Match the ana-recognized nursing terminology system with the content that it includes. quizlet

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Terms in this set (18)

CCC

Clinical Care Classification.

- This is a nursing classification designed to document the six steps of the nursing process and care continuum.

- The CCC classification facilitates patient care documentation at the point of care

ICNP

International Classification of Nursing Practice.

- Has been implemented as both a point of care and a reference terminology.

- ICNP has developed specific guidelines to develop nursing diagnosis, outcome, and intervention statements.

NANDA

North American Nursing Diagnosis Association International.

What does NANDA do?

- NANDA - Diagnoses are used to identify human responses to health promotion, risk, and disease.

- This was the first terminology to be recognized by the ANA committee for nursing practice information infrastructure.

- NANDA nursing diagnoses describe the patient's reaction to the disease and the treatment.

Each nursing diagnosis has what?

Each nursing diagnosis has a description, definition and defining characteristics.

ICD-9

ICD-9 codes describe the disease or injury.

NOC. (Nursing Outcomes Classification).

- This is a classification system that describes patient outcomes sensitive to nursing interventions.

- The NOC is a system to evaluate the effects of nursing care as part of healthcare.

- NOC consists of outcomes for individual patients, families, and communities.

- NOC can be used across clinical settings and specialties.

What is an Outcome?

An outcome is: A Measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions.

NIC -- Nursing Interventions Classifications.

This is a standardized classification of interventions that describe activities that nurses perform.

NMDS - Nursing minimum DATA set.

Three elements that make up the NMDS: Nursing care elements, nursing diagnosis, intervention outcome, and the intensity of care.

- This is described as the minimum data elements necessary for defining the cost and quality of nursing care.

PNDS - Perioperative Nursing data set

Provides wording and definitions for nursing diagnosis interventions and outcomes.

Provides nurses a clear, precise, and universal language for clinical problems and surgical treatments.

It provides a foundation for determining the patients needs and establishing the plan of care for the perioperative clinical setting.

A Decision Support System (DSS) is what?

Computer applications designed to facilitate human decision-making processes.

· Usually rule-based.
· Example: Alert for abnormal vital signs. Alert on gathering data and alerts sepsis protocol.

Expert Systems

This is a type of decision support system that gathers data and then implements on that data without the need for a user like in the DSS. An example would be an insulin pump.

· Another example of an expert system would be those that are capable of interpreting clinical images (X-Ray, MRI, CT SCAN).

Do Decision Support Systems have an impact on Medication Administration?

Yes.

- They can ensure the 5 rights are implemented

- Check for drug-to-drug interactions or allergies

- When ordering it can prompt physician to select the appropriate medication based on client data.

Do Decision Support Systems have an impact on Health care spending?

Yes.

Decision Support Systems do have an impact on Health care spending

- They aid in diagnosis and provide access to practice guidelines which helps decrease the length of hospital stay and treatment.

Clinical Decision Support (CDS) -

Suggests appropriate medical and nursing interventions based on patient data.

CDS can organize information and trigger prompts thereby decreasing patient safety risks and increasing positive patient outcomes.

Dashboard Reporting

Example National Database of Nursing Quality Indicators (NDNQI).

· Quality indicators such as infection rates, falls and pressure ulcers can be tracked and comparisons can be made from one facility to another.

Smart Technology

These help improve quality, safety and efficiency of patient care.

· Example: Smart Pump.

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