Applying Standardized Terminology in Nursing Essay

1508 Words Nov 10th, 2014 7 Pages
Applying Standardized Terminologies in Practice
Chamberlain College of Nursing
NR 512: Nursing Informatics
Fall 2014

Introduction
As a result of the introduction of computer technology and the combination of evidence-based practice in nursing; standardization of terminologies has become imperative in the classification of nursing diagnosis, interventions and expected outcomes. The most popular and successful systems are the North American Nursing Diagnosis Association International (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Intervention Classification (NIC) (de Lima Lopes, de Barros, & Marlene Michel, 2009). This paper aims to provide a brief outline of these standardized terminologies (STs) as they relate to a
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Nurses should take care to select the proper outcomes to ensure optimum care is provided to patients with CHF. The plan of care is dependent on the nursing diagnosis and the desired nurse-sensitive outcomes. The priority NOC outcome for the diagnosis of CHF is Fluid Balance and Fluid Overload Severity. Other related NOC outcomes are Knowledge: Cardiac Disease Management, Knowledge: Energy conservation, Knowledge: Medication, Knowledge: Prescribed Activity, Knowledge: Treatment, and Knowledge: Weight Management (Johnson et al., 2012). These are only a select few of the multiple outcomes available; care should be modified as the disease progresses through the problems which evolves over the lifetime of patients diagnoses with CHF. Once all these determinants are established, the nurse will be prepared to determine which level of NOC is essential to effectively manage the disease.
Nursing Intervention Classification
Nursing interventions are focused on nursing behaviors to guide the patient in the direction of the most preferred outcome (Johnson et al., 2012). Fluid management, fluid/electrolyte management, and hypervolemia management are the major interventions in effective management of CHF. Fluid management is the most difficult intervention for all patients suffering from CHF. Evaluation of the patient’s ability to make the appropriate lifestyle changes required to
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