight Loss
1 2 3 4 5
Tumors (Immature WBCs)
1 2 3 4 5
(NOC, 2008 p.399)

NOC: Wound Healing (1102)

1=none thru 5= extensive
Wound approximation
1 2 3 4 5
Wound edge approximation
1 2 3 4 5
Granulation/scar formation
1 2 3 4 5
1= extensive thru 5= None
Surrounding skin erythema
1 2 3 4 5
Wound edema
1 2 3 4 5
Increased skin temperature
1 2 3 4 5
Wound odor
1 2 3 4 5
(NOC, 2008 p.730)

NIC: Infection Protection 6550

Definition: Prevention and early detection
of infection in a patient at risk
Activities:
Monitor for systemic and localized sign &
symptoms of infection (wound site check
every 4 hours.)
Monitor WBC, and differential results (qd or
qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors

NIC: Infection Protection 6550 (Cont.)

Activities (Cont.)
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for
redness, extreme warmth or drainage (q4 hours)
Inspect condition of surgical incision ( central
line insertion site q 4 hours)
Obtain cultures, as needed (Blood cultures prn
T>38.3 C q 24 hours)
Promote Nutritional intake (1500 kcal per day, Pt.
likes cereal)

NIC: Infection Protection 6550 (cont.)

Activities (cont.)
Encourage fluid intake (+ 2500 cc per day, Pt
likes Guava Juice)
Encourage rest (naps every afternoon from 13 PM, bedtime at 2030)
Monitor for change in energy level/malaise
Instruct patient to take anti-biotic as
prescribed
Teach Family about s & sx of infection and
when to report them to Health Care Prof (NIC,
2008)

NIC: Wound Care 3660

Definition: Prevention of wound
complications and promotion of wound
healing
Activities:
Remove dressing & adhesive tape
Monitor characteristics of the wound
Measure the size of the wound
Cleanse with normal saline
Apply a dressing
Maintain sterile technique

NIC: Wound Care 3660

Activities:
Change dressing according to amount of exudate
Regularly compare and record any change in the
wound
Position to avoid placing tension on the wound
Reposition patient at least every 2 hours
Encourage fluids, as appropriate
Assist patient and family to obtain supplies
Instruct patient or family member(s) wound care
procedure

Sample Care Plan using Case

Study
NANDA Nursing
Diagnoses

NOC Outcomes and Indicators

NIC Intervention Label and select nursing

activities

Risk for infection

related to chronic
disease: DM,
inadequate primary
defenses: broken
skin.

0702Immune Status
Definition: Natural and acquired
appropriately targeted resistance to
internal and external antigens.
1=severely compromised thru 5=
not compromised
Absolute WBC values WNL(within
normal limits)
1 2 3 4 5
Differential WBC values
WNL(within normal limits)
1 2 3 4 5
Skin integrity
1 2 3 4 5
Mucosa integrity
1 2 3 4 5

6550 infection protection

Definition: Prevention and early detection of
infection in a patient at risk
Activities:
Monitor for systemic and localized signs &
symptoms of infection (central line site check
every 4 hours.)
Monitor WBC, and differential results (qod)
Follow neutropenic precautions
Provide a private room
Limit number of visitors
Screen all visitors for communicable disease
Maintain asepsis
Inspect skin and mucous membranes for
redness, extreme warmth or drainage (q4 hours)
Inspect condition of surgical incision
(central line insertion site q 4 hours)

Sample Care Plan using Case Study

NANDA Nursing
Diagnoses
Risk for infection
related to chronic
disease: DM,
inadequate primary
defenses: broken
skin.

