Introduction
There were many terminologies in nursing that pertain to the same thing. As such, there were confusions since one may document differently from another or perform another method differently. Furthermore, to address this, a standardized nursing language with standardized terminologies was born. Moreover, a standardized nursing language is defined as a language that are understood by every nurse with regards to health care (Rutherford, 2008). The use of standardized terminologies in nursing is likewise considered important in the health care industry to ensure that the services delivered are of high quality. This helps documentation and data management to become efficient and effective as a result (Park, 2010).
NANDA (North American Nursing Diagnosis Association), NIC (Nursing Intervention Classification), and NOC (Nursing Outcome Classification) were introduced to allow nurses to communicate efficiently. They are likewise standardized classifications in terms of diagnosis, interventions, and patient outcomes in nursing (NANDA International, n.d.). Moreover, the purpose of this paper is to identify elements from NANDA, NIC and NOC and apply standardized terminologies. Additionally, this paper will also help develop an appreciation of the relationship between standardized terminologies and the data-information-knowledge-wisdom continuum. This paper will likewise accomplish the said purposes in conjunction with a patient scenario—a four year old girl with acute lymphoblastic leukemia.
Body
Patient Scenario
The patient is a four year old girl with acute lymphoblastic leukemia. After a week with chemotherapy, she was admitted because of fever (102.5 F). A new central line was placed nine days ago prior to admission. Her absolute neutrophil count is zero while her white blood count (WBC) is 0.3. The patient is nauseated and constantly vomits (Smith, 2001).
NANDA: Nursing Diagnosis
According to NANDA, nursing diagnosis is a “clinical judgment about an individual, family or community responses to actual and potential health problems/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (2009). This is critical in the nursing practice and allows the identification in how to improve the health of the patients in which the nurses play a huge role. Additionally, it also helps identify the priorities when dealing with a patient.
Furthermore, there are variations in the diagnosis: (a) the actual diagnosis that describes the current condition based on specific characteristics, (b) the risk diagnosis that described other conditions that may arise based from risk factors, and (c) the wellness diagnosis that describes potential of one to improve function. Likewise, there are three components in the diagnosis: the label, risk factors, and defining characteristics. The label is determined by matching with related factors or definitions. Risk factors are factors which may be environmental, genetic or both that increase the sensitivity of a patient to a specific health condition. Defining characteristics are signs that are evident of a diagnosis (NANDA, 2009).
NOC: Outcome
NOC is a classification regarding outcomes that are influenced by the health care provided by nurses. NOC outcomes may likewise provide a measure of the progress of a patient that may be understood by relatively everyone in the health care industry. Furthermore, NOC has three components: a label used to illustrate the behavior or status of the patient; indicators, and; a five point scale to evaluate a patient based on specific indicators. Moreover, NANDA diagnosis and NOC outcomes are linked since every outcome is dependent from the diagnosis done. The diagnosis influence the sets of suggested outcomes that may be individualized to cater to the needs of the patients or the choosing of the family (Denehy & Poulton, 1999).
NIC: Intervention
NIC is a language that is used to describe the treatment that are performed by nurses in specific settings or specialties. Interventions, according to the Iowa Intervention Project, are treatments that are nurse performs based from objective clinical knowledge that are directed to improve the patient’s condition. Similar to NANDA and NOC, NIC has three components: a label, a definition and the activities carried out by nursed to intervene. Furthermore, NANDA and NIC are linked since each diagnosis serves as a basis for making a list of interventions that may improve the patient’s condition. Interventions, like outcomes, should be individualized to meet the patient’s needs (2000).
Data, Information, Knowledge, and Wisdom
Applying Nursing Diagnosis to our patient, the patient was diagnosed to have an increased chance of contracting infection. The label is the increase in the probability that the patient was affected by pathogenic organisms. The risk factors include the decline in the primary and secondary defenses or from the use of immunosuppressant from undergoing chemotherapy a week prior to admission. The nausea and vomiting are also attributed to chemotherapy (Smith, 2001).
The following are NOC examples with regards to the increased risk of infection of the patient: immune status, knowledge of infection control, infection severity, nutritional status, integrity of the line of defenses (tissues such as skin or mucous membrane), and wound healing from the previously installed central line. The immune status or the resistance to antigens has a five point scale (1 being highly compromised and 5 being not compromised at all) which may be evaluated through many indicators (WBC values, skin and mucous membrane integrity, body temperature, and weight loss). Moreover, the following are NIC examples with regard to the increased risk of infection: infection protection, skin surveillance, wound care, and nutrition management. Infection protection may be done by monitoring the WBC count, provision of an isolated room, or by limiting the visitors. Additionally, infection protection may be done by inspection of the skin, mucous membrane, and any wounds. Nutritional status may also be improved by close monitoring (Smith, 2001).
The data in the patient scenario are the presented signs or symptoms that the patient had when she was admitted such as the WBC count, elevated temperature, her vomiting and nausea experienced, and the previously placed central line. This data was then used to obtain information or the diagnosis, which is the possible infection. Likewise, from the knowledge and wisdom of health from scholarly sources, specific lists of outcomes and intervention was come up with to improve the patient’s condition such as monitoring of her nutrition, her line of defenses, among others.
Conclusion
NANDA, NIC and NOC are all part of a standardized language with standardized terminologies that may help improve communication, and data handling among nurses. Without the standardized terminologies, the diagnosis, outcomes, and interventions done on one patient like in this paper may be misinterpreted by another nurse. Furthermore, standardized terminologies are helpful to process data, information, knowledge, and wisdom into outputs that are directed to help patients improve or function better. Standardizing, in all fields, including in nursing or the health care industry, may help reduce confusion and focus on more important things like the improvement of the field and the people who are dependent on it.
References
Denehy,J. & Poulton,S. (1999). Journal of School Nursing, 15 (1), 38-45
Iowa Intervention Project. (2008). Nursing Interventions and Classification (NIC) (3rd Ed.).
NANDA. (2009). Nursing Diagnosis: Definitions and Classifications. Indianapolis, IN: Wiley-Blackwell.
NANDA International. (n.d.). Knowledge-Based Terminologies Defining Nursing. Retrieved March 7, 2016, from http://www.nanda.org/nanda-i-nic-noc.html
Park, H.J. (2010). NANDA-I, NOC, and NIC Linkages in Nursing Care Plans for Hospitalized Patients with Congestive Heart Failure. University of Iowa.
Rutherford, M. (2008). Standardized Nursing Language: What Does It Mean for Nursing Practice? Journal of the American Nurses Association.
Smith, K. (2001). Standardized Nursing Language. University of Iowa: College of Nursing.
