Standardized Nursing Terminology Essay

Among the Resources in this module is the Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice? In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.Standardized Nursing Terminology Essay

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During the visit, one of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1).

How would you respond to a comment such as this one?

To Prepare:

  • Review the concepts of informatics as presented in the Resources, particularly Rutherford, M. (2008) Standardized Nursing Language: What Does It Mean for Nursing Practice?
  • Reflect on the role of a nurse leader as a knowledge worker.
  • Consider how knowledge may be informed by data that is collected/accessed.Standardized Nursing Terminology Essay

The Assignment:

In a 2- to 3-page paper, address the following:

  • Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.
  • Describe the benefits and challenges of implementing standardized nursing terminologies in nursing practice. Be specific and provide examples.
  • Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.

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.Standardized Nursing Terminology Essay 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…show more content…
Nurses should take care to select the proper outcomes to ensure optimum care is provided to patients with CHF. The plan of care is dependent on the nursing diagnosis and the desired nurse-sensitive outcomes. The priority NOC outcome for the diagnosis of CHF is Fluid Balance and Fluid Overload Severity. Other related NOC outcomes are Knowledge: Cardiac Disease Management, Knowledge: Energy conservation, Knowledge: Medication, Knowledge: Prescribed Activity, Knowledge: Treatment, and Knowledge: Standardized Nursing Terminology Essay Weight Management (Johnson et al., 2012). These are only a select few of the multiple outcomes available; care should be modified as the disease progresses through the problems which evolves over the lifetime of patients diagnoses with CHF. Once all these determinants are established, the nurse will be prepared to determine which level of NOC is essential to effectively manage the disease. Nursing Intervention Classification Nursing interventions are focused on nursing behaviors to guide the patient in the direction of the most preferred outcome (Johnson et al., 2012). Fluid management, fluid/electrolyte management, and hypervolemia management are the major interventions in effective management of CHF. Fluid management is the most difficult intervention for all patients suffering from CHF.
In order to increase nursing knowledge, according to Nelson and Staggers (2015), the ability to extract the unique data that nurses provide is essential. Utilizing a common language, standardized nursing terminology (SNT), allows for the organization of data, information and knowledge. Park (2014) asserted, coded SNT in the electronic health record EHR, allows for a comprehensive means to portray the “art of nursing”, the interventions and outcomes which are a direct result of nursing actions.Standardized Nursing Terminology Essay The 3 most frequently utilized SNTs are: North American Nursing Diagnosis-International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcome Classification (NOC). Used together, also known as NNN (Park, 2014). Incorporating NNN into the EHR will allow the ability to examine the data provided by the bedside nurse in a logical, easy to extract manner. In so doing, the actual work of the nurse is transformed into concrete information, resulting in, as discussed by, Marques da Cruz, Bonfim, Gaidzinshi, Fufulin, and Laus (2014): improved staffing ratios, evidenced-based practice, quality and safety; resulting in improved patient outcomes and patient satisfaction. The heart failure (HF) patient, utilizing NNN charted in the EHR will be discussed. A newly admitted HF patient into a critical care unit. The patient requiring inotropes, pulmonary artery (PA) catheter, IV diuretics and the thought process of the bedside nurse.

As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty.Standardized Nursing Terminology Essay In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care? Standardized Coding Systems Essay.

According to Rutherford (2008, para. 15), “Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language.” In this Discussion you consider the reasoning behind and the value of standardized codification. Standardized Coding Systems Essay.

To prepare

Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.

Reflect on the importance of continuity in terminology and coding systems.Standardized Nursing Terminology Essay

In the article, “Standardized Nursing Language: What Does It Mean for Nursing Practice?” the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.

Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.Standardized Nursing Terminology Essay

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