Nursing Terminologies for Nursing Information

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Questions and Answers

What is the primary purpose of the Perioperative Nursing Data Set (PNDS)?

To make visible to administrators the patient problems that perioperative nurses manage (correct)

To develop standardized nursing terminologies

To provide a limited list of responses for nurses

To code assessment data for the EHR

How many nursing diagnoses are included in the Perioperative Nursing Data Set (PNDS)?

100

93 (correct)

151

What percentage of users found the Perioperative Nursing Data Set (PNDS) helpful for generating appropriate interventions and outcomes?

80% (correct)

70%

60%

90%

What is the primary purpose of the Logical Observation Identifiers, Names, and Codes (LOINC)?

To communicate laboratory assessments Signup and view all the answers

What did LOINC users give the highest percentage of any of the terminologies to?

Retrieving information on the same term for many patients Signup and view all the answers

Which of the following is NOT a recognized interdisciplinary terminology by the ANA?

Perioperative Nursing Data Set (PNDS) Signup and view all the answers

What is the name of the organization that recognized the three interdisciplinary terminologies?

American Nurses Association (ANA) Signup and view all the answers

What is the result of having to manoeuvre the system to force it to work?

A statement that is applicable to other terminologies Signup and view all the answers

What is the NMMDS framework guided by?

The Iowa Model of Nursing Administration and Donabedian's components Signup and view all the answers

What is a characteristic of NANDA's approach to nursing terminology?

Representation of words or phrases in a list or simple hierarchy Signup and view all the answers

What is the purpose of the example terminologies in the content?

To demonstrate the relative extremes of the terminological evolutionary path Signup and view all the answers

What is a key feature of the evolution of nursing terminologies?

The refinement of description logic Signup and view all the answers

What is the structure of the NMMDS framework?

18 elements associated with the nursing environment and financial resources Signup and view all the answers

What is a characteristic of the enumerative approach to nursing terminology?

Representation of words or phrases in a list or simple hierarchy Signup and view all the answers

What is the relationship between the two example terminologies (NANDA and ICNP)?

They are complementary and serve to illustrate different approaches Signup and view all the answers

What is a feature of a nursing diagnosis in NANDA?

An associated name or label and a textual definition Signup and view all the answers

What is the primary purpose of standardized nursing terminologies?

To facilitate the efficient delivery of high-quality health care Signup and view all the answers

When were nursing terminologies and vocabulary structures first developed?

1973 Signup and view all the answers

What is the main challenge with nursing terminologies?

Inability to ensure availability of sharable and comparable nursing data Signup and view all the answers

What organization created a process to recognize languages, vocabularies, and terminologies that support nursing practice in 1989?

ANA Signup and view all the answers

What is a term at the simplest level?

A word or phrase used to describe something concrete or abstract Signup and view all the answers

Who contributed to the development of nursing terminologies?

James J. Cimino Signup and view all the answers

What do nursing terminologies allow us to do with nursing data?

Capture, represent, access, and communicate Signup and view all the answers

What is a nursing terminology?

A body of terms used in nursing Signup and view all the answers

What is the primary purpose of Nursing Outcomes Classification (NOC)?

To provide a measurable way to evaluate the effect of nursing interventions on patient progress Signup and view all the answers

How many outcomes are included in the Nursing Outcomes Classification (NOC)?

490 outcomes Signup and view all the answers

What is the most useful task of NOC in clinical care?

Generating appropriate outcomes Signup and view all the answers

What is the original purpose of the Omaha System?

To document care in home healthcare settings Signup and view all the answers

What is included in the Omaha System?

Terminology for nursing diagnosis, interventions, and outcomes Signup and view all the answers

What is the most helpful task of the Omaha System?

Planning care Signup and view all the answers

What is a limitation of the Omaha System?

It does not address lactation at all Signup and view all the answers

What is an additional use of NOC?

As an educational tool for nursing students Signup and view all the answers

What is the primary purpose of accurately quantifying the contribution of each care team member?

To optimize care workflows across settings Signup and view all the answers

What is the focus of high-quality nursing data in longitudinal care?

Integrating registered nurses into high-value, lower-cost approaches Signup and view all the answers

What is the primary characteristic of ANA-recognized, standardized nursing terminologies?

They are specific to nursing Signup and view all the answers

How many recognized terminologies are designed specifically for use in nursing?

7 Signup and view all the answers

What was the original name of the Clinical Care Classification (CCC)?

Home Health Care Classification Signup and view all the answers

What was the purpose of the Clinical Care Classification (CCC) when it was originally designed?

To predict home healthcare use for Medicare patients Signup and view all the answers

What is a common feature of ANA-recognized, standardized nursing terminologies?

They address many specific nursing situations Signup and view all the answers

What is the primary benefit of using standardized nursing terminologies?

Enhanced documentation and communication Signup and view all the answers

Study Notes

Standardized Nursing Terminologies

Importance of Standardized Nursing Terminologies

Advanced practice nurses need to understand standardized nursing terminology lists and classification systems to deliver high-quality healthcare efficiently.
Standardized nursing terminologies facilitate capturing, representing, accessing, and communicating nursing data, information, and knowledge.

History of Nursing Terminologies

Nursing terminologies and vocabulary structures first developed in 1973 and have undergone significant changes since then.
The American Nurses Association (ANA) created a process to recognize languages, vocabularies, and terminologies that support nursing practice in 1989.

ANA-recognized Standardized Terminologies

There are seven recognized terminologies specifically designed for use in nursing, including:
- Clinical Care Classification (CCC)
- Nursing Outcomes Classification (NOC)
- Omaha System
- Perioperative Nursing Data Set (PNDS)
These terminologies address specific nursing situations, both dependent and independent nursing functions.

Clinical Care Classification (CCC)

Originally designed for electronic coding to predict home healthcare use for Medicare patients.
Enables efficient documentation and prediction of healthcare use.

Nursing Outcomes Classification (NOC)

Intended to provide a measurable way to evaluate the effect of nursing interventions on patient progress.
Consists of 490 outcomes with indicators to evaluate patient status.
Used as an educational tool for nursing students.

Omaha System

Originally devised for home healthcare nurses to document care.
Includes terminology for nursing diagnosis, interventions, and outcomes.
Helpful for planning care and communicating between disciplines.

Perioperative Nursing Data Set (PNDS)

Intended to make visible to administrators the patient problems that perioperative nurses manage.
Includes 93 nursing diagnoses, 151 nursing interventions, and 38 nurse-sensitive patient outcomes.
Helpful for generating appropriate interventions and outcomes.

Interdisciplinary Terminologies

ANA-recognized interdisciplinary terminologies include:
- SNOMED CT
- LOINC (Logical Observation Identifiers, Names, and Codes)
LOINC was originally designed for communicating laboratory assessments but has expanded to include coding of assessment data for EHR.
SNOMED CT and LOINC are used for retrieving information on the same term for many patients.

Approaches to Nursing Terminology

Nursing terminologies have evolved significantly over the past several decades, from simple lists to large, complex ontologies.
Evolution has been facilitated by advances in knowledge representations and technologies, such as automated reasoners.
Examples of terminologies that demonstrate different approaches include NANDA and ICNP.

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Description

This quiz covers the importance of standardized nursing terminology and classification systems for efficient healthcare delivery. It's essential for advanced practice nurses to understand these systems to provide high-quality care.