...Applying Standardized Terminologies in Practice Evidence based interventions are playing an increasingly more important role in nursing practice. With the increased utilization of nursing research comes a need for a form of communication that classifies diagnosis, applies interventions, and expected patient outcomes. In order to unify nursing communication and support nursing practice, standardized terminology has been developed. This paper will introduce three forms of standardized terminologies in nursing which are the North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Intervention Classification (NIC). The purpose of this paper is to define the three standardized terminologies, processes developed, and to provide and example of their useful application in patients at risk for or diagnosed with pressure ulcers. The NANDA was established with the goal of enhancing all aspects of nursing practice by refining and promoting terminology to accurately reflect the clinical judgment of nurses (Azzolin et al., 2013). The mission of NANDA if to facilitate the refinement, dissemination, and development, and utilization of nursing standard terminology (Peres et al., 2015). Their main focus is to utilize this communication to promote evidence based practice and care, thereby improving care for everyone. NANDA promotes their missions and goals by publishing the world leading evidence based nursing diagnosis, funding research, establishing...
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...Applying Standardized Terminologies in Practice Introduction Nursing professionals have standardized terminology they use to communicate with each other and other medical professionals. Standardized terminology (ST) has allowed nurses to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care. Nurses from different units, hospitals, geographic areas, and countries will be able to use commonly understood terminology to identify the specific problem or intervention implied and the outcome observed (Rutherford, 2008). Within ST there are organizations that have standardized the terminology for nurses. NANDA, NOC, and NIC are the organizations that will be discussed throughout this paper and how they related to patient care based on a provided scenario. The scenario I will be discussing is: 47yr male patient presenting to the ED with c/o SOB and CP x 3 days. Pt is pale and diaphoretic on arrival. VSS are HR 130; BP 123/74; O2 sat 96% on 4L NC; pt. with shallow rapid respirations rate 36. NANDA is an organization that has developed more than 200 nursing diagnoses. “NANDA International will be a global force for the development and use of nursing's standardized terminology to ensure patient safety through evidence-based care, thereby improving the health care of all people” (NANDA, 2014). NANDA committed to improving the quality of nursing care and improvement of patient safety through evidence-based practice...
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...forward thinking innovators, and an interoperable electronic medical record system that includes standard nursing terminology. The technology needed in this scenario that would make this combination successful consist of network security measures to ensure security of protected health information under the federal requirements of HIPPA and HITECH. The use of emerging technology such as cellphones, tablets and remote technology should also be included in the discussions of creating a telehealth system that would accommodate both of the combining organizations. Telehealth not only includes communication between patients and healthcare providers, but also communication between healthcare providers in both of the combining organizations. Video conferencing can save healthcare providers time and money by allowing them to collaborate with one another without being physically near one another. A3. Identification of Team The interdisciplinary team on the project committee will consist of four team members. Team member A would be the project team lead in which I would nominate myself. It is important to have a nurse as project team lead because they understand the needs of the patients, the work flow of the unit and also how the system will affect those working at the point of care. The project lead should be an experienced nurse who is proficient within their specialty of nursing and is comfortable in a leadership role. The role of the project team lead can make the...
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...Meaningful Use for Nurses The goal of meaningful use is to improve the quality, safety, efficiency, access and continuity of healthcare. This paper will provide an overview of the Meaningful Use program. An analysis of Meaningful Use implications for nurses, nursing, national health policy, patient outcomes and population health associated with the collection of core criteria will also be discussed. Recommendations for additional core criteria will also be presented. Overview of Meaningful Use NANDA International (NANDA-I) was developed to identify and classify health problems within nursing, increase the visibility of nursing, organize nursing data and allow for accurate reimbursement for nursing care (Thede & Schwirian, 2015). NANDA-I states that it’s diagnoses are intended to communicate the professional judgements that nurses make every day to patients, other healthcare professional and the public (NANDA International, 2015). NANDA-I diagnoses relevant to the patient scenario given are 1) fluid volume deficit related to increased fluid loss and insufficient fluid intake 2) electrolyte imbalance related to increased fluid loss and insufficient fluid intake 3) knowledge deficit. The Center for Nursing Classification and Clinical Effectiveness, CNC (2015) defines the Nursing Intervention Classification (NIC) as a comprehensive, research-based, standardized classification of nursing interventions. “The Classification includes the interventions that nurses do on behalf of patients...
