Medical terminologyfornurses -final


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Medical terminologyfornurses -final

  1. 1. Medical Terminology For Nurses Presented By________________________________________________________ Siraj Fatima Haleem Ph.D (Education), M.A, Dipl .Tefl (U.K) King Khalid University College Of Applied Medical Science,Mohayl,Aseer Kingdom Of Saudi Arabia
  2. 2. Introduction: Standardized Nursing terminologies are structured vocabularies which present nurses auniform mode of communication. Within the framework of Nursing, the genesis of terminologieshas been more than a century old since the legendary Florence Nightingale ushered the modernchapter of nursing. With the rising roles of professional nurses across various domains of nursingpractice, a number of initiatives to develop standardized terminologies for nursing practice havebeen undertaken. These standardized nursing terminologies render a lot of benefits to patients,establishments and the nursing profession can be utilized to compare data both within thecountry as also abroad. These advantages cover enhancing communications among the nursesand added healthcare providers as also patients, enhancing presence of nursing interventions andimproving data collection to monitor nursing care outcomes. (Structural validation of nursingterminologies) 3 Patients also benefit from the application of standardized terminologies in the form ofenhanced continuity of care with unequivocal communication among healthcare providers.Healthcare organizations are also benefited by using electronic health records (EHR) throughapplication of these terminologies in place of manual procedures. The purpose of nursing’sinfluence on patient and organizational outcomes is important to legitimize the involvement ofnursing to health care and patient safety. Besides, the institution also profits from the applicationof standard terminologies by giving administrators with the precise costs and advantages ofnursing care. Application of standardized terminologies therefore lets them to arrive atappropriate decision as regards staffing ratios. Through the use of standardized nursing terminologies, the nursing fraternity is able tokeep records, store them and retrieve for evidence-based practice in a systemic manner so as to
  3. 3. help nursing research and publicize the effect of nursing care through electronic modes. This hasa far reaching effect in the international arena as well. Through the use of standardized nursingterminologies, every nation benefits in the shape of having retrievable data that are able to besummarized into informative reports or data sets. These reports permit nations to weigh againstthe contribution of nursing to care, patient outcomes and Frequently Used Nursing Diagnoses.These assist in the preparation of interventions and outcomes for specific populations at thenational as well as international level through the use of the International Nursing MinimumData Set. (Overview of Standardized Nursing Terminologies: NANDA-I. NOC and NIC linkagesin nursing care plans for hospitalized patients with congestive heart failure) 1 Uniform nursing vocabularies have been made in order to explain the nursing process,and document nursing care. These assist in the summarization of data for evaluation at the local,provincial, national and global levels. In the US, the American Nurses Association (ANA)formed the Steering Committee on Databases in order to Support Clinical Nursing Practice tomonitor and support the development and advancement of the application of several vocabulariesand classification schemes within the universe of the Nursing Minimum Data Set. Thereafter, theANA formed criteria and a procedure for its official recognition. Currently, the followingrecognized nursing classifications exists. These are (i) North American Nursing DiagnosisAssociation (NANDA) Taxonomy 1, (ii) Nursing Outcomes Classification (NOC). (iii) NursingInterventions Classification (NIC) (iv) Home Health Care Classification (HHCC) (v) MedicalEntities Dictionary (MED) (vi) CEN TC251 (vii) The International Classification of NursingPractice (ICNP) (viii) The Clinical LOINC (Logical Observation Identifiers, Names and Codes)(ix) The Universal Medical Language System (UMLS) (x) Systematized Nomenclature ofHuman and Veterinary Medicine – Reference Terminology (SNOMED-RT) (xi) Omaha System
  4. 4. (A Review of the Major Nursing Vocabularies and the extent to which they have thecharacteristics required for implementation in Computer-based systems) 2(i) North American Nursing Diagnosis Association Taxonomy (NANDA): Users of modern-day nursing systems normally feed and extract structured data by theuse of “interface terminologies” – terminologies which are optimized for end-user utilization likemenu-driven data entry. These terminologies usually assume the form of enumeratedclassifications wherein the enumerated terms are associated by hierarchic and other linked andpractical relationships. This is an example of NANDA or the NANDA Taxonomy. EspeciallyNANDA claims to provide a fruitful means to conceptualization of nursing science andconcentrating for clinical decision making. The fundamental specified approach renders thispossible through provision of a comparatively homogenous