Applying Standardized Terminologies in Practice

911 Words4 Pages
Applying Standardized Terminologies in Practice Standardized Nursing terminologies (SNTs) are classifications, or taxonomies created to be shared among healthcare users. In the nursing field, the use of SNTs is essential to help nurses to document accurately, and clearly patient care information. The use and implementation of Standardized Nursing Terminologies add descriptions of nursing practice into the health record in a way that nursing personnel understand. The use of standardized terminologies is vital to the development of nursing as a profession. This article main purpose is to provide evidence of the importance and application of standardized terminologies in the Nursing practice. A patient care scenario will be used to identify how NANDA, NOC, and NIC elements are applicable. Data, information, knowledge, and wisdom (DIKW) framework will be used to create the patient care scenario. Standardized Nursing terminologies are used by most of healthcare settings as part of Electronic Health Records, and represent nursing data, information, and knowledge that can be stored in the electronic systems to be used as a reference by health care professionals. Scenario A female is referred to home health services for skilled nursing evaluation, and observation. The patient was discharged from the hospital a few weeks ago diagnosed with a Cerebrovascular Accident (CVA). The skilled nurse was recommended to teach, train, and monitor the effectiveness of new prescribed Coumadin therapy. Standardized Terminology Application The registered nurse selected the appropriate clinical diagnoses using the North American Nursing Diagnosis Association (NANDA) terminology based on patient’s actual needs, and comprehensive assessment. The care plan was created using a linkage between diagnoses, interventions and patients’ desirable goals. Using the Nursing

More about Applying Standardized Terminologies in Practice

Open Document