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

The knowledge of nursing sensitive indicator can be helpful in providing the patient care which meets the quality and ethical standards. Nursing sensitive indicators rely on evidence to take patient care decisions (Patrician, 2010). According to Patrician (2010), Evidence Based Nursing is the use of personal expertise and research to take decisions on patient care. In case of Mr. J, there is a clear lack of evidence based nursing. Mr. J was kept in restraint without considering that Mr. J was not trying to get out of bed by himself. When the pressure ulcer was identified, the nurse

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

Nursing is a field that requires all people involved in a patient’s care to be able to speak the same language, and to understand what is begin done to improve each patient’s outcome. There is no room for error or misinterpretation. This is the reason that it is critical to implement standards for nursing terminology. The Center for Nursing Classification and Effectiveness (CNC) is the organization responsible for ongoing research and development of the Nursing Interventions Classification and the Nursing Outcomes Classification (“Center for Nursing Classification and Effectiveness”, n.d.). The Nursing Interventions Classification and the Nursing Outcomes Classification, “are standardized nursing terminologies focused on nursing treatments and patient outcomes for use across settings and specialties” (“Center for Nursing Classification and Effectiveness”, n.d.). Both nursing classifications are recognized by the American Nurses’ Association.

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.

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

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).

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.

The benefits of using evidence based assessment terminology for documenting are better communication and improved patient care. There are different types of nursing terminology utilized in nursing such as; NANDA, NIC, NOC etc. Nursing terminology is a language understood by all nurses (McGonigle &Mastrian, 2012). A nurse knows that a specific word or phrase has a specific

Every profession has standardized terminology as seen in generalized nursing practice. Harriet Werley promoted the development of the Nursing Minimum Data Set (NMDS), which consists of a minimum set of items of information with uniform definitions and categories concerning the specific dimension of nursing which meets the information needs of multiple data users in the health care system (as cited in Schwirian & Thede, 2012). The NMDS consist of diagnoses, interventions, & outcome which has been further standardized by the American Nurses Association with specific terminologies. Advance practice nursing roles is often a mix of leadership and or direct clinical care where interdisciplinary communication is part of the standardized practice for

Nursing terminology could be described as the formal and informal communication that occurs in a nurses daily activity. According to McGonigle & Mastrian (2009) nursing terminology allows nurses to communicate nursing data, information and knowledge specific to nursing. In addition, standardized nursing terminology refers to a system. This means they have undergone approval by a specific authority. The American Nurses Association (ANA) is one authority with a standardized nursing practice and information infrastructure committee, which recognizes twelve standardized terminologies, both nursing specific and interdisciplinary (p. 98). The Clinical Care Classification system and the International

The study examined the effectiveness of the multiple interventions used in transitions of care. Thus, reducing patient readmission. In this research, a qualitative method was incorporated and adults that will discharge to home, are included in this study.

A ninety-two year old Caucasian male was brought to the emergency room by his son. Patient was admitted to the hospital with a chief complaint of difficulty breathing; diagnosis includes congestive heart failure exacerbation (CHF) with pneumonia (PNA). He has a full code status. Past medical history includes congestive heart failure, COPD, peptic ulcer, chronic kidney disease stage 3, anemia, and hypernatremia. Patient is a widower who lives with son and consumes no alcohol or illicit drugs, he has is an ex-smoker with a 70 pack year history. Patient is a retired mechanic with no family medical history on file; it is suspected that father had heart issues. He has no known allergies although is contraindicated to take aspirin due to GI bleeding.

In the past, nurses have documented their work using individual and “unit-specific” methods (Keenan). Consequent to this, there is a wide range of terminology to describe the same care. With this learning curve in place, a nurse must work even harder by familiarizing themselves with the new terminology, and caring for patients. “Nurses need to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care” (Rutherford). This will enable all nurses whether they are from different units, hospitals or even geographic areas to produce the same level of quality care. Say a nurse previously worked in a family clinic in a small city where they did only moderate procedures. Due to their medical training, they are familiar with what a coronary artery bypass graft is; however, when they transfer to a hospital’s cardiovascular department in a big city, and the doctor says that the patient will need a CABG, the acronym for coronary artery bypass graft pronounced “cabbage”. I personally would be concerned as to why the doctor would be suggesting a leafy vegetable for a patient who has narrowing coronary arteries cutting off blood supply to their heart.

The use of nursing diagnosis is a mechanism for identifying the domain of nursing. The formulated nursing diagnosis provides direction for the planning process and the selection of nursing interventions to achieve the desired outcome. The care plan is a mechanism for demonstrating accountability, In addition, the nursing diagnosis and subsequent care plan assist in communicating to other professionals the client centered problems through the nursing care plan, consultations, and discharge planning and client care conferences. Making accurate nursing diagnosis helps to ensure that clients receive quality nursing care. Nursing diagnosis help to increase the specificity of nursing interventions for each client. Coding of nursing diagnosis in computerized systems allows direct reimbursement for nurses. Studies of specific nursing diagnosis improve understanding of nursing diagnostic process and contribute to examination of nurse's role in health care, The development of taxonomy of nursing diagnosis should significantly affect practice, education, research, legislation, and nursing as a profession, A nursing diagnosis will help to bridge a gap between knowledge and practice and will articulate the scope of nursing practice, essential to developing nursing professional role in

Patient L is a 14 years old Chinese girls and she came to hospital complaint of cough with greenish sputum as long as 2 weeks, she had fever at home and complaint of chest pain. She came from A&E admitted at ward 3 at 30/4/2012 (Monday), 3.35pm accompanied with PPK. She admitted at the ward 3 as long as 5 days and she discharge at 4/5/2012 (Friday), 10.20am.