Applying Standardized Terminologies in Practice

Applying Standardized Terminologies in Practice
Guidelines with Scoring Rubric
This assignment is designed to help students
apply standardized terminologies; and
develop an appreciation of the relationship between standardized terminologies and the
data-information-knowledge-wisdom continuum.
Course Outcomes
Through this assignment, the student will demonstrate the following ability.
(CO 4) Assess the value of standardized terminologies in supporting nursing in all four
practice settings. (POs 5, 11)
Total Points Possible: 200
For a selected patient scenario, identify related NANDA, NIC, and NOC elements.
Describe in detail the data, information, knowledge, and wisdom that guided you. The
scenario is one that you choose and is in a context familiar to you so that you can
provide the detail requested and apply your learning from this point forward.

Applying standardised terminologies


Nursing professionals has developed standardised terminologies in order to improve
communication between nurses and other healthcare professionals. The terminologies help in
describing assessments, patient’s interventions and the patient outcomes. This helps nurses
from different healthcare settings to understand a patient’s report. This ensures that patient
information is easily accessible which promotes rapid delivery of care. It also promotes
ubiquity (Bickley, 2013).
With the increased dynamics in patient’s demand, it is important for the healthcare providers
to rapidly access patient’s information. The standardization of terminologies also improves
longevity, i.e. it is used beyond immediate clinical encounters to evaluate the effectiveness of
the healthcare facility’s policies. Lastly, standardization of terminologies promotes re-
usability of patient information for a range of purposes. Without standardized terminologies,
the nurses run at a risk of becoming invisible. This is because it becomes difficult to quantify
the effectiveness of nursing practice. Our unique contribution will remain unrecognized.

Applying standardised terminologies

Additionally, the absence of standardized terminologies would impede the development of
nursing knowledge which would result in a delay in the integration of evidence based care
(Ho, Bryson, and Rumsfeld, 2010).
Standardized terminologies facilitate the accumulation of data which describes the
effectiveness of interventions used in clinical decision making processes. ANA recognizes
about 12 standardized nursing terminologies. However, the most commonly used are
NANDA-1, Nursing Intervention Classification (NIC) and Nursing Outcome Classification
(NOC). This is attributable to the fact that these terminologies are widely recognized in
nursing practice. The contributions of the standardized terminologies facilitate the
identification, categorization, and classification of nursing knowledges (Dains, Bauman, and
Scheibel, 2012).
Integration of standardized terminologies in nursing practice
The concepts of nursing process have transformed over the past six decades. Initially, the
nursing processes focused on disease management, particularly in diagnosis. The current
concept of nursing processes focuses on a patient centred care. Most of the healthcare
facilities (including my work place), apply these terminologies to diagnose and guidelines
when making clinical decisions. The integration of the nursing Standardized terminologies in
health informatics has facilitated quick delivery of care. This is because they replace the
conventional method where nursing notes were done manually. This increases the probability
to medical errors associated with poor communication and interpretation errors. This paper
samples out a Diabetic Mellitus type II patient using NANDA-I, NIC and NOC
The patient, Mrs. BG visited the healthcare facility for regular check-ups. However, the
patient had complaints of general weaknesses and fatigues. The patient has a history of
cardiovascular diseases and obese (Azzolin et al., 2013).

Applying standardised terminologies

NANDA-I is a global force that focuses on developing standardized terminologies to ensure
that patient safety is maintained as illustrated by the evidence based care. NANDA-I is
generally patient diagnoses/ assessment strategies used by nurses to reach to their clinical
judgement on the patient’s health condition. Diabetes Mellitus (DM) is a health condition
characterised by defective metabolism of carbohydrates, which is normally characterised by
abnormal levels of glucose in blood circulation. The patient type of diabetes is associated
with the patient’s body inability to effectively use insulin. The NANDA-I diagnosis of the
disease includes insulin deficiency, abnormal levels of glucose levels, weight loss, high
frequency of urine elimination and fatigue. Imbalanced nutrition is occurs because of
reduced metabolism of carbohydrates. This is attributable to insulin deficiency. Fluid deficit
is associated with polyuria. Impaired skin integrity and activity intolerance are also common
to patients diagnosed with diabetes mellitus Type II (Young, 2011).
NOC describes the expected outcome of the proposed interventions. NOC development is
done through teamwork of the healthcare professionals such as nurses, dieticians, the
psychiatrist and general practitioners. NOC is aligned in a manner that ensures that patient
health and social functioning is improved. The NOC domains that were applied in this case
study were meant to improve the patient’s physiologic, functional and physiological health.
To begin with, the patient must be educated on nutrition to ensure that they digest amount of
calories in right quantity to balance energy levels needed (Park, 2010).
For the fluid Volume Deficit, the patient must be treated until she demonstrate stable vital
signs, skin turgor gets normal, well-defined capillary refill, and balanced electrolytes
concentration. For activity intolerance, the patient must be advised on physical activity to
improve her muscle strengths. At the end of treatment regimen, the patient can withstand 30
minutes of physical activeness at-least five times a week. The other nursing outcomes are
increase patient knowledge through patient education/training on how to manage and control

