Transcript Standardized Nomenclature in Nursing NANDA

MED INF 405-0 HIT Integration, Interoperability & Standards
Standardized Nursing Language
NANDA
NOC
Lemuel Dizon, RN
NIC
Definition
NANDA
taxonomy of nursing diagnosis
North American Nursing Diagnosis Association
NOC
nomenclature of nursing outcomes
Nursing Outcomes Classification
NIC
nomenclature of nursing interventions
Nursing Interventions Classification
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Scope
NANDA
172 diagnosis
47 classes
13 domains
NOC
385 outcomes
31 classes
7 domains
NIC
542 interventions
31 classes
7 domains
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Organizational Structure
Nursing Information and Data Set Evaluation Center (NIDSEC)
Evaluates information systems along Four dimensions:
1. Nomenclature (terms used)
2. Clinical content (the “linkages” among terms)
3. Clinical data repository (how the data are stored and made accessible for retrieval)
4. General system characteristics (i.e., performance, security, confidentiality, etc.)
NANDA International
Center for Nursing Classification and Clinical Effectiveness (NIC/NOC)
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Formulation of a Nursing Diagnosis
Format: Problem related to cause of problem evidenced by symptoms of
problem.
Examples:
Impaired gas exchange related to excessive secretions as evidenced by
O2 saturation of 86%.
Fluid volume deficit related to frequent vomiting for three days as
manifested by increased pulse rate.
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Format Features of NIC
ELECTROLYTE MANAGEMENT 2000
Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormal or undesired serum
electrolyte levels
Activities:
- Monitor for manifestations of electrolyte imbalance
- Maintain patent IV access Administer fluids, as prescribed, if appropriate
- Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate
- Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate
- Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate
- Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as prescribed, if appropriate
- Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as
appropriate
- Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and
diaphoresis)
- Irrigate nasogastric tubes with normal saline
- Provide diet appropriate for patient's electrolyte imbalance (e.g., potassium-rich, low-sodium, and low-carbohydrate
foods)
- Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate
- Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen
- Monitor patient's response to prescribed electrolyte therapy
- Place on cardiac monitor, as appropriate
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Components of NOC
Fluid Balance 0601
Balance of water in the intracellular and extracellular compartments of the body
Extremely Compromised Substantially Compromised Moderately Compromised Mildly Compromised Not Comprised
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Indicators:
BP IER
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Mean arterial pressure IER
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Pulmonary wedge pressure IER
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Peripheral pulses palpable
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Ascites not present
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Neck vein distention not present
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Peripheral edema not present
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Sunken eyes not present
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Confusion not present
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NIC/NOC Inclusion
• SNOMED multidisciplinary record system
• National Library of Medicine’s Metathesaurus for a
Unified Medical Language
• Joint Commission
• Alternative Billing Concepts (ABC) codes
• Registered in HL7
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Vendors who have licenses for NIC & NOC
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AtStaff, Inc., Durham, NC, www.atstaff.com
NOC integrated within their ClairVia® outcomes-driven acuity and patient management solutions for use by hospitals.
Healthland (Formerly Dairyland Healthcare Solutions), Louisville, KY, www.healthland.com
NIC and NOC integrated with their Clinical Documentation software system for care planning. System is used by small
to midsize hospitals
DIPS ASA, www.dips.com
NIC integrated within their Electronic Patient Record System for care planning. Company located in Norway.
DxR Development Group, Carbondale, IL, www.dxrgroup.com
Web based system for teaching students nursing process. Product called DxR Nursing.
eClinical Notes, LLC, Centreville, VA,
NIC and NOC are being integrated within a nursing documentation section of an electronic documentation system for
hospice providers.
Ergo Partners, Lake Quivira, KS, www.ergopartners.com
Product is EMRitus software
McKesson Corporation, Alpharetta, GA, www.mckesson.com
NIC and NOC integrated within Horizon Expert Plan for use in Care planning
MedSoftCCS, LLC., Vancouver, WA, www.medsoftccs.com
NIC integrated within Medtrack CCS job specific Orientation e-checklists.
Nurse's Aide LLC, Keller, TX, www.nursesaide.net
Product for School Nurses to assist with their care plans for students.
Purkinje, Inc., www.purkinje.com
Electronic clinical documentation tool. Company located in Canada.
Sanum AS, www.sanum.no
Sanum system used within hospitals and the educational market. Company located in Norway.
IHTSDO (SNOMED-ownership has transferred), Northfield, IL. www.snomed.com
NIC and NOC used within mapping tool.
Tech-Time, Inc., Billings, MT, www.techtimeinc.com
Clinical documentation system
Typhon Group, LLC, Metairie, LA, www.typhongroup.com
NIC and NOC integrated within their Registered Nurse Student Tracking (RNST) program used by Nursing Schools. 9 /
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Product helps student users develop patient care plans.
Impact: A call for nursing standards
• Developing standards would improve vendor-supplied
nursing information systems.
• Standards from the nursing community would significantly
reduce the cost and time of developing the nursing
component of clinical systems.
• Nursing-developed standards would enhance nurse’s
efficiency.
• Automated information systems would help the current
nursing shortage crisis by supporting the work of nurses.
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Reference
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www.nanda.org
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www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness
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Simpson, R. What’s in a name? The taxonomy and nomenclature puzzle, part 2.
Nursing Management. August 2003, p. 12, 14, 16.
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Simpson, R. Setting the Informatics Standards: An Overview of NIDSEC’s
Information Systems Evaluation Criteria. Nursing Economic$. SeptemberOctober 1998, Vol. 16, No. 5, pp.279-281.
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Simpson, R. Finally, a Central Place to Evaluate Nursing Systems. Nursing
Management. July 1997, pp.17-18.
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