don't chastise yourself. this concept is not easy to grasp. i really didn't understand it fully until well after i had graduated and was doing care plans
at a workplace.
think of the care plan format as just that--a way to present it. it is still the problem solving process. the actual format is just the physical way it is presented. there are care maps (concept maps) which are picture boxes. there are critical pathways which are the nursing interventions presented in a day-by-day event format. and, there is a kind of traditional chart where you have columns of information. they all incorporate the basics of the nursing process. the first 3 steps (assessment, problem determination, planning) are the most important because those are the guts of your care plan.
nic and noc are fancy names that a bunch of professors over at the university of iowa came up with. they are doing research on them and getting their phds in the process. nics and nocs (i love saying that out loud!) are nothing more than lists of interventions and outcomes (goals) that they came up with and that they have been able to cross match with the nanda nursing diagnoses. these people work hand-in-hand with nanda. one of their reasons for doing this, get this, is to code and store these things in computers so they can be easily retrieved. have you heard the expression "canned care plan"? well, that is what these things were partly developed for. it is also partially because advanced care nurses and other ancillary healthcare practitioners have to have a way to bill for their services which are done by computer, and also because the healthcare industry as a whole is moving toward reducing the patient medical record to electronic storage--no more paper records are their goal--and they decided long ago that they wanted a systematized way to store the nursing care plan. that is part of the reason that nanda came into existence. shoving this stuff down working nurses throats just happened as facilities became computerized. when nursing instructors saw the rationale behind the use of nursing diagnosis it started to catch on in educational circles. when i went to school back in the 70s our care plans didn't use nursing diagnoses. we just listed patient problems that we found during our assessments. some smarty pants realized that some of the symptoms grouped together and could be lumped together with similar interventions. thus, a diagnostic label could be slapped onto them--thus, nanda stepped in. since i have also been a medical coder (coding medical diagnoses from doctor's discharge summaries for payment of medical bills) i think that what nanda is trying to do is eliminate the problems that medical coders have had with the coding of medical diagnoses. you see, there really is no taxonomy of medical diagnoses like nanda has created for nursing diagnoses. in a way, nanda has made nursing diagnosing pretty cut and dry. you merely have to know what your patient's symptoms are and check them against a nanda reference. bingo! you've got your diagnosis. it's not that easy in the medical diagnosis world. then coding medical diagnoses can be a nightmare because a doctor can use a medical diagnosis and put all kinds of other symptoms in his documentation that have coders scratching their heads. their problem is they have to have a valid medical diagnosis to match the procedures and supplies that are used or the insurance companies won't pay for the stuff.
if you truly want a bit of a cheat and want to see the nics and nocs, there are complete listings of them in these publications:
- nursing interventions classification (nic), by joanne mccloskey mccloskey dochterman, gloria m. bulechek, gloria m. bulechek. cost is $49.95.
- nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean maas. cost is $49.95.
otherwise, your nursing textbooks should have nursing interventions in them. outcomes are really quite rational. they are the opposite of your problems and symptoms with specific measurements on them as well as time limits. to formulate them you have to know some of the underlying pathophysiology and how the body heals and corrects it's imbalances to know how fast you can expect an intervention to work.
renal patients are funny ducks. when they have dialysis the techs usually pull off water during a treatment. these people don't usually make any urine, so the water goes into the intracellular spaces. yes, it is a fluid volume excess
. you won't often see the usual outward signs. the fluid is pulled off in two days with the next treatment. but, look at their electrolytes. the swelling of the tissues is also very subtle. it's more of an anasarca (all over the body) and it's hard to notice if you've never seen the patient in their normal state. so, ask the patient next time, have you noticed places in your body where you are swelling since you've been on dialysis, and where are they? weight gain is a symptom that is valid in order to use the nursing diagnosis of excess fluid volume and you have that symptom
. you need to understand that you don't need to have all the defining characteristics that are listed under a nursing diagnosis. as long as the patient meets the criteria for the definition of the diagnosis and has one or more of the symptoms and at least one of the related factors, you are good to go in using it. some of the nursing diagnoses are kind of broad in their scope of use, but not all. one that is not is decreased cardiac output. the airway ones are not either.
i used to work on a renal unit and i started asking the long term renal failure patients about their lives and got some interesting answers. most of them told me that they often were nauseated and that they never felt well or they never felt normal like they did before they went into full blown failure. that was a eye opener to me who was healthy all my life. it was a great learning experience. when we had rf patients who got very confused or obtunded i would ask their relatives what the person had been like before the rf and the stories i heard would have made you cry. these chronic diseases bring people down in the worst way sometimes. what i learned is not to be fooled by a patient seeming to act normally. we do things by routine. i have learned over the years to take time to sit and talk with people who are willing to talk about how their chronic disease has affected their lives. you will be amazed at what you hear. and, now, i find myself in that situation every day as my health declines. not many healthcare workers are really interested in listening to what i'm trying to tell them. i "look" fine to them. inside i feel like a mess. a lot of nurses just don't "get" that. and, this is what nurses are supposed to be doing--attending to people's adl problems. that's what we do. but many forget that in the excitement of carrying out medical orders. we nurses are about the person
and how they function in their environment, not the medical orders. that's where we differ from medicine.
sorry for the lecture. hope i answered your question satisfactorily.