F.M.C.

YENAGOA
NURSES’ MONTHLY CONTINUING EDUCATION PROGRAMME

TOPIC: THE USE OF STANDARDIZED NURSING LANGUAGES (SNLs) IN NURSING CARE

PRESENTED BY

DIGITEMIE MARGARET (ADNS)

MSc, BNSc, RPON, RM, RN
OCT. 2018.
 Objectives of the presentation

• At the end of this presentation, participants should be

able to:

1. Define standardized nursing language (SNL)

2. Enumerate benefits of SNL

3. Discuss nursing process

4. Plan the care of patient using the SNLs; NANDA-I,

NOC, and NIC (NNN).
 Background
• Nursing care means diagnosing and providing interventions with
expected outcomes.

• So quality nursing care means improving our diagnosing and

interventions.

• And there is no denying the fact that nursing contributes greatly to the
quality of care given to patients/clients.

• But much of what we do remains invisible or immeasurable.

• So how can we make our quality nursing care identifiable and

measurable?

• One way to do this is to use a standardized (unified) language to

describe the care we provide.
 Background contd.
• The use of standardized language by physicians has been a long tradition.

• And nursing from the onset was used to medical language (medical diagnoses and
interventions).

• Throughout history, nurses have documented their care using individual and unit-
specific methods, resulting in a wide range of terminology describing the same care.

• Our healthcare data have been buried in long narrative, (or sometimes very scanty)
under-structured format.

• Hence we have been under-represented in the communication of healthcare data.

• But nursing of now is of age to use its unique language to express what it does in
order to be adequately compensated for the care we provide.

• A very important element in distinguishing the purposes and practices between

nursing and medicine lies in their professional languages.
 Background contd.
• Currently, many organizations are moving to electronic
documentation (ED) and the use of electronic health records
(EHR).

• And it is impossible for any healthcare discipline, including

medicine and nursing, to implement ED without having a
standardized language (vocabulary) to describe the key
components of the care process.

• Hence, with the growing use of ED, there is need for nurses to
agree on common terminology to describe assessments,
interventions and outcomes in documenting our nursing care.

• Hence, the development of SNLs.

 Definition of SNL
• “Standardized nursing language is a commonly-
understood set of terms used to describe the clinical
judgments involved in assessments, (nursing
diagnoses), along with the interventions, and
outcomes related to the documentation of nursing
care” (NANDA International).

• SNL is a unified vocabulary describing nursing

diagnoses, interventions, and outcomes, used in
documenting nursing care.
 What is SNL?
• It is a concise and clear communication method.

• It is an effective means of interdisciplinary

communication.

• It quickly communicates essential patient care

information.

• It ensures consistent communication and clarity, thereby

giving a better direction for patient care.
 SNL and patient safety
• Patient safety is fundamental in healthcare.

• And to ensure patient safety, all clinicians need to

quickly understand and act on the patient’s priority
needs.

• Hence the need to replace long written narrative

language with concise and clear standardized
language to enable all healthcare providers understand
what is meant and the appropriate plan of care.
 Development of SNLs
• Nursing terminologies and vocabulary structures first
developed more than four decades ago (1973), and
have been evolving since then (Yoost & Crawford, 2016).

• Currently, there are twelve (12) terminology sets

(SNLs) that support nursing practice approved by the
American Nurses Association (ANA) (National Association of
School Nurses, 2012).

• The terminologies are as follows:

 The SNLs
1. NANDA International (NANDA-I). {NANDA in 1973, NANDA-I in 2002}
2. Nursing Interventions Classification (NIC). {1987}
3. Nursing Outcomes Classification (NOC). {1991}
4. Clinical Care Classification (CCC) System
5. The Omaha System
6. Perioperative Nursing Data Set (PNDS)
7. International Classification For Nursing Practice (ICNP)
8. Systematized Nomenclature of Medicine Clinical Terms
(SNOMED CT)
9. Logical Observation Identifiers Names and Codes (LOINC)
10.Nursing Minimum Data Sets (NMDS)
11.Nursing Management Minimum Data Sets (NMMDS)
12.Alternative Billing Concepts (ABC) Codes.
 The SNLs contd.
• Among the SNLs, NANDA-I, NIC and NOC are probably
the best known, well-developed, and most applicable in most
systems, particularly in developing nations like ours where
ED and EHR are scarcely in use.

