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To interactively build a careplan using the Library, NANDA-I, NIC and NOC; go to your
"My Account" and select "Resident Administration"
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Problem Statements
Search Results for: falls
Confined to a chair with safety belt or positioning pillow that prevents rising related to [ SPECIFY ]
Decreased endurance related to [ SPECIFY ]
Frequent falls due to impaired balance and unsteady gait.
Has fallen [ ] times in the last [specify]
High risk for falls related to [SPECIFY]
Hypotension, potential for complications.
Limited physical mobility secondary to [specify]
Mobility impaired related to: [ SPECIFY ]
Multiple falls over last ____.
Noncompliance related to [ SPECIFY ]
Potential for complications (discomfort, phantom pain, infection, altered body image, depression) related to new amputation of: __________________
Potential for complications related to dx of Huntington’s disease, including cognitive impairment, communication impairment, mood/behavior problems, nutritional/swallowing problems, deterioration in ADL function, and risk for falls/injuries.
Potential for complications related to dx of Parkinsons disease, including poor balance, constipation, poor coordination, drooling, tremors, dysphagia, gait disturbance.
Potential for complications, discomfort, s/sx related to dx of Multiple Sclerosis.
Potential for complications, discomfort, skin breakdown, infection related to dx of Systemic Lupus Erythematosus
Potential for complications, s/sx related to dx of myasthenia gravis.
Potential for discomfort, complications related to dx of scleroderma
Potential for drug-related movement disorder or gait disturbance related to taking [MEDICATION] and [(Parkinsons/poor balance/tardive dyskinesia/loss of limb movement/motor agitation/swallowing problem/vertigo/accidents)].
Potential for falls due to side effects of medication [ SPECIFY MEDICATION ]
Potential for infection, complications related to foot or toenail problems: - Onychomycosis (fungal infection) - Onychocryptosis (ingrown toenail) - Onychauxis (overgrowth of toenails) - Bunions - Corns - Calluses
Potential for injury, complications, discomfort related to dx of osteoporosis.
Potential for pain, complications related to fracture of [specify]
Potential for s/sx, complications related to dx of Guillain-Barre Syndrome or other polyneuritis as evidenced by: __ Weakness __ Numbness __ Paralysis __ Respiratory Insufficiency __ Autonomic nervous system involvement (tachycardia, bradycardia, blood pressure changes, cardiac dysrhythmia, facial flushing, urinary retention, inability to perspire, ileus, increased respiratory secretions) __ Dysphagia __ Aphasia __ Paresthesias
Potential for seizure activity, injury related to seizure disorder.
Requires [#] siderails when in bed related to [ SPECIFY ]
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(NANDA International, 2005)
NANDA-I NURSING DIAGNOSES: Definitions & Classification 2009-2011. Click here to buy.

NANDA International Logo NANDA International has approved more than 200 diagnoses for clinical use, testing, and refinement. A dynamic, international process of diagnosis review and classification approves and updates terms and definitions for identified human responses. NANDA International has developed a nursing practice taxonomy with domain and class structure. A second taxonomy, the NNN Taxonomy, developed in collaboration with the Nursing Classification Center at the University of Iowa (USA), allows for the placement of NANDA International diagnoses in an organizing framework that accommodates interventions and outcomes from the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC), thus creating a comprehensive language system capable of documenting nursing care in a safe standardized manner. (NANDA International, 2005)

NANDA International Logo A nursing diagnosis is "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability" (NANDA International, 2009) Nursing Diagnoses are both actual (including problems and health promotion foci) and potential (at risk for development). The elements of an actual NANDA-I diagnosis are the label, the definition of the diagnosis, the defining characteristics (signs and symptoms), and the related factors (causative or associated). The elements of a potential diagnosis as defined by NANDA are the label, definition, and the associated risk factors. (NANDA, NOC, and NIC Linkages, 2nd Edition, 2006)

