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CNC - Outcome Example (NOC)

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Hydration--0602

DEFINITION: Adequate water in the intracellular and extracellular compartments of the body

OUTCOME TARGET RATING:          Maintain at______  Increase to_______

 

Severely compromised

Substantially compromised

Moderately compromised

Mildly compromised

Not     compromised

 

OUTCOME OVERALL RATING

1

2

3

4

5

 

Indicators:

 

 

 

 

 

 

060201

Skin turgor

1

2

3

4

5

NA

060202

Moist mucous membranes

1

2

3

4

5

NA

060215

Fluid intake

1

2

3

4

5

NA

060211

Urine output

1

2

3

4

5

NA

060216

Serum sodium

1

2

3

4

5

NA

060217

Tissue perfusion

1

2

3

4

5

NA

060218

Cognitive function

1

2

3

4

5

NA

 

Severe

Substantial

Moderate

Mild

None

 

060205

Thirst

1

2

3

4

5

NA

060219

Dark urine

1

2

3

4

5

NA

060208

Soft, sunken eyeballs

1

2

3

4

5

NA

060220

Sunken fontanel

1

2

3

4

5

NA

060212

Decreased blood pressure

1

2

3

4

5

NA

060221

Rapid thready pulse

1

2

3

4

5

NA

060213

Increased hematocrit

1

2

3

4

5

NA

060222

Increased blood urea nitrogen

1

2

3

4

5

NA

060223

Weight loss

1

2

3

4

5

NA

060224

Muscle cramps

1

2

3

4

5

NA

060225

Muscle twitching

1

2

3

4

5

NA

060226

Diarrhea

1

2

3

4

5

NA

060227

Body temperature elevation

1

2

3

4

5

NA


Domain-Physiologic Health (II)      Class-Fluid & Electrolytes (G)      1st edition 1997; revised 2004, 2013


OUTCOME CONTENT REFERENCES:

Arieff, A. (1986). Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. The New England Journal of Medicine, 314(24), 1529-1534.

Carcillo, J. A., Davis, A. L., & Zaritsky, A. (1991). Role of early fluid resuscitation in pediatric septic shock. Journal of the American Medical Association, 266(9), 1242-1245.

Gilski, D. (1993). Controversies in patient management after cardiac surgery. Journal of Cardiovascular Nursing, 7(4), 1-13.

Hill, P., & Aldag, J. (1991). Potential indicators of insufficient milk supply syndrome. Research in Nursing & Health, 14(1), 11-19.

Innerarity, S. A. (1997). Fluids and electrolytes (3rd ed.). Springhouse, PA: Springhouse.

The Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (2000). Identification and nursing management of dysphagia in adults with neurological impairment. Best Practice, 4(2), Blackwell Science-Asia, Australia.

Mentes, J., Culp, K., Wakefield, B., Gaspar, P., Rapp, C., Mobily, P., & Tripp-Reimer, T. (1998). Dehydration as a precipitating factor in the development of acute confusion in the frail elderly. In B. Vellas, J. Albarde, & P. Garry (Eds.), Facts, research, and intervention in geriatrics: Hydration and aging (pp. 83-100). Paris: Serdi.

Reese, J. L. (2001). Fluid volume deficit – dehydration: Isotonic, hypotonic, and hypertonic. In M. Maas, K. Buckwalter, M. Hardy, T. Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes & interventions (pp. 183-200). St. Louis: Mosby.

Wakefield, B., Mentes, J., Digglemann, L., & Culp, K. (2002). Monitoring hydration status in elderly veterans. Western Journal of Nursing Research, 24(2), 132-142.

Source: Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (Eds.). (2013). Nursing Outcomes Classification (NOC): Measurement of Health Outcomes (5th ed, p. 253.). St. Louis, MO: Elsevier.

 

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