The Careplan Builder and the Use of
NANDA - I, NIC & NOC
The Careplan builder is set up in a way that you can build care plans using either/both the Careplans.com library and the classifications of NANDA-I, NIC and NOC.
The Careplans.com library is set up to work with your assessment of a patient by allowing you to select Problems, Goals, and Approaches for a particular patient's status. The classifications provide the official languages of nursing, including the labels, and definitions of the Diagnoses, Outcomes, and Interventions used when assessing a patient's needs and planning treatment.
Both informal and formal languages are used in practice as the informal language will help to individualize and personalize the care plan to the individual patient, while the formal language is necessary when identifying the diagnosis, related factors, risk factors, outcomes and interventions. It should be noted that the language in the NANDA-I diagnosis should never be changed and the NIC and NOC should only rarely be modified by the end user.
When you are selecting the Diagnosis, Outcome and intervention for a patient, resident, or client it should always be based on your assessment and clinical judgment.
The Use of NANDA-I, NIC & NOC
The inclusion of NANDA-I
nursing diagnoses in conjunction with the Nursing Intervention Classification (McCloskey and Bulechek, 2004) and the Nursing Outcome Classification (Moorhead et al., 2004)in the EHR provides a comprehensive means for capturing the unique contribution of nursing in a consistent and quantifiable format. This consistency can provide the following benefits:
- Facilitate communication efforts of the healthcare team. These nursing terms, along with uniform medication and medical terms, will provide continuity of care within nursing units and across nursing settings (Figoski and Downey, 2006).
- A language that links nursing concepts for the nursing process within the EHR and facilitates the eventual data exchange of nursing process concepts.
- A means of describing the knowledge and skills essential to nursing practice (Lunney, 2006).
- A common method to allow nurse executives and administrators to collect and analyze nursing-specific data that will provide evidence of the effects and contributions that nursing care provides, as well as the ability to cost out nursing services to third party payers (Jerant et al., 2001).
- A common means to capture data on patient outcomes that will assist design and build new knowledge to support evidence-based practice (Lavin et al., 2004).
- A mechanism to facilitate health ministry and legislative debate with policy development (Lavin et al., 2004).
- A common language in the education process to teach clinical decision-making to nursing students (Garcia et al., 2006; Gloskey et al., 2006; Gordon, 2006; Johnson, 2006).
- Information to advance the science of nursing care.
- In order for the EHR to truly reflect the total care provided by healthcare professionals, it must include nursing data to reflect the nursing process (von Krogh et al., 2005).
Standardized nursing terminologies such as NANDA-I
, and NOC
provide the means of collecting nursing data that are systematically analyzed within and across healthcare organizations. Furthermore,
these data are essential to provide the foundation for any cost/benefit analysis for nursing practice.