conceptual structure which to attachimportant constituents of the diagnostic procedures. Hence NANDA taxonomy is an illustrationof an enumerated classification. (Structural validation of nursing terminologies) 3 These terminologies are made through the enumeration of almost all terms that arerepresented and through organizing the terms into a hierarchy. For instance, in case of acondition under which a patient experiences pain that prolongs for more than six months istermed as “Chronic Pain. Thus the term characterizes a “Nursing Diagnosis”. Nursing diagnosescan be seen as understood statements for diagnostics ideas”. Every “labels” or diagnosticprocedures in NANDA consist of an associated collection of components. This comprises adefinition, the characteristics of the definition and the associated or risk factors. Thus thesecomponents are viewed as important constituents in the process of diagnosis. (Structuralvalidation of nursing terminologies) 3
  5. 5. (ii) The Nursing Outcome Classification (NOC): This system comprises in excess of 190 patient outcomes used by the Nursing fraternity.The outcomes being used follow a three-layered system of seven domains, 29 outcome classesand as many as 260 outcomes. These outcomes are centered on people, family, and communityclients. Every outcome is known by its code. For example, dizziness could be called under NOCas “fluid balance” i.e. the balance of water in the intracellular and extracellular spaces inside thebody. Several of the linked outcome indicators cover stable body weight, nonappearance ofsunken eyes, and lack of presence of abnormal thirst. These Standardized Nursing Languages,when used in conjunction with a coding system, help in the collection of data as well as analysis.(Electronic Implementation of the National Nursing Standards- NANDA, NOC and NIC as anEffective Teaching Tool) 4(iii) Nursing Interventions Classification (NIC): The application of NIC helps the analysis of the effect of activities on patient outcomes.At present NIC has 542 interventions and in excess of 1200 activities. Every intervention has alabel name having a definition and a unique numeric code which can be utilized forreimbursement of nursing interventions. These codes are used for facilitation of computerizeduse permitting communication along with added coded systems for instance SNOMED CT,NANDA and NOC. The NIC nomenclature which describes the domain of nursing comprises of7 domains and 30 classes. NIC are capable to be used in every clinical setting, i.e. from criticalcare, ICU to home care as well as prolonged care and primary care. The seven domains of NICare (i) Physiological: i.e. Basic (ii) Physiological: complex (iii) Behavioral (iv) Safety (v) Family
  6. 6. (vi) Health safety (vii) Community. (Selecting a Standardized Terminology for ElectronicHealth Record that reveals the impact of Nursing on Patient Care) 5(iv) Home Health Care Classification (HHCC): HHCC is intended to lend a framework for preservation and classification of home healthas well as ambulatory care. HHCC comprises of two interconnected terminologies i.e. HHCC ofNursing Diagnoses and the HHCC of Nursing Interventions. Within a framework of 20 CareComponents symbolizing health, functional, behavioral, physiologic and psychological patternsof patient care being used by these two terminologies. Within its fold HHCC has 146 nursingdiagnoses which are based on NANDA and include more diagnoses which are specific to homecare. (Integrating Nursing Diagnostic Concepts into the Medical Entities Using the ISOReference Terminology Model for Nursing Diagnosis) 6(v) Medical Entities Dictionary (MED): MED is a concept-oriented terminology and also a semantic network which implementsmultiple hierarchies. Here every node in the network happens to be a concept in the MED whichis being viewed as a slot-based frame. The slots and their values happen to be the crucialproperties of the underlying concept. Two types of slots are there. First is the string slot whosevalue is inherent to the concept viz. its chosen name and the other is the semantic slots whichrelate an idea to other concepts in the dictionary. Every slot possesses a distinctive point oforigin at a precise MED concept. Every descendant of the concept inherits that particular slot.Software applications have been formulated which let the semantic network to be editedconstantly. For instance the editing software permits a slot’s initiation point to be shifted with
  7. 7. ease with certain conditions. (Integrating Nursing Diagnostic Concepts into the Medical EntitiesUsing the ISO Reference Terminology Model for Nursing Diagnosis) 6(v) The Health Informatics Technical Committee of the European Committee forStandardization (CEN TC251): CEN permits several specialized terminologies which match with a universalintermediary form. The eventual objective is adherence to compatibility and not uniformity. Theconcept of a categorial structure is the focus of within CEN. A categorial structure is aterminology model which explains the high level semantic structure in a specific subject field.For instance, a categorial structure on Nursing Interventions may cover the categories i.e.