Standards Terminology Paper : Nursing Intervention Classification And The Nursing Outcome Classification

1493 Words Nov 2nd, 2014 6 Pages
Standards Terminology Paper
Elizaveta Pavlenko
Frostburg State University

Preface In standards terminology paper one patient’s assessment will be presented along with Nursing Diagnosis, Nursing intervention Classification and the Nursing Outcome Classification.
In conclusion part of the paper, the summary of these systems will be provided.
Clinical Encounter Mary Smith, Female, 56 years old, presented to Emergency Department with abnormal Chest Xray, fever, chills and generalized weakness on Friday, 10/31/2014. Per patient, she came to visit her physician after she started feeling abnormally tired at work. After consult, physician ordered Chest Xray that showed bilateral infiltrates in lungs. Given previous lung disease history, and history of COPD, physician suggested a visit to a local Emergency Room, after which Mary Smith was admitted to an outpatient unit for observation. Additional investigation of past medical history revealed that patient has Chronic Pneumonia due to Mycobacterium Avium Complex and Gastroesophageal reflux disease. Admission history revealed that Mary Smith lives with her spouse and work in a local retail store. Patient denied smoking history, alcohol consumption history, drug use history. Psychosocial assessment revealed that patient’s house was burglarized few months ago, otherwise no other stressful factors added. Patient presented with no known allergy history. Current medication assessment showed that patient takes probiotics,…
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