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. Introduction:
Standardized Nursing terminologies are structured vocabularies which present nurses a
uniform mode of communication. Within the framework of Nursing, the genesis of terminologies
has been more than a century old since the legendary Florence Nightingale ushered the modern
chapter of nursing. With the rising roles of professional nurses across various domains of nursing
practice, a number of initiatives to develop standardized terminologies for nursing practice have
been 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 the
country as also abroad. These advantages cover enhancing communications among the nurses
and added healthcare providers as also patients, enhancing presence of nursing interventions and
improving data collection to monitor nursing care outcomes. (Structural validation of nursing
terminologies) 3
Patients also benefit from the application of standardized terminologies in the form of
enhanced continuity of care with unequivocal communication among healthcare providers.
Healthcare organizations are also benefited by using electronic health records (EHR) through
application of these terminologies in place of manual procedures. The purpose of nursing’s
influence on patient and organizational outcomes is important to legitimize the involvement of
nursing to health care and patient safety. Besides, the institution also profits from the application
of standard terminologies by giving administrators with the precise costs and advantages of
nursing care. Application of standardized terminologies therefore lets them to arrive at
appropriate decision as regards staffing ratios.
Through the use of standardized nursing terminologies, the nursing fraternity is able to
keep records, store them and retrieve for evidence-based practice in a systemic manner so as to

3. help nursing research and publicize the effect of nursing care through electronic modes. This has
a far reaching effect in the international arena as well. Through the use of standardized nursing
terminologies, every nation benefits in the shape of having retrievable data that are able to be
summarized into informative reports or data sets. These reports permit nations to weigh against
the 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 the
national as well as international level through the use of the International Nursing Minimum
Data Set. (Overview of Standardized Nursing Terminologies: NANDA-I. NOC and NIC linkages
in 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 to
monitor and support the development and advancement of the application of several vocabularies
and classification schemes within the universe of the Nursing Minimum Data Set. Thereafter, the
ANA formed criteria and a procedure for its official recognition. Currently, the following
recognized nursing classifications exists. These are (i) North American Nursing Diagnosis
Association (NANDA) Taxonomy 1, (ii) Nursing Outcomes Classification (NOC). (iii) Nursing
Interventions Classification (NIC) (iv) Home Health Care Classification (HHCC) (v) Medical
Entities Dictionary (MED) (vi) CEN TC251 (vii) The International Classification of Nursing
Practice (ICNP) (viii) The Clinical LOINC (Logical Observation Identifiers, Names and Codes)
(ix) The Universal Medical Language System (UMLS) (x) Systematized Nomenclature of
Human and Veterinary Medicine – Reference Terminology (SNOMED-RT) (xi) Omaha System

4. (A Review of the Major Nursing Vocabularies and the extent to which they have the
characteristics 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 the
use of “interface terminologies” – terminologies which are optimized for end-user utilization like
menu-driven data entry. These terminologies usually assume the form of enumerated
classifications wherein the enumerated terms are associated by hierarchic and other linked and
practical relationships. This is an example of NANDA or the NANDA Taxonomy. Especially
NANDA claims to provide a fruitful means to conceptualization of nursing science and
concentrating for clinical decision making. The fundamental specified approach renders this
possible through provision of a comparatively homogenous conceptual structure which to attach
important constituents of the diagnostic procedures. Hence NANDA taxonomy is an illustration
of an enumerated classification. (Structural validation of nursing terminologies) 3
These terminologies are made through the enumeration of almost all terms that are
represented and through organizing the terms into a hierarchy. For instance, in case of a
condition under which a patient experiences pain that prolongs for more than six months is
termed as “Chronic Pain. Thus the term characterizes a “Nursing Diagnosis”. Nursing diagnoses
can be seen as understood statements for diagnostics ideas”. Every “labels” or diagnostic
procedures in NANDA consist of an associated collection of components. This comprises a
definition, the characteristics of the definition and the associated or risk factors. Thus these
components are viewed as important constituents in the process of diagnosis. (Structural
validation of nursing terminologies) 3