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...Electronic health records (EHR) are the central database for all patient related data, both clinical and financial for many healthcare organizations. The EHR must have the ability to send and receive data to other systems within and outside the healthcare organization. Standardized terminologies in and EHR makes the sharing of data or interoperability possible. Having a common interface design, such as health level-7 (HL7) allow this to happen. (McGonigle & Mastrian, 2015). Standard terms that describe health conditions, labs, and medications further allow for the transfer of data. At my organization we transmit continuity of care documents or CCD that allows for our data to flow into our community physicians EHR. There are also nursing...
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...Nurse Informatics Shannon S Goff Western Governors University Nursing Assignment The technology necessary to meet the federally mandated requirements which will affect the merged healthcare organizations. Electronic health records with satellite facilities supported by remote technology. Electronic health records emerged as one of the most relevant topics in health care; EHRs are central in the strategy of federal government to transform health care providing in the U.S. (Henricks, 2011). Federal actions are promoting EHR in order to guarantee important implications for nursing practices. The technology implies also payment penalties for those providers who do not manage to meet the requirements of EHRs use. EHR technology has to be certified according to technical and functional criteria that are set forth by the government. The using of EHR technology is significantly important for laboratories (Henricks, 2011) since the certification criteria of EHR have to be related directly to laboratory testing or laboratory management. Federal government identified the goals for improving healthcare and EHRs are central for these goals. EHRs with satellite facilities aims at the following points, it should: * improve safety, efficiency, and quality of public healthcare and reduce people's health disparities; * engage the patients and their families in healthcare services; * improve healthcare coordination; * improve public health and population in general; ...
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...understand how to comprehend what may be wrong with them is important in the medical field. Doctors tend to give the specific terminology that many patients do not understand, whereas nurses are the ones who explain what the doctor has said in simpler terms. Another discourse that can be included in the nursing profession is the ability to communicate with patients directly and to comfort patients as well as their family and friends. Nurses must be alert and quick to respond because they are usually the first people in a patient’s room. By building responsive relationships with patients one will gain the respect, trust and mutuality from the patient.4 This can provide the framework of caring relationships between nurses and patients. If a nurse is alert and able to communicate with patients on a level that they understand, then that nurse has become more than just a nurse; he or she has become a person with morals. “For each one to take on the needs, wishes, desires of others and make them into his goal is the beginning of ethical”.4p233 To be able to put aside the needs or wants of oneself can be a hard thing to do for some people. To be a nurse, a person has to be willing to care for a patient not to follow the rules, but by explaining things, making small talk with them, being responsive, and to be their friend. The kind of trust a patient has towards a nurse can alter that patient’s attitude towards that hospital, which is why gaining the trust of patients is key. It all starts...
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...| Role | Expertise | Nursing Educator | Will evaluate the new system’s usability compared to the old system. Will also be responsible arranging training sessions for all staff. | RN with MSN in Education. Ability to train all staff will make the system change successful | IS manager | Manages the staff that will implement the new system. Must make sure all tech support has proper training | BS in Informatics. Training his staff to effectively help users with technical issues are imperative to system’s success | Chief Nursing Officer | Will be the voice of the nursing staff, bringing concerns to the table. | Determining if the usability of the system from the viewpoint of the nurses (the largest number of users) is imperative. | Chief Medical Officer | Will be the voice of the physicians, bringing concerns to the table. | Determining if the usability of the system from the viewpoint of the doctors is imperative. | Project Committee Interoperability The National Alliance for Health Information Technology defined interoperability as the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged (Olaronke & Rhoda, 2013) Interoperability is important because it enables medical organizations to operate much more efficiently; it makes it easier for staff to manipulate information quickly; it enhances safety and the quality...
