NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay
In our current practice nursing professionals have an agreed standardized terminology in which they use to connect amongst each other and additional healthcare professionals. According to Moorhead (2013), standardized terminology (ST) has facilitated nurses to collectively agree upon mutual terminology to describe assessments, interventions, and results related to nursing care documentation. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay. Nurses from various settings, practices, and demographic areas will be able to use and understand common terminology to recognize a patient specific problem, the implemented intervention, and the observed outcome. NANDA, NOC, and NIC are the organizations within standardized terminology that will be conversed throughout this paper and how they relate to patient care based on the scenario provided. The scenario is as follows: A 89 year old female is admitted for complaints of SOB and difficulty breathing. She is anxious, tachypnic, tachycardic, and blood pressure is elevated. Her lung sounds are rhonchi throughout, and she is currently saturating 93% on 5L O2. She has a chest x-ray and swallow evaluation ordered and her lab work is pending.
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NANDA International also known as the North American Nursing Diagnosis Association is a qualified organization of standardized nursing terminology that develops, researches, and refines the standards and principals of nursing diagnoses. NANDA is dedicated to improving the quality and improvement of nursing care and patient safety through evidence-based research and practice. Park (2014) describes this organization as a “global force” for the development and use of nursing’s standardized terminology to guarantee patient safety and well-being through evidence-based care, ultimately refining the health care of all individuals. Based on the mentioned scenario useful nursing diagnoses would be: Impaired gas exchange r/t increased fluid volume or Ineffective airway clearance r/t altered delivery of oxygen. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay.
Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of desired patient outcomes established to appraise the effectiveness of interventions implemented by nursing professionals. The outcomes are developed for use in all healthcare settings and can be used across the care continuum to monitor patient outcomes throughout an illness or over an extended period of care. Since the outcomes describe patient or client status, other disciplines may find them useful for the evaluation of their interventions. In addition, standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, and for the development of nursing knowledge and the education of professional nurses (Moorhead, 2013). NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay. Desired outcomes for the above scenario and mentioned nursing diagnoses includes: Client will display patent airway with breath sounds clearing and absence of dyspnea in 48 hours. Client will demonstrate improved ventilation and oxygenation by SPO2 WNL, decreased need for supplemental oxygen, and absence of respiratory distress.
Nursing Interventions Classifications (NIC) is a complete, evidence and research-based, standardized classification of interventions that nurses provide to patients. An intervention is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (Park, 2014). NIC is valuable for nurses in clinical research, management, documentation, communications, and evaluations. Park (2014) also says that the interventions identified by NIC can be independent or collaborative, direct or indirect patient care. It can also include administration, preventions, reductions, and advancement. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay. Nursing interventions that I would implement based on the above scenario include assessing the rate and depth of respirations and chest movement, auscultating lung sounds noting areas of decreased air flow and adventitious breath sounds, administering adequate oxygen therapy, and assessing the level of patient anxiety. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay.
Nursing professionals gather data and information from patients, apply the knowledge learned, and use the wisdom we have developed through experience to guide us in implementing an appropriate plan of action for our patients. Matney et al. (2011) stated, “The metastructure of nursing informatics is combining data and information that is gathered, and knowledge that is remembered from previous teaching to form wisdom that can be translated into a situation.” Data to information to knowledge to wisdom (DIKW) is considered an overarching concept that supports all of nursing and informatics practice. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay.
Data is the simplest part of the DIKW framework. A sole piece of data does not have any true meaning, but it will lead to additional conversation, testing, and evaluation. Information is the assembly of data in a definite framework. Information can be described as the “who, what, when, where, and how” related to data. Knowledge is converting the information into an understanding and answering the “how” and “why” related to the available information. Lastly, wisdom is the suitable use of knowledge to manage and resolve the patients’ problem. Wisdom is often denoted to as the “thinking in action” approach to a situation. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay. The difference between knowledge and wisdom is memorizing the knowledge verses actually understanding the knowledge and how it converts to wisdom. As each level of DIKW evolves further critical thinking is applied and progression occurs (Matney et al., 2011).
I recently had an 89 year old female patient who was admitted for dyspnea and SOB. Her vital signs were: HR was in the 150’s, her BP was 189/98, RR were at 32, and she was saturating 93% on 5L O2. In order to gather more data and information I completed her physical assessment NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay. She was anxious and confused which was not her baseline. Her lung sounds were rhonchi throughout, her respirations were shallow and rapid. Based off the information I gathered, I knew the patient was not receiving an adequate amount of oxygen to her brain causing her to be more confused and anxious. Chest x-ray results revealed that she had severe pneumonia. It was also reported that the patient was having difficulty swallowing. A swallow exam was performed and the patient did not pass so it was determined that the patients pneumonia was due to aspiration. At that the point the patient was to be NPO with no exceptions. Blood cultures were obtained to make sure that the patient was not septic and then IV antibiotic therapy was initiated. I also received orders for IV Lasix to help rid the patient of the excess fluid in her lungs and a foley catheter to monitor her output. Respiratory treatments were also implemented as well as IV medication to help stabilize her heart rate and blood pressure. It was anticipated that the patient may go into further into respiratory distress and become unstable therefore vital signs were obtained more frequently, suction was set up at the bedside, and the doctors were made aware of current status. The patient was also stated on IV fluids at a low rate with added dextrose for temporary hydration. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay.
In closing, Standardized Terminology from organizations NANDA, NIC, NOC, and DIKW has benefited the nursing profession by acquiring a common understanding of implemented interventions for patients. Nurses who use ST are able to communicate efficiently to each other and further communicate with other health care disciplines by certifying that there is a mutual understanding or meaning of a given concept. STs are also used to escalate the prominence of nursing interventions, improve patient care and satisfaction, and improve data and information collection. Consequently, nursing care outcomes are evaluated which will help simplify the overall nursing practice. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay.
References
Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6-18.
Moorhead, S. (2013). Nursing Outcomes Classification (NOC), Measurement of Health Outcomes, 5: Nursing Outcomes Classification (NOC). Elsevier Health Sciences. NR 512 Nursing fundamentals – Applying Standardized Terminology in Nursing Practice Essay
Park, H. (2014). Identifying Core NANDA‐I Nursing Diagnoses, NIC Interventions, NOC Outcomes, and NNN Linkages for Heart Failure.International journal of nursing knowledge, 25(1), 30-38.