MAPPING CARE USING STANDARDIZED TERMINOLOGIES

MAPPING CARE USING STANDARDIZED TERMINOLOGIES

                The use of standardized nursing language and terminologies has dramatically influenced the provision of comprehensive and quality care across all the aspects of patient care. The commonly used standardized terminologies are NANDA-I, NIC and NOC, and they are used concurrently in planning patient care (Herdman, 2014). They are used as a means of providing a comprehensive, research-based, standardized classification of nursing diagnosis, nursing interventions and a set of nurse-sensitive patient outcomes.

Pressure ulcers are localized areas of tissue necrosis caused continuous and increased pressure between two planes; in this case, the patients’ skin and the bed. They develop due to moisture, pressure and poor blood circulation, which leads to the death of skin tissues causing abrasions and skin friction (Grey, Harding, & Enoch, 2016). With continued contact, it results in the development of pressure ulcer wounds. I am interested in pressure ulcers as a nursing diagnosis because its development is contributed by nurses’ failure to manage the patient effectively. The nurses’ inability to turn the patient two hourly, change linen, provide adequate hydration and nutrition results to the development of pressure ulcers.

NURSING CARE MAP

A standardized care map for nurses is a set of standardized terms used to document patient assessment data, circumstances or problems, determine appropriate diagnosis, intervention and with sufficient details to support clinical care, decision making and basis for quality improvement (Taylor, & Wros, 2017). Developing a care map for nursing is essential in ensuring the provision of standardized, evidence-based and holistic care. It will help guide the nurses on which care I provided to which patient, family or community.

A care map helps in providing the continuity of care, safety, quality care and compliance. It ensures patient care is documented hence promoting accountability in the outcomes of patient care. Since it directs the nurses on the management of a patient condition, that is, after documenting findings, the nurse can come up with appropriate interventions. It also enables the nurse to prioritize patient problems and needs through proper assessment and planning.  It also supports the use of care pathways and care bundles (Taylor, & Wros, 2017). Care pathways involve the use of team effort to reach an agreement in the standards of patient care. In contrast, care bundles involve implementing the best practice in applying specific care regarding patient condition.

NURSING DIAGNOSES

NANDA-I nursing diagnoses consist of clinical judgement of patient, family and community responses to problems/ life processes and it provides a basis for selection of appropriate nursing interventions to achieve outcomes in which the nurse is responsible and accountable (Herdman, 2014). The nursing diagnoses are classified into 13 domains based on health care patterns. The classifications include health promotion, nutrition, exercise and rest, growth and development, comfort, self-perception, cognition, safety, role relationship, elimination and exchange, sexuality, life principles and coping stress/tolerance.

The nursing diagnoses include impaired tissue integrity, ineffective tissue perfusion and risk for infection. Impaired skin integrity and ineffective tissue perfusion are actual nursing diagnosis due to the presence of supporting signs and symptoms. At the same time, the risk for infection is a risk nursing diagnosis indicating that the problem does not exist, but the person is susceptible, or there is the presence of risk factors. Impaired tissue integrity is defined as the damage of the mucous membrane, integumentary and subcutaneous tissues. Ineffective tissue perfusion refers to a decrease in oxygen supply failing capillary tissue nourishment.

NURSING INTERVENTIONS

Nursing Intervention Classification is a care classification that describes the activities that a nurse can perform to manage a nursing diagnosis (Butcher,2018). The nursing interventions for impaired tissue integrity per NIC are incision site care, pressure ulcer care, wound care, skin surveillance and wound care. You assess the site and aetiology, size and depth of the wound. Monitor the location of impaired tissue for colour changes, warmth, pain and changes in sensation. Monitor patient wound care techniques and teach them appropriate ways to maintain wound hygiene. Lastly, implement the treatment plans, i.e. administering topical and other medications to improve healing and prevent infections.

The nursing intervention of ineffective tissue perfusion per NIC labels is circulatory care. You check for optimal fluid balance, administer intravenous fluids, maintain input and outputs. In peripheral tissue perfusion, you assist the patient in position changes to relieve pressure and facilitate circulation. Promote an active and passive range of motion to prevent venous stasis, and further circulatory compromise and the prescribed medications are administered to treat the underlying cause (Butcher, 2018). The NIC labels for risk for infection are infection control and infection protection. The signs of infection are assessed, and the patient is counselled on proper hygiene.

NURSING OUTCOMES

The NOC describe patient outcomes related to the nursing interventions and they are used to evaluate the effectiveness of nursing care (Moorhead, Johnson, Maas, & Swanson, 2018).   The expected nursing outcomes per NOC for impaired tissue integrity are tissue integrity, wound healing (primary intention) and wound healing (secondary intention). The clients’ outcomes include wound decrease in size and increased granulation, improved skin and tissue integrity, reporting understanding of the plan to heal tissue and prevent further injury and to report any altered sensation or pain in the wound site.

The expected outcomes in ineffective tissue perfusion are improved tissue perfusion and maintenance of circulation in vital organs, patient identifying necessary lifestyle changes and also display activity tolerance (Moorhead et al. 2018). Besides, there is improved cardiac output and a balanced input and output chart. The patient will experience adequate perfusion to promote prompt wound healing and also recognize alterations skin that indicates diminished tissue perfusion.

The NOC labels for risk for infection are risk control, risk, detection, knowledge on infection control and improved immune status. The client expected outcomes are that they remain free from infection, demonstrate appropriate wound care and hygienic measures and maintenance of optimal defence system. The client should not be susceptible to infections and demonstrate knowledge of infection prevention and control measures. They should also be knowledgeable about the signs and symptoms of infection to be addressed immediately.

In conclusion, the use of NNN in planning patient care has proved an effective way of promoting patient safety and patient-centred care. The nurse should be well equipped with the knowledge and skills to plan the care of a patient using the nursing process. By incorporating NNN in the assessment and planning interventions appropriate to the nursing diagnosis will facilitate the attainment of the expected outcomes and provision of quality holistic care. The use of standardized nursing language and terminologies has facilitated communication among nurses globally, and this has promoted unity and teamwork in the development of new methods and better interventions. Through it, nursing gained popularity by continuing the work of Florence Nightingale, where the nurse determines the outcome of patient care. Therefore, patient safety goals, nursing code of ethics and professionalism should guide the nurse in their daily patient care activities.

References

Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. M. (2018). Nursing Interventions Classification (NIC)-E-Book. Elsevier Health Sciences.

Grey, J. E., Harding, K. G., & Enoch, S. (2016). Pressure ulcers. Bmj, 332(7539), 472-475.

Herdman, T. H. (Ed.). (2014). Nursing Diagnoses 2012-14: Definitions and Classification. John Wiley & Sons.

Moorhead, S. A. (2019). The nursing outcomes classification. Acta Paulista de Enfermagem, 22(SPE), 868-871.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2018). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Taylor, J., & Wros, P. (2017). Concept mapping: a nursing model for care planning. Journal of Nursing Education, 46(5), 211-216.