Development of Consensus-Based Clinical Guidelines in Critical Care Through Standardized Nursing Language

International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 51

PURPOSE. To detect the areas of most need for careand the prevalence of the nursing diagnoses inmethadone maintenance programs.

METHODS. The study was carried out with a sampleof 131 subjects (average age 33 years) included in amethadone maintenance program. There was a predomi-nance of males (76%). A high percentage (72%) were dis-abled or unemployed.

The evaluation was done by students in an alcoholand drug dependency nursing course at the School ofNursing of the University of Barcelona, trained and su-pervised by nurses from the clinical area. Assessmentstook place in methadone maintenance program units.The Sociodemographic and Assessments of Needs Ques-tionnaire was developed to collect data. NANDA�s Tax-onomy was used to determine nursing diagoses.

FINDINGS. Rest and Sleep were the areas that demon-strated the greatest need. Eleven diagnostic labels cov-ered 75% of cases. The six most frequent diagnoses weresleep pattern disturbance, altered nutrition: less than body re-quirements, constipation, self-care deficit, altered role perfor-mance, and self-esteem disturbance.

CONCLUSIONS. Results obtained in the assessment ofneeds agreed with NANDA�s nursing diagnoses andwith the proposed �Standards of Addictions NursingPractice with Selected Diagnoses and Criteria� by theAmerican Nurses Association, the Drug and AlcoholNursing Association, and the National Nursing Societyon Addictions. Based on the results of this study, we areworking to validate the Nursing Intervention Programusing NIC for the six prevalent nursing diagnoses identi-fied in patients in the methadone maintenance program.

Author contact [Apalategui]: [email protected]

Poster Presentations: Support of Nursing Effort

Quality Nursing Care of Drug-Dependent Patients

Mercedes Ugalde Apalategui and Teresa Lluch Canut

PURPOSE. To demonstrate the use of standardizednursing language for a client with a severe traumaticbrain injury, from the time of admission to the emer-gency center to the client�s admission to the rehabilita-tion unit.

BACKGROUND. A client with increased intracranialpressure based on pertinent assessment data was followed.

MAIN CONTENT POINTS. Although the client�s out-comes remained consistent, the indicators reflected theclient�s recovery and decreased risk of increased intracra-nial pressure. The nursing activities were individualizedas the client moved from the emergency center, to the in-tensive care unit, to the acute care unit, and eventually tothe rehabilitation unit.

CONCLUSIONS. Challenges to the use of standardizednursing languages include development of software forcomputer documentation and retrieval. Legend-codecharting rather than text-based charting must be used.Nurses need to understand the value of taxonomies andstandardized nursing languages, and that NOC out-comes and NIC activities are easily individualized forspecific client populations.

Author contact: [email protected]

52 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003


Cognitive Coherence: Use of Nursing�s Standardized Language

Mary M. Graiver, Marcia Shannon, and Sally Decker

BACKGROUND. The framework of regulation/cogni-tion/perception can be used in a baccalaureate curricu-lum to explore mental health and medical-surgical lifeprocesses in a population of clients experiencing alteredlife processes.

MAIN CONTENT POINTS. An example from mentalhealth is the phenomenon of mood. Specific NANDA la-bels include impaired social interaction and ineffective indi-vidual coping. NIC labels that apply include �socializationenhancement� and �behavior management: self-harm.�NOC labels include Social Involvement and DecisionMaking. In a medical-surgical setting the phenomenonof nutrition can be used as an example. NANDA labelsinclude altered nutrition: more than body requirements. NIClabels include �nutrition management,� �weight reduc-tion assistance,� and �weight management.� NOC labelsinclude Weight Control, Knowledge: Diet, and NutritionStatus: Food and Fluid Intake.

CONCLUSIONS. These examples of the use of stan-dardized language within a nursing curriculum demon-strate the linkages that are possible within specificcourses as well as throughout those courses united by acommon conceptual framework.

Author contact [Graiver]: [email protected]


Use of Standardized Language in Neuroscience Nursing

Cynthia Finesilver


BACKGROUND. A pediatric burn nursing internshipprogram was developed to train new graduate nurses tobecome competent and confident in their practice. Thegoals were to teach critical thinking, develop individual-ized plans of care for patients with burns, and guide thedevelopment of sound nursing practice. The strategywas to build the curriculum around nursing diagnoses.Theoretical content of the program included pediatrics,burns, and critical care nursing.