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 classes
and as many as 260 outcomes. These outcomes are centered on people, family, and community
clients. Every outcome is known by its code. For example, dizziness could be called under NOC
as “fluid balance” i.e. the balance of water in the intracellular and extracellular spaces inside the
body. Several of the linked outcome indicators cover stable body weight, nonappearance of
sunken 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 an
Effective 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 a
label name having a definition and a unique numeric code which can be utilized for
reimbursement of nursing interventions. These codes are used for facilitation of computerized
use permitting communication along with added coded systems for instance SNOMED CT,
NANDA and NOC. The NIC nomenclature which describes the domain of nursing comprises of
7 domains and 30 classes. NIC are capable to be used in every clinical setting, i.e. from critical
care, ICU to home care as well as prolonged care and primary care. The seven domains of NIC
are (i) Physiological: i.e. Basic (ii) Physiological: complex (iii) Behavioral (iv) Safety (v) Family

6. (vi) Health safety (vii) Community. (Selecting a Standardized Terminology for Electronic
Health 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 health
as well as ambulatory care. HHCC comprises of two interconnected terminologies i.e. HHCC of
Nursing Diagnoses and the HHCC of Nursing Interventions. Within a framework of 20 Care
Components symbolizing health, functional, behavioral, physiologic and psychological patterns
of patient care being used by these two terminologies. Within its fold HHCC has 146 nursing
diagnoses which are based on NANDA and include more diagnoses which are specific to home
care. (Integrating Nursing Diagnostic Concepts into the Medical Entities Using the ISO
Reference Terminology Model for Nursing Diagnosis) 6
(v) Medical Entities Dictionary (MED):
MED is a concept-oriented terminology and also a semantic network which implements
multiple hierarchies. Here every node in the network happens to be a concept in the MED which
is being viewed as a slot-based frame. The slots and their values happen to be the crucial
properties of the underlying concept. Two types of slots are there. First is the string slot whose
value is inherent to the concept viz. its chosen name and the other is the semantic slots which
relate an idea to other concepts in the dictionary. Every slot possesses a distinctive point of
origin 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 edited
constantly. For instance the editing software permits a slot’s initiation point to be shifted with

7. ease with certain conditions. (Integrating Nursing Diagnostic Concepts into the Medical Entities
Using the ISO Reference Terminology Model for Nursing Diagnosis) 6
(v) The Health Informatics Technical Committee of the European Committee for
Standardization (CEN TC251):
CEN permits several specialized terminologies which match with a universal
intermediary form. The eventual objective is adherence to compatibility and not uniformity. The
concept of a categorial structure is the focus of within CEN. A categorial structure is a
terminology 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’ within
which are grouped together descriptors like ‘diabetes’. This categorial arrangement may also
denote the manner in which these categories might be pooled. For instance, ‘informing’ may be
linked to a ‘condition’ through a link which ‘has a topic’. This type of structure would let a
terminological phrase like ‘teaching on diabetes’ to be depicted in a common form. (Standards
of Nursing Terminology) 7
Of late the approach has been made more inclusive to cover not just the terminological
part of health documents, but the structure of clinical information in health records, models of
information and data dictionaries as well. This generality of categorial structure assumes the
structure of a model which portrays the properties of a specific subject field, sans any conjecture
regarding the manner in which the various components will find representation. Like this it aims
to provide a link across terminologies, various models of terminologies, information models as
also the semantics of health records. Initial CEN contribution on nursing has incorporated a brief
strategic study. The span of the study was developing a strategy for the CEN TC251 contribution

8. on nursing terminology through examining the issues emanating from undertaking two very
preliminary series of formation of a categorial structure. In the first series, a collection of present
terminologies was applied in the formation of a temporary categorial structure. Under the second
series, four diverse terminologies were applied as instances for substantiation as also
sophistication of the categorial form. (Standards of Nursing Terminology) 7
This study covers several recommendations (i) elucidation of scope and purpose: Within
the healthcare domain, terminology models are a comparatively new concept. Their importance
is yet to be understood or proven. Pending that, pragmatic objectives are required to be
maintained and expectations of users managed consequently. (ii) Preparation of a process for
alteration: As success will be attained in the later years of the work, thus the framework within
which 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 is
accomplished across the world and it will be vital to include this contribution in the CEN work
item 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. The
objectives of the ICNP program is to (i) ground a common language for outlining nursing
practice 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 diverse
environments, institutional as well as non-institutional. (iii) Facilitate comparison of nursing data
across clinical populations, environments, territories, and time. (iv) Reveal or project patterns in
the provisions of nursing treatments and care as also resource allocation in favour of patients as

