Running head: APPLYING STANDARDIZED TERMINOLOGIES IN PRACTICE 1

Applying Standardized Terminologies in Practice

Victoria Blauvelt

Chamberlain College of Nursing

NR512: Nursing Informatics

11/10/15
APPLYING STANDARDIZED TERMINOLOGIES IN PRACTICE 2

Applying Standardized Terminologies in Practice

The use of standardized nursing language is an important part of the nursing profession

and nursing care. The American Nurses Association currently provides thirteen standardized

languages that are approved in the support of nursing practice. A standardized nursing language

should be defined so that nursing care can be communicated accurately among nurses and other

health care providers (Rutherford, 2008). Standardized language is essential in the development

of critical thinking skills, diagnoses and interventions. The benefits of a standardized nursing

language include: better communication among nurses and other health care providers, increased

visibility of nursing interventions, improved patient care, enhanced data collection to evaluate

nursing care outcomes, greater adherence to standards of care, and facilitated assessment of

nursing competency (Rutherford, 2008). In this paper three terminologies will be discussed

including North American Nursing Diagnosis Association (NANDA), Nursing Interventions

Classification (NIC) and Nursing Outcomes Classification (NOC) and their elements. The data,

information, knowledge and wisdom (DIKW) model will be discussed with regards to fluid

volume loss and the paper will conclude with a summary of the contents discussed.

NANDA, NIC and NOC

The term NANDA represents the North American Diagnosis Association. This acronym

is a list of diagnosis that are based on evidence, definitions related to risk factors, and

interventions carried out by nurses during his/her assessment and treatment. NANDA undergoes

constant refining to develop health responses for risk conditions as well as providing diagnostic

support to promote health and may be utilized for collecting the compulsory information for

deciding most proper intervention (Johnson, 2012).

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The term NIC stands for Nursing Interventions Classification and is essential to the

documentation of care along with communication among health care professionals. NIC is a

standard classification of interventions based on research, that can be used in acute care settings,

home care, Hospice, and primary care offices that utilize interventions for both direct and

indirect care. NIC is used by physicians, nurse practitioners, nurses, physical therapists and

many other members of the medical profession.

The term NOC represents the Nursing Outcomes Classification and is a wide-ranging

classification of patient outcomes that evaluate the effectiveness of the interventions performed

by health care specialists, based on knowledge and specialty. According to Jarvis, 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

(2012). The outcomes can be used in every clinical setting for any patient across the lifespan.

Data, Information, Knowledge and Wisdom

DIKW model or data, information, knowledge, and wisdom is an essential aspect of our

nursing care. Data is simply the information we collect and according to McGonigle, used by

itself it is meaningless and not useful (2015). Information is defined as giving meaning to the

data collected while knowledge is using this information in a given setting to make a decision

and wisdom is the last step, that involves using gained experience and knowledge to make

decisions in practice (McGonigle 2015).

A patient arrives to the Emergency Department with signs of dehydration such as

weakness, dry mucus membranes, decreased urinary output and change in mental status. The

first step is to gather data, such as vital signs, lab values including electrolytes, a complete
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assessment, medication list, and history. Once the data has been collected, it can be organized

and a plan of care can be developed based on the patients individual needs.

The NANDA diagnosis of risk for fluid volume deficit would be used, related to

decreased oral intake, as evidence by decreased urinary output, weakness, change in mental

status, increased pulse rate, decreased blood pressure, dry skin/mucous membranes, decreased

skin turgor and thirst. Based on knowledge, the nurse would incorporate the necessary nursing

interventions into his/her patient care. The NIC interventions include fluid management,

hypovolemia management and shock management related to fluid loss. Some of the

interventions include, but are not limited to: monitor strict intake and output, monitor daily

weights, monitor for weakness, muscle cramping, vital signs every hour and note tachycardia or

hypotension, monitor skin turgor and mucus membranes, provide oral hygiene, intravenous fluid

replacement, and promote skin integrity. Another important aspect of our nursing interventions

includes teaching of both the patient and family members. NOC outcomes would include: fluid

balance and hydration and evaluating the effectiveness of these outcomes based on lab values,

vital signs and pt symptoms. Another important part of the process is educating the patient and

family members. Some examples include: teaching regarding appropriate diet and fluid intake,

how to record and measure intake and output, how to prevent or treat fluid volume loss and when

to seek emergency medical attention. "Appropriate practical application of knowledge is

achieved through wisdom- a combination of experience, insight, knowledge and understanding,

which adds value to the interplay of nursing informatics and nursing science," (Matney, Brewster,

Sward, Cloyes, & Staggers, 2011). With time, experience and reflection comes wisdom.

According to Catherine Knox, reflective practice is an activity that encourages development of

clinical judgment. Reflection on an actual clinical experience can yield a wealth of wisdom for
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the nurses involved. By guiding the discussion toward analysis and synthesis of information, the

experience can expand both individual and group learning (2013).

Conclusion

The use of NANDA, NIC, and NOC in our daily nursing care is essential to maintaining a

standardized language throughout the practice. A single standardized terminology offers

enhanced quality, reduced effort, a greater coherence and compatibility (Schwirian, 2013). The

standardization of care, makes documentation easier to interpret and information can be found

much more efficiently. It also makes it easier to develop a standard electronic health record with

boxes that can be clicked, rather than typing out every intervention. This can save a great deal of

time when it comes to documentation. This can also make it easier for a patient's records to be

retrieved at other facilities. Dehydration or fluid volume deficit are common among the patients

that arrive to the emergency department and the use of NANDA, NIC and NOC are useful in

providing quality nursing care, can be incorporated into the DIKW model and the interventions

can be individualized to each patient and have the potential to improve patient satisfaction

overall.
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References

Jarvis, C., & Jarvis, C. (2012). Student laboratory manual, Physical examination and health

assessment. (6th ed.). St Louis, Mo,: Elsevier Saunders.

Johnson, M. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: supporting

critical thinking and quality care (3rd Ed.). Maryland Heights, MO: Elsevier Mosby.

Knox, C. (2013). Developing expertise in clinical judgment. Essentials of Correctional Nursing.

Retrieved from http://essentialsofcorrectionalnursing.com/2013/10/15/developing-

expertise-in-clinical-judgment/

Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical

approaches to the nursing informatics data-information-knowledge-wisdom

framework. Advances in Nursing Science, 34(1), 6-18.

McGonigle, D., & Mastrian K. G. (2015). Nursing informatics and the foundation

of knowledge (3rd ed.). Sudbury, MA: Jones and Bartlett.

Rutherford, M., (Jan. 31, 2008) Standardized nursing language: What does it mean for nursing

practice? OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1.

Schwirian, P. M. (2013). Informatics and the future of nursing: Harnessing the power of

standardized nursing terminology. Associations for Information Science and Technology,

39(5), 20-24.