MAIN CONTENT POINTS. The format for linking thepatient, the problem, and nursing practice was nursingrounds. Each class day began with a nursing round fo-cused on an assigned topic for the day: growth and de-velopment, pulmonary, cardiovascular, gastrointestinal,fluid and electrolytes, integumentary, resuscitation of aburn patient, or nutritional/metabolic and psychosocialneeds. A student assessed the assigned patient, reviewedexisting patient data, identified the appropriate nursingdiagnoses, and recommended changes to the existingplan of care. A concept map (a schematic representationof the relationship of defining characteristics, related fac-tors, and nursing interventions) was developed as an ad-junct tool to diagram the desired components. The pre-sentations were made to senior nursing staff andpreceptors who critiqued the work and provided otherfeedback.

CONCLUSIONS. This educational process was aguided learning activity with multiple benefits, includ-ing incorporation of critical thinking into practice by in-dividualizing the plans of care and recognizing relation-ships between nursing theory and practice. Theunexpected benefits were the increased presence of thenurturing role by senior staff, increased familiarity of stu-dents with other staff members, and increased awarenessof the plan of care by all staff. A future study of this pro-cess includes outcome evaluation as it is incorporatedinto daily practice for senior as well as novice nurses.

Author contact [Jaco]: [email protected]

BACKGROUND. Thirteen residents of a long-term carefacility participated in a study on the use of caretracker, asystem to use �real time� data to code the minimum dataset by tracking activities of living and providing support-ive documentation.

MAIN CONTENT POINTS. With the caretracker data,more individualized care plans were produced andmodified. Nursing interventions could be seen to facili-tate the desired outcomes based on the behavior-moni-toring forms and the caretracker entries. This, in turn,validated the NOC scores.

CONCLUSIONS. Caretracker data can be used to sup-port nursing efforts and patient outcomes.



Nursing Rounds Link Nursing Diagnoses to Clinical Practice

Mary K. Jaco, Mary D. Gordon, and Janet A. Marvin


Using Caretracker to Validate NOC Scores

Peggy Jenkins


Development of Consensus-Based ClinicalGuidelines in Critical Care Through Standardized Nursing Language

Jose Miguel Morales, A. Torres, F. Muñoz, J. León, and L. Miralles

PURPOSE. To suggest appropriate classification labelsand definitions that accurately reflect family presence.

METHODS. Based on a comprehensive review of theliterature, content analysis of selected case studies wasperformed. Themes and details were identified. Conceptanalysis was then performed sequentially for the impliednursing diagnoses, outcomes, and interventions to deter-mine labels and definitions, based on the discoveredthemes and details.

FINDINGS. Family nursing care is oriented toward di-agnosis and treatment of family responses to illnesswithin the family unit. It is clear from the current litera-ture that many families wish to be present when a familymember undergoes resuscitation; however, no nursingdiagnosis exists for this identifiable response to an acutecrisis within the family unit. Based on the data gathered,a family nursing diagnosis, �supportive family,� is pro-posed. Taxonomically this diagnosis best fits in the RoleRelationships domain of the NANDA Taxonomy II. Ad-ditionally, a new label needs to be created in NIC withinthe Family domain, under the class of �life span care� la-beled family presence facilitation. The goal of familypresence facilitation as a family systems nursing inter-vention is to ease normal grieving, support normal fam-ily coping, and empower families. NOC includes severaloutcomes that may be appropriate for evaluating indi-vidual and family responses to family presence facilita-tion; however, an outcome focused on the specific assess-ment findings diagnostic of a supportive family, labeledFamily Member Support, within the Family Health do-main is proposed.

CONCLUSIONS. Further research must be done to val-idate the nursing classification language appropriate forthis practice. Additionally, research using these proposedterms must be performed to demonstrate both clinicalusefulness and the outcomes actually achieved. Amethod for tracking outcomes and identifying problemsmust be developed, and the data captured must bebroadly shared.


PURPOSE. To develop regional clinical practice guide-lines for nurse decision making in critical care settings.

METHODS. In the health department of the Andalu-sian region in Spain, a critical care nursing expert panelwas created to develop clinical practice guidelines. Atotal of 14 critical care nurses (scholars, clinical nurses,managers) comprised the panel. The first obstacle was alack of systematic reviews or clinical trials about theseconcerns. Therefore, the first version of the guidelineswas consensus based. In order to strengthen the guide-lines� structure, standardized nursing language systemsand nursing process were employed as a conceptualframe. Problem identification using collaborative prob-lems or nursing diagnoses (NANDA), literature review,recommendations presented by NIC labels, peer reviewof the recommendations, drafting the guidelines, andsecond peer review by the expert panel members re-sulted in the final version of each guideline.

