Standardized Nursing Terminology STANDARDIZED TERMINOLOGY TO COMMUNICATE NURSING INTERVENTIONS

STANDARDIZED TERMINOLOGY TO COMMUNICATE NURSING

Nursing practice is the fabric of patient care with threads running through nearly every patient experience. While a medical diagnosis is typically the catalyst for a nursing care plan, it does not completely define patient care. In this paper, I hope to demonstrate the crucial role that a nursing diagnosis plays in establishing and maintaining quality patient care. I write first about nursing diagnoses, then frame the discussion with a scenario of presenting symptoms and a medical diagnosis. The next sections of the paper address the elements of data collection, integration of information and knowledge, accessing wisdom, and the conclusions drawn from the discussion.

The Nursing Diagnosis

It is helpful to begin with a definition of nursing diagnosis, so as to distinguish it from a medical diagnosis and as a way to lay a path to nursing interventions and outcomes. A nursing diagnosis is a clinical judgment with an ecological basis. That is to say that a nursing diagnosis takes into consideration the individual patient, as well as aspects of the family and community that are related to the health circumstances or medical problem of the patient. A nurse is accountable for articulating a nursing diagnosis that uses a standardized frame derived from the relation of the various elements (NANDA, NOC, and NIC) and from a consistent use of terminology to describe both the elements and the relationships between the elements. From this, it should be apparent that a nursing diagnosis does not serve as a way of recasting or renaming the medical diagnosis, but rather enables the nurse to look at the entire constellation...

In essence, the nursing diagnosis enables the nurse to understand the ecological context in which the patient seeks wellness. The mechanism that enables the nursing diagnosis is a holistic nursing assessment that provided information that is, at a minimum, useful, and that has the potential to drive the identification of interventions that will achieve outcomes that are characteristic of high quality nursing care.
Presenting Symptoms and Medical Diagnosis

A 94-year-old woman is recovering from hip surgery and is currently bedridden for a substantial part of each day. The patient is beginning to ambulate with a wheeled-walker in the facility. Her frailty is noteworthy, and there is concern she may be at risk of bed sores (pressure ulcers).

The NANDA diagnosis that reflects the patient's vulnerability to pressure ulcers (PU) is as follows:

Risk for Impaired Skin Integrity (00047), which is found in Domain 11, Safety / Protection in Class 2 of Physical Injury.

A NANDA recommendation for this nursing diagnosis is the use of a standardized risk evaluation instrument (Bavarescol & de Fatima Lucenall, 2012). The Braden Scale is commonly used as it enables nursing staff to assess the risk of pressure ulcers for individual patients (Bavarescol & de Fatima Lucenall, 2012). It is important to note that the nursing diagnosis focuses on a determination of the risk to the skin's integrity, rather than specifically seeking to determine the risk of pressure ulcers occurring (Bavarescol & de Fatima Lucenall, 2012).

The risk factors associated with the development of pressure ulcers include the following: Constrained mobility,…