Standardized Terminology Paper : Standards Terminology

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

I performed assessments every day of preceptorship. Lung sounds can be difficult for me to identify, so I liked being able to listen and ask my preceptor if she heard the same thing. I heard a whooshing sound over the heart of one of my patients and spent extra time listening to it. I guess he noticed that I was confused because he told me that he has a Pig Valve. Some of the other sounds I could verify were crackles and wheezes.

The ASPIRE framework, also referred to as the nursing process (Barratt, Wilson and Wollands, 2012) was used to structure and develop Susan’s care plan. Introduced by Barrett, Wilson and Wollands (2012), following on from APIE developed by Yura and Walsh (1967), ASPIRE stands for assessment, systematic nursing diagnosis, planning, implementation, recheck and evaluation. Hogston and Marjoram (2006) believe that systematic nursing diagnosis was added to offer direction and time for the nurse to reflect on gathered information and systematically develop a diagnosis. Also the aspect of rechecking is to enable the nurse to monitor and plot a patient’s progress contributing to the final stage of evaluation of care and if its successfulness (Barratt, Wilson and Wollands, 2012).

The World Health Organization recommends the standardized communication process, called SBAR, an acronym which simplifies a patient’s situation and background and the patient care provider’s assessment and recommendations (Wacogne & Diwakar, 2010). The situation, background, assessment, and recommendation (SBAR) protocol is a technique that provides structure for

Write a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the “related to” (r/t) factors.

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.

Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.

Communication is any form of expressing and receiving of messages between individuals. The importance of Communication in the nursing profession is to maintain high quality care for the patient but also maintain effective collaboration between professionals. Boykins, D (2014) states that the “registered nurse is expected to communicate in various formats and in all areas of practice”. Various formats include speaking to patients and coworkers as well as utilizing appropriate protocols and systems to effectively communicate regards to patient’s status.

Patient outcome consisted of performing 10 deep breaths per hour. We have reviewed details that were difficult for the patient to remember, such as breathing out before placing the lips on the mouthpiece, and holding breath for 3 to 5 seconds at the top of each inhalation. With empathy, I provided understanding that being hospitalized is never easy due to sensory overload, pain and lack of privacy. Additionally, we have discussed the basic pathophysiology of lung inflammation and what it can do to a person. So overall, the outcome included enhanced disease knowledge with effective use of incentive spirometer.

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

In standards terminology paper one patient’s assessment will be presented along with Nursing Diagnosis, Nursing intervention Classification and the Nursing Outcome Classification.

According to Keenan (1999), standardized nursing language is a “common language, readily understood by all nurses, to describe care” (p. 1 2). The American Nurses Association (ANA) has 13 recognized standardized nursing terminologies that support nursing practice. The following are the terminologies and the year they were recognized.

Nursing interventions that are appropriate for Mrs. J. at the time of her admission includes comprehensive nursing assessment

It is during the second phase that the nurse must establish a nursing diagnosis. Only diagnosis approved and listed through The North American Nursing Diagnosis Association (NANDA) may be used. Ineffective airway clearance, risk for impaired skin integrity, risk for infection and ineffective coping are just a few examples of NANDA approved diagnosis. A nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (Defining the Knowledge,” 2012).

Breathing is an activity of living that is essential in order for other activities of living to be achieved with ease. Individuals are not usually aware that they are breathing, and it should be effortless. When breathing becomes difficult, an assessment must be undertaken by a nurse in order to make a nursing diagnoses. Once the assessment is completed, interventions are put in place in order for the health issue to be corrected, and an evaluation is done to examine whether or not the interventions were successful. If unsuccessful, the assessment process is repeated. This essay will discuss the information that should be gathered during an assessment, and the possible interventions that may be put in place to correct the issue.