• NANDA-I is commonly used with NIC and NOC (the NNN

link).

• NNN is a means of providing comprehensive evidence-based

standardized classifications of nursing diagnoses, nursing
interventions, and nursing-sensitive patient outcomes.

• NNN represents the nursing process.

 Benefits of SNLs
• Better communication among nurses and other
healthcare providers.

• Increased visibility of nursing interventions and

resultant patient outcomes.

• Improved patient care.

• Greater adherence to standards of care.

• Furthering the nursing research agenda by generating

data about patient care in a consistent manner.
 SNLs and the Nursing Process
• Nursing process is the framework for implementing our
standardized professional language.

• The nursing process comprises the following six (6) steps with an
acronym ‘ADOPIE’:

1. A= Assessment
2. D= Diagnosing (NANDA-I)
3. O= Outcome Identification (NOC)
4. P= Planning
5. I= Implementing (NIC)
6. E= Evaluating the outcomes (NOC)
The modified nursing process (adapted). (Herdman & Kamitsuru, 2018, p. 36)
Theory/nursing
science/underlying
nursing concepts: e.g of
critical concepts include
breathing, elimination,
themoregulation, physical
comfort, self-care, and
skin integrity.

Continual Assessment/
re-evaluation patient history

Planning
• Nursing diagnosis
Implementation • Nursing outcomes
• Nursing
interventions
 Step 1: Assessment
• This first step involves 2 activities;

i. Assess for cues (hints, signals): means collect, validate,

organise, and document patient data.

ii. Cluster cues, and identify nursing diagnoses.

• Means of data collection include:

-nursing history
-physical assessment
-review of lab and diagnostic test results
-review of other available health information.

• A comprehensive nursing assessment is completed using the

 Step 2: Nursing Diagnosis
• “In the early 1970s nurses and educators uncovered the fact that nurses
independently diagnosed and treated “something” related to patients and their
families, which was different from medical diagnoses” (Herdman & Kamitsuru,
2018, p. xvii)

• “A nursing diagnosis is a clinical judgment concerning a human response to

health conditions/life processes, or vulnerability for that response, by an
individual, family, group, or community”. (NANDA International, 2013 cited by
Herdman & Kamitsuru, 2018, p. 38 ).

• It provides a basis for the selection of nursing interventions to achieve

nursing outcomes for which the nurse is accountable.

• Nursing diagnoses foster nurses’ independent practice as opposed to

dependent interventions driven by physician’s orders.

• Whereas a medical diagnosis identifies a disorder, a nursing diagnosis

identifies problems resulting from that disorder.
Comparison of selected medical and nursing
diagnoses (in their professional languages)

Medicine Nursing

• Chronic obstructive • Ineffective Breathing

pulmonary disease Pattern

• Cerebrovascular accident • Impaired Physical Mobility

• Appendicectomy • Acute Pain

• Amputation • Disturbed Body Image

• Tonsilitis • Hyperthermia
 Types of Nursing Diagnosis

• Currently, NANDA International identifies 4

types of nursing diagnoses (Herdman & Kamitsuru, 2018, p.
35):

1. Problem-focused diagnosis
2. Risk diagnosis
3. Health promotion diagnosis
4. Syndrome diagnosis
 Types of Nursing Diagnosis contd.
• Problem-focused diagnosis = a clinical judgment that an
undesirable human response exists in the patient/client.

• Risk diagnosis (a potential risk) = a clinical judgment

that the patient is susceptible to developing an undesirable
human response to the health condition/life processes.
E.g., ‘Risk for aspiration’.

• Health promotion diagnosis = a clinical judgment that

the patient is motivated and desires to increase well-being,
and to actualise health potential, usually expressed by a
patient’s readiness to enhance specific health behaviour.
E.g, ‘Readiness for enhanced knowledge’.
 Types of Nursing Diagnosis contd.
• Syndrome diagnosis = a clinical judgment about a
specific cluster of nursing diagnoses that occur together,
and so are best addressed together through similar
interventions. E.g., ‘Chronic pain syndrome’ = chronic
pain, disturbed sleep pattern, fatigue, impaired physical
mobility, social isolation.

