Standardized Terminology Paper : Standards Terminology

1738 WordsMar 12, 20177 Pages
Standardized Terminology Paper Tracy Bell Frostburg State University Running head: STANDARDIZED TERMINOLOGY PAPER 1 STANDARDS TERMINOLOGY PAPER 6 STANDARDIZED TERMINOLOGY PAPER 2 Standardized Terminology Paper 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).…show more content…
Nursing Diagnosis A nursing diagnosis is used during the nursing process in order to identify and treat the main complaint the patient presents with. After the assessment a nurse develops a care plan based on the nursing diagnosis. This helps navigate how to effectively approach the patient’s condition and promote positive outcomes. The nursing diagnosis formulated for my infant was as follows: Ineffective breathing pattern related to an increase in work of breathing as evidenced by substernal retractions and decreased oxygen saturation. Domain: Class Ineffective breathing pattern (00032) (NANDA International, 2012) Nursing Interventions Classification (NIC) Interventions The following is a list of interventions using the nursing intervention classification (NIC) system and activities to support this nursing diagnosis of ineffective breathing pattern related to an increase in work of breathing as evidenced by substernal retractions and decreased oxygen saturation. Intervention 1 (3140) Airway Management: Facilitation of patency of air passages (Bulechek & McCloskey-Dochterman, 2008). Activities: · During my assessment and as needed I auscultated the lungs to assess for changes in lungs sounds. For example, by listening to the lungs I can assess if air is moving and if additional interventions are needed such as a nebulizer treatment by a respiratory therapist or nasal suctioning. · Administration of oxygen with humidification was used to help maintain an oxygen
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