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Standarized Terminology

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Submitted By shlee1182
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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 (NANDA, 2014). From NANDA, two branches, Nursing Outcomes Classification (NOC) and Nursing Interventions Classifications (NIC), were developed to evaluate the effects of interventions provided by nurses and other health care professionals (Moorhead et al., 2013). Nursing diagnosis that would be useful for the above scenario would be: excessive fluid volume r/t compromised regulatory...

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