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...1541-5147 ARTICLES International of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman With Diabetes IJNT Malden, USAJournal Inc Blackwell Publishing of Nursing Terminologies and Classifications Application of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman with Diabetes This paper aims to illustrate the process Coleen P. Kumar, RN, MSN, CNS, is Assistant Professor of Nursing, Kingsborough Community College, Brooklyn, New York. Introduction As the average lifespan is extended, more individuals are coping with chronic illnesses such as diabetes, which has reached epidemic proportions with more than 20 million people in the United States having this diagnosis (Gordois, Scuffham, Shearer, Oglesby, & Tobian, 2003). The American Diabetes Association (ADA) estimates that a million people will be diagnosed of diabetes every year (2004). Long-term complications of diabetes are costly to both the individual and the healthcare system. Over the past decade, diabetes research has focused on pharmacological approaches and lifestyle interventions to the illness (Odegard, Setter, & Iltz, 2006). Recent evidence in the forum of diabetes care revealed a need for healthcare professionals to assess and empower individuals in the self-management of this illness. For the purposes of this case study, health assessment by nurses was defined by Fuller and Schaller-Ayers (2000) as a process of systematically collecting...
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...follows: curriculum, patient outcomes and the approach used to nursing care. Patient care scenario that shows the differences in the approach to decision-making based upon the educational preparation of a BSN versus an ADN will be presented. Mildred Montag developed the associate degree program. The two-year program was designed to deal with the nursing shortage during war times. Montag’s vision was to have these ADN working along side the BSN, who provided guidance. Nursing is an educated based career, with a strong knowledge for the sciences, organization and critical thinking. “Associate degree programs focus on the clinical skills needed for basic nursing tasks, but the baccalaureate degree add the component of a liberal arts education that is based on humanities, arts, philosophical, and theoretical approaches”(Shipman, Roa, & Hooten, 2011, p. 309). The associate program is usually found at a junior college. There is an even mix between education and clinical nursing courses. ADN nurses sit for the NCLEX exam to obtain their license, the same as the BSN. The associate degree program became very attractive to students because it was cost effective and it took half the time to start working. According to Associate Degree Nursing, (2009) “by 1973 approximately 600 associate degree programs existed in the United States. Today NLNAC states that nearly 1000 state-approved associate degree nursing programs exist”(Creasia & Friberg, 2011, p. 26). According...
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...Standardized Terminology BY Bolajoko Olagbaju American Sentinel University Introduction Knowledge deficit is a prevalent condition among patients, characterized by the lack of both cognitive information and psychomotor skills that are necessary for promotion and maintenance of health, and for a healthy recovery. The nursing profession is faced with the need to address this problem, whether in the hospital, in ambulatory care, or in-home setting. To address knowledge deficit, the learning process involves three domains: the psychomotor domain, the affective domain, and the cognitive domain. The involved nurse engages the patients in making vital decisions on what and how the patient will be taught. Addressing knowledge deficit in nursing care is necessitated by the high number of patients with inaccurate perception concerning their health statuses (Billay, Myrick, Luhanga, & Yonge, 2007). Misinformation and lack of information associated with knowledge deficit can culminate in psychological alteration, which manifests in anxiety and depression. NANDA Nursing Diagnoses, Definition and Classification As mentioned above, knowledge deficit is marked by lack of crucial cognitive information, which is related to specific health topics. This problem is classified as among the main health conditions inherent in patients who have suffered from chronic illnesses. The defining characteristics of knowledge deficit are inaccuracy in adhering to instruction from nurses, inaccurate...
