Standardized nursing language for healthcare information systems.

Since a substantial component of health care delivery is reflected in nursing's work, it is imperative that nursing expedites implementation of a standardized language that reflects nursing's work and ultimately allows outcome evaluation. This paper will summarize the state of development and related issues of standardized language in nursing, including: Nursing Minimum Data Set, Taxonomies of Nursing Diagnoses, Nursing Interventions, Outcomes, and the Nursing Management Minimum Data Set. The Nursing Minimum Data Set, including nursing care, patient or client demographic, and service elements, reflects a standardized collection of essential nursing data used by multiple data users in the health care delivery system across all types of settings. The nursing care elements include nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. Currently, more than 100 nursing diagnoses have been accepted for clinical testing by the North American Nursing Diagnosis Association (NANDA) and have been incorporated into a taxonomy of nursing diagnoses that reflects patient responses to actual or potential health problems that nursing can address. A current formulation of a taxonomy of nursing interventions for the treatment of the nursing diagnoses yielded 336 nursing intervention labels organized at three or four levels of abstraction. Concomitant with these endeavors is the necessity for identifying outcomes associated with each diagnosis and its treatment. Concepts and a classification for indicators of these outcomes are being reviewed. Last, to address the contextual covariates of patient outcomes, a collection of core variables needed by nurse managers to make management decisions and compare nursing effectiveness across institutions and geographic regions is under development. In summary, standardized measures to determine cost effective, high quality, appropriate outcomes of nursing care delivered across settings and sites are being developed.

Validating impaired physical mobility.

The clinical presence of impaired physical mobility documented for acute-care patients was studied. The frequency, individual, and group sensitivity levels of the defining characteristics documented as empirical referents for the diagnosis were examined. The frequency of the related factors associated with the diagnosis, patient demographics, length of stay (LOS), discharge destination, and diagnostic-related groups (DRGs) were also examined. Data were obtained from electronic tapes of patient information. Support was found for impaired mobility, as a high-frequency diagnosis, in heterogeneous acute-care patients. No support was found for any major defining characteristics across the heterogeneous sample. A cluster of three defining characteristics: (a) inability to purposefully move within the environment; (b) decreased muscle strength, control, or mass; and (c) imposed restrictions of movement was supported by group sensitivity measures. Major defining characteristics were supported in two DRG subsets. Clusters of defining characteristics varied among four DRGs. The NANDA-preidentified related factors were associated with the diagnosis. Electronic storage and retrieval of computerized nursing data, including the elements of the Nursing Minimum Data Set (NMDS), was an effective, efficient method for data collection and analysis.

Validation of defining characteristics of four nursing diagnoses using a computerized data base.

As the use of nursing diagnoses in clinical practice increases, systematic research is necessary to appropriately validate them. Validity studies could be expedited by the use of information technology and computerized clinical data bases. The purpose of the following descriptive study was to validate the defining characteristics (risk factors for potential diagnoses) of the four nursing diagnoses related to alterations in fluid volume proposed by the North American Nursing Diagnosis Association using a nursing minimum data set (NMDS) collected from a computerized nursing data base. A sensitivity measure, the proportion of subjects with specific defining characteristics for a given diagnosis among the total number of subjects with the respective diagnosis, was used to estimate validity. The study was conducted in a 265-bed, mid-western, community hospital in which computerized nursing diagnosis care planning is used. The elements of the NMDS and defining characteristics were collected from a systematic sample (N = 191). The sample consisted of a proportion of about half of computerized discharge patient care plan summaries from each of the four diagnostic labels related to alteration in fluid volume obtained from medical records during the 1987 calendar year. Discharge patient care plan summaries contained at least one of four nursing diagnoses related to alteration in fluid volume. The results show the existence of individual defining characteristics as well as combinations of defining characteristics meeting validation criteria for each diagnostic label. Never-documented defining characteristics also were identified.

Bathing/hygiene self-care deficit: defining characteristics and related factors across age groups and diagnosis-related groups in an acute care setting.

The purpose of this descriptive study was to validate the nursing diagnosis, bathing/hygiene self-care deficit. Defining characteristics and related factors were abstracted retrospectively from a computerized patient care planning database. Data were treated to descriptive statistics and chi-square analysis to determine frequencies and percentages. Major support was found for the defining characteristic "inability to wash body or body parts" (84%) and minor support was garnered for "inability to obtain/access water source" (77%). Related factors associated with the diagnosis were also examined for this acute-care patient population. The percentages of occurrence were decreased activity tolerance (40%); mobility impairment (24%), pain (19%), musculoskeletal impairment (19%), neuromuscular impairment (9%), and perceptual or cognitive impairment (4%). The diagnosis was found among 80 DRGs and across all age groups (range, 9-92 years).

A nursing information system. The outcome of implementing nursing diagnoses.

The use of nursing diagnosis, as the focus for care planning and as a role expectation for professional nursing practice, has evolved throughout the years into a concept that has permeated all other systems in the Department of Nursing. Systems that were previously mutually exclusive were organized through the use of nursing diagnosis-based care planning and were integrated to improve both nursing efficiency and efficacy. Full computerization of the Nursing Information System Model (Fig. 1) will have the nursing diagnosis-based patient care plan and the medical orders for nursing intervention as the source of all clinical nursing data and will provide the majority of nursing administrative management data.