9. per their requirements, on the basis of nursing diagnoses. (v) Conjure up research in the areas of
nursing by links to data which are obtained in nursing information as well as health information
systems. (vi) supply data regarding nursing practice in order to impact health policy making. The
ICNP product is described as a categorization of nursing phenomena, nursing actions, and
nursing outcomes which portray nursing practice. (Collaborative Efforts for Representing
Nursing 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 and
coordination. (Collaborative Efforts for Representing Nursing Concepts in Computer-based
systems) 8
(vii) The Clinical LOINC (Logical Observation Identifiers, Names and Codes):
This is a Semantic Structure as a Terminology Model for Standardized Assessment
Measures is another concept under Medical Terminology for Nurses. During its formative stage
of development LOINC concentrated on a public set of codes and names for electronic reporting
of laboratory test results. The initial objective of the LOINC Committee was to launch a code
system that would include 98% of the tests undertaken in the average laboratory. Among the
initial tasks of the Committee was to outline a prescribed semantic structure for observation of
names which would differentiate experiments which were different from the clinical point of
view and thereafter utilize this structure to build database of clinically different names and its
associated 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 to
match common characteristics of their respective approaches while making sure that a scope

10. exists within the overall framework in order to explore distinctive approaches and to fulfill
specialized requirements. The UMLS is an applied exercise. It looks forward to develop content
as well as applications for a specific objective. Two reasons are there for evaluation. (i) the
quality of the ULMS content and (ii) the capability for applications to render conceptual
connections among the users and machine-readable information using the ULMS content. It is a
fact that medical terminologies include phrases that are made use of in our language. These are
codified so as to aid communication of medical thoughts in a manner that is reproducible. The
capability of these terminologies to include pertinent concepts within a particular domain has
been portrayed as the ‘content coverage’ of the terminology. (The Unified Medical Language
System – Journal of the American Medical Informatics Association) 10
. Through objective evaluation of the wide-ranging aspect of the linkages and the
properties of the semantic neighbourhood, we are able to gather knowledge regarding the manner
in 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 Informatics
Association) 10
(ix) SNOMED CT:
This system has been developed through the collaboration between the College of
American Pathologists and the National Health Services (NHS), is a concept-oriented
terminology. It is based on the SNOMED RT (Reference Terminology) and the CT version 3 of
the 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 the
reference terminology needs. The objective of the body of SNOMED CT developers ensure that

11. (i) SNOMED CT is founded on the present nursing terminologies such that there is extensive
coverage for the domain of nursing and (ii) ideas and concepts from the nursing domain are
rightly modeled inside SNOMED CT and (iii) relationships among the nursing terminologies and
SNOMED CT are legitimate and dependable. As of now, four nursing terminologies which cover
nursing diagnostic concepts are scheduled for integration into the SNOMED. These are
NANDA, Omaha, HCC and the Per-Operative Nursing Data Set. (An evaluation of the
usefulness of two terminology models for integrating nursing diagnosis concepts SNOMED
Clinical Terms) 11
(x) OMAHA System of Nursing Terminologies:
The OMAHA System is a comprehensive practice and documentation of nursing
terminologies. It has been designed to document patient care from the stage of admission to
ultimate discharge. This system comprises of three relational, reliable and valid constituents
crafted to be used in conjunction. These are (i) problem classification scheme (ii) Intervention
Scheme and (iii) problem rating scale for outcomes. It is a research-based wide-ranging
standardized taxonomy which is present in the public domain for viewing. It has been designed
to augment practice, documentation and information management. Under the OMAHA system
the terms are arranged in a hierarchy e.g. form the initial general stage to more specific. The
terms have been so designed that it can be easily understood by professionals belonging to the
health care fraternity as also people from the general public. It lends a structure to keep records
regarding the needs of the patient and strengths, explain the multidisciplinary interventions of the
practitioner 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 in
the improvement of quality, critical thinking and communication. (OMAHA Systems Overview)12

12. References
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Accessed on 14.2.12