NANDA International has international networks in Brazil, Ecuador, and Nigeria/Ghana, as well as a German-language Group; other countries and/or language groups interested in forming a NANDA International Network should contact the Executive Director of NANDA International at NANDA-I also has collaborative links with nursing terminology societies around the world such as the Japanese Society of Nursing Diagnoses (JSND), the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO), the Asociacíon Española de Nomenclatura, Taxonomia y Diagnóstico de Enfermeria (AENTDE) and the Association Francophone Européenne des Diagnostics Interventions Résuitats Infi rmiers (AFEDI). (NANDA International , 2005)

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About NIC

Overview of the Nursing Interventions Classification

(Below information as stated in, Nursing Interventions Classification (NIC) 5th edition, by Gloria M. Bulechek, Howard K. Butcher, and Joanne McCloskey Dochterman, 2008) Get the book here

NIC Logo The Nursing Interventions Classification (NIC) is a comprehensive standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An interaention is defined as any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes. Although an individual nurse will have expertise in only a limited number of interventions reflecting her or his specialty, the entire classification captures the expertise of all nurses. NIC can be used in all settings (from acute-care intensive care units, to home care,to hospice care, to primary care) and all specialties (from critical care to ambulatory care and long-term care). The entire Classification describes the domain of nursing; however, some of the interventions in the classification are also done by other providers. Other health care providers are welcome to use NIC to describe their treatments.

NIC interventions include both the physiological (e.9., Acid-Base Management) and the psychosocial (e.g., Anxiety Reduction). Interventions are included for illness treatment (e.g.,Hyperglycemia Management), illness prevention (e.9., Fall Prevention), and health promotion (e.g., Exercise Promotion). Most of the interventions are for use with individuals, but many are for use with families (e.g., Family Integrity Promotion) and some for use with entire communities (e.g., Environmental Management: Community). Indirect care interventions (e.9., Supply Management) are also included. Each intervention as it appears in the Classification is listed with a label name, a definition, a set of activities to carry out the intervention, and background readings

There are 542 Interventions and more than 12,000 Activities. The portions ofthe intervention that are standardized are the intervention labels and the definitions-these should not be changed when they are used. This allows for communication across settings and comparison of outcomes. Care can be individualized, however, through the activities. From a list of approximately 10 to 30 activities per intervention, the provider selects the activities that are appropriate for the specific individual or family and then can add new activities if desired. All modifications or additions to activities should be congruent with the definition of the intervention. For each intervention, the activities are listed in logical order, from what a nurse would do first to what he or she would do last. For many activities the placement is not crucial, but for others, the time sequence is important.

NIC - Nursing Interventions Cassifications

Use of NIC

(Below information as stated in, Nursing Interventions Classification (NIC) 5th edition, by Gloria M. Bulechek, Howard K. Butcher, and Joanne McCloskey Dochterman, 2008) Get the book here
"A nursing intervention is any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes. The Nursing Interventions Classification (NIC) should be used to communicate the interventions that nurses use with patients, families, communities, or health systems. When NIC is used to document practice, then we have the beginning of a mechanism to determine the impact of nursing care on patient outcomes."
When selecting an intervention 6 factors should be considered:
  1. The desired patient outcome
  2. Characteristics of the Nursing Diagnosis
  3. Research Base for the Intervention
  4. Feasibility for Performing the Intervention
  5. Acceptability to the Patient
  6. Compatibility of the nurse
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About NOC

(Below information as stated in Nursing Outcomes Classification 4th edition by Sue Moorhead, Marion Johnson, Meridean L. Maas, Elizabeth Swanson) Get the book here

NOC Logo "Successful implementation of NOC in a practice setting requires strong leadership and administrative commitment during both the planning and implementation phases. An area of paramount importance that must receive adequate attention in both phases is staff education. Without adequate education and sufficient opportunity to practice the use of a scaled outcome rather than an outcome goal, the implementation process will be faced with more problems than necessary."(NOC 2008 p. 83)

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