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Standardized Nursing Terminologies

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Standardized Nursing Terminologies

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:

  • Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.
  • Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.

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.

 

SAMPLE ANSWER

Standardized Nursing Terminologies

Introduction

Standardized nursing terminologies refer to a wide range of vocabularies that are used by nurses to describe standard care. The common language is understood by all nurses from different geographical areas and various health institutions. Nurses agree on a common form of communication to ensure that there is no confusion on patient health history even when given care by different nurses of health professionals in various hospitals, units, and countries. For instance, nurses document postpartum vaginal bleeding as large, moderate, or small. The terms small, large, and moderate describe a standard amount that is known by the nurse (Topaz, 2013). Thus, if a patient is treated in a different hospital by different nurses, their health information would remain clear without causing any confusion or inconveniences. This paper aims to review the concepts of informatics as described by Rutherford (2008), in “Standardized Nursing Language; What Does It Mean for Nursing Practice?”. The paper also describes the importance of standardized nursing terminologies.

In the “Standardized Nursing Language: What Does It Mean for Nursing Practice?”, the author describes how he visited a delivery and labor unit in a local community hospital with the aim of observing the implementation of the recent Nursing Outcome Classification and the Nursing Intervention Classification. One of the nurses commented that they document their care through the use of standardized nursing terminologies, but they do not understand why they do so. Therefore, Rutherford (2008) thought of writing an article describing the importance of Standardized Nursing Terminologies in improving patient care and evidence-based patient outcome for the nurses. Besides, based on various studies, there is a wide range of benefits of using the terminologies to both nursing practice and patient outcome.

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Benefits of Standardized Nursing Terminologies

Nurses should understand why they use standardized terminologies in documenting their care and their importance to nursing practice as well as patient outcome. Some of the benefits are outlined below:

  1. Improved Patient Care

The use of Standardized Nursing Terminologies helps in reducing misunderstandings and medical errors. The use of unstandardized data may cause a lot of challenges when it comes to data analysis and processing. When data is unstandardized, similar terminologies may have different meanings depending on the institutions since cultures and standards of care can considerably vary (Wang, Kung & Byrd, 2018). Medical errors and misunderstandings may lead to poor treatment of a patient which may lead to health emergencies such as the death of worsening of a patient’s health condition (Macieria, et al.2017). Therefore, nurses should be informed that its is highly beneficial to quality patient outcome.

  1. Improved communication among nurses and other health practitioners

The use of Standardized Nursing Terminologies enhances clear communication among health practitioners, such as administrators of health institutions and other health practitioners. For instance, through the use of the International Classification of Diseases, physicians can have a standard understating of various health conditions (Rutherford, 2008). The Diagnostic and Statistical Manual Disorders gives a common language for psychological disorders (Macieria, et al.2017). When a psychologist indicates the status of a patient on the patient chart using SNTs, other health practitioners, physicians, and nurses understand the diagnosis of the patient.

  • Enable Data Collection to Evaluate Nursing Care Outcomes

Application of Standardized Nursing Terminologies to document nursing care may provide the necessary consistencies when comparing care quality for different interventions. Many health organizations are adopting the use of electronic health records (Rutherford, 2008). When nursing care is documented electronically in a common language, data from large state, local and national institutions can be used for benchmarking with other institutions that give nursing care.

  1. Easy assessment of competencies in nursing

The use of Standardized Nursing Terminologies can be used in examining the competencies of nurses in the field. It is a requirement for the healthcare institutions by the joint commission to demonstrate the competency of the nursing staff (Macieria, et al.2017). The interventions which are described in the terminologies can be used to evaluate the competencies of nurses in performing those interventions (Rutherford, 2008). Besides, the documentation of care done by different nurses using the standardized language can be used to tell whether a nurse is giving the right care to a patient.

  1. Enhances the visibility of nursing interventions

Most nurses use non-formal notes or verbal communication when communicating with each other about patient care. Therefore, their interventions main remain invisible. Nurses need to understand that the use of Standardized Nursing Terminologies to document their care helps in making their interventions visible. Besides, the documentation of nursing interventions in computers helps describe their contributions to patient outcome, thereby making them more visible.

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Challenges in implementation of Standardized Nursing Terminologies

  1. Lack of professional practice understanding

One of the challenges in the implementation of Standardized Nursing Terminologies is that in most of the health institutions, nursing care is fails to be represented the documentation value of Standardized Nursing Languages (Topaz, 2013). Thus, there is no familiarity of nursing practice with Nursing Standardized Terminologies represented.

  1. Lack of proficiency with electronic health records and computers

Most nurses fail to understand the Standardized Nursing Terminologies. Besides, some nurses do not understand the application of Electronic health documentation and the use of computers (Topaz, 2013). Therefore, the implementation of the terminologies becomes a great challenge.

