Applying Standardized Terminology in Nursing
Applying Standardized Terminologies in Practice
Chamberlain College of Nursing
NR 512: Nursing Informatics
Fall 2014
Introduction
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. 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 patient with congestive heart failure (CHF), to identify the elements of NANDA-I, NIC, and NOC, and describe the data, information, knowledge and wisdom (DIKW) used during the process.
NANDA-I, NOC and NIC Elements
The University of Iowa developed The North American Nursing Diagnosis Association (NANDA-I) which provides a clear outline to assist nurses in diagnosing various disease states. The Nursing Intervention Classification (NIC) is used for selection of the nursing interventions related to the nursing diagnosis, whereas NOC is the nursing outcomes that should be obtained from the NANDA-I diagnosis and NIC interventions. Standardization of clinical documentation is essential in nursing and should be implemented to combine all three of the nursing languages into one standardized terminology integrated into healthcare information systems. The writer will now illustrate how the NANDA-I, NIC, and NOC relate to patients in congestive heart failure (CHF).
Congestive heart failure occurs when the heart is unable to fill with or eject blood efficiently enough to nourish the body tissues and is a potentially fatal condition which is caused by weakness of the heart muscle. One of the most common risk factor for CHF is high blood
Chamberlain College of Nursing
NR 512: Nursing Informatics
Fall 2014
Introduction
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. 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 patient with congestive heart failure (CHF), to identify the elements of NANDA-I, NIC, and NOC, and describe the data, information, knowledge and wisdom (DIKW) used during the process.
NANDA-I, NOC and NIC Elements
The University of Iowa developed The North American Nursing Diagnosis Association (NANDA-I) which provides a clear outline to assist nurses in diagnosing various disease states. The Nursing Intervention Classification (NIC) is used for selection of the nursing interventions related to the nursing diagnosis, whereas NOC is the nursing outcomes that should be obtained from the NANDA-I diagnosis and NIC interventions. Standardization of clinical documentation is essential in nursing and should be implemented to combine all three of the nursing languages into one standardized terminology integrated into healthcare information systems. The writer will now illustrate how the NANDA-I, NIC, and NOC relate to patients in congestive heart failure (CHF).
Congestive heart failure occurs when the heart is unable to fill with or eject blood efficiently enough to nourish the body tissues and is a potentially fatal condition which is caused by weakness of the heart muscle. One of the most common risk factor for CHF is high blood