Standardized Terminologies In Nursing Practice

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.

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

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.

Nursing-sensitive indicators are defined by the American Nursing Association (ANA) as “indicators that reflect the structure, process and outcomes of nursing care” (ANA, 2014). These indicators help define how nursing care is given by measuring the amount of nursing staff, skill level of the nursing staff, and the education level of nursing staff. These indicators depict the quality of care provided to patients and the outcomes of the care provided. Careful tracking of these indicators provides evidence for keeping current practices or for implementing new policy and procedures. A formal set of indicators measuring the impact nursing interventions have on patient care was not implemented until 1998 (Montalvo, I. (2007). With the establishment of the National Database of Nursing Quality Indicators (NDNQI), hospitals and other care settings are able to assess how nursing interventions impact patient outcomes, quality of care, and the overall work environment in health care facilities. Nursing-sensitive indicators are a quality improvement measure used to determine how the quality of nursing care is evaluated in hospitals and other healthcare facilities. Nurse sensitive indicators allow healthcare facilities to evaluate how the care they are providing is following evidence-based practices and how they can improve their practices to achieve better patient outcomes. The American Nurses Association is promoting these indicators as the definitive standards for patient care

The Nurse Practitioner, Nurse Educator, Nurse Informaticist, and Nurse Administrator have different educational background and training, thus they play a different role in the field of advance practice nursing but they have a common goal, and that is to ensure a safe and effective delivery of care to every patient, regardless of the type of health care setting. The difference is their roles lies in the fact that the Nurse Practitioner practices in the advanced clinical role while the Nurse Educator, Nurse Informaticist, and Nurse Administrator have the non-clinical roles. Having a clinical role means that the having a direct contact with patient. The NP’s main role is to provide direct care to patient, making diagnosis

To further evaluate the usefulness of the 5 remaining articles, their abstracts were read to identify any relevant information. Information is data that has some meaning to it. Davenport and Prusak (1989) describes information as data that makes a difference to the receiver of the data. The data which is now aggregated into informational sentences and paragraphs (complete thoughts) reveal that the NANDA Nursing Diagnoses, the Iowa Nursing Interventions, and Iowa Nursing Outcomes Classification SNLs have been explored for use in Nurse Practitioner practice. This is information as it has context to the reason the literature search is being performed.

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

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

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 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

The nursing diagnosis is Ineffective health Maintenance related to poor dietary habits, lack of regular exercise, smoking and lack of information about lifestyle factors that increases the risk of hypertension and it’s complications

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

Hyperemesis gravidarum is a severe condition that occurs during pregnancy in which severe nausea, vomiting, dehydration, and weight loss is experienced. HG is the abbreviation for the condition. HG has a great effect on the baby and mom. Eating small, frequent meals and dry foods such as crackers may help relieve uncomplicated nausea.

Nursing is a complicated profession requiring a broad knowledge base, discipline, and a deep desire to understand and interpret scientific data with a goal of obtaining the best possible patient outcomes. This can be very difficult to achieve, requiring the nurse to process a variety of information, prioritize, and problem solve at a critical level (Wilkinson, Treas, Barnett, Smith, 2016). The nursing process is a scientific approach, utilized by nurses to systematically improve patient care by following five steps: assessment, diagnosis, planning, implementation, and evaluation (Wilkinson et al., 2016). A good nurse is someone who understands these phases, continues to build on them, and uses the information to create the best possible, individualized, healthcare plan for the patient. It is a mastery of art to find a way to include all of these concepts with so many diverse medical diagnoses. Having a structural way, such as the nursing process, paves a strong foundation for the nurse to maintain a patient centered approach to implement exceptional nursing care (Goncalves, Spiri, Ortolan, 2017).