Nursing Terminologies

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Introduction

I am a Certified Emergency Room Nurse and Nursing has a very special role to play in health care...but

"Despite considerable changes to nursing practice in the last 10-15 years, certain procedures remain unchallenged. Nursing is gaining increasing autonomy, but evidence suggests that many widely accepted and practiced routines and procedures have little clinical value due to the unreliability of the measurements." (Aileen Hemmisley download 9/18/2009 from http://www.rihleageofnurses.org.uk)

Nursing classifications have been developed to code and classify the six steps of the Nursing Process:

Assessment
Diagnosis
Outcome Identification (Expected Outcome/Goal)
Planning (Nursing Intervention)
Implementation (Type Intervention Action)
Evaluation (Actual Outcome)

Or using Terminology Domains

Diagnoses/Judgments
Interventions
Outcomes
Goals

Some of the major classification systems are:

ABCC Codes Terminology that describes alternative medicine, nursing and other integrative healthcare interventions. Includes type of provider and recognized level of licensed practitioner by state
AORN Perioperative Data Set (Diagnoses, Interventions, Outcomes)
American Nursing Diagnosis Associations (NANDA). NANDA nomenclature represents clinical nursing judgments about actual or potential health problems. NANDA diagnoses describe a patient’s reaction to disease or injury and could be compared to the medical communities ICD-9-CM codes, which describe the actual disease or injury. NANDA currently contains 167 approved diagnoses classified into nine domains. Each diagnosis consists of a label, definition, major and minor defining characteristics, and related factors.
Automated Community Health Information System (ACHIS) Since the late 1970s, AHS' overall goal has been the promotion of health. The pursuit of this goal has been manifested in the development, implementation, and management of quality EPSDT programs for Medicaid eligible infants, children, and adolescents. Over two million children under the age of 21 have received comprehensive preventive health services through the programs we have administered in six states.
CareMap Care plan system for case management resource overview.
Center for Nursing Classification & Clinical Effectiveness The Center for Nursing Classification and Clinical Effectiveness was established in 1995 to facilitate the ongoing research of the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC).
Clinical Care Classification (CCC) System. The CCC consists of two interrelated taxonomies. The CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions. Each of the two Taxonomies are classified by Care Components which provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other health care settings.
Georgetown Home Health Care Classification
Hettinger and Brazile System
Home Health Care Classification System (HHCC) This web site will give readers an introductory knowledge of Home Health Care Classification System, a standardized nursing language that can be used to document the provision of nursing care to patients in their homes
International Classification of Nursing Practice (ICNP) - Combinatorial terminology for nursing practice that facilitates cross-mapping of local terms and existing vocabularies and classifications. Includes Nursing phenomena (nursing diagnoses), Nursing actions, Nursing outcomes(Diagnoses, Interventions, Outcomes.The ICNP provides a nursing practice terminology that supports the comparison of nursing data by providing a framework to cross map other nursing terms, vocabularies and classifications
LOINC Set of universal names and ID codes for identifying laboratory and clinical test results which can be used to describe laboratory and clinical results when store in computer databases or transmitted in electronic messages
NANDA Taxonomy I
Nursing Interventions Classification (NIC) . The NIC is a comprehensive listing of nursing interventions that are grouped based on labels that describe nursing activities. It is divided into seven domains and 30 classes. The system was created to be used in various nursing and healthcare settings. NIC can be used with various other languages. There is a linking mechanism from NIC to the North American Nursing Diagnosis Association (NANDA) nursing diagnosis language. The Nursing Outcomes Classification (NOC) also links with the NIC items
Nursing Minimum Data Set (NMDS) Minimum set of items of information with uniform definitions and categories concerning the specific dimension of professional nursing, which meets the information needs of multiple data users in the health care system
Nursing Management Minimum Data Set Data variables categorized into environment, nurse resources, and financial resources that are needed to inform the decision making process of nurse executives related to leading and managing nursing services delivery and care coordination
Nursing Outcomes Classification (NOC) A comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. An outcome is a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions(Outcomes)
Omaha System. The Omaha System is a comprehensive practice and documentation tool that can be used by multidisciplinary health care practitioners in any setting from the time of client admission to discharge. It includes an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes) (Diagnoses, Interventions, Outcomes)
Patient Care Data Set. The Patient Care Data Set is a data dictionary of elements that may be included in and extracted from a clinical information system
Perioperative Nursing Data Set (PNDS) Standardized nursing vocabulary that addresses the perioperative patient experience from preadmission until discharged
Rural Elder Outreach Program

Introduction

Some of the major classification systems are:

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