Introduction
Nursing practice requires proper maintenance of patient records to ensure that accurate information is shared among the health workers. The status of a patient should be described in depth to boost understanding about their conditions among nurses and other clinical specialists. This method of recording patient information involves the use of Standardized Nursing Terminologies (SNTs). In the context of this essay, three components namely NANDA, NIC, and NOC will be reviewed. STP techniques are applied in electronic record keeping in healthcare systems. It stores crucial information for future reference by nurses among other healthcare providers. This essay describes the application of standardized terminologies to nursing practice.
Scenario
A child is admitted to the emergency department after being diagnosed with influenza. A highly skilled nurse is required to attend to the patient, provide education to the caretaker, and then discharge the patient.
Using Standardized Terminologies
Determination of the medical techniques was based on the North American Nursing Diagnosis Association (NANDA). The nurse related the diagnoses procedures to the patient’s desired aims. Both the nurse and patient set these goals using the Nursing Outcome Classification (NOC) (NANDA International, 2011).
The nurse recorded the information on the child’s profile as follows.
- The age of the child is 10 years
- The breathing rate is high
- Increased pulse rate of 104 degrees F
- Fever, cough, nasal congestion, and a history of chronic pulmonary disease (COPD)
Next, the nurse and child’s caretaker discuss the findings. The nurse who handles the patient realizes that shallow breathing difficulty can be due to posthepatic neuralgia, a situation that makes the child feel a lot of pain. The nurse regards the pain, headache, and cough as chronic. A care plan is then formulated to cure the headache, cough, and chronic pains. It is realized that the child has developed a shallow breathing problem due to fever and posthepatic neuralgia. The treatment criterion is established to heal the coughing, breathing, and fever. The design of the intervention is aimed at preventing any likelihood of recurrence of the condition.
The diagnosis is accomplished due to the assessment skills and critical thinking abilities of the nurse. The nurse also uses medical diagnosis to check the problem of gas exchange, headache, fatigue, petechial rash, and diarrhea resulting from the influenza. Due to critical thinking, she uses both methods of diagnosis (McGonigle, Kirkwood, Mastrian, & Rich, 2014).
Various management activities that the nurse performs during the NIC include observation of non-verbal behavior to investigate discomforts such as movements resulting from hard breathing and indication of pain. Comprehensive assessment of the pains is accomplished by identifying the location, features, calming duration, frequency, severity, and quality of pain among others. Other activities that have been conducted include how to reduce or eliminate the pain felt by the patient. Issues related to fatigue, fear and unconsciousness among others are also recorded.
The nurse then recorded a decrease in symptoms as per the outcome classification as listed below.
- The intensity of general symptoms reduced by 7-percent
- The persistence of symptoms also decreased by 5-percent
- The frequency of symptoms decreased by 4.5-percent
Various NOC outcomes that the nurse came up with include the prevention and avoidance of risk factors that can enhance the development of influenza such as age, behavior of the persons who care for the child, living conditions of the child, and immune system (McGonigle et al., 2014; American Nurses Association, 2012). Other underlying factors such as chronic illnesses were taken into account. The nurse then rated the factors using a scale of five from 1 (no demonstration) to five (demonstrated consistently) (McGonigle et al., 2014).
The information is used in tracking the trends of risk factors for influenza during the period of hospitalization. This practice also helps the nurse to note the compliance level of the patient, adherence to prevention measures, and successful education and guidance that is offered to the patient (McGonigle et al., 2014).
Data, information, and knowledge that was used
Data-information-knowledge-wisdom is a process that involves the conversion of data into wisdom through cognitive processes. Critical thinking must be implemented to enable the efficient delivery of information to the patient during the care process. Sensitizing patients to knowledge about their ailments is paramount to successful healing (McGonigle et al., 2014).
Various data that was collected from the medical diagnoses included nasal congestion, pulse rate detection (indicated a fever of 104 Farad degrees), past data on the underlying sickness, temperature of 39 degrees Celsius, difficulty in breathing and age (10 years). Other data that were taken include the living conditions where the patient taken care of by his parents (McGonigle et al., 2014). The data about the nasal congestion facilitated the detection congestion. The information on the use of decongestants such as the nasal spray form enabled the nurse to reduce the swollen nasal way of the patient. The running nose was cleared by administering antihistamine that resulted in reduced sneezing, itching, and discharges from the nose. Various recordings pertaining to temperature, pulse rate, and fever were used to compare, contrast, and differentiate diagnostic conditions to reveal the symptoms of influenza (Thede & Sewell, 2010). The information about the family background, caretakers, and the history of other underlying complications helped in arrangement of healthcare providers who conduct home visits after the patient is discharged (Thede & Sewell, 2010; McGonigle et al., 2014).
Various risks that were identified during the NOC session were essential for planning efficient ways of handling the patient after discharge. The planning incorporated various activities that were supposed to be accomplished during the transition of the patient from the hospital to home setting. Poor planning can result in illnesses that are related to transition (Johnson, Bergren, & Westbrook, 2012). This situation enabled the nurse to educate the caretaker on cleanliness of the patient. The presence of the family members was an indication of immense support for the patient. Therefore, the patient’s needs be accomplished due to the presence of a caregiver and family members. Essential knowledge about nursing such as ethics and regulations among others will be used together with the information gathered to define the systems and tools to manage the risk factors and future occurrences of the illness (Thede & Sewell, 2010).
Conclusion
A number of elements have been deemed essential for improving patient care and collecting data that are used in the evaluation of nursing care outcomes. The information is interpreted to shed light to the required nursing standard procedure to be used in patient care. Therefore, it is necessary to follow the DIKW guidelines with a view of ensuring efficient delivery of healthcare in the nursing field.
Reference List
American Nurses Association. (2012). ANA recognized terminologies that support nursing practice. Web.
Johnson, K., Bergren, M., & Westbrook, L. (2012). The promise of standardized data collection: School health variables identified by states. Journal of School Nursing, 28(2), 95-102.
McGonigle, D., Kirkwood, B., Mastrian, K., & Rich, K. (2014). Nursing informatics and the foundation of knowledge. Sudbury, MA: Jones & Bartlett Publishers.
NANDA International. (2011). Nursing diagnoses – Definitions and classifications 2012-2014. West Sussex, United Kingdom: John Wiley & Sons.
Thede, L., & Sewell, J. (2010). Informatics and Nursing: Opportunities and Challenges. Philadelphia: Lippincott, Williams & Wilkins.