• N/B: problem-focused diagnoses are not more important

and may not always be of higher priority than risk
diagnoses. E.g., for a patient with the following diagnoses:
activity intolerance, impaired memory, readiness for
enhanced health management, and risk for falls;
• which one is the highest priority diagnosis???
 Structure of nursing diagnosis
• Nursing diagnoses can be one-part, two-part, or
three-part statements.

• Health promotion and syndrome nursing diagnoses

are one-part statements.

– Health promotion diagnoses always have the same

related factor, which is; ‘motivated to achieve a higher
level of wellness’. E.g. ‘Readiness for enhanced coping’

– Syndrome diagnoses have no related factor. E.g. ‘Rape

trauma syndrome’
 Structure of nursing diagnosis
contd.
• Risk diagnoses are two-part statements; the
diagnostic label and the presence of risk
factors. E.g. ‘Risk for infection related to
compromised host defenses’.

• Problem-focused diagnosis is a three-part

statement; the diagnostic label, related factor,
and signs & symptoms. E.g. ‘Acute pain
related to tissue ischaemia as evidenced by
statement of “I feel severe pain on my chest”’.
 Step 3: Outcome identification
(NOC)
• The nurse defines the expected outcomes of managing the identified
nursing diagnoses.

• Patient outcomes should be specified before choosing interventions.

(Bulechek et al., 2013, p.13)

• The nurse must identify the outcomes that can be reasonably expected
and attained as a result of nursing care.

• NOC has about 490 outcomes.

• NOC is “a taxonomy of patient outcomes that are sensitive to nursing

interventions” (Gulanick et al., 2003, p.2).

• NOC provides outcomes that can be used to assess patient status

following nursing interventions, i.e., the effectiveness of their
 Examples of NOC
NANDA-I NOC
1. Ineffective Airway Clearance 1. Respiratory Status: Airway Patency

2. i. Anxiety Control; ii. Coping

2. Anxiety
3. i. Risk Control; ii. Risk Detection; iii. Respiratory
3. Risk for Aspiration Status: Ventilation

4. i. Immune Status; ii. Risk Control; iii. Knowledge:

4. Risk for Infection Infection Control

5. i. Comfort Level; ii. Medication Response; iii. Pain

5. Acute Pain Control

6. Diarrhoea 6. i. Bowel Elimination; ii. Fluid Balance; iii. Medication

Response

7. Fatigue 7. i. Activity Tolerance; ii. Endurance; iii. Energy

Conservation

8. Deficient Fluid Volume

8. i. Fluid Balance; ii. Hydration

9. Impaired Gas Exchange 9. Respiratory Status: Gas Exchange

 Step 4: Planning of care
• The nurse makes plans with the patient and family to deal
with the diagnoses in order to achieve the identified
outcomes.

• This is when the nurse draws up a nursing care plan.

• Care planning is an ongoing dynamic process.

• Hence, care plans are modified, updated, corrected and

extended according to the patient’s changing needs.

• Basically, the nursing care plan is a written reflection of the

nursing process (Gulanick et al., 2003, p.2).
 Steps in care planning
1. Prioritize the identified diagnoses/problems.

2. Differentiate problems that can be resolved by nursing

intervention.

3. Set goals of actions (immediate, intermediate and long-term).

4. Select nursing interventions.

5. Draw a nursing care plan.

6. Communicate the plan of care to all who will be involved in

the care.
Guidelines for writing nursing care plans
• Date and sign the identified nursing diagnoses and the evaluations.

• Use category headings as follows: Nursing Diagnosis, Goals/Desired

outcomes, Nursing Intervention, and Evaluation.

• Use acceptable medical abbreviations rather than full sentences. E.g.,

IBP=ineffective breathing pattern; IAC=ineffective airway clearance;
IGE=impaired gas exchange; etc.

• It should contain interventions for ongoing assessment of the client.

• Include collaborative interventions.

• Include plans for the client’s discharge and home needs care.

• NB: care plans on the job are less detailed. Nurses are generally not
 Step 5: Interventions (NIC)
• Implement the identified nursing interventions in the care plan.

• A nursing intervention is “any treatment, based upon clinical judgment and

knowledge, that a nurse performs to enhance patient/client outcomes”. (Bulechek et
al., 2013, p.2).

• Nursing activities are the specific actions nurses do to implement an intervention

towards a desired outcome. (Bulechek et al., 2013, p.2).