FINDINGS. A consensus-based clinical practice guide-line manual prepared for critical care nursing in thehealth system in the southern region of Spain coveredprehospital emergency care, health department services,and ICUs. These guidelines contain nurse-sensitive situa-tions and are nurse oriented, using standardized nursinglanguages for clinical decision making.

CONCLUSIONS. Evidence-based clinical practiceguidelines are needed in nursing decision making, butthere is a lack of solid research-based results for develop-ing recommendations. The use of standardized nursinglanguage for guidelines development decreases the vari-ability of clinical practice, fosters homogeneity in nurses�problem-solving schemes, and opens new research areasin clinical effectiveness. In future guidelines reviews,NOC and available systematic review-based recommen-dations will be included. More quality research is neededin critically ill patient human responses.

Author contact [Morales]: [email protected]


Nursing Classification Language to DescribeFamily Presence During Resuscitation and Invasive Procedures

Scott Chisholm Lamont


BACKGROUND. The Alverno is a 135-bed long-termcare facility. All long-term care facilities are required bythe Center for Medicare and Medicaid Services to per-form a common assessment using the Minimum DataSet format. This assessment can trigger up to 24 qualityindicators that directly affect resident care and quality oflife. Each facility average is compared with the state av-erage for that quality improvement. A facility percentileis derived from this comparison. High percentiles are in-dicative of problems.

MAIN CONTENT POINTS. The 24 quality indicatorstriggered as part of the assessment provided a focal pointfor state surveys as well as individual facility qualitycommittees. Nursing outcomes using NOC labels can belinked to these quality indicators, but the number islarge.

CONCLUSIONS. A large number of NOC labels, al-though appropriate in acute care, cannot be implementedin long-term care settings without some modification.

Author contact [Nielsen]: [email protected]

PURPOSE. To evaluate selected nursing diagnoses andinterventions for their capacity to accurately documentpublic health field nursing (PHFN) practice; to describethe most common nursing diagnoses and interventionsused by public health nurses.

METHODS. A retrospective review of family chartswas conducted to analyze the use of nursing diagnosesand interventions.

FINDINGS. The frequency pattern of nursing diag-noses and nursing interventions used in care plans isconsistent with the scope of public health nursing prac-tice, whose emphasis is on health promotion and diseaseprevention.

DISCUSSION. These commonly used diagnoses andinterventions provide evidence of a core set of interven-tions useful for practice in public health. In addition,linking the NANDA diagnoses and the NIC interven-tions revealed that public health nurses have an inven-tory of frequently used interventions that crosses visittype and nursing diagnoses.

CONCLUSIONS. Identifying the use rate of particular di-agnoses and interventions will help determine which diag-noses and interventions should be included in the PHFNelectronic medical record. Also, linking diagnoses and in-terventions will allow PHFN to build a body of knowledgebased on actual patient care and, ultimately, to assist publichealth nurses to make better clinical decisions.

Author contact [Rivera]: [email protected]

Editor�s note: Full text of this presentation was published inIJNTC, 2002, Vol. 13, No. 1, pp. 15�23.


Linking Nursing Outcomes To Long-TermCare Quality Indicators

Theresa Nielsen and Sheryl Schutte


Use of NANDA- and NIC-Based NursingCare Plans in Public Health Nursing Practice

Jennifer C. Rivera and Kathleen M. Parris



Nursing Diagnoses in Japan and Issues Related to Their Development

Makiko Tanaka

BACKGROUND. Chemical dependency (CD) documenta-tion and nursing documentation within a hospital have dif-fered in many ways. The organization�s direction toward amultidisciplinary patient record using NANDA, NIC, andNOC standardized nursing languages (SNL) was a chal-lenge for the CD counselors. The use of SNLs caused somediscord with the counseling staff as to how a care plan couldbe individualized with the use of standardized language.

MAIN CONTENT POINTS. The CD counselors needed toresolve some issues before the change in documentationcould proceed. The words �standardized language� pro-voked thoughts of �cookbook� care, so the counselorsneeded to reconcile the use of SNLs and the ability to de-velop individualized treatment plans. The counselors wereinitially uncertain about using nursing languages to describetheir practice and the minimal counseling terms within thelanguages. These issues were overcome by studying the lan-guages and seeing that they did address the practice of theCD counselors even though nursing developed the SNLs.Implementation included education about NANDA, NIC,and NOC. The staff needed time to accept the need for stan-dardized languages to enhance interdisciplinary documen-tation and to remove the attitude barrier of �we�ve alwaysdone it this way.� The next step was to create and revise careplans and documentation screens.

CONCLUSIONS. The practice of providing care to pa-tients in CD treatment is enhanced by using NANDA,NIC, and NOC because of the ability to develop a true in-terdisciplinary patient record, retain individualization ofpatient plans of care, use the outcomes to substantiate dis-charge status and recommendations, and assess effective-ness through use of outcome data. Pilot outcomes data in-dicate that CD counselors and nursing exhibit statisticallysignificant results related to coping, decision making,knowledge: substance use control, leisure participation,psychosocial adjustment, life change, substance addictionconsequences, self-esteem, and spiritual well-being. Futureresearch efforts should include monitoring patient out-comes over the continuum of care. Most patients partici-pate in an aftercare program following inpatient or outpa-tient treatment. It would be beneficial to follow outcomesthroughout the entire course of a patient�s treatment.

Author contact [Cox-Kolek]: [email protected]

PURPOSE. To examine the awareness of nursing diag-nosis in Japan by investigating the reality of its spreadand permeation.

METHODS. One group (X) consisted of 67 individualswho were unfamiliar with nursing diagnosis, while theother group (Y) consisted of 20 who were practicing it.The awareness of nursing diagnosis was measured via aresearcher-developed questionnaire. A comparativeanalysis was made between the two groups.

FINDINGS. The cross analysis for group X between�the awareness of improving the nursing diagnosis abil-ity� and �the awareness of the necessity for nursing di-agnosis� was significant (p<0.001). Open-ended re-sponses to the question, �What does nursing as aprofession consist of?� were categorized into five factors.Triple cross-analysis of both groups on each factoryielded one significant result for Group Y with the factor�nursing diagnosis was necessary but improving abilityto use it was another matter� (p<0.05).

CONCLUSIONS. The subjects� familiarity with nursingdiagnosis was systematically related to its evaluation,causing ambivalent feelings toward it. Also, regardless ofsubjects� familiarity with nursing diagnosis, there was afeeling that it is a difficult skill to master. While subjectsfelt skill using nursing diagnosis was prestigious, theirsense of a lack of this skill led to blocking its spread andpermeation.



Chemical Dependency and StandardizedNursing Language

Cindy A. Scherb and Marlae Cox-Kolek


PURPOSE. To identify nursing diagnoses identified inpatients in a medical-surgical unit.

METHODS. Data were collected through interviewsand physical examination of 60 patients on a femaleward in order to formulate NANDA diagnoses. The datacollection tool was based on Gordon�s 11 FunctionalHealth Patterns. Four researchers with medical-surgicalnursing expertise reached the nursing diagnosis throughconsensus.

FINDINGS. A total of 338 diagnoses were identifiedfrom 49 different categories. Nineteen categories wereidentified in more than 10% of the sample: risk for infec-tion (58%), pain (50%), constipation (42%), activity intoler-ance (35%), sleep pattern disturbance (28%), altered physicalmobility (27%), impaired skin integrity (27%), fatigue (25%),sexual pattern dysfunction (23%), anxiety (23%), risk for inef-fective manipulation of therapeutic regimen (20%), risk fortrauma (20%), risk for impaired skin integrity (18%), ineffec-tive coping (18%), altered nutrition: more than body require-ments (12%), impaired communication (12%), urinary incon-tinence (10%), fluid volume excess (10%), and alterednutrition: less than body requirements (10%).

The most frequent diagnoses related to Health Func-tional Patterns were identified in health control and per-ception, with 28% of the 338 formulated diagnoses, activ-ity-exercise and nutritional-metabolic with 20% each.

CONCLUSIONS. There was great diversity in the qual-ity of the reported needs in the studied sample, whichdemands extensive knowledge and a wide range of abili-ties to identify needs as well as implement care in the af-fected patients. Studies such as this one will enhance de-lineation of the nursing knowledge base in order tojustify allocation of human resources in specific areas.

Author contact [Volpato]: [email protected]


Nursing Diagnosis in Medical-Surgical Patients

Márcia Paschoalina Volpato and

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Development of Consensus-Based Clinical Guidelines in Critical Care Through Standardized Nursing Language