Assignment: The Impact of Standardized Nursing Terminology

Among the Resources in this module is the Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice? In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.

During the visit, one of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1).

How would you respond to a comment such as this one?

To Prepare:

· Review the concepts of informatics as presented in the Resources, particularly Rutherford, M. (2008) Standardized Nursing Language: What Does It Mean for Nursing Practice?

· Reflect on the role of a nurse leader as a knowledge worker.

· Consider how knowledge may be informed by data that is collected/accessed.

The Assignment:

In a 2- to 3-page paper, address the following: Excluding the cover page and reference page.

· Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.

· Describe the benefits and challenges of implementing standardized nursing terminologies in nursing practice. Be specific and provide examples.

· Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.

At least 3 peer reviewed citations.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

• Chapter 25, “The Art of      Caring in Technology-Laden Environments” (pp. 525–535)
• Chapter 26, “Nursing Informatics and the      Foundation of Knowledge” (pp. 537–551)

American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf 

Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05. 

Note: You will access this article from the Walden Library databases.

Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs

Topaz, M. (2013). The hitchhiker’s guide to nursing theory: Using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics, 17(3). 

Note: You will access this article from the Walden Library databases.

Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.12.019. 

Note: You will access this article from the Walden Library databases.

Required Media

Laureate Education (Executive Producer). (2012). Data, information, knowledge and wisdom continuum [Multimedia file]. Baltimore, MD: Author. Retrieved from http://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6051/03/mm/continuum/index.html

Laureate Education (Producer). (2018). Health Informatics and Population Health: Analyzing Data for Clinical Success [Video file]. Baltimore, MD: Author.

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Vinay Shanthagiri. (2014). Big Data in Health Informatics [Video file]. Retrieved from https://www.youtube.com/watch?v=4W6zGmH_pOw.

  

In the Discussion for this module, you considered the interaction of nurse informaticists with other specialists to ensure successful care. How is that success determined?

Patient outcomes and the fulfillment of care goals is one of the major ways that healthcare success is measured. Measuring patient outcomes results in the generation of data that can be used to improve results. Nursing informatics can have a significant part in this process and can help to improve outcomes by improving processes, identifying at-risk patients, and enhancing efficiency.

To Prepare:

· Review the concepts of technology application as presented in the Resources.

· Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies.

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

• Chapter 25, “The Art of      Caring in Technology-Laden Environments” (pp. 525–535)
• Chapter 26, “Nursing Informatics and the      Foundation of Knowledge” (pp. 537–551)

American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/

Glassman, K. S. (2017). Using data in nursing practice. American Nurse Today, 12(11), 45–47. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2017/11/ant11-Data-1030.pdf 

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf 

Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05. 

Note: You will access this article from the Walden Library databases.

Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs

Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.12.019. 

Note: You will access this article from the Walden Library databases.

The Assignment: (4-5 pages)

In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient-care efficiency. Your project proposal should include the following:

· Describe the project you propose.

· Identify the stakeholders impacted by this project.

· Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving and explain how this improvement would occur. Be specific and provide examples.

· Identify the technologies required to implement this project and explain why.

· Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team.

 

Case Study: Mrs. J.

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mrs. J., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.

Health History and Medical Information

Health History

Mrs. J. is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two packs of cigarettes a day and has done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms including fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to perform ADLs and has required assistance in walking short distances. She has not taken her antihypertensive medications or medications to control her heart failure for 3 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD.

Subjective Data

1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is “running away.”
4. Reports that she is exhausted and cannot eat or drink by herself.

Objective Data

1. Height 175 cm; Weight 95.5kg.
2. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation.
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%.
5. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.

Intervention

The following medications administered through drug therapy control her symptoms:

1. IV furosemide (Lasix)
2. Enalapril (Vasotec)
3. Metoprolol (Lopressor)
4. IV morphine sulphate (Morphine)
5. Inhaled short-acting bronchodilator (ProAir HFA)
6. Inhaled corticosteroid (Flovent HFA)
7. Oxygen delivered at 2L/ NC

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mrs. J.’s situation. Include the following:

1. Describe the clinical manifestations present in Mrs. J.
2. Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed.
3. Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.
4. Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend.
5. Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients’ transition to independence.
6. Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale.
7. Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.’s current and long-term tobacco use, discuss what options for smoking cessation should be offered.

You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. 

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance. 

Please complete ALL THREE of the Professional Development exercises.

• Conduct a literature search to locate a nursing intervention delivered via telehealth. Summarize the findings of the literature review in the form of a table. This table should include the article title, database used, summarize the key points of article, summarize findings, Is this applicable to patient population
• Imagine that you are a public health informatics specialist and you and your colleagues have determined that the threat of a new strain of influenza indicates a need for a mass inoculation program. What public health data would have been used to determine the need for such a program and what data will be collected to determine the success of such a program?
• What are the ethical considerations related to interoperability and a shared electronic health record?

Please submit the literature review table and one APA formatted analysis for bullets 2 and 3 between 500-1000 words, not including the title and reference page. The assignment should have a minimum of two scholarly sources, in addition to the textbook.

 

Assignment Description

Signature Assignment Title: The Holistic Patient Assessment

Part 1: Choose an adult (over the age of 18) friend or relative and perform a holistic health assessment. Clearly document your holistic health assessment data

Your assessment should include the following parts:

• Health History
• Physiological Assessment
• Psychological Assessment
• Social Assessment
• Cultural Assessment
• Developmental Assessment
• Spiritual Assessment

Part 2: Interpret the findings in your holistic health assessment data according to pathophysiologic disease states.  

• Choose one physiologic abnormality and discuss possible pathophysiologic reasons for the abnormality.  
• Look at the abnormality on a holistic basis.  
• How does this abnormality impact the other areas of the patient’s life, especially those areas discussed in this course?
• Discuss the client’s stress and coping mechanisms.  
• Are they healthy?  
• What improvements could be made?

Part 3: Create a teaching plan that addresses the client holistically by applying the assessment data you have analyzed.  

• Describe at least one client goal for each of the categories (physical, psychological, social, cultural, developmental, and spiritual).
• How will you teach the client about the goal?  
• How will you evaluate your teaching?  

Part 4: Prepare a PowerPoint presentation for your patient teaching.  

• You should have at least six slides (one for each type of goal – physical, psychological, social, cultural, developmental, and spiritual), in addition to the title slide, objective slide, and references slide.  
• Please be sure to have at least one scholarly source in the PPT.

Assignment Expectations:

• Length: Essay of 1200 words; PP of 6-12 content slides (and include a title, objective, and reference slides – these do not count towards the required content slides)
• Structure: PP as noted above. Essay: Include a title page and reference page in APA format. These do not count towards the minimum word count for the essay part of the assignment. Your essay must include an introduction and a conclusion. 
• References: Use appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of three scholarly sources plus the textbook are required.