Introduction
Standardized terminologies as specific systems for stating diagnosis, interventions, and outcomes are actively used in nursing because of their appropriateness to document or record patient conditions. Using North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcomes Classification (NOC) terminologies, nurses enter diagnoses, interventions, and outcomes in the Electronic Health Records (McGonigle, Kirkwood, Mastrian, & Rich, 2014, p. 65). It is also possible to apply these standardized terminologies for discussing the patient care scenario. The patient is a 51-year-old male having the following vital signs and values: blood pressure (BP) is 144/95 mmHg; blood urea nitrogen (BUN) is 35 mg/dL; the creatinine clearance is reduced; the uric acid is 4.8 mg/dL; the urinary retention is not stated. The patient complains of the lower back pain, fatigue, and often headaches. Thus, the paper aims to apply the NANDA, NOC, and NIC elements to the presented patient scenario and discuss the data, information, knowledge, and wisdom associated with the case.
Application of NANDA, NOC, and NIC Terminologies
In order to develop the effective patient care plan, it is necessary to assess the patient’s state using the standardized terminologies. While focusing on the patient’s vital signs and complaints, it is important to refer to the NANDA terminology in order to determine the appropriate diagnosis for the case. Thus, the nursing diagnosis includes the following elements: risk for or the altered renal perfusion, acute pain, decreased cardiac output, and activity intolerance.
Interventions for the observed conditions need to be determined with the help of the NIC terminology. Thus, the following interventions should be discussed in relation to the patient scenario: the invasive hemodynamic monitoring to measure the hemodynamic parameters and conclude on the further therapy to support the cardiovascular function; the vital signs monitoring as the collection of the cardiovascular data along with the body temperature data; the cardiac care; the pain management to help the patient to reduce the acute pain; and the emotional support to encourage the patient who feels fatigue.
The NOC elements related to the above-mentioned patient scenario are the following ones: the improved kidney function; the improved cardiac tissue perfusion; the enhanced circulation status; the decreased pain level; the developed risk control; the improved knowledge regarding the treatment procedures and regimen. When the diagnoses are determined with the help of the NANDA terminology, the interventions are proposed with references to the NIC language, and the outcomes are identified with the focus on the NOC terms, the nurse can develop the appropriate nursing plan to address the specified conditions.
The Data, Information, Knowledge, and Wisdom Framework
The process of developing the effective nursing plan for the patient case involves such steps related to the data, information, knowledge, and wisdom (DIKW) framework as the data analysis, the collection of the required information, references to the existing knowledge, and the application of the knowledge to practice (nursing wisdom) (Safdari & Azadmanjir, 2014, p. 5; Topaz, 2013). As a result, the process of decision-making regarding the patient’s diagnosis and effective interventions plan is based on the synthesis of the available data and information. It is important to state with the focus on references to the standardized terminologies that the first step is the data analysis (Lee, Chen, Kuo, & Chou, 2014, p. 157). It includes the thorough examination of the laboratory results, vital signs, and values. In addition, it is also necessary to communicate with the patient and determine what symptoms caused him to visit a doctor in order to have the full picture of the disease development and signs.
The next step is the collection of the necessary information with the help of examining and using the NANDA, NIC, and NOC terminologies. This process includes reviewing the classifications with the focus on the available data and labels. The NIC and NOC choices recorded for the case depends on the identified NANDA diagnoses. The knowledge is synthesized with the focus on analyzing how specific interventions proposed can contribute to achieving the expected outcomes and the relief for the patient (Fernandez, Doña, Raya, & Gallardo, 2013, p. e121). The stage associated with the nursing wisdom includes the development of the appropriate nursing plan and communication with the patient on the proposed procedures and treatment.
Discussing the use of the DIKW framework when working with the computer programs and software, it is possible to state that the time spent by a nurse for the necessary decision-making can decrease significantly. Thus, using the Electronic Health Recorders and the computer, a nurse can analyze the received data and then search the NANDA database in order to determine what diagnoses are correlated with the present conditions and signs. In this case, the search can be organized to examine labels of diagnoses, their codes, descriptions, and related factors (Daniel & Oyetunde, 2013, p. 92). When the nurse identified and recorded the appropriate diagnoses, the next stage is the search for relevant interventions with the help of the NIC database. This information can also be categorized and coded with numbers; as a result, the effectiveness of the search increases. The nurse can also examine the lists of proposed activities and select the most appropriate for the concrete case. The NOC domains can be associated with the NIC lists to determine the most suitable outcomes that respond to the selected nursing interventions, or interventions can be chosen depending on the desired outcomes (Fernandez et al., 2013, p. e121). Having received all the necessary information and recording it electronically, a nurse can develop the efficient nursing plan provided in the digital form. The next step associated with the stage of generating the wisdom is the practical application of proposed treatments and the direct communication with the patient. While being presented in the electronic form, the recorded data can be shared among nurses and physicians.
Conclusion
In order to propose the effective plan of interventions for the patient described in the scenario, it is necessary not only to refer to the standardized terminologies but also to apply the DIKW framework. As a result, the nurse can propose the most relevant plan of activities for the person with the kidney disease and hypertension while completing such stages as the collection of the data and its analysis; the search for the information and its recording with the help of the NANDA, NIC, and NOC terminologies; the synthesis of the knowledge and the actual development of the nursing plan; and the practical use of recommendations. The proposed framework is effective to describe how a nurse usually makes decisions regarding the patient cases and documents or records the information with the help of the standardized terminologies. The use of the NANDA, NIC, and NOC elements in nursing allows the effective exchange of the information when it is presented in the electronic form.
References
Daniel, G. O., & Oyetunde, M. O. (2013). Nursing informatics: A key to improving nursing practice in Nigeria. International Journal of Nursing, 5(5), 90-98.
Fernandez, J. P., Doña, A. M., Raya, P. C., & Gallardo, J. C. (2013). Importance of nurse intervention in the adaptation of patient treated with CPAP. Sleep Medicine, 14(1), e120-e131.
Lee, Y., Chen, S., Kuo, J., & Chou, H. (2014). The status of nursing leadership studies: its invisible network of knowledge. International Journal of Model Optimization, 4(2), 157-162.
McGonigle, D., Kirkwood, B., Mastrian, K., & Rich, K. L. (2014). Nursing informatics and the foundation of knowledge. New York, NY: Jones & Bartlett Publishers.
Safdari, R., & Azadmanjir, Z. (2014). Solutions and strategies for nursing informatics development. Health, 1(1), 4-12.
Topaz, M. (2013). The Hitchhiker’s Guide to nursing informatics theory: Using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics, 17(3), 25-39.