Standardized Terminology Paper Standards Terminology

Standardized Terminology Paper Tracy Bell Frostburg State University Running head: STANDARDIZED TERMINOLOGY PAPER 1 STANDARDS TERMINOLOGY PAPER 6 STANDARDIZED TERMINOLOGY PAPER 2 Standardized Terminology Paper Nurses every day work together as a team in implementing individual care plans specific to patient care to meet needs. For this reason nurses must use a language when documenting details of patient care that is universal and easily understood by others. This type of communication is called standardized terminology. Standardized terminology is an important communication tool in nursing because it is a universal language that aides in describing patient care and can be understood by all parties included. (Keenan, 1999).†¦show more content†¦Nursing Diagnosis A nursing diagnosis is used during the nursing process in order to identify and treat the main complaint the patient presents with. After the assessment a nurse develops a care plan based on the nursing diagnosis. This helps navigate how to effectively approach the patient’s condition and promote positive outcomes. The nursing diagnosis formulated for my infant was as follows: Ineffective breathing pattern related t o an increase in work of breathing as evidenced by substernal retractions and decreased oxygen saturation. Domain: Class Ineffective breathing pattern (00032) (NANDA International, 2012) Nursing Interventions Classification (NIC) Interventions The following is a list of interventions using the nursing intervention classification (NIC) system and activities to support this nursing diagnosis of ineffective breathing pattern related to an increase in work of breathing as evidenced by substernal retractions and decreased oxygen saturation. Intervention 1 (3140) Airway Management: Facilitation of patency of air passages (Bulechek McCloskey-Dochterman, 2008). Activities:  · During my assessment and as needed I auscultated the lungs to assess for changes in lungs sounds. For example, by listening to the lungs I can assess if air is moving and if additional interventions are needed such as a nebulizer treatment by a respiratory therapist or nasal suctioning.  · Administration of oxygen with humidification was used to help maintain an oxygenShow MoreRelatedNursing : An Explosive Increase Of Nursing Knowledge Worldwide1279 Words   |  6 Pagesinformatics and computer technology have broad implications for this knowledge explosion and can facilitate the collection, manipulation, and retrieval of essential nursing data for practice and research. (AJPH, 1991). The Nursing Minimum Data Set is a standardized tool used for the collection of important nursing data, which are frequently utilized by nurses to provide accurate evidence- based care. This tool enables healthcare providers and nurses to collect and compare nursing data from different sourcesRead MoreNursing Terminology System Vs. The International Classification Of Nursing Practice1208 Words   |  5 PagesNursing Terminology System Comparison Nursing terminology could be described as the formal and informal communication that occurs in a nurses daily activity. According to McGonigle Mastrian (2009) nursing terminology allows nurses to communicate nursing data, information and knowledge specific to nursing. In addition, standardized nursing terminology refers to a system. This means they have undergone approval by a specific authority. The American Nurses Association (ANA) is one authority with aRead MoreThe Use Of Medical Terminology Among Nurses1277 Words   |  6 Pagesa specialized language has been developed consisting of medical terminology, extensive documentation, and body language. With such a large amount of complicated information being transferred in medical occupations, naturally, there are many variations of the standard â€Å"nursing language†. Currently, the American Nurses Association has approved thirteen languages that support nursing care. With this lack of consistency and no standard vernacula r among all medical workplaces, decreases in efficiencyRead MoreGlobal Usage Of Electronic Health Record ( Ehr ) Systems Essay1461 Words   |  6 Pagesdemanding field of health care. The advancement and widespread usage of Electronic Health Record (EHR) systems is predominantly dependent on standardized clinical terminology in the respective systems to ensure leveled communication among all professionals. Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) is one of many clinical terminologies currently in use for the purpose of documenting by healthcare professionals and specialists in Electronic Medical Records. The mapping ofRead MoreStandards Terminology Paper : Nursing Intervention Classification And The Nursing Outcome Classification1493 Words   |  6 Pages Standards Terminology Paper Elizaveta Pavlenko Frostburg State University Preface In standards terminology paper one patient’s assessment will be presented along with Nursing Diagnosis, Nursing intervention Classification and the Nursing Outcome Classification. In conclusion part of the paper, the summary of these systems will be provided. Clinical Encounter Mary Smith, Female, 56 years old, presented to Emergency Department with abnormal Chest Xray, fever, chills and generalized weaknessRead MoreOrganization and Management1109 Words   |  5 PagesPathology. Published by the American College of Pathologists, it has been â€Å"useful in classifying pathological specimens† (McWay, 2008). Although SNOP was commonly used in pathology departments, it has gradually lost favor because focus was placed on standardized nomenclatures by accrediting agencies (McWay, 2008). 2. What are the four approaches taken by HIM professionals to address the complexities brought on by the introduction of PPS and DRGs? The four approaches taken by HIM professionalsRead MoreThe Use Of Medical Terminology Among Nurses1658 Words   |  7 Pagesconsisting of medical terminology, extensive documentation, and body language. With such a large amount of complicated information being transferred in medical occupations, naturally, there are many variations in language. Currently, thirteen languages are approved by the American Nurses Association supporting nursing care. If we cannot name it, we cannot control it, practice it, teach it, finance it, or put it into public policy† (Rutherford). With this lack of consistency and no standard vernacular amongRead MoreThe International Classicfication of Nursing Practice in Electronic Health Record Provides a Standard Language for Assessments528 Words   |  2 PagesHealth Record (EHR) provides a standardized language for nursing assessment documentation. The ICNP is a standardized nursing language that promotes unity among existing nursing standards and de monstrates the nurses’ contribution to health care (McGonigle Mastrian, 2012). A term is known as a word or a phrase. Nursing terminology is a group of terms used to collect, represent, or communicate data and information collected by the nurse. Standardization of nursing terminology is accepted by a proper authorityRead MoreIntroduction. This Paper Provides A Discussion Of The Electronic1523 Words   |  7 PagesIntroduction This paper provides a discussion of the Electronic Health Record for healthcare, explains why it is important for nursing to have a standard nomenclature for nursing care, and compares and contrasts two of the nursing terminologies currently recognized by the American Nursing Association. Body Organized information allows inferences to be made that answer questions greater than those answered by the information alone. (Moss, Damrongsak, Gallichio, 2005, p. 545). Medical care isRead MoreThe Impact Of A Merged Healthcare Organization Essay1341 Words   |  6 Pagesgeographical location. Standardized nursing terminology The importance of applying standardized nursing terminology in capturing nursing-specific data include, making it easy to identity and monitor health needs and outcomes by pooling data from different sources. Standardized nursing terminology is also important in the process of auditing the quality of service and benchmarking in the healthcare sector (Lazakidou, 2016). Additionally, the standardized nursing terminology is very important in the