Nursing Informatics

Topics: Nursing, Electronic health record, Health care Pages: 15 (2581 words) Published: November 17, 2012

and the Foundation of Knowledge

Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice (McGonigle, 2009). Most hospitals now utilize computer systems to track patient health information. The purpose of this paper is to show how a computerized system can help the health care worker provide the best care for the patient by utilizing available programs that when implemented will aide staff in detecting weight gain in a patient with a diagnosis of heart failure. Concept Map

The patient comes to the unit where admission history information is gathered,

vital signs obtained and a head to toe assessment is completed. The patient has a

diagnosis of hypertension and diabetes which is currently be treated with medication and

is now having signs and symptoms of congestive heart failure (CHF). Nurses may

generate and record the data from their own observations or with the assistance of various

devices. In this way, data (often qualitative data that cannot be traditionally measured)

can be organized and processed (McGonigle 2009).

More information is needed so the nurse logs onto the hospital computer system
and checks the patient’s previous admission history, including previous vital signs, lab

results, and any testing that has been completed in the past few months for comparison.

She also reviews physician notes, dietary, and social services for education given related

to diagnosis of hypertension and diabetes. The nurse sorts through useful information that

pertains to the patient’s current condition and complaints. The nurse notes the patient has

gained some weight, her blood pressure is higher than previous readings and her mother

recently died from complications of CHF. The computer system allows the nurse to see

results along a linear time line during any specific time chosen. This gives the nurse a

clear picture of trending. The data is interpreted, organized and structured into useful

information (McGonigle, 2009).

The knowledge the nurse has acquired during her educational years combined

with life experience allows her to put the signs and symptoms together to formulate the

next step of action. She knows that the patient meets common criteria for CHF; the

patient has a diagnosis of diabetes and hypertension, is overweight, an older female, is

having fluid retention in the lower extremities, shortness of breath and noted crackles in

the lungs. The nurse anticipates the doctor will order various labs to check current levels

of lipids, enzymes, BNP, liver, kidney and thyroid function that will be used to compare

against past results, stored in the computer system for easy access. The doctor may also

order chest x-ray, echocardiogram, check ejection fraction, and EKG/ECG to verify

suspected diagnosis. All results are entered into the computerized system by each area of

discipline and transferred into the a review results “tab” for easy access. The information

gained from testing will be synthesized so that relationships are identified and formalized

(McGonigle, 2009). All disciplines have access to patient testing results via the

computerized charting system, to assist them in formulating a plan of care for the patient

while in the hospital and upon discharge to home.

Wisdom is sometimes thought of as the highest form of common sense resulting

from accumulated knowledge or erudition (deep, thorough learning) or enlightenment

(education that results in understanding and the dissemination of knowledge)

(McGonigle, 2009). A plan of action is formulated at this point based in knowledge.

Daily weights are ordered and recorded, IV or oral diuretics,...
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