NOC Outcomes and Indicators

0702Immune Status
Body temperature IER( in
expected range)
1 2 3 4 5
Gastrointestinal function
1 2 3 4 5
Respiratory Function
1 2 3 4 5
Genitourinary Function
1 2 3 4 5
1= severe thru 5= None
Recurrent Infections
1 2 3 4 5
Weight Loss
1 2 3 4 5
Tumors (Immature WBCs)
1 2 3 4 5
(NOC, 2008 p.399)

NIC Intervention Label and select nursing

activities
6550 infection protection
Activities:
Obtain cultures, as needed (Blood cultures prn
T>38.3 C q 24 hours)
Promote Nutritional intake (1500 kcal per day, Pt
likes cereal)
Encourage fluid intake (1225 cc per day, Pt likes
orange Gatorade)
Encourage rest (naps daily 1-3 PM, bedtime t 8:30
PM)
Monitor for change in energy level/malaise
Instruct patient to take anti-infective as prescribed
(Bactrim po BID; Nystatin 5cc,swish & swallow,
TID)
Teach Family about s & symptoms of infection and
when to report them to HCP
-Teach patient and family how to avoid infections
(NIC, 2008)

Sample Care Plan using Case Study

NANDA Nursing
Diagnoses

NOC Outcomes and Indicators

NIC Intervention Label and select nursing

activities

Impaired skin
integrity
(00046) related
to impaired
metabolic state

1=none thru 5= extensive

Wound approximation
1 2 3 4 5
Wound edge approximation
1 2 3 4 5
Granulation/scar formation
1 2 3 4 5
1= extensive thru 5= None
Surrounding skin erythema
1 2 3 4 5
Wound edema
1 2 3 4 5
Increased skin temperature
1 2 3 4 5
Wound odor
1 2 3 4 5
(NOC, 2008 p.730)

Definition: Prevention of wound

complications and promotion of wound
healing
Activities:
Remove dressing & adhesive tape
Monitor characteristics of the wound
Measure the size of the wound
Cleanse with normal saline
Apply a dressing
Maintain sterile technique

Sample Care Plan using Case Study

NANDA Nursing
Diagnoses

NOC Outcomes and Indicators

Impaired skin
integrity
(00046) related
to impaired
metabolic state

1=none thru 5= extensive

Wound approximation
1 2 3 4 5
Wound edge approximation
1 2 3 4 5
Granulation/scar formation
1 2 3 4 5
1= extensive thru 5= None
Surrounding skin erythema
1 2 3 4 5
Wound edema
1 2 3 4 5
Increased skin temperature
1 2 3 4 5
Wound odor
1 2 3 4 5
(NOC, 2008 p.730)

NIC Intervention Label and select nursing

activities

Activities:
Change dressing according to amount of
exudate
Regularly compare and record any change
in the wound
Position to avoid placing tension on the
wound
Reposition patient at least every 2 hours
Encourage fluids, as appropriate
Assist patient and family to obtain
supplies
Instruct patient or family member(s)
wound care procedure

Sample Blank Care Plan

Nursing Diagnosis and Interventions:

Choose the highest priority Nursing Diagnosis as indicated on the clinical reasoning
web. Include problem statement (NANDA), related to or risk factors (etiology), and defining characteristics (as evidenced by or AEB) as
appropriate. List all of the appropriate NOC Outcome labels and indicators and NIC intervention labels and nursing activities which will best
help your client achieve those outcomes. List the rationale for each and determine where your client falls on the outcome indicator scale (1-5)
at the specified time intervals. In the final column summarize why you gave your client the indicator scores that were given and any changes
in your care plan that should be made.
Briefly describe how the plan of care is helping the patient meet the desired outcomes and any changes that need to be made:

Nanda Nursing
Diagnosis

NOC Outcome
Label(s) and
indicators
Complete NANDA NOC label and
Nursing Dx
appropriate
Statement
indicators and
including related rating on scale
or risk factors and with date (s)
defining
characteristics

Rationale for NOC

chosen
and indictor score
Describe your
rationale for
choosing this NOC
label and the
indicator ratings that
you chose for this
patient.

NIC Intervention label(s) Rationale for NIC Chosen

and nursing activities
NIC label and appropriate
activities with
individualized information
added.

Describe your rationale for

choosing this NIC label

Kesimpulan
- Perlu proses pengenalan bertahap
- Perlu bimbingan senior atau mereka yang
telah mendapatkan program pendidikan
yang menggunakan NANDA, NIC, NOC
(mis. S1, atau S2)
- Sedikit lebih membutuhkan proses
analisa & sintesa permasalahan pasien
- Digunakan untuk mempermudah
pengembangan riset keperawatan

TERIMA KASIH