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Tuesday, 8 May 2012

ANA RECOGNIZED TERMINOLOGIES

NANDA

Defining the Knowledge of Nursing

Words are powerful. They allow us to communicate ideas and experience to others so they may share our understanding.Nursing diagnoses communicate the professional judgments that nurses make every day to our patients, colleagues, members of other disciplines and the public.

Nursing diagnoses define what we know - they are our words.

•NURSING DIAGNOSES

–Nursing Diagnosis
Nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

–Actual Nursing Diagnosis
A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community.

–Health-Promotion Nursing Diagnosis
A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.

–Risk Nursing Diagnosis
Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community. It is supported by risk factors that contribute to increased vulnerability.

–Syndrome
A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.

•COMPONENTS OF A DIAGNOSIS

–Label
Provides a name for a diagnosis. It is a concise term or phrase that represents a pattern of related cues. It may include modifiers.

–Definition
Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.

NIC

•CNC - Overview: Nursing Interventions Classification (NIC)

–OVERVIEW OF NIC

The Nursing Interventions Classification (NIC) is a comprehensive, research-based, standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design.

CCC

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. CCC provides a unique framework and coding structure for capturing the essence of patient care in all health care settings.

OMAHA SYSTEM

•The Omaha System is a research-based, comprehensive practice and documentation standardized taxonomy or classification designed to document client care from admission to discharge. The hierarchy and terms of the Omaha System are summarized in the Overview, and include an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes).

PERIOPERATIVE NURSING DATASET

•Periop 101 is a program used by educators to train new perioperative nurses and consists of 25 online learning modules, delivered through AORN's e-learning platform. Each learning module includes required reading and suggested videos from AORN's Perioperative Nursing Video Library. Periop 101 is designed as a blended program to be given in conjunction with a clinical preceptorship.

•The Periop 101 Demo allows you to preview the course and the learning components included in the course.

SNOMED CT

•SNOMED Clinical Terms (SNOMED CT) is the most comprehensive, multilingual clinical healthcare terminology in the world.

•SNOMED CT contributes to the improvement of patient care by underpinning the development of Electronic Health Records that record clinical information in ways that enable meaning-based retrieval. This provides effective access to information required for decision support and consistent reporting and analysis. Patients benefit from the use of SNOMED CT because it improves the recording of EHR information and facilitates better communication, leading to improvements in the quality of care.

ICN

The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations (NNAs), representing the more than 13 million nurses worldwide. Founded in 1899, ICN is the world’s first and widest reaching international organization for health professionals. Operated by nurses and leading nurses internationally, ICN works to ensure quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce.

ABC CODES

•ABC codes and terminology are maintained and developed annually as individuals and health industry organizations submit code requests that reflect current practices in integrative healthcare. ABC Coding Solutions encourages the public to request and/or suggest additions, deletions, or changes to ABC codes and terminology.

–New Code and Terminology Request

•ABC Coding Solutions works closely with individuals and entities requesting codes and/or terminology to assure that the information required for a new code is complete. This information is then verified through our Research Department. Once all relevant information has been collected, a draft version of the proposed ABC Terminology (code description and expanded definition) is developed in accordance with the ABC Terminology lexicon and style sheet. This draft terminology is presented to the requesting party and, once approved, remitted to subject matter experts (SMEs) for review.

LOINC

•A universal code system for identifying laboratory and clinical observations.

•From serum levels of hepatitis B surface antigen to diastolic blood pressure, LOINC has standardized terms for all kinds of observations and measurements that enable exchange and aggregation of electronic health data from many independent systems.

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ABOUT

Anne Sophia Perez. SHAWOL. Nursing Student. Requirement for Nursing Informatics