INFORMATION SYSTEMS PAPER 2 Standardized Nursing Language: A Nursing Vocabulary Bridgette Rodriguez Chamberlain College of Nursing NR361: RN Information Systems in Healthcare July 2017 Running head: INFORMATION SYSTEMS PAPER 1 INFORMATION SYSTEMS PAPER 6 Standardized Nursing Language: A Nursing Vocabulary The National Association of School Nurses (NASN) states that standard nursing languages (SNL) are essential communication tools to assist in the planning, delivery and the evaluation of quality nursing care (Lundberg, 2008). Using a standardized nursing language for documenting nursing care is important to both the nursing profession and to the nurse’s …show more content…
(Rutherford, 2008). A strong standard language provides the RN with diagnostic terms, their associated signs and symptoms, as well as the scientific research. How the Tool is Applied Nursing needs to describe exactly the scope of practice and measure its contribution to patient care. Without trusted and acceptable clinical data, no one would think that nurses make a difference. Using standardized language for nursing diagnosis and nursing interventions allows nurses ' activities to be described next to medical diagnoses and medical interventions, and their impact is measured in relation to patient outcomes. For example, chronic renal failure is a medical diagnosis identified by ICD-9 code #585 (CMS.GOV, 2012). Chronic renal failure is linked with the following nursing diagnoses: activity intolerance, decreased cardiac output, excess fluid volume, fatigue, imbalanced nutrition, impaired comfort, impaired urinary elimination, ineffective coping, the risk for infection, the risk for injury and the risk for noncompliance (CMS.GOV, 2012). Each North American Nursing Diagnosis Association nursing diagnosis can be connected to a series of Nursing Interventions Classification (NIC) nursing interventions. Each nursing intervention can be evaluated based on the available evidence and its appropriateness to the
By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)
As a provider of care, professional nurses depend on research, theories, and evidence based practice to guide the care they provide to patients. Nurses deliver care to their patients based on information they have learned through many years of school and training. Training for nurses and other providers of care is founded on theories, research, and evidence based practice in the healthcare field. Theories, research, and evidence based practice are all important for providing care to patients and each can be used in a different manner depending on the situation. Clinicians often use research based evidence to design and implement care that is high-quality and cost effective for patients. Evidence based practice can be used to provide care to patients in a steadily changing clinical environment. (PDF page 8-9). Nursing theories are frequently used as frameworks for establishing nursing care interventions and assessing
“If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault of not of the disease, but of the nursing. I use the word nursing for want of a better” (Nightingale, 1860, p. 8). While Nightingale stressed the impact of one’s environment to promote healing, Virginia Henderson aimed to establish on the fundamental needs as a knowledge base to guide Professional nursing practice. Henderson emphasized on fourteen components required for effective nursing care which includes: breathing normally, eating and drinking adequately, elimination of body wastes, movement and posturing, sleep and rest, select suitable clothes-dress and undress, maintaining body temperature, keeping body clean and well groomed, avoiding dangers in the environment, communication, worship according to one’s faith, work accomplishments, play or participate in various forms of recreation, and learn, discover, or satisfy the curiosity (Fernandes et al., 2015). Her division of the fourteen components acknowledged patient needs with a holistic approach that is applied through the nursing process in a clinical setting.
1. Comprehensive Nursing Care, Revised 2nd Edition. (2012). Ramont, Reberta P.; Niedringhaus, Dolores M.; Towle, Mary A.
In the article “What Do Nurses Really Do?”, Suzanne Gordon explores what nurses truly do. She concludes that nurses “save lives, prevent complications, prevent suffering, and save money” (Gordon 2006). Nurses provide care for their patients in the physical and emotional sense. Emotionally caring for a patient and being sensitive to his or her needs result from interacting with patients while performing the skills and using the knowledge that nurses learned in school. Nurses grow in their skills, knowledge, and attitudes through practice. Quality and safety education for nursing incorporates competencies that all nurses must use in their practice. These nursing competencies include evidence-based nursing practice, quality improvement, safety, teamwork and collaboration, patient-centered care, and informatics.
