Standardized Terminologies in Nursing Practice - Essay Example

Standardized Terminologies in Nursing Practice Introduction Nursing diagnosis comprises making clinical judgment about a person, afamily, or community reactions to potential or actual life processes, or health problems. Any nursing diagnosis helps nurses to come up with the best nursing intervention and achieve results that the nurse on a particular patient’s case is accountable for. This paper uses a case study of a 4-year old boy suffering from Acute Lymphoblastic Leukemia (ALL). He was admitted a week after chemotherapy. He had a fever of 102.5F. His WBC count was 0.3; total neutrophil count was zero. New central line was administered ten days ago. The boy complained of nausea and vomiting. He cried and hid behind his mother whenever the nursing staff approached by. Nursing diagnoses are usually chosen by employing objective and subjective data. The symptoms shown by the boy are examples of infection risk as related to immunosuppression usually a result of chemotherapy; chronic disease such as ALL; inadequate primary defense, as well as developmental level. Preliminary observation shows that the boy is at risk of pathogenic invasion. Nursing interventions classification (NIC) and nursing outcomes classification (NOC) come in handy when it comes to effectively treating various conditions. For effective treatment, a label is created. A label simply means the symptoms a patient exhibits. They are useful in formulating the best nursing care for such patients. In the boy’s case, the label is defined as increased risk of pathogenic infection. This could have been accelerated by inadequate knowledge to avoid pathogenic exposure; insufficient secondary defenses, lack of enough defenses such as evidenced by broken skin above the central line; and immunosuppressant caused by chemotherapy. Given these factors, it is not necessary to define characteristics for this diagnosis as it falls under “Risk for” type of diagnosis. NANDA, NIC, and NOC Elements NANDA is a general term used to denote nursing diagnosis. In the case of the 4-year old boy, nausea seems to result from chemotherapy. The major symptom is vomiting. Some patients complain of a tummy ache and have an aversion for food. This is another pertinent diagnosis for ALL. NOC or nursing outcome classification, as well as nursing indicators, allow measurements of a patient, family or the community results at any point from the most positive to the most negative at various points in time. NOC outcomes allow for a quantitative measure of a patient’s progress. This makes it easy for providers of health care to understand and use. A neural name characterizes a patient’s status and behavior. For instance, the symptoms shown by the boy are usually associated with ALL. List of indicators describes status or behaviors of a client. A 5-point scale is used to rate status of a patient for every indicator listed above. When employing NOC results, the nurse must make use of labels and clear definitions. However, the outcomes are usually individualized by using suitable indicators where appropriate. The link between NANDA and NOC is that every nursing diagnosis is trailed by suggested results to measure if the chosen interventions can solve the problem identified. Every outcome can be specific to the patients or their family. This is possible due to use of suitable indicators as well as the incorporation of other indicators. Examples of NOC include infection severity, immune status, infection control (based on available knowledge), wound healing with regards to location of the wound, and tissue integrity. Immune status refers to acquired or natural resistance to antigens (both internal and external). For, instance, in the case identified, the appropriate scale used would be 1-5, where 1 means SEVERY COMPROMISED, and 5 means NOT COMPROMISED. These values would be investigated: Absolute WBC values Skin integrity Differential WBC values Body temperature Mucosa integrity Gastrointestinal function Weight loss Recurrent infections Tumors Apart from the above-listed NOC outcomes, other labels would be healing of the wound (primary intention), and control of infection (knowledge). NIC stands for nursing interventions classification. A standardized and comprehensive language describes treatments and interventions, which nurses conduct under all settings in their various specialties. It was designed for its simple organizational structure and familiar language that is clinically useful. Interventions would refer to suitable treatments based on clinical knowledge and judgment that a nurse carries out to improve outcomes for their patients or clients. For instance in the case of the 4-year-old boy suspected to be suffering from ALL, the label was Increased Risk of Pathogenic Infection. Appropriate specific activities make disease diagnosis and treatment easier and efficient. The linkage between NANDA and NIC is such that every NANDA diagnosis is a precedent of suggested interventions for solving the problem identified. Activities and interventions are chosen to meet specific needs of a patient. Specific information about a client further helps in coming up with solutions that will address their problems. Some activities and interventions are general while others are specific. Some NIC examples associated with “Risk for Infection” include, skin surveillance, infection protection, nutrition management, wound care, and surveillance. Data, Information, Knowledge, and Wisdom Based on the symptoms and signs exhibited by the boy used for this case study, protection of infection would entail detecting an infection early enough, prevention, and reducing risks of infection. Individualized activities, in this case, would include: Monitoring localized, systematic and extent of infection; this is done by use of central line check after 4 hours. Monitoring WBC count as well as differential outcomes Following neutropenic safety measures Providing a private room Controlling the number of visitors (the boy was afraid of strangers). Usually, all subjective and data are collected from the patient. These come in the form of symptoms and behaviors they exhibit. The information gathered, helps the nurse on a particular case to come up with a label. They then use current research and nursing diagnosis to come up with better interventions and disease control. A particular health worker can formulate information such as age, institution as well as any other specific information. More information can also be collected from the patient. To prevent information, the following activities come in handy: Screen visitors for contagious and communicable diseases Inspect mucous and skin membranes for redness, drainage, or extreme warmth. Ensure proper state of surgical incision Obtain cultures where they are needed Encourage nutritional intake such as 1500kcal every day Promote intake of fluid Ensure the patient has adequate rest Ensure the patient takes prescribed anti-infective. In case they feel something should be added, each nurse will rely on their experience, available information, wisdom and skills in addressing them. Conclusion Standardized nursing terminologies come in handy for nurses across different and cultural divides in coming up with possible interventions, prevention, and treatment of various conditions. They enable heath care providers to use data, facts, information, wisdom, as well as knowledge in dealing with various situations. The paper has looked at important terminologies such as NANDA, NOC, and NIC and how they relate to each other. Coming up with a diagnosis, or a label, entails more than just physical observation. Rather, it entails using scientifically proven process and clinically tested designs in dealing with various conditions. Of course, all these factors are meant to simply the process of diagnosis. For instance, making individualized diagnosis works better than general diagnosis. As a result, the four nursing practice settings of Data, Information, Knowledge, and Wisdom are explored and their relationship to each other thoroughly investigated. The case of the 4-year-old-boy suffering from ALL is used to help the reader understand the concepts of NANDA, NOC, and NIC of nursing. Reference Brunner, L. S. (2010). Brunner & Suddarths textbook of medical-surgical nursing (Vol. 1). S. C. C. Smeltzer, B. G. Bare, J. L. Hinkle, & K. H. Cheever (Eds.). Lippincott Williams & Wilkins. Read More