• 23 AUG 18
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    Applying Standardized Terminologies

    There are two different postings below. Can you please paraphrase both of the postings below. Being sure not to plagiarize them. APA format. The references are listed below. You can use additional references if you need to. I just need you to change the way they are worded so its not plagerized .

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    1) I think there is no question that nurses across the board should use a standardized nursing language, and that each specialty area can then expand upon that standardization for their particular needs. Having one set standard of documentation across the world allows a more fluid communication and understanding of practice between nurses everywhere.

    In many hospitals now, electronic health records (EHR’s) are the standard form of charting versus paper charting. There needs to be a standardization across these EHR’s for any nurse to be able to come from one facility to another and understand the plan of care, teaching, testing and so on done for their patients. “Standardizing the language of care (developing a taxonomy) with commonly accepted definitions of terms allows a discipline to use an electronic documentation system.” (Marjorie A. Rutherford, 2008)

    In nursing we are constantly learning and growing in our practice every day and to be able to access information across different spectrums that all use a standardized language helps us grow and learn from mistakes. “Consistency in accessing and communicating information throughout the continuum is important, and by having a standardized language to do so helps facilitate and improve this process.” (McGonigle & Mastrian, 2012)

    Having this standard documentation for patient outcomes and plans allows me to better describe the patients needs for treatment, that’s why i feel it is so important for all RN’s across the board to be able to coherently understand one another in our charting.

    References

    Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing

    practice? The Online Journal of Issues in Nursing, 13(1). Doi: 10.3912/OJIN.Vo113

    No01PPT05.

    McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge

    (2nd ed.). Burlington, MA: Jones & Bartlett Learning

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    2) Applying Standardized Terminologies

    The standardized language is an essential part of nursing studies and application. It helps in creating awareness of the nursing language and helps in supporting the learning processes in nursing. Knowing standardized language helps in providing consistency in practicum and developing of critical thinking knowledge. Furthermore, it improves communication skills, which is essential in diagnoses, interventions and outcomes classifications. In this context, we discuss three terminologies that include NANDA, NIC and NOC[BS1] . The term NANDA represents the definitions and classification of nursing diagnoses. NIC represents the classification of nursing interventions, while NOC represents the classification of nursing outcomes. Ineffective breathing patterns are among conditions whose nursing responses apply NANDA, NIC and NOC terminologies[BS2] .

    NANDA

    The term NANDA is an acronym, which stands for the North American Nursing Diagnosis Association. It refers to the development of diagnoses through peer-reviewed processes based on standardized evidence, definitions and characteristics relating to risk factors, that nurses use during assessments to identify potential diagnoses. The term is based on the idea that nurses need to use standardized language to integrate diagnostic processes and the clinical and research knowledge. NANDA undergoes constant refining to develop health responses for risk conditions, as well as providing diagnostic support to promote the patient health (Johnson, 2006). The NANDA diagnoses lists are applicable for individuals, groups, families and communities.

    The NANDA diagnoses system in the context of nursing can be elaborated in four categories, which include actual diagnosis, risk diagnosis, health promotion diagnosis, and syndrome diagnosis. The actual diagnosis refers to the clinical judgment concerning the responses and experience to health status, which exist in an individual, his or her family, or community (Brennan & Mazanec, 2011). Risk diagnosis, refers to the responses to health conditions and life processes, which might develop in a vulnerable individual, family or community. Risk diagnosis is based on risk factors, which contribute to the increased exposure. Health promotion diagnosis is a clinical judgment based on the motivation and desire of an individual, family or community to promote well-being and health conditions. Syndrome diagnosis is the clinical judgment, which describes a specific group of nursing diagnoses that take place simultaneously and exhibit similar interventions.

    NIC

    The term NIC is an acronym used in the nursing contest, which stands for the Nursing Interventions Classification. It refers to a comprehensive and standardized research based classification of the clinical interventions by nurses. The NIC features are necessary for clinical communication and documentation of care, as well as the data integration across various contexts. These include effectiveness in research study, measurement of productivity, and evaluation of competency among others (Jarvis, 2012). Classification involves the nurses’ interventions on behalf of patients. They do these in collaborative and independent interventions, as well as direct and indirect care. Intervention refers to any kind of treatment a nurse performs to improve health outcomes. Even though a nurse will have expertise in limited interventions reflected in his or her specialty, the entire concept of classification deals with all interventions within the nursing field (Johnson, 2006).

    The NIC is useful in all care settings, which include home care intensive care units, primary care and hospitals among others. It also applies to all specialties within the nursing sector. Although the entire classification defines the nursing domain, some care providers other than nurses also provide certain interventions. Other non-physician providers can also use NIC to describe treatments for their patients. The NIC interventions are both physiological and psychological in nature. Many interventions are applied on individuals, while others are applied on families and the entire community. They also include direct care interventions. Each of the interventions has a label name, definition, and specific activities carried out during the intervention. The classification is often updated based on the current changes and ongoing processes for review and feedback. Many health care agencies have adopted the NIC in setting standards, planning care, evaluating competency and information system (Brennan & Mazanec, 2011).

    NOC

    The term NOC in nursing contexts stands for the Nursing Outcomes Classification. It refers to a comprehensive and standardized classification patient outcomes, which are develop to evaluate the effectiveness of clinical interventions and other healthcare provisions. The standardized outcomes are necessary for the electronic recording of data to be used for clinical information systems, the development of nursing knowledge, and professional nursing education (Jarvis, 2012). An outcome is a measurable behavior, condition or perception of a person, family or community, as well as a continuum. The developed outcomes are application in all care settings for all patients. The clinical settings where NOC is tested include community hospitals, tertiary care hospitals, nursing centers, community care agencies and nursing homes (Johnson, 2006).

    Just like NANDA and NIC, NOC is a standardized language that the American Nurses Association (ANA) recognizes. Since it is one of the recognized languages, it meets the ANA’s standard guidelines for nursing information and data evaluation, which is based on nursing knowledge and specialty. It has shown an accurate indicator in terms of its usefulness in the nursing practice, education and research. Various clinical settings continue to adopt NOC in evaluating the nursing practices. In addition, educational settings use it to structure and set curricula, as well as the clinical evaluation of students. Many countries across the world continue to show interest in NOC (Brennan & Mazanec, 2011[BS3] ).


    [BS1]Make sure that you fully define (write out) every abbreviation the first time you use them in your paper. After that you can abbreviate.

    [BS2]Make sure you also include the concept of DIKW in your introduction as a key element of the paper.

    [BS3]Good descriptions of NANDA, NIC and NOC.

    References

    Brennan, C., & Mazanec, P. (2011). Dyspnea management across the palliative care continuum. Journal of Hospitals & Palliative Nursing, 13(3), 130-139[BS1].

    Jarvis, C., & Jarvis, C. (2012). Student laboratory manual, Physical examination & health assessment (6th ed.). St. Louis, Mo.: Elsevier Saunders.

    Johnson, M. (2006). NANDA, NOC, and NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). St. Louis, Mo.: Mosby Elsevier.

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