Ms. Conlon applies the nursing process to systems or processes at the unit/team/work group level to improve care. Deirdre has been the primary nurse for 6 hemodialysis patients. She has involved patients and families in monthly interdisciplinary meetings to promote self-efficacy and quality of life. With the help of the interdisciplinary team Deirdre has worked collaboratively to address and reinforce nutritional needs, social/family issues, barriers to care, and safety concerns. All of her primary care patients have maintained a goal of 100% for dialysis adequacy (benchmark is 85%) and a vascular access rate of 100% and dictated by KDOQI standards.
The changes to both student health needs and healthcare during the 21st century have an impact on school nursing practice today. It was because of these changes that the “National Association of School Nurses (NASN) developed the visual and conceptual Framework that explains the key principles of school nursing and provides structure and focus to current evidence-based school nursing practice” (NASN, 2016, p.45). The ultimate goal of the framework for the 21st century “is to provide a resource to guide school nurses in their practice” in order “to help students be healthy, safe, and ready to learn” (NASN, 2016, p.45). The framework for the 21st century school nursing practice consist of
Nursing care is focused on the assessment, nursing diagnoses, planning, implementation, and evaluation of patients. This nursing process can also be implemented in aspects outside of nursing and on the nursing field as a collective group. The nursing role is evolving, following the process the outcomes have to be evaluated and put into perspective. Research is being completed the conclusions are all the same, the higher education of nursing care the better the patient outcomes.
Most of the avoidable conditions that are identified by the Center for Medicare and Medicaid Services (CMS) are nurse sensitive, and what nurses do, or do not do, based on scientific evidence, will influence patient care outcomes. Furthermore, research that was published over 10-years ago, correlated a decrease in patient morbidity and mortality proportionate to the number of Bachelor of Science in Nursing (BSN), or higher educated bedside Registered Nurses (RN) (Edwards, 2013).
I will methodically analyze all parts of the study to assess the validity of the article, by contrasting and comparing the information provided, with previous literature. I will try to make sure that recommendations provided by the authors are congruous with nursing practice and beneficial to the advancement of it. I will as much as possible provide in depth detail of previous studies on the same topic that either support or contradict the analysis provided by this study and its authors.
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
The authors recommend that the findings originating from this study can be used as a basis to initiate protocols for implementation of bedside nursing
Nursing-sensitive indicators can be an important tool in identifying patient care issues that could potentially arise during a hospital stay. By analyzing the data on specific nursing-sensitive indicators, the quality of patient care can be optimized and patient satisfaction can be improved. The American Nurses Association (ANA) and the National Database of Nursing Quality Indicators (NDNQI) are two sources of information and guidelines for nurses and nurse managers to use in planning patient care and workloads for each nursing unit. The use of available resources, staffing by acuity and patient needs, appropriate referral indicators, and cooperation
Best Practice Guidelines (BPG) have become a global movement in nursing. Healthcare organizations, practitioners, and nursing associations have an opportunity to provide quality and accountability to patients at the time of care. (RNAO, 2012) The Registered Nurses Association of Ontario (RNAO) (n.d., p.2) said that “since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nursing contributions to shaping the health-care, and influenced decisions that affect nurses and the public they serve.”. To achieve some of these goals, the Registered Nurses of Ontario have developed an important program guiding nurses to implement evidence-based strategies into their
Nursing is a unique profession which is built upon theories that guide everyday nursing practice. According to Taylor, Lillis, & Lynn (2015), “Nursing theory differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices” (p. 27). Many nurses may unknowingly apply a theory or a combination thereof, along with critical thinking to get the best outcome for a patient. Theories are used in practice today because they have been supported by research and help the profession uphold its boundaries. Most nursing theories consist of four concepts which are the patient, the environment, health, and nursing. Each patient is at the center of focus and they have the right to determine what care will be given to them using informed