  • Technology and Information System barriers

Information System and technology barriers may include such factors as insufficient ability to retrieve or document nursing practice in form of Standardized Nursing Terminologies. Also,  its unavailability  in the Electronic Health Records poses great challenges during the implementation of SNTs. In addition, the Standardized Nursing Terminologies acts as one of the major challenges in the implementation of SNTs.

Conclusion

In conclusion, the nurses who commented that they do not understand why they document their care through Standardized Nursing Terminologies should first learn the importance of the common terminologies. They enhance easy communication between nurses, other health practitioners, and administrators in health institutions. The languages also reduce the instances of misunderstandings and medical errors when patients are treated by different health practitioners in different geographical areas and various health institutions. Besides, it is easy to assess the competencies of nursing interventions through the use of Standardized Nursing Terminologies. Data collection and benchmarking are also quickly done when Standardized Nursing Terminologies are used in healthcare.

 

References

Macieira, T. G., 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. In AMIA Annual Symposium Proceedings (Vol. 2017, p. 1205). American Medical Informatics Association.

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice. OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.

Topaz, M. (2013). Invited Editorial: The Hitchhiker’s Guide to nursing informatics theory: using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics (OJNI), 17(3).

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, 3-13.

 

 

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Cognitive Behavioral Therapy: Family versus Individual Settings

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Cognitive Behavioral Therapy: Family versus Individual Settings

Whether used with individuals or families, the goal of cognitive behavioral therapy (CBT) is to modify client behavior. Although CBT for families is similar to CBT for individuals, there are significant differences in their applications. As you develop treatment plans, it is important that you recognize these differences and how they may impact your therapeutic approach with families. For this Discussion, as you compare the use of CBT for families and individuals, consider challenges of applying this therapeutic approach to your own client families.

Learning Objectives

Students will:

  • Compare the use of cognitive behavioral therapy for families to cognitive behavioral therapy for individuals
  • Analyze challenges of using cognitive behavioral therapy for families
  • Recommend effective cognitive behavioral therapy strategies for families

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To prepare:

  • Review the media, Johnson Family Session 3, in this week’s Learning Resources and consider the insights provided on CBT in family therapy.
  • Reflect on your practicum experiences with CBT in family and individual settings.

Post an explanation of how the use of CBT in families compares to CBT in individual settings. Provide specific examples from your own practicum experiences. Then, explain challenges counselors might encounter when using CBT in the family setting. Support your position with specific examples from this week’s media (see upload)

 

SAMPLE ANSWER

Cognitive Behavioral Therapy: Family Settings versus Individual Settings

During family therapy, Cognitive Behavioral Therapy (CBT) is used to identify behavioral goals, achieve goals using theoretical techniques, and learn social reinforces to accomplish the goals. CBT for family therapy helps to identify strengths and weaknesses of family. Individuals and groups of the family are in behavioral, emotional, and cognitive aspects of interaction to help plan for care or as an intervention plan (Nichols, 2014).  During family therapy, family members influence each other including the group behaviors. Therefore, during group therapy, paying attention to individual’s cognitions, emotions, and practices is critical.  For example what can be observed is the actions of the group towards an individual and the essential aspects of family relationships as seen in Johnson’s family.

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Individual CBT looks into the personal experiences especially how the client behaves, feels, and responds to therapy questions. Besides, the therapy leads to behavioral change and both primary and secondary thinking (Wheeler, 2014). Therefore, the main aim of a therapist is to ensure the care plan intervention is individualized to help respond and react to specific stimuli or challenges — the primary techniques to change the patient’s way of thinking using reattribution as observed in the film.  For example, the lady in the movie shared her story and accounts of how she was raped in a party, and she has since blamed herself and accepted all the blame Laureate Education, 2013). Therefore, individual therapy will aim at changing her feelings, cognitions, and emotions and to help her understand that it was not her fault but the rapist fault.

The major challenge that therapist face during both group and individual therapy are that clients are sometimes not willing to share their stories. For example, the lady mentioned that she often feels hurt whenever she shares the story with anybody and in some instances interrupted the therapist (Laureate Education, 2013). Thus, therapies need to understand that individuals in a family deal with emotions differently and it is essential to use individualized focused treatment during family therapy.

 

References

Laureate Education (Producer). (2013c). Johnson family session 3 [Video file]. Author: Baltimore, MD.

Nichols, M. P. (2014). The essentials of family therapy. Boston: Pearson.

Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse a how-to guide for evidence-based practice. New York, NY: Springer Publishing Company, LLC.

