Standardized Language

Diabetic Ketoacidosis (DKA) is an acute complication of uncontrolled glucose levels characterized by reduced levels of insulin and presence of ketones. It is a medical emergency and results can be detrimental if left untreated. DKA is commonly seen in patients with type 1 diabetes mellitus (type 1 DM). However, critically ill patients with type 2 diabetes mellitus (type 2 DM) such as trauma, surgery or infection, are also at risk for DKA (Ignatavicius & Workman, 2013). Patients with type 1 DM are predisposed to DKA if their underlying conditions are not diagnosed early and in some cases, they may experience similar signs and symptoms without actually developing DKA. Comorbidities involving parts of

This essay will be divided into two sections. The first section will analyse communication strategies used by nurses during clinical placement. The second section will demonstrate how the nursing process and nursing model has been used to assess, plan, implement and in addition created a care plan for a patient in the scenario. The essay will also briefly describe the role of the Multidisciplinary Team (MDT) in the delivery of care for the patient. Finally, it will highlight key policies that were adhered to in the delivery of patient care.

Patient G.M. is a four-year-old female from a middle class family living in San Diego. She originally presented with her mother and father to her general practitioner with lethargy and several vomiting episodes in the past few days. Her father stated concern after realizing her frequent urination in the past week. Her vital signs upon initial assessment were HR 140 RR 22 Temperature 102.7 degrees Fahrenheit, BP 70/62, O2 saturation 97%, 32 pounds, and 40 inches tall. Her General practitioner was concerned about type I diabetes and performed a blood sugar check. Upon assessment the monitor read HI, indicating that the level was above 500 and too high for the monitor to read. The doctor informed them she needed immediate treated in the closest pediatric ER due to the potential for diabetic ketoacidosis.

With the rapid growth in the implementation and use of electronic medical records, there is an increase in how we define the role of nurses and other team member’s (Deese & Stien, 2004). Along with providing optimal care, nurses are also responsible for interpreting and accurately documenting large amounts of information. According to, (Ericksen, 2009) nursing informatics is defined as the integration of nursing, its information, and information management with information processing and communication technology to support the health of people worldwide. In this

Nursing informatics (NI) has become a vital part of healthcare delivery and has become a defining factor in the selection, execution, and assessment of technology that supports safe, exceptional quality and patient-centered care. Nursing has become so uniform. The data in patient records has become a valuable resource and has improved assessments and overall patient care. Before the launch of nursing informatics throughout the second half of the 20th century there were not any real standards for language. The use of data restricted the function and

In order to practice as a nurse informatics or NI specialist, one must know and understand the standard to which he or she is held. The purpose and function of scopes and standards of practice for nursing informatics is to provide an overview of the specialty, assist future specialists understand their scope of practice, and practice at a competent level to guide and support nursing care. The scopes and standards of practice further provides an insight into the foundation of clinical decision making processes and cognitive concepts as the nurse moves data to wisdom in the clinical setting. As a NI specialist, the informatics nurse follows the concepts, scopes and standards of practice to guide and define their profession. This paper will further discuss the principles that guides nurse informatics specialist, the scope and standards of practice, professional performance, functional areas for nurse informatics, competencies, evolution, progress, and the future the specialty.

DKA is presented with three major physiological disturbances which are hyperosmolality due to hyperglycemia, metabolic acidosis because of the buildup of ketoacids, and hypovalemia from osmotic diuresis. Diabetic ketoacidosis is caused by a profound deficiency of insulin, its most likely occur in people with type 1 diabetes, inadequate insulin dosage, poor self management, undiagnosed type 1 diabetes, illnesses and infections. In type 1

The use of data is essential for nursing professionals to care for patients. Clinical data is used to support clinical decision making. With the introduction of technology and the electronic health record (EHR) and the amount of available data is insurmountable. It is estimated that nurses spend up to 50% of their work day recording, seeking, processing, and managing data, Access to clinical data has the potential to be very powerful for nurses, however data must be accurate, complete, reliable, and accessible to be of value (Hebda & Czar, 2013). Through the use of standard nursing language and the alignment of nursing sensitive quality measures the nursing profession will define the work of nursing through data and improved outcomes (Dykes

“Diabetes is a silent killer” (Demille 2005, p.5). It is a metabolic disorder that can result in impaired quality of life and serious complications. This study aims to understand the case of Mr. Skyler Hanson who is newly diagnosed with Diabetes Mellitus Type 1 that leads to diabetic ketoacidosis which was confirmed by the presence of moderate to high ketones in the urine and a high blood glucose level. It was noted that he has a history of fatigue, headache, abdominal pain, nausea and frequent urination. Furthermore, it was disclosed that he has difficulty in adjusting to his diagnosis and he occasionally missed administration of insulin dose when socialising. Subsequently, he was admitted in the Critical Care Unit for rehydration,

Nurses every day work together as a team in implementing individual care plans specific to patient care to meet needs. For this reason nurses must use a language when documenting details of patient care that is universal and easily understood by others. This type of communication is called standardized terminology. Standardized terminology is an important communication tool in nursing because it is a universal language that aides in describing patient care and can be understood by all parties included. (Keenan, 1999).

According to Dr. Ken Majowski (Laureate, 2011) health care informatics has been in existence for at least the past two to three decades. Ozbolt & Saba (2008) state that “in the second half of the 20th century” the focus of nursing informatics was on the development of “a standardized language” (p. 199). In the 1970’s, informatics included “nursing care planning and documentation” (Ozbolt & Saba, 2008, p. 200). In the 1980’s, nursing informatics research and education led to the “establishment of data standards … unleashing the potential of nursing informatics to improve practice” thus giving nursing the opportunity to “translate knowledge to practice via decision support, and to create new knowledge from the data generated in nursing practice” (Ozbolt & Saba, 2008, p 201). In the 1990’s the “Nursing Terminology Summit Conferences” met “to develop concept-oriented reference terminology models for nursing” (Ozbolt & Saba, 2008, p. 203). The 2000’s proved to be a decade of additional progress with the call for “an electronic health record” for every

Dr. Murray’s article states that nursing informatics is the combination of sciences; computer, information and nursing which helps to “manage and process nursing data, information and knowledge to support the practice of nursing and the delivery of care” (Murray, 2010, p. 3). Collecting information while

There is a new and growing field in the healthcare industry that is known as nursing informatics. Nursing informatics (NI) “integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and

Nursing informatics is a branch of nursing or area of specialty that concentrates on finding ways to improve data management and communication in nursing with the sole objective of improving efficiency, reduction of health costs, and enhancement of the quality of patient care (Murphy, 2010). It is also described as a growing area of nursing specialty that combines computer science, information technology, and nursing science in the management and processing of nursing information, data, and knowledge with the sole objective of supporting nursing practice and research. Various nursing theorists have formulated various theoretical frameworks or models related to nursing informatics (Wager, Lee, & Glaser, 2013), and they are defined as a

Nursing Informatics is a union of nursing, technology, and data assimilation. Nursing Informatics deals with using technologies to organizing and delivering healthcare in the most efficient and safest manner. Nursing Informatics consist of countless tools ranging from simple computers to the complex electronic medical records systems (EMR), diligently designed to organize and deliver information. Nursing informatics silently streamlined into the management and delivery of healthcare; you have probable used nursing informatics without even knowing it.