Applying standardised terminologies

her sugar levels. This is aimed at empowering the patients with effective coping strategies by
transforming the patient’s attitudes and perception. The patient should also be enrolled in
support groups within the healthcare facility in order to improve her social functioning
(Hasan, Zodpey & Saraf, 2012).
NIC is basically the nursing interventions designed to enhance a patient outcome. Designing
of a patient’s intervention is done through inter-profession collaboration. Seven domains of
interventions are established for this patient. The physiological domain consists of nursing
interventions that supports homeostatic regulations. This was restored using insulin lispro
protamine. Other medications include furosemide (Lasix) 80 mg each morning, Digoxin 0.25
mg per day and Cardizem CD180 mg daily. These medications help improve the patient
condition and protect the patient from adverse reactions or harm (safety domain. Coping
strategies are enhanced if the patient has supportive social functioning. This calls for the
family domain which involves integration of the patient’s close friends and relatives in care.
The psychosocial domain facilitates lifestyle modification, so that the patient adapts the best
attitudes to cope with the disease. Other interventions included non-therapeutic and
therapeutic interventions such as emotional and economic support of the patient, fluid
monitoring, cardiac acer, control of infection and nutritional support (Young, 2011).
Undeniably, NANDA-I, NOC and NIC interact and link with each other during the delivery
of care. For example, a patients knowledge deficit (NANDA-I) demands patient education
(NIC) in order to empower and deliver quality care (NOC). The linkages are well illustrated
in the table 1.1 below;
Table 1: Indicating the linkages between NANDA-I, NOC and NIC

(Source Park, 2010)


Applying standardised terminologies

The studies objectives were to evaluate the benefits of integrating standard terminologies in
care plan for a patient diagnosed with DM type II. This is particularly vital as the increase in
technologies and health complexities make demands of healthcare to increasingly become
diverse and complicated. This calls for accurate diagnoses, designing of interventions and
nursing outcomes. Therefore, by applying the terminologies, a large amount of information
can be gathered, which will guide the healthcare providers to make their most effective
decisions. The standardized terminologies are important in the nursing profession as they
facilitate development of an individualised care plan based on nursing theoretical
perspectives. This helps by creating clear communication between the healthcare providers
promoting teamwork and effective delivery of care.

Applying standardised terminologies


Azzolin, K., Mussi, C., Ruschel, K., de Souza, E., de Fátima Lucena, A. and Rabelo-Silva,
E. (2013). Effectiveness of nursing interventions in heart failure patients in home care
using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), pp.239-244.
Bickley, I.S .(2013). Bates Guide to physical examination and history taking .Wolters
Kluwer/ Lippincott Williams&Wilkins.
Dains, J.E., Bauman, L.C., and Scheibel, P. (2012). Advanced Health Assessment and
Clinical Diagnosis in Primary Care.
Hasan, H., Zodpey, S., & Saraf, A. (2012). Diabetologist’s perspective on practice of
evidence based diabetes management in India. Diabetes Research And Clinical
Practice, 95(2), 189-193.
Ho, M., Bryson, C., and Rumsfeld, J., (2010). Key issue in outcome research. Circulation
119: 3028-3035
Park, Hye Jin. (2010). “NANDA-I, NOC, and NIC linkages in nursing care plans for
hospitalized patients with congestive heart failure.”

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