 

 

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Vargas Family-Discharge Summary

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Vargas Family-Discharge Summary

Read the entire “Vargas Family Case Study” (all eight sections). Consider the progress (or lack thereof) over the past eight sessions. Using the “Discharge Summary Outline” template; include the following in your outline:

1. A brief summary of what was going on with the family

2. A review of the initial treatment goals

3. Theories and interventions used

4. A brief discharge summary for the family treatment

5. Clinical recommendations for sustained improvement or referrals for additional services

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a scoring guide. Please review the scoring guide 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 directions in the Student Success Center.

 

SAMPLE ANSWER

PCN-521 Module 8:Vargas Case Study Discharge Summary Outline

  1. A brief summary of what was going on with the family at the onset of counseling:

 

  1. At the onset of counseling, the family was divided. The main reason behind the division was the constant disagreement between Bob and Elizabeth concerning Frank’s bad behavior. Frank was impulsive, consistently lost things, did not listen and was consistently picking on his sister, Heidi. While Elizabeth believed that Frank had ADHD, Bob minimized his behavior claiming that it was normal behavior for a boy. Bob and Elizabeth constantly argued with each other and this created tension in their marriage and the family in general.

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  1. A review of the initial treatment goals:

 

  1. The main goal of the first session was to develop a hypothesis that was maintaining the problem.
  2. The second goal was to develop a therapeutic relationship with each family member to improve the therapy session.
  • Theories and interventions used
    1. Week 1:
      1. Rapport building
      2. Family fun day out
    2. Week 2:
      1. Weekly soccer matches
    3. Week 3:
      1. Developing a family tree
    4. Week 4:
      1. Structural family therapy
      2. Family structure chart
  • Mirroring activity
  1. Constructing genogram
  1. Week 5:
    1. Bateson’s cybernetic model
    2. Strategic family therapy
  • Mental research institute model
  1. The Milan Family system model
  2. Haley and Madanes Strategic Approach

Vargas Family-Discharge Summary

  1. Week 6:
    1. Act and talk it out
    2. Soccer for the mind
  • Paint your feelings
  1. Week 7:
    1. Narrative therapy
  2. Week 8:
    1. Solution-focused brief therapy

Vargas Family-Discharge Summary

  1. A brief discharge summary for the family treatment:

 

  1. Reasons for seeking therapy: the family came to therapy to work on their communication problems. Elizabeth and Bob were fighting in front of their children, Frank was attacking his sister while Heidi’s achievements were ignored leaving her exposed to developing attention deficit disorder.
  2. Significant findings: Frank should get an official ADHD diagnosis and if he has the disorder, proper treatment interventions should be administered. The interventions proposed are designed to facilitate a state of wellness for the entire family. The weekly soccer matches appear to be working as the family report progress and improved interaction. Bob has shown the most transformation towards the end of therapy. He understands the amount of work Elizabeth puts in to take care of Frank. Heidi is also closer to Frank and she no longer feels ignored

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  1. Treatment: solution focused brief therapy was used where solutions were identified. Several sessions were held with the entire family where observations were made. Narrative therapy was also used together with solution-focused brief therapy
  2. Termination of therapy condition: the family has improved its communication strategies, Bob is more passionate about Elizabeth’s struggles and Frank and Heidi are interacting positively. The family is holding weekly bonding sessions over soccer matches and everyone is enjoying each other’s company.
  1. Clinical recommendations for sustained improvement or referrals for additional services:
    1. Frank is referred to a pediatrician for further analysis according to the American Psychiatric Association’s Diagnostic and Statistical Manual
    2. The family should continue to have weekly family time
    3. The family should hold therapy sessions with the extended family
    4. Frank should be enrolled in a soccer camp to improve his soccer skills

 

 

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Ethnicity and Pharmacotherapy for Cardiovascular Diseases

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Ethnicity and Pharmacotherapy for Cardiovascular Diseases

examine how patient factors may influence pharmacokinetic and pharmacodynamic processes of pharmacotherapeutics used in the treatment of cardiovascular disorders.  You also explore ways to improve drug therapy plans for cardiovascular disorders based on patient factors and overall health needs.

 

When writing your Week 2 Assignment, consider the following scenario:

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:

  • Atenolol 12.5 mg daily
  • Doxazosin 8 mg daily
  • Hydralazine 10 mg qid
  • Sertraline 25 mg daily
  • Simvastatin 80 mg daily

o Prepare

  • Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
  • Review the case study assigned by your Instructor for this Assignment.
  • Select one the following factors: genetics, gender, ethnicity, age, or behavior factors.
  • Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
  • Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
  • Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

 

Write a 2- to 3-page paper that addresses the following:

  • Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
  • Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
  • Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.

