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MED INF 405-0 HIT Integration, Interoperability & Standards Standardized Nursing Language NANDA NOC Lemuel Dizon, RN NIC Definition NANDA taxonomy of nursing diagnosis North American Nursing Diagnosis Association NOC nomenclature of nursing outcomes Nursing Outcomes Classification NIC nomenclature of nursing interventions Nursing Interventions Classification 2/ Title or job number / Scope NANDA 172 diagnosis 47 classes 13 domains NOC 385 outcomes 31 classes 7 domains NIC 542 interventions 31 classes 7 domains 3/ Title or job number / Organizational Structure Nursing Information and Data Set Evaluation Center (NIDSEC) Evaluates information systems along Four dimensions: 1. Nomenclature (terms used) 2. Clinical content (the “linkages” among terms) 3. Clinical data repository (how the data are stored and made accessible for retrieval) 4. General system characteristics (i.e., performance, security, confidentiality, etc.) NANDA International Center for Nursing Classification and Clinical Effectiveness (NIC/NOC) 4/ Title or job number / Formulation of a Nursing Diagnosis Format: Problem related to cause of problem evidenced by symptoms of problem. Examples: Impaired gas exchange related to excessive secretions as evidenced by O2 saturation of 86%. Fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate. 5/ Title or job number / Format Features of NIC ELECTROLYTE MANAGEMENT 2000 Definition: Promotion of electrolyte balance and prevention of complications resulting from abnormal or undesired serum electrolyte levels Activities: - Monitor for manifestations of electrolyte imbalance - Maintain patent IV access Administer fluids, as prescribed, if appropriate - Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate - Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed, if appropriate - Consult physician on administration of electrolyte-sparing medications (e.g., spiranolactone), as appropriate - Administer electrolyte-binding or -excreting resins (e.g., Kayexalate) as prescribed, if appropriate - Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as appropriate - Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and diaphoresis) - Irrigate nasogastric tubes with normal saline - Provide diet appropriate for patient's electrolyte imbalance (e.g., potassium-rich, low-sodium, and low-carbohydrate foods) - Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate - Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen - Monitor patient's response to prescribed electrolyte therapy - Place on cardiac monitor, as appropriate 6/ Title or job number / Components of NOC Fluid Balance 0601 Balance of water in the intracellular and extracellular compartments of the body Extremely Compromised Substantially Compromised Moderately Compromised Mildly Compromised Not Comprised 1 2 3 4 5 Indicators: BP IER 1 Mean arterial pressure IER 1 Pulmonary wedge pressure IER 1 Peripheral pulses palpable 1 Ascites not present 1 Neck vein distention not present 1 Peripheral edema not present 1 Sunken eyes not present 1 Confusion not present 1 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5Title or job number7 // NIC/NOC Inclusion • SNOMED multidisciplinary record system • National Library of Medicine’s Metathesaurus for a Unified Medical Language • Joint Commission • Alternative Billing Concepts (ABC) codes • Registered in HL7 8/ Title or job number / Vendors who have licenses for NIC & NOC • • • • • • • • • • • • • • AtStaff, Inc., Durham, NC, www.atstaff.com NOC integrated within their ClairVia® outcomes-driven acuity and patient management solutions for use by hospitals. Healthland (Formerly Dairyland Healthcare Solutions), Louisville, KY, www.healthland.com NIC and NOC integrated with their Clinical Documentation software system for care planning. System is used by small to midsize hospitals DIPS ASA, www.dips.com NIC integrated within their Electronic Patient Record System for care planning. Company located in Norway. DxR Development Group, Carbondale, IL, www.dxrgroup.com Web based system for teaching students nursing process. Product called DxR Nursing. eClinical Notes, LLC, Centreville, VA, NIC and NOC are being integrated within a nursing documentation section of an electronic documentation system for hospice providers. Ergo Partners, Lake Quivira, KS, www.ergopartners.com Product is EMRitus software McKesson Corporation, Alpharetta, GA, www.mckesson.com NIC and NOC integrated within Horizon Expert Plan for use in Care planning MedSoftCCS, LLC., Vancouver, WA, www.medsoftccs.com NIC integrated within Medtrack CCS job specific Orientation e-checklists. Nurse's Aide LLC, Keller, TX, www.nursesaide.net Product for School Nurses to assist with their care plans for students. Purkinje, Inc., www.purkinje.com Electronic clinical documentation tool. Company located in Canada. Sanum AS, www.sanum.no Sanum system used within hospitals and the educational market. Company located in Norway. IHTSDO (SNOMED-ownership has transferred), Northfield, IL. www.snomed.com NIC and NOC used within mapping tool. Tech-Time, Inc., Billings, MT, www.techtimeinc.com Clinical documentation system Typhon Group, LLC, Metairie, LA, www.typhongroup.com NIC and NOC integrated within their Registered Nurse Student Tracking (RNST) program used by Nursing Schools. 9 / Title or job number / Product helps student users develop patient care plans. Impact: A call for nursing standards • Developing standards would improve vendor-supplied nursing information systems. • Standards from the nursing community would significantly reduce the cost and time of developing the nursing component of clinical systems. • Nursing-developed standards would enhance nurse’s efficiency. • Automated information systems would help the current nursing shortage crisis by supporting the work of nurses. 10 / Title or job number / Reference • www.nanda.org • www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness • Simpson, R. What’s in a name? The taxonomy and nomenclature puzzle, part 2. Nursing Management. August 2003, p. 12, 14, 16. • Simpson, R. Setting the Informatics Standards: An Overview of NIDSEC’s Information Systems Evaluation Criteria. Nursing Economic$. SeptemberOctober 1998, Vol. 16, No. 5, pp.279-281. • Simpson, R. Finally, a Central Place to Evaluate Nursing Systems. Nursing Management. July 1997, pp.17-18. 11 / Title or job number /