‘informing’ within which are grouped together descriptors like ‘teaching’ and ‘condition’ withinwhich are grouped together descriptors like ‘diabetes’. This categorial arrangement may alsodenote the manner in which these categories might be pooled. For instance, ‘informing’ may belinked to a ‘condition’ through a link which ‘has a topic’. This type of structure would let aterminological phrase like ‘teaching on diabetes’ to be depicted in a common form. (Standardsof Nursing Terminology) 7 Of late the approach has been made more inclusive to cover not just the terminologicalpart of health documents, but the structure of clinical information in health records, models ofinformation and data dictionaries as well. This generality of categorial structure assumes thestructure of a model which portrays the properties of a specific subject field, sans any conjectureregarding the manner in which the various components will find representation. Like this it aimsto provide a link across terminologies, various models of terminologies, information models asalso the semantics of health records. Initial CEN contribution on nursing has incorporated a briefstrategic study. The span of the study was developing a strategy for the CEN TC251 contribution
  8. 8. on nursing terminology through examining the issues emanating from undertaking two verypreliminary series of formation of a categorial structure. In the first series, a collection of presentterminologies was applied in the formation of a temporary categorial structure. Under the secondseries, four diverse terminologies were applied as instances for substantiation as alsosophistication of the categorial form. (Standards of Nursing Terminology) 7 This study covers several recommendations (i) elucidation of scope and purpose: Withinthe healthcare domain, terminology models are a comparatively new concept. Their importanceis yet to be understood or proven. Pending that, pragmatic objectives are required to bemaintained and expectations of users managed consequently. (ii) Preparation of a process foralteration: As success will be attained in the later years of the work, thus the framework withinwhich the assignment is accomplished is required to be flexible adaptable to alteration. (iii)Participation of the greater international nursing community. Bulk of the relevant contribution isaccomplished across the world and it will be vital to include this contribution in the CEN workitem as also the ISO work item. (Standards of Nursing Terminology) 7(vi) The International Classification of Nursing Practice (ICNP): ICNP was founded by and is a program of the International Council of Nurses (ICN)which is an association of national nurses association that comprises of 120 member nations. Theobjectives of the ICNP program is to (i) ground a common language for outlining nursingpractice so as to enhance the communication among nurses and between nurses and others (ii)Explain the nursing care of people i.e. persons, patients, families, and communities in diverseenvironments, institutional as well as non-institutional. (iii) Facilitate comparison of nursing dataacross clinical populations, environments, territories, and time. (iv) Reveal or project patterns inthe provisions of nursing treatments and care as also resource allocation in favour of patients as
  9. 9. per their requirements, on the basis of nursing diagnoses. (v) Conjure up research in the areas ofnursing by links to data which are obtained in nursing information as well as health informationsystems. (vi) supply data regarding nursing practice in order to impact health policy making. TheICNP product is described as a categorization of nursing phenomena, nursing actions, andnursing outcomes which portray nursing practice. (Collaborative Efforts for RepresentingNursing Concepts in Computer-based systems) 8 . The development of the ICNP product is a constituent of three groups of activities viz(i) communication and marketing (ii) research and development (iii) project management andcoordination. (Collaborative Efforts for Representing Nursing Concepts in Computer-basedsystems) 8(vii) The Clinical LOINC (Logical Observation Identifiers, Names and Codes): This is a Semantic Structure as a Terminology Model for Standardized AssessmentMeasures is another concept under Medical Terminology for Nurses. During its formative stageof development LOINC concentrated on a public set of codes and names for electronic reportingof laboratory test results. The initial objective of the LOINC Committee was to launch a codesystem that would include 98% of the tests undertaken in the average laboratory. Among theinitial tasks of the Committee was to outline a prescribed semantic structure for observation ofnames which would differentiate experiments which were different from the clinical point ofview and thereafter utilize this structure to build database of clinically different names and itsassociated codes. (Evaluation of the Clinical LOINC) 9(viii) The Universal Medical Language System (UMLS): ULMS lends a framework within which researchers as well as developers are able tomatch common characteristics of their respective approaches while making sure that a scope