 

SAMPLE ANSWER

Ethnicity and Pharmacotherapy for Cardiovascular Diseases

Introduction

Drug prescription is considered to an essential aspect in patient care. When done properly, it leads to effective control of diseases and other health conditions, thereby improving the health of patients. Contrarily, poor prescriptions of drugs may lead to health problems. In some cases, it may lead to death. To achieve the aim of this process, practitioners need to adhere to suitable drug concentrations basing on different health factors (Ladd & Hoyt, 2016). One of the issues that may affect the effectiveness of drug dosages is ethnicity. This factor refers to the state of being in a social setting with common traditions. This paper tries to establish the impact of ethnicity on cardiovascular pharmacotherapy of a patient. The patient’s initials are AO and he is viewed to have had obesity in his life. He is diagnosed with hypertension and hyperlipidemia.

Ethnicity and Pharmacotherapy for Cardiovascular Diseases

Effect of Ethnicity on PD and PK Processes

There is a higher prevalence of cardiovascular diseases in African Americans than in other ethnic groups in the country. African Americans are depicted to have the highest prevalence of hypertension in the world. In addition, hypertension also develops earlier in blacks than in any other ethnic group. It is suggested that African Americans may carry a gene that increases their sensitivity to salt, thereby increasing their risk of attaining hypertension (Diaz et al., 2017). This group is also viewed to experience a high burden of morbid factors such as hyperdilipidemia, diabetes, heart disease, and obesity. These issues lead to elevated blood pressures in the ethnic group. The factors also increase the body’s resistance to drugs’ effects.  Assuming that AO is African American, he tends to have a lower control of hypertension than patients from other ethnic groups (Arcangelo et al., 2017).

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Changes in the Pharmacotherapy

Research shows that African American respond well to beta blockers in the treatment of hypertension. Therefore, Atenolol intake is suitable for AO. However, its dosage should start at 50 mg due to the patient having obesity. Doxazosin is viewed to be an essential add-on to calcium-channel blockers. However, it is discouraged in a monotherapy. Therefore, its 8mg dosage is suitable for the patient during a combinative therapy. Hydralazine is a vasodilator which is essential for relaxing the patient’s blood vessels. The drug may not be suitable for the patient when diuretics are involved (Sessoms et al., 2015). Simvastatin is suitable in the treatment of hyperlipidemia in African Americans. However, since the patient is obese, the starting dosage should 40mg. Sertraline is a suitable antidepressant whose intake is recommended to start between 50mg and 100mg. However, its interaction with simvastatin may lead to liver damage. Therefore, its 25mg dosage is safe for AO (Arcangelo et al., 2017).

Improving AO’s Therapy

Treatment of hyperlipidemia and hypertension for a patient with obesity also needs the use of physical exercises. In addition, the patient needs to have a healthy diet. Both approaches are considered suitable in reducing the patient’s weight (Diaz et al., 2017). In addition, control the amount of salt in the body, thereby making the patient to reduce effects of salt sensitivity. The practitioner also needs to engage in effective follow-ups to ensure that the patient’s liver is not affected by the interaction between simvastatin and sertraline. If its functionality is within the normal range, sertraline’s intake level may be increased to improve on the patient’s activeness (Whelton et al., 2016).

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Conclusion

Pharmacotherapy for hypertension and hyperlipidemia is depicted to be affected by ethnicity of the patient. The paper focuses on treatment basing on an African American ethnicity. The ethnic choice is essential for the disease because African Americans have a higher prevalence of hypertension than other ethnic groups. From the paper, it can be shown that proper consideration of changes in pharmacodynamic and pharmacokinetic processes leads to a safe prescription for the patient. Additional therapeutic measures such as exercises and a suitable diet are considered to improve the patient’s pharmacotherapy.

 

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).

Pharmacotherapeutics for advanced practice: A practical approach (4thed.). Ambler, PA: Lippincott Williams & Wilkins.

Diaz, K. M., Booth III, J. N., Seals, S. R., Abdalla, M., Dubbert, P. M., Sims, M., … & Shimbo,

  1. (2017). Physical activity and incident hypertension in African Americans: the Jackson Heart Study. Hypertension, 69(3), 421-427.

Ladd, E., & Hoyt, A. (2016). Shedding light on nurse practitioner prescribing. The Journal for

            Nurse Practitioners, 12(3), 166-173.

Sessoms, J., Reid, K., Williams, I., & Hinton, I. (2015). Provider adherence to national

guidelines for managing hypertension in African Americans. International Journal of Hypertension, 1-7. Doi:10.1155/2015/498074.

Whelton, P. K., Einhorn, P. T., Muntner, P., Appel, L. J., Cushman, W. C., Diez Roux, A. V., …

& Arnett, D. K. (2016). Research needs to improve hypertension treatment and control in African Americans. Hypertension, 68(5), 1066-1072.

 

 

 

 

 

 

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