• There are therefore several activities per intervention. (Interventions = about 554,
and activities = about 13,000).

• It is a comprehensive standardized classification of evidence-based interventions

that nurses perform. (Bulechek et al., 2013, p.2, Gonen, Strauss & Oren-Landes, 2017).

• It includes both nurse-initiated and physician-initiated nursing treatments. (Bulechek &

McCloskey, 1995).
 NIC interventions include the following
aspects:

1. Physiological: e.g., Acid-Base Management, Airway

Suctioning, Pressure Ulcer Care, Medication Administration,
Pain Management, etc.

2. Psychosocial: e.g., Anxiety Reduction, Emotional Support,

Coping Enhancement, Emotional Support, Presence, etc.

3. Illness Treatment: e.g., Hypoglycaemia Management, Ostomy

Care, Shock Management, etc.

4. Illness Prevention: e.g., Fall Prevention, Infection Protection,

Immunization/vaccination Administration, etc.

5. Health Promotion: e.g., Exercise Promotion, Nutrition

Nursing interventions vs Activities
intervention (NIC) activities
• Admission Care • Introduce yourself and role in providing care
• Orient pt/family to expectations of care
• Provide appropriate privacy/family
• Orient them to immediate environment
• Obtain admission history
• Perform admission physical
assessment……………………..
• Document pertinent information
• Establish plan of care
• Notify physician of admission
• Obtain physician’s orders for care.

• Airway Suctioning
• Use standard precautions
• Determine the need for oral/tracheal suctioning
• Auscultate breath sounds before and after suctioning
• Inform pt/family about suctioning
• Aspirate the nasopharynx with suction device
• Instruct pt to take several deep breaths before
suctioning……………………………..
• Stop tracheal suctioning and provide supplemental
oxygen if pt experiences bradycardia……………etc.
 Nursing interventions vs Activities contd.
intervention (NIC) activities
• Anxiety Reduction • Use a calm reassuring approach
• Explain all procedures including sensations likely to be experienced
during the procedue
• Seek to understand the pt’s perspective of a stressful situation
• Provide factual information about diagnosis, treatment and
prognosis
• Stay with pt to promote safety and reduce fear
• Encourage verbalization of feelings, perceptions and fears
• Provide diversional activities geared toward reduction of tension
• Help pt identify situations that precipitate anxiety…..........................
• Administer prescribed anxiolytics.

• Body Image • Determine pt’s body image expectations based on developmental

Enhancement •
stage
Use anticipatory guidance to prepare pt for predictable changes in
body image
• Assist pt to discuss changes caused by illness
• Help pt determine the extent of actual changes in the body or its
level of functioning
• Assist pt to separate physical appearance from feelings of personal
worth
• Monitor whether pt can look at the changed body part
• Monitor frequency of statements of self-criticism…….etc.
 Example of using the NNN
• Case scenario 1:
• 8/10/18
• Miss Efemsi, a 25-year old spinster and television
broadcaster who was involved in a fire incident and
sustained about 20% burns to the face, neck, and both
arms, was rushed into the A&E unit, crying and
moaning in pains.

• There are burn injuries with blisters in the affected

areas.

• She is not pale, not dehydrated. Her vital signs are T

36.7ᵒc, P 80b/m, R 23c/m, BP 110/70mmHg.
 Case scenario 1 contd:
• She had just been employed last year, and not in any serious
sexual relationship.

• Three days after, she views her face in the mirror, and her
mood changes, becomes withdrawn, and starts crying silently.

• At this point, there is no increase in the pain level as

admitted by her, but her vital signs are raised to T 37.4ᵒc, P
110b/m, R 38c/m, BP 140/90mmHg.

• She expresses worries about the effect of her disfigured face

on her new job and life generally, with statements such as “I
can’t appear on screen any more with this face”, “will any
man want to marry me with this face?”.
 Case scenario 1 contd.
• Cues: 25-year old spinster, television
broadcaster, burn injuries, crying and moaning
in pain, moody attitude, crying silently, raised
vital signs, statements of worry.

• Cluster cues:
1. Burn injuries, crying, and moaning
2. 25-year old spinster, television broadcaster,
moody attitude, crying silently, raised vital
signs, statements of worry.
 Case scenario 1 contd.
• Nursing diagnoses from above cues:
1. Acute Pain r/t skin tissue damage AEB crying and
moaning.

2. Risk for Infection r/t break in skin integrity.

3. Disturbed Body Image r/t alterations in physical

appearance AEB verbalization of “I can’t appear on
screen any more with this face”, “will any man want to
marry me with this face?”.

4. Anxiety r/t perceived threat to physical and emotional

integrity AEB crying silently, raised vital signs.
 Case scenario 2
• 10/10/18
• Mrs. Broomstick, a 37-year old nulliparous woman
with amenorrhoea of about 7 weeks presents in the
Gynae Emergency ward with severe lower abdominal
and pelvic pains which she says is more on the left
side, vaginal bleeding, and weakness.

• LMP was 26/8/18. She reports that pain is sharp, and

frequent, lasting for more than 30 minutes per
episode. She is crying and guarding the abdomen in
pains. Abdomen is tender, and said there is vomiting
during pain, having vomited 3 times at home.
 Case scenario 2 contd.
• Bleeding was said to have started as spotting 3 days ago, and
gradually became heavy, having changed 4 heavily soaked
sanitary pads within 2 hours prior to presentation.

• Vital signs on admission are T 37.3ᵒc, P 120b/m, R 40c/m,

BP 100/50mmHg. Lab results reveal urinalysis: positive PT,
PCV: 25%, and abdomino-pelvic USS shows ruptured left
tubal pregnancy.

• Emergency exploratory laparotomy for salpingectomy was

done. Postoperatively, she expresses worry about her chances
of childbearing with only one fallopian tube left now, saying,
“age is not on my side, and now, only one tube is left”.
 Case scenario 2 contd.
• Cues: 37-year old nulliparous woman, 7 weeks
amenorrhoea, crying and guarding the abdomen in
pain, abdominal tenderness, vaginal bleeding, PCV
25%, ruptured tubal pregnancy, statement of worry.

• Clustering cues:
1. Heavy vaginal bleeding, vomiting, altered vital
signs, PCV: 25%.
2. Severe, sharp and frequent pain, abdominal
tenderness, crying, and guarding behaviour.
3. 35-year old nulliparous married woman, statement
of worry.
 Case scenario 2 contd.
• Nursing diagnoses from above cues:

1. Deficient fluid volume r/t bleeding and vomiting

AEB weakness, altered vital signs, and PCV: 25%.

2. Acute pain r/t peritoneal irritation AEB abdominal

tenderness, crying, and guarding behaviour.

3. Anxiety r/t loss of pregnancy and fallopian tube in

advanced age (37yrs) AEB statement of “age is not
on my side, and now, only one tube is left”.
 Examples of NNN links
S/N NANDA-I NOC NIC
1. Deficient Fluid •Fluid Balance •Fluid Monitoring
Volume •Hydration •Fluid Management

2. Acute Pain •Comfort Level •Analgesic Administration

•Medication Response •Pain Management
•Pain Control

3. Risk For Infection •Immune Status •Infection Control

•Knowledge: Infection Control •Infection Protection

4. Disturbed Body Image •Body Image •Body Image Enhancement

•Self-Esteem •Coping Enhancement

5. Anxiety •Anxiety Control •Anxiety Reduction

•Coping •Presence
•Emotional Support
 Sample care plan
S/N Date/ NOC/Expected NIC/Nursing Actions Evaluation &
Diagnosis Outcome Re-planning
(NANADA-I)

1. 8/10/18 •Pain Control; •Pain Management: •She verbalizes

Acute Pain r/t •Medication -Assess the pain characteristics ability to cope
skin tissue Response: -Observe S/S associated with the with the pain,
damage AEB -Patient pain though she
crying and verbalizes -Assess her expectations for pain reports that pain
moaning. ability to cope relief is still severe.
Digitemie M. with -Respond immediately to The cry has
incompletely complaint of pain reduced.
relieved pain -Eliminate additional sources of •Continue pain
within 24hrs of discomfort management.
action. -Provide rest periods to facilitate 9/10/18
comfort, sleep and relaxation Digitemie M.
-Administer prescribed analgesics.
 Sample care plan contd.
S/N Date/ NOC/Expected NIC/Nursing Actions Evaluation &
Diagnosis Outcome Re-planning
(NANADA-I)

2. •Immune Status; •Infection protection. •Wounds appear

8/10/18 •Knowledge: •Infection Control. clean, no
Risk For Infection -Ensure monitoring of WBC obvious signs
Infection r/t Control: (4000-11,000 mmᵌ) of infection on
break in skin -Burn injuries are -Monitor for signs of infection 3rd day of
integrity. free from -Assess nutritional status, dressing.
Digitemie M. infection. including weight •Continue
-Infection is -Ensure hand hygiene and teach aseptic wound
recognised and other caregivers to do same before care.
promptly and between procedures 11/10/18
controlled -Maintain asepsis with prompt Digitemie M.
throughout and daily wound care
hospitalization. Encourage intake of protein- and
calorie-rich foods
Limit visitors
Encourage adequate fluid intake
(2000-3000ml daily)
Administer prescribed antibiotics.
 Sample care plan contd.
S/N Date/ NOC/Expected NIC/Nursing Actions Evaluation &
Diagnosis Outcome Re-planning
(NANADA-I)

3. 11/10/18 •Body Image; •Body Image Enhancement •One week

Disturbed Body •Self-Esteem: •Coping Enhancement: after, she shows
Image r/t -Patient -Assess her perception of the enhanced body
alterations in demonstrates change in physical appearance image, as she is
physical enhanced body -Encourage verbalization of able to look at
appearance image and self- positive or negative feelings her face without
AEB esteem before about the change crying, seeing
verbalization of discharge. -Assess perceived impact of the that the facial
“I can’t appear change on personal relationships wounds are
on screen any and occupational activities beginning to
more with this -Acknowledge normalcy of her show sings of
face”, “will emotional response to the change healing.
any man want -Help her identify actual changes 18/10/18
to marry me -Assist her in accommodating the Digitemie M.
with this change to be able to return to
face?”. normal social and occupational
Digitemie M. activities.
 Summary and Conclusion
• SNL is unique to nursing.

• It helps to make nursing visible and better understood in the care provided
to clients.

• SNLs are extensive, and may seem difficult to know and utilize, but can be
simple to use.

• They only require our regular use in order to make them part of us.

• Nursing Process is the framework for documenting our nursing care.

• And SNL is the language for the documentation of the Nursing Process.

• It is therefore important that the care we provide; to sustain life, alleviate

suffering, enable recovery, and promote health, be captured within the
standardized language and electronic health record, so that the contribution
of nursing profession to patient care is recognized and understood.
 References
• Bulechek G. M., & McCloskey C.J. (1995).Nursing Intervention Classification (NIC).Medinfo.MEDINFO.8pt2.1368.

• Bulechek G.M., Butcher H.K., Dochterman J.M., & Wagner C.M. (2008). Nursing Interventions Classification (NIC), 6 th Edn. Elsevier
Mosby: St. Louis.

• Gonen A., Strauss E. & Oren-Landes S. (2017). Promoting the use of nursing terminology classification among nursing students: An action
study. Journal of Nursing and Health Studies. 02.10.21767/2574-2825.1000018.

• Gulanick M., Myers J.L., Klopp A., Galanes S., Gradishar D., & Puzas M.K. (2003). Nursing Care Plans: Nursing Diagnosis and Intervention.
5th Edn. Mosby: St. Louis.

• Herdman H.T., & Kamitsuru S. (2018).NANDA International Nursing Diagnosis Definitions and Classification 2018-2020. 11 th Edn. Thieme;
New York.

• Johnson M., & Maas M. (1998). The Nursing Outcomes Classification. Journal of nursing care quality. 12(5):9-20. Retrieved from
https://www.ncbi.nim.nih,gov/pubmed/9610010.

• NANDA International. What is standardized nursing language? Retrieved from www.nanda.org on 22/5/18.

• NANDA International (2012). Nursing Diagnoses 2012-2014: Definitions and Classification e-Book. Retrieved from https://www.wiley.com
on 6/7/18.

• National Association of School Nurses (2012). Standardized Nursing Languages: Position Statement. Retrieved from https://files.eric.ed.gov
on 13/6/18.

• Wikipedia. Nursing Diagnosis. Retrieved from https://en.wikipedia.org on 20/6/18.

• Yoost B., & Crawford L. (2016). Fundamentals of Nursing: Active Learning for Collaborative Practice. Elsevier: St. Louis
THANKS