Applying Standardized Terminologies in Practice - Assignment Example

Applying Standardized Terminologies in Practice Introduction Standardized Nursing Terminologies (SNTs) are taxonomies or ifications developed to be used by healthcare providers. Most healthcare settings use SNTs as an element of Electronic Health Records (EHR) and typify nursing knowledge, data, and information, which can be kept in the electronic systems to be utilized as reference by healthcare providers. In the field of nursing, SNTs application is crucial in assisting nurses to accurately and clearly document patient care data. The utilization and implementation of the SNTs include explanations of nursing practice into health records in such a way that the nursing personnel easily understand. Application of SNTs is fundamental to the advancement of nursing as a career (NANDA International, 2014). This article tries to identify related elements of North American Nursing Diagnosis Association (NANDA), Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC). A patient scenario will be used in the identification of how the elements of NANDA, NOC, and NIC are applicable. The patient scenario will be created using the framework of Data, Information, Knowledge, and Wisdom (DIKW). Patient Scenario At a local hospital, in the Pediatric Acute room, a four year old female child gets an admission one week after undergoing chemotherapy. The child has a fever of 102.5 F. Her white blood cells (WBC) are 0.3 and the neutrophil count (absolute) is 0. A new central line was placed about 10 days ago. In addition, the child has nausea and vomiting (C/O). She also cries a lot and when the nurse approaches, she hides behind her mother. Components of SNTs NANDA often comprises nursing diagnosis, which includes classifications and definitions (NANDA International, 2014). NOC comprises the categorization of nurse responsive results. It is a categorization of the nurse sensitive outcomes. The indicators and outcomes provide a chance for the measurement of the outcomes of the patient, community, or family at any juncture on a scale from most negative to most positive at different junctures. A name or a neutral label is used to characterize patient status or behavior. Also, there is utilization of list of indicators, which describes patient status or behavior. In addition, it involves a five point scale used in rating the status of a patient for every indicator (Iowa Outcome Project, 2012). NIC describes treatments used by nurses during practice in all facilities and all specialties. Actually, it comprises the interventions made by nurses. Further, NIC comprises a label or name, a definition, and a set of practices that nurses use in implementing and performing their interventions (Iowa Intervention Project, 2012). Considering the above mentioned patient scenario the nursing diagnosis are as follows: Infection risk related to immune-suppression as evidenced by chronic disease (Acute Lymphocytic Leukemia), insufficient primary defenses, developmental level, and chemotherapy. Nausea primary to chemotherapy as evidenced by patient c/o (stomach ache), avoidance of food, and vomiting (Iowa Outcomes Project, 2012). Fear and anxiety related to unfamiliarity with the experiences of the environment as evidenced by crying and evasion behaviors (for instance, infant hides behind the mother). With regards to the first nurse diagnosis, the label definition depicts an elevated risk for the child immunity being attacked by pathogenic organisms. The risk factors include: Inadequate knowledge on how to avoid or prevent exposure to pathogenic organisms (developmental level). Leukopenia (insufficient secondary defenses). Skin lesions resulting from the central line (insufficient primary defenses). Immunosuppressant such as chemotherapy or rather pharmaceutical agents. According to Van De Castle, 2011 when linking NANDA and NOC, a list of proposed results follows every nurse. These proposed outcomes measure the possibility of the selected interventions assisting the identified problem. Also, during the linkage, every outcome is individualized to a patient or the patient’s family through selecting the most suitable indicators or through including additional indicators. Some of the NOC examples that can be linked to the NANDA (infection risk) include: Immune status, Severity of infection, Nutritional status, Knowledge; control of infection, Wound healing; wound location (front of neck) and primary intention, and Tissue integrity; mucous membranes and skin. In the case of immune status, it is a natural or acquired suitably aimed resistance to external and internal antigens. To rate the status of a patient for every indicator, a five point scale is used. For instance, in the case of the indicator: immune status the rating can be done using the point “1=severely compromised through 5 = none/not compromised” (severe = 1, substantial = 2, moderate = 3, mild = 4, & none = 5). For the patient scenario, the scale is 1. Van De Castle, 2011 further asserts that when linking NANDA and NIC: Every NANDA diagnosis is accompanied by list indicating proposed interventions for finding a solution for the identified problem. Activities and interventions must be selected to achieve the individual patient needs. Individualization of the activities can also be done through addition of patient specific information. Extra activities may be included if necessary and suitable. For the scenario, some of the NIC examples that can be linked to NANDA (infection risk) may include: Protection and prevention of infection, Skin surveillance, Nutritional management, Wound care, and Surveillance. In the case of infection prevention and protection, for instance, NIC can be incorporated in the patient scenario as follows: Definition: Infection protection is early infection detection in a vulnerable patient. Activities: Monitoring for localized and systemic signs and symptoms of infection (check the site of central line every 4 hours). Monitoring white blood cells and any differential outcomes. Following neutropenic safety measures. Providing the patient a private room. Limiting the number of patient’s visitors. Maintaining asepsis. Screening patient’s visitors for infectious disease. Inspecting the mucous membranes and the skin for extreme drainage or warmth, and redness (every 4 hours). Obtaining cultures as required. Promoting proper nutritional management (patient prefers cereals; 1500 kcal each day). Inspecting the surgical incision point’s condition (after every 4 hours). Encouraging intake of fluids (patient prefers orange Gatorade; 1225 cc each day). Monitoring for change in the level of energy or malaise. Encouraging rest. Ensuring patient adheres to the prescribed anti-infective. Educating the family concerning signs and symptoms of an infection and when they should report such occurrences to the healthcare practitioner. Generally, after the infant’s admission, the pediatric unit’s case manager should meet with the family of the patient in order to carry out an initial assessment. At the time of the assessment, the manager must make inquiries concerning the current insurance information, medical equipment used, transportation technique, feeding regimen, and validate the medications of the patient. Also, the case manager must discuss the plan of care for the patient, barriers that may probably hinder discharge, and address the concerns that the family presents. Actually, the case manager should exhibit a strong understanding of the treatment plan of the patient before meeting the patient’s family. This ascertains that a healthy working atmosphere is built. Further, the case manager must have the ability to clarify to the patient’s family the treatment plan, which comprises: diagnosis risk factors, assessment of areas that will receive close monitoring, suitable nursing interventions, and personalized goals of patient (NANDA International, 2014). Conclusion The utilization of the standardized terminology formulated by NANDA, NIC, and NOC in the above described scenario permit for the evidence-based care plans development, which employ research based nursing information to provide quality nursing care that improves patient results. Further, these terminologies are used by nurses in acute care, rehabilitation, long-term care setting, and outpatient to ensure consistency across the scale of care, with regards to identification and application of nursing diagnoses, care plans and interventions. References Iowa Intervention Project. (2012). Nursing interventions and Classification (NIC). (4th ed.) St. Louis: Mosby, Inc. Iowa Outcomes Project. (2012). Nursing outcomes classification (NOC). (3rd ed.) St. Louis: Mosby, Inc. NANDA International. (2014). Nursing Diagnosis: Definitions and Classifications 2012-14. West Sussex: John Wiley & Sons Ltd. NANDA. (2011). Nursing Diagnosis: Definitions and Classifications. Indianapolis, IN: Wiley- Blackwell. Van De Castle, B. (2011). Comparisons of NANDA/NIC/NOC linkages between experts and nursing students. International Journal of Terminologies and Classifications: 14(4) Read More