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...should be displayed within nursing practice, communication, and documentation. Institute of Medicine reports that there are over 98,000 deaths caused by preventable errors (1999). The purpose of this paper is to respond to a peer reviewed concept analysis article, describing the method of analysis, the steps of the process, results for each step and to apply the concept to a practice situation. Concept Analysis The Electronic Health Record (EHR) improves the exchange of patient data, accuracy, and quality of patient care. Poor communication and technology can impede a positive outcome for the patient. A core competence of nursing is documentation of patient’s response to nursing interventions and effectively communicating the care given. In the article Concept Analysis of Similarity Applied to Nursing Diagnoses: Implications for Educators the author uses the Walker and Avant concept analysis of similarity. In nursing, concept analysis clarifies unclear concepts and gives a mean to common understanding within nursing practice. “The purpose of a concept analysis is to describe the concept well enough so that defining characteristics can be determined and used to distinguish “likeness or unlikeness” between concepts” (Walker & Avant, 2005, p. 64). Wilson developed an 11 step process in 1963 that defined the concepts to improve communication and comprehension of the meanings of terms in scientific use (McEwen & Willis, 2011, p.53). Numerous nurses have used Wilson’s process...
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...Annotated Bibliography: Quantitative Critique This assignment is an annotated bibliography on resources that Team C will use for the quantitative nursing critique that is due in week three. It should also be noted that some of sources from this annotated bibliography will also be applicable for the qualitative nursing critique that is due in week five. Coughlan, M., Cronin, P., Ryan, F. (2007), Step-by-step guide to critiquing research. Part 1: Quantitative research. British Journal of Nursing, 16(11), 658-663. This article provides a step-by-step approach to understanding research terminology and provides the nurses with a basis for understanding quantitative research. The article points out that being able to read nursing research is the first step in incorporating evidence based best practices into nursing care. As referred to in the article, each stage of the process must be thoroughly examined and this article walks the inexperienced nurse through the process. Duffy, J. R. (2005). Critically appraising quantitative research. Nursing & Health Sciences, 7(4), 281-283. doi:10.1111/j.1442-2018.2005.00248.x Critical appraisal of quantitative research is important to evidence-based practice. It allows a clinician to determine whether a study is scientifically rigorous. This article describes critical appraisal as a careful process of judging the worth of a quantitative study that guide clinical decisions, as well as a structured approach for understanding the...
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...a looming nursing crisis in health facilities. This problem has posed crisis towards establishing better health for those in need. The primary concern concerning this looming nursing shortage is identifying the root cause. Apparently, it appears as if that this crisis established its primary source in nursing training and retention in hospitals, care facilities, and other institutions. It appears as if there is serious downfall in the practicum of nurse-executive. Consequently, the concerned authority seems to portray weakness strategies in conducting this nursing practicum that has led to shortages of faculty. The big inquiry is whether these training facilities offer standardized training that would present the needed feedback facilitating nursing transition and retaining nursing staff. The central focus would then be whether this strategy would pose positive impacts in nursing training. This capstone project will explore these nursing concepts with a primary intention of presenting the root cause of nursing crisis in health facility. Annotated Bibliography Seago, A. J., Alvarado, A., Keane, D., Grumbach, K., & Spetz, J. (2006). The nursing shortage: is it really about image? Journal of Health Management, 51(2), 96-10. A research conducted in tertiary institutions Central Valley by Seago and the rest confirmed that nursing occupation lagged behind other occupations. This perspective is attributed by work independence perception and the perception that nursing is women’s...
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...Registered Nurse Language Laura Lynch Nevada State College ABSTRACT This paper discusses the significance of utilizing standard language and writing skills as it relates to multiple tiers of communication required in the nursing profession, as well as the importance of maintaining these elite level communication skills. In addition, this paper also includes a comparison between two minority authors that argue for the importance of their respective Chicana and black, “native tongues “. The pros and cons of their arguments is contrasted against authors’ Allen, Chapman, O’Connor and Francis (2007), whom address the significance of language and writing within the area of professional nursing that upholds the elite verbal and written communication standards practiced in nursing today. The Communications and the Language of Nursing The language spoken in the profession of nursing requires a wide spectrum of core communication skills that provide a verbal bridge of common understanding of illness, healing, wellness or prevention. These skills require the continual change and transformation of the nursing profession’s language. From the perspective of the patient’s bedside and nurse-to-nurse communications, through the nurse to the specialist, the criteria for common core can be acknowledged. Additionally, the personal slang and reflections of self identification shared in Anzaldua and hooks’ essays demonstrates the immediate need for the requirement of a common core language...
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