  10. 10. exists within the overall framework in order to explore distinctive approaches and to fulfillspecialized requirements. The UMLS is an applied exercise. It looks forward to develop contentas well as applications for a specific objective. Two reasons are there for evaluation. (i) thequality of the ULMS content and (ii) the capability for applications to render conceptualconnections among the users and machine-readable information using the ULMS content. It is afact that medical terminologies include phrases that are made use of in our language. These arecodified so as to aid communication of medical thoughts in a manner that is reproducible. Thecapability of these terminologies to include pertinent concepts within a particular domain hasbeen portrayed as the ‘content coverage’ of the terminology. (The Unified Medical LanguageSystem – Journal of the American Medical Informatics Association) 10 . Through objective evaluation of the wide-ranging aspect of the linkages and theproperties of the semantic neighbourhood, we are able to gather knowledge regarding the mannerin which the UMLS can be modified to make headway towards the objective linking concepts’and machine readable representations in manner that show how they are intelligible by humans.(The Unified Medical Language System – Journal of the American Medical InformaticsAssociation) 10(ix) SNOMED CT: This system has been developed through the collaboration between the College ofAmerican Pathologists and the National Health Services (NHS), is a concept-orientedterminology. It is based on the SNOMED RT (Reference Terminology) and the CT version 3 ofthe NHS thesaurus of healthcare terminology. Created on the strengths of the two terminologies,the projected design for SNOMED CT is supposed to be compatible the interface as well as thereference terminology needs. The objective of the body of SNOMED CT developers ensure that
  11. 11. (i) SNOMED CT is founded on the present nursing terminologies such that there is extensivecoverage for the domain of nursing and (ii) ideas and concepts from the nursing domain arerightly modeled inside SNOMED CT and (iii) relationships among the nursing terminologies andSNOMED CT are legitimate and dependable. As of now, four nursing terminologies which covernursing diagnostic concepts are scheduled for integration into the SNOMED. These areNANDA, Omaha, HCC and the Per-Operative Nursing Data Set. (An evaluation of theusefulness of two terminology models for integrating nursing diagnosis concepts SNOMEDClinical Terms) 11(x) OMAHA System of Nursing Terminologies: The OMAHA System is a comprehensive practice and documentation of nursingterminologies. It has been designed to document patient care from the stage of admission toultimate discharge. This system comprises of three relational, reliable and valid constituentscrafted to be used in conjunction. These are (i) problem classification scheme (ii) InterventionScheme and (iii) problem rating scale for outcomes. It is a research-based wide-rangingstandardized taxonomy which is present in the public domain for viewing. It has been designedto augment practice, documentation and information management. Under the OMAHA systemthe terms are arranged in a hierarchy e.g. form the initial general stage to more specific. Theterms have been so designed that it can be easily understood by professionals belonging to thehealth care fraternity as also people from the general public. It lends a structure to keep recordsregarding the needs of the patient and strengths, explain the multidisciplinary interventions of thepractitioner and calculate the patient outcomes in a manner which is simple and yet user-friendly.Besides, it also aids in the collection, aggregation as well as analysis of clinical data. It helps inthe improvement of quality, critical thinking and communication. (OMAHA Systems Overview)12
  12. 12. References1. “Overview of Standardized Nursing Terminologies (Page 34) : NANDA-I. NOC and NIClinkages in nursing care plans for hospitalized patients with congestive heart failure”. Retrievedfrom Accessed on 10.2.122. “A Review of the Major Nursing Vocabularies and the extent to which they have thecharacteristics required for implementation in Computer-based systems.” Retrieved fromhttp:// Accessed on 10.2.123. . “Structural validation of nursing terminologies.” Retrieved fromhttp:// Accessed on 13.2.124. “Electronic Implementation of the National Nursing Standards- NANDA, NOC and NIC as anEffective Teaching Tool.” Retrieved from Accessed on 13.2.125. “Selecting a Standardized Terminology for Electronic Health Record that reveals the impact ofNursing on Patient Care.” Retrieved from Accessed on 13.2.126. “Integrating Nursing Diagnostic Concepts into the Medical Entities Using the ISO ReferenceTerminology Model for Nursing Diagnosis.” Retrieved from Accessed on 14.2.127. “Standards of Nursing Terminology.” Retrieved fromhttp:// Accessed on 14.2.128. “Collaborative Efforts for Representing Nursing Concepts in Computer-based systems.”Retrieved from Accessed on 13.2.129. “Evaluation of the Clinical LOINC.” Retrieved fromhttp:// Accessed on 13.2.1210. “The Unified Medical Language System – Journal of the American Medical InformaticsAssociation.” Retrieved from Accessed on 13.2.12
  13. 13. 11. “An evaluation of the usefulness of two terminology models for integrating nursing diagnosisconcepts SNOMED Clinical Terms.” Retrieved from Accessed on 14.2.1212. “OMAHA Systems Overview.” Retrieved from on 14.2.12