A patient care scenario will be discussed to discern how NANDA, NOC and NIC elements were applied. The data, information, knowledge and wisdom framework will be applied to develop the patient care scenario. STNs are utilized as part f the Electronic Health Records in healthcare setting and symbolize the nursing data, information, as well as knowledge, which can be kept in the electronic systems to be utilized as a reference by doctors or nurses.
The scenario that this paper will be discussing is: 40 year old male patient presenting to the ED with CP x 3 days and c/o SOB. Pt is diaphoretic and pale on arrival. VSS are BP 123/74; HR 130; pt. with shallow rapid respirations rate 36; O2 sat 96% on 4L NC.
The registered nurse chose the correct clinical diagnoses make use of the North American Nursing Diagnosis Association (NANDA) terminology rooted in the patient’s immediate needs, as well as her comprehensive evaluation. The care plan she developed has a linkage between patients’ needed goals, interventions and diagnoses. Utilizing the Nursing Outcomes Classification (NOC), the patient and nurse set the desired short-term and long-term goals. Nursing diagnosis, which would be practical for the scenario might be: reduced cardiac output r/t compromised regulatory mechanism; excessive fluid volume r/t compromised regulatory mechanism; fear r/t unknown outcome of developing situation, nervousness r/t situation of sickness and knowledge deficit r/t nonconformity with medication. Nursing Outcomes Classification (NOC), on the other hand, is an all-inclusive, standardized classification of clinical outcomes developed to assess the impact of interventions offered by nurses (Müller‐Staub et al., 2006). Rooted in the scenario, the NOC might be: Excessive Fluid Volume: Fluid Balance, Electrolyte and Acid-Base Balance, Hydration; Fear: States precise information on the situation, Verbalizes known fears; Anxiety: ...
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