Nursing Care Documentation Using NANDA, NIC, and NOC

BACKGROUND Professional nurses worldwide are concerned as we struggle to communicate and document what a nurse actually does, and how nursing decisions and actions contribute to the care component of health care. Nurses are confident that their actions affect patient care quality through improved patient outcomes, but data collection is the only way to defend this position. To enable nurses to contribute to these data, we need to expose them to the new languages in a pragmatic rather than theoretical format. Nurse-friendly documents must be made available to assist the practitioner to assimilate the new languages into the daily practice of nurses who work with and care for real clients. MAIN CONTENT POINTS This tool, organized according to the NIC taxonomy, begins appropriately with patient assessment and guides the nurse to courses of action that increase the probability of producing effective outcomes. As suggested interventions reflect current nursing practice gathered from expert clinicians in most specialties, the learning curve is not overwhelming. CONCLUSIONS While this document focused on the elderly, the format can be adapted for any patient population by a facility's expert clinicians, who would choose the most appropriate interventions and outcomes for the population served.