Applying Standardized Terminology in Nursing

Introduction
As a result of the introduction of computer technology and the combination of evidence-based practice in nursing; standardization of terminologies has become imperative in the classification of nursing diagnosis, interventions and expected outcomes. The most popular and successful systems are the North American Nursing Diagnosis Association International (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Intervention Classification (NIC) (de Lima Lopes, de Barros, & Marlene Michel, 2009). This paper aims to provide a brief outline of these standardized terminologies (STs) as they relate to a patient with congestive heart failure (CHF), to identify the elements of NANDA-I, NIC, and NOC, and describe the data, information, knowledge and wisdom (DIKW) used during the process. NANDA-I, NOC and NIC Elements

The University of Iowa developed The North American Nursing Diagnosis Association (NANDA-I) which provides a clear outline to assist nurses in diagnosing various disease states. The Nursing Intervention Classification (NIC) is used for selection of the nursing interventions related to the nursing diagnosis, whereas NOC is the nursing outcomes that should be obtained from the NANDA-I diagnosis and NIC interventions. Standardization of clinical documentation is essential in nursing and should be implemented to combine all three of the nursing languages into one standardized terminology integrated into healthcare information systems. The writer will now illustrate how the NANDA-I, NIC, and NOC relate to patients in congestive heart failure (CHF). Congestive heart failure occurs when the heart is unable to fill with or eject blood efficiently enough to nourish the body tissues and is a potentially fatal condition which is caused by weakness of the heart muscle.

One of the most common risk factor for CHF is high blood pressure (hypertension), which increases the required work of the heart muscle to pump blood through the coronary arteries. The coronary arteries are responsible for delivering oxygen enriched blood to the heart muscle. When the patient is suffering from hypertension and the heart has to work harder against the tension applied by the elevated blood pressure; the end result is increased tension on the walls of the coronary arteries causing a decrease in oxygenated blood flow to the heart muscle; usually leading to increase fluid retention in the body (Haider, Larson, Franklin, & Levy, 2003). NANDA-I is appropriate in this case to use for collection of the necessary data and information required to determine which intervention is appropriate. The most important NANDA-I diagnoses associated with NOC outcomes and NIC interventions are Knowledge Deficit (NANDA-I) – Knowledge: Treatment regimen (NOC) – Teaching Procedure/Treatment (NIC) and Cardiac Output Alteration (NANDA-I) – Cardiac Pump Ineffectiveness (NOC) – Cardiac Care (NIC) are the top NANDA-I, NOC AND NIC linkages for CHF (Johnson et al., 2012).

The most common diagnosis in people with CHF is Cardiac Output Alteration which leads to hypervolemia (excess fluid volume). There are three NIC interventions that are considered top priority: fluid management, fluid monitoring, and hypervolemia monitoring (Haider, Larson, Franklin, & Levy, 2003). The three most common NOC outcomes for CHF are: fluid balance, hydration, and electrolyte and acid/base balance. In spite of, or because of the above outcomes and interventions, the patient must be encouraged to maintain their health and be active participants in their plan of care. Nursing Outcome Classification

The NOC classification stage allows the nurse to incorporate the findings discovered in the diagnosis. They serve as the measuring tool in order to determine how successful the nursing interventions are (Johnson et al., 2012). According to Moorhead et al., “an outcome is defined as “an individual, family, or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention(s)” (as cited in Johnson et al., 2012). Nurses should take care to select the proper outcomes to ensure optimum care is provided to patients with CHF. The plan of care is dependent on the nursing diagnosis and the desired nurse-sensitive outcomes. The priority NOC outcome for the diagnosis of CHF is Fluid Balance and Fluid Overload Severity.

Other related NOC outcomes are Knowledge: Cardiac Disease Management, Knowledge: Energy conservation, Knowledge: Medication, Knowledge: Prescribed Activity, Knowledge: Treatment, and Knowledge: Weight Management (Johnson et al., 2012). These are only a select few of the multiple outcomes available; care should be modified as the disease progresses through the problems which evolves over the lifetime of patients diagnoses with CHF. Once all these determinants are established, the nurse will be prepared to determine which level of NOC is essential to effectively manage the disease. Nursing Intervention Classification

Nursing interventions are focused on nursing behaviors to guide the patient in the direction of the most preferred outcome (Johnson et al., 2012). Fluid management, fluid/electrolyte management, and hypervolemia management are the major interventions in effective management of CHF. Fluid management is the most difficult intervention for all patients suffering from CHF. Evaluation of the patient’s ability to make the appropriate lifestyle changes required to maintain a homeostasis state should be the top priority in patients with CHF. This will require intense education on the disease process. Family members and caretakers will be an essential part of the plan of care. Education of both the patient and family will be the focus in order to modify a lifetime of learned behavior (Sewell & Thede, 2013).

The disease state and underlying abnormality of the heart needs to be examined at length to determine the stage of CHF and whether it includes the pulmonary and renal system as well (Jenkins & Kirk, 2010). Appropriate medications for treatment and diet for maintenance will require nutritional counseling for prescribed diet teaching and weight management as well as pharmacological teaching for prescribed medications. A program focusing on cardiac rehabilitation will allow for activities aimed at improving activity tolerance by reducing overall oxygen requirements of the body tissues. In order to enhance patient outcomes and ensure successful maintenance of the disease process of CHF, nursing interventions must be based upon the knowledge, clinical judgment, critical thinking, and wisdom of the nurse (Johnson et al., 2012). Conclusion

With the aging population and technology enhanced healthcare; patient care is becoming so much more complex. There is an increased need for standardized nursing language in hospital electronic charting to reflect the provision of safe, quality and evidence-based nursing care. NANDA-I supplies nurses with a flexible and adaptable worldwide standardized language. Through the NANDA-I specifications, nurses are able to determine the outcomes (NOC) and apply the necessary interventions (NIC) that will ensure the proper treatment and best possible outcomes for the patient. Nurses, with education and experience will be able to link their skills, knowledge, and wisdom to the data and information collected during the initial and subsequent interview process with the patient. Therefore, this writer believes that all nurses should seriously adopt the principles and strategies of NANDA-I, NIC, and NOC.

Reference
de Lima Lopes, J., de Barros, A. L., & Marlene Michel, J. L. (2009). A pilot study to validate the priority nursing interventions classification interventions and nursing outcomes classification outcomes for the nursing diagnosis “excess fluid volume” in cardiac patients. International Journal Of Nursing Terminologies & Classifications, 20(2), 76-88. doi:10.1111/j.1744-618X.2009.01118.x Haider, A.W., Larson, M.G., Franklin, S.S., Levy, D. (2003). Systolic blood pressure, diastolic blood pressure, and pulse pressure as predictors of risk for congestive heart failure in the Framingham heart study. Annals of Internal Medicine, 138(1), 22 Jenkins, K., & Kirk, M. (2010). Heart failure and chronic kidney disease: an integrated care approach. Journal Of Renal Care, 36127-135. doi:10.1111/j.1755-6686.2010.00158.x Johnson, M. & Moorhead, S. & Bulechek, G. & Butcher, H. & Maas, M. & Swanson, E. (2012). Noc and nic linkages to nanda-i and clinical conditions. Retrieved from http://www.r2library.com.proxy.chamberlain.edu:8080/Resource/Title/032307703X Sewell, J. & Thede, L. (2013). Informatics and nursing: Opportunities and challenges (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.