STANDARDIZED

NURSING
TERMINOLOGY
Presented by: Alyssa Mae Orande
BSN2A
 Define “Standardized
01 Nursing Terminology

Describe the impact of

02 terminologies on
nursing.

Describe the features of

OBJECTIVES 03 advance nursing

terminology system
INTRODUCTION
The Nursing profession needs to conduct research
and generates measures and evidence to prove
that their nursing care improves quality, safety,
and healthcare outcomes.
Nursing data are critical to the development of
data sets that can be used for analysis and
integrated with the data of healthcare disciplines
Capture of Clinical care data is needed for better
patient care coordination and management
INTRODUCTION
Standardized Nursing Terminologies are
needed to:
1. Provide valid clinical care data
2. Allow data sharing across today’s HIT and
EHR systems
3. Support evidence based decision making
4. Facilitate evaluation of nursing processes
5. Permit the measurement of outcomes.
HISTORICAL EVENTS

IN 1859, Florence Nightigale named her six cannons of care as “ what nurses
do?” in her text Notes on Nursing (1859)
She considered the six cannons to be measure of “Good Standards” essential
for the practice of nursing
In 1939, Virginia Henderson published “Textbook of the Principles and
Practices of Nursing in which she delineated her “14 patterns of daily living”
Then her works are followed by several theories.

Many models were all developed as approaches to patient care; none

referred to or predicted the use of computers to support the
implementation of nursing practice standards
HISTORICAL EVENTS

In 1970, American Nurses

Association (ANA) approved nursing
process as the standard of
professional nursing practice.
HEALTH
TERMINOLOGIES
International Classification of Disease (ICD)
was being used internationally for the reporting of mortality
and morbidity statistics, was also being used by the U. S
federal government for payment of healthcare services.
HEALTH
TERMINOLOGIES
Other hospital specialty departments initiated different terminologies
for payment of their specific services
Physician Current Procedural Terminology (CPT)-for surgical procedures
Logical Observation Identifier Names and Codes -for laboratory test
HEALTH
TERMINOLOGIES
Nursing terminology development
was motivated by a number of factors:
1. The need to quantify nursing
resources
2. The introduction of the electronic
health record in healthcare facilities
3. The development of knowledge
bases and growth of evidence
based nursing practice.
 NURSING AND
COMPUTERS The CCAN’s name was changed to
the CCAN supported the conduct
the Database Steering Committee
1985 of several conferences on
computers in nursing practice such
1992 and continued its involvement by
approving Nursing Informatics as
as werley and her development of
new nursing specialty.
the NUrsing Minimum DAta Set
(NMDS) The Council developed the criteria
for Nursing Terminology as
Nursing Informatics combines
appropriate for the documentation
nursing science, information
of Nursing practