Applying Standardized Terminologies in Practice Order Instructions: Integration of standardized terminologies in nursing practice. Applying Standardized Terminologies in Practice
Guidelines with Scoring Rubric
Purpose
This assignment is designed to help students
•apply standardized terminologies; and
•develop an appreciation of the relationship between standardized terminologies and the data-information-knowledge-wisdom continuum.
Applying Standardized Terminologies in Practice Course Outcomes
Through this assignment, the student will demonstrate the following ability.
(CO 4) Assess the value of standardized terminologies in supporting nursing in all four practice settings. (POs 5, 11)
Total Points Possible: 200
Requirements
For a selected patient scenario, identify related NANDA, NIC, and NOC elements. Describe in detail the data, information, knowledge, and wisdom that guided you. The scenario is one that you choose and is in a context familiar to you so that you can provide the detail requested and apply your learning from this point forward.
PREPARING THE PAPER
1. Required texts may be used as references, but a minimum of three sources must be from outside of course readings.
2. All aspects of the paper must be in APA format as expressed in the 6th edition.
3. The paper (excluding the title page and reference page) is 3–5 pages in length.
4. Ideas and information from professional sources must be cited correctly.
5. Grammar, spelling, punctuation, and citations are consistent with formal academic writing.
Category Points % Description
Introduction 45 22.5 Introduction presents a brief overview of the scenario and of the parts of the paper.
NANDA, NIC, and NOC Elements 45 22.5 Clearly identifies related NANDA, NIC, and NOC elements.
Data, Information, Knowledge, and Wisdom 45 22.5 Describes in detail the data, information, knowledge, and wisdom that guided you.
Conclusion 45 22.5 Concluding statements summarize insights about the key elements of the paper gained during the assignment.
APA Style 6 3 Text, title page, and reference page(s) are completely consistent with APA format.
Citations 7 3.5 Ideas and information from other sources are cited correctly.
Writing Mechanics 7 3.5 Rules of grammar, spelling, word usage, and punctuation are consistent with formal written work, and page restrictions are met.
Total 200 100%
A quality assignment will meet or exceed all of the above requirements.
GRADING RUBRIC
Assignment Criteria Exceptional
(100%)
Outstanding or highest level of performance Exceeds
(88%)
Very good or high level of performance Meets
(80%)
Competent or satisfactory level of performance Needs Improvement
(38%)
Poor or failing level of performance Developing
(0)
Unsatisfactory level of performance
Content Possible Points = 180 Points
Introduction 45 Points 40 Points 36 Points 17 Points 0 Points
Introduction presents a brief overview of the scenario and names the key parts of the paper.
Introduction presents one of the two required elements.
Introduction does not include either of the two required elements.
Minimal attempt at introduction. No introduction is present.
NANDA, NIC, and NOC Elements 45 Points 40 Points 36 Points 17 Points 0 Points
NANDA, NIC, and NOC elements are clearly identified for a selected patient scenario. Only two of the three elements are clearly identified for a selected patient scenario.
Only one of the three elements is identified for a selected patient scenario. Mention of one of the elements but not for a selected patient scenario. Does not make an attempt at criteria.
Data, Information, Knowledge, and Wisdom 45 Points 40 Points 36 Points 17 Points 0 Points
Provides a detailed description of the data, information, knowledge, and wisdom that provided guidance through the selected scenario with support from scholarly literature. Provides a partial description of the data, information, knowledge, and wisdom that provided guidance through the selected scenario. DIKW are discussed but not analyzed. There are major gaps in the identification/analysis of DIKW. Does not make attempt at criteria.
Conclusion 45 Points 40 Points 36 Points 17 Points 0 Points
Provides a summary of key points of the paper as well as insights gained during the assignment.
Provides a summary of key points and a partial summary of insights gained during the assignment. Concluding statements are present but do not address insights.
Minimal concluding statement. No conclusion.
Content Subtotal_____/180 Points
Format Possible Points = 20 Points
APA Style 6 Points 5 Points 4 Points 2 Points 0 Points
0–1 APA format errors in text, title page, and references.
2-3 APA format errors in text, title page, and references.
4-6 APA format errors in text, title page, or references.
7-9 APA format errors in text, title page, or references.
10 or more APA format errors in text, title page, or references.
Citations 7 Points 6 Points 5 Points 3 Points 0 Points
0–1 errors in identifying ideas, and information from other sources are cited. 2-3 errors in identifying ideas, and information from other sources are cited.
4-6 errors in identifying ideas, and information from other sources are cited.
7-9 errors in identifying ideas, and information from other sources are cited.
10 or more errors in identifying ideas, and information from other sources are cited.
Writing Mechanics 7 Points 6 Points 5 Points 3 Points 0 Points
0–3 errors in grammar, spelling, word usage, punctuation, and other elements of formal academic writing AND page limits are met. 4–6 errors in grammar, spelling, word usage,
punctuation, and other elements of formal academic writing
AND page limits are met. 7–9 errors in grammar, spelling, word usage, punctuation, and other elements of formal academic writing
OR
page limits are not met. 7–9 errors in grammar, spelling, word usage, punctuation, and other elements of formal academic writing
AND
page limits are not met. 10 or more errors in grammar, spelling,
word usage, punctuation, and other elements of formal academic writing.
Format Subtotal_____/20 Points
Total Points____/200 Points
Applying Standardized Terminologies in Practice Sample Answer
Introduction
Nursing professionals has developed standardised terminologies in order to improve communication between nurses and other healthcare professionals. The terminologies help in describing assessments, patient’s interventions and the patient outcomes. This helps nurses from different healthcare settings to understand a patient’s report. This ensures that patient information is easily accessible which promotes rapid delivery of care. It also promotes ubiquity (Bickley, 2013).
With the increased dynamics in patient’s demand, it is important for the healthcare providers to rapidly access patient’s information. The standardization of terminologies also improves longevity, i.e. it is used beyond immediate clinical encounters to evaluate the effectiveness of the healthcare facility’s policies. Lastly, standardization of terminologies promotes re-usability of patient information for a range of purposes. Without standardized terminologies, the nurses run at a risk of becoming invisible. This is because it becomes difficult to quantify the effectiveness of nursing practice. Our unique contribution will remain unrecognized. Additionally, the absence of standardized terminologies would impede the development of nursing knowledge which would result in a delay in the integration of evidence based care (Ho, Bryson, and Rumsfeld, 2010).
Standardized terminologies facilitate the accumulation of data which describes the effectiveness of interventions used in clinical decision making processes. ANA recognizes about 12 standardized nursing terminologies. However, the most commonly used are NANDA-1, Nursing Intervention Classification (NIC) and Nursing Outcome Classification (NOC). This is attributable to the fact that these terminologies are widely recognized in nursing practice. The contributions of the standardized terminologies facilitate the identification, categorization, and classification of nursing knowledges (Dains, Bauman, and Scheibel, 2012).
Integration of standardized terminologies in nursing practice
The concepts of nursing process have transformed over the past six decades. Initially, the nursing processes focused on disease management, particularly in diagnosis. The current concept of nursing processes focuses on a patient centred care. Most of the healthcare facilities (including my work place), apply these terminologies to diagnose and guidelines when making clinical decisions. The integration of the nursing Standardized terminologies in health informatics has facilitated quick delivery of care. This is because they replace the conventional method where nursing notes were done manually. This increases the probability to medical errors associated with poor communication and interpretation errors. This paper samples out a Diabetic Mellitus type II patient using NANDA-I, NIC and NOC terminologies.
The patient, Mrs. BG visited the healthcare facility for regular check-ups. However, the patient had complaints of general weaknesses and fatigues. The patient has a history of cardiovascular diseases and obese (Azzolin et al., 2013).
NANDA-I is a global force that focuses on developing standardized terminologies to ensure that patient safety is maintained as illustrated by the evidence based care. NANDA-I is generally patient diagnoses/ assessment strategies used by nurses to reach to their clinical judgement on the patient’s health condition. Diabetes Mellitus (DM) is a health condition characterised by defective metabolism of carbohydrates, which is normally characterised by abnormal levels of glucose in blood circulation. The patient type of diabetes is associated with the patient’s body inability to effectively use insulin. The NANDA-I diagnosis of the disease includes insulin deficiency, abnormal levels of glucose levels, weight loss, high frequency of urine elimination and fatigue. Imbalanced nutrition is occurs because of reduced metabolism of carbohydrates. This is attributable to insulin deficiency. Fluid deficit is associated with polyuria. Impaired skin integrity and activity intolerance are also common to patients diagnosed with diabetes mellitus Type II (Young, 2011).
NOC describes the expected outcome of the proposed interventions. NOC development is done through teamwork of the healthcare professionals such as nurses, dieticians, the psychiatrist and general practitioners. NOC is aligned in a manner that ensures that patient health and social functioning is improved. The NOC domains that were applied in this case study were meant to improve the patient’s physiologic, functional and physiological health. To begin with, the patient must be educated on nutrition to ensure that they digest amount of calories in right quantity to balance energy levels needed (Park, 2010).
For the fluid Volume Deficit, the patient must be treated until she demonstrate stable vital signs, skin turgor gets normal, well-defined capillary refill, and balanced electrolytes concentration. For activity intolerance, the patient must be advised on physical activity to improve her muscle strengths. At the end of treatment regimen, the patient can withstand 30 minutes of physical activeness at-least five times a week. The other nursing outcomes are increase patient knowledge through patient education/training on how to manage and control her sugar levels. This is aimed at empowering the patients with effective coping strategies by transforming the patient’s attitudes and perception. The patient should also be enrolled in support groups within the healthcare facility in order to improve her social functioning (Hasan, Zodpey & Saraf, 2012).
NIC is basically the nursing interventions designed to enhance a patient outcome. Designing of a patient’s intervention is done through inter-profession collaboration. Seven domains of interventions are established for this patient. The physiological domain consists of nursing interventions that supports homeostatic regulations. This was restored using insulin lispro protamine. Other medications include furosemide (Lasix) 80 mg each morning, Digoxin 0.25 mg per day and Cardizem CD180 mg daily. These medications help improve the patient condition and protect the patient from adverse reactions or harm (safety domain. Coping strategies are enhanced if the patient has supportive social functioning. This calls for the family domain which involves integration of the patient’s close friends and relatives in care. The psychosocial domain facilitates lifestyle modification, so that the patient adapts the best attitudes to cope with the disease. Other interventions included non-therapeutic and therapeutic interventions such as emotional and economic support of the patient, fluid monitoring, cardiac acer, control of infection and nutritional support (Young, 2011).
Undeniably, NANDA-I, NOC and NIC interact and link with each other during the delivery of care. For example, a patients knowledge deficit (NANDA-I) demands patient education (NIC) in order to empower and deliver quality care (NOC). The linkages are well illustrated in the table 1.1 below;
Table 1: Indicating the linkages between NANDA-I, NOC and NIC
(Source Park, 2010)
Applying Standardized Terminologies in Practice Conclusion
The studies objectives were to evaluate the benefits of integrating standard terminologies in care plan for a patient diagnosed with DM type II. This is particularly vital as the increase in technologies and health complexities make demands of healthcare to increasingly become diverse and complicated. This calls for accurate diagnoses, designing of interventions and nursing outcomes. Therefore, by applying the terminologies, a large amount of information can be gathered, which will guide the healthcare providers to make their most effective decisions. The standardized terminologies are important in the nursing profession as they facilitate development of an individualised care plan based on nursing theoretical perspectives. This helps by creating clear communication between the healthcare providers promoting teamwork and effective delivery of care.
Applying Standardized Terminologies in Practice References
Azzolin, K., Mussi, C., Ruschel, K., de Souza, E., de Fátima Lucena, A. and Rabelo-Silva, E. (2013). Effectiveness of nursing interventions in heart failure patients in home care using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), pp.239-244.
Bickley, I.S .(2013). Bates Guide to physical examination and history taking .Wolters Kluwer/ Lippincott Williams&Wilkins.
Dains, J.E., Bauman, L.C., and Scheibel, P. (2012). Advanced Health Assessment and Clinical Diagnosis in Primary Care.
Hasan, H., Zodpey, S., & Saraf, A. (2012). Diabetologist’s perspective on practice of evidence based diabetes management in India. Diabetes Research And Clinical Practice, 95(2), 189-193. http://dx.doi.org/10.1016/j.diabres.2011.09.021
Ho, M., Bryson, C., and Rumsfeld, J., (2010). Key issue in outcome research. Circulation 119: 3028-3035
Park, Hye Jin. (2010). “NANDA-I, NOC, and NIC linkages in nursing care plans for hospitalized patients with congestive heart failure.” Retrieved from .http://ir.uiowa.edu/etd/570.
Young, D. (2011). Diabetes management can be safely transferred to practice nurses. Evidence-Based Nursing, 15(1), 17-17. http://dx.doi.org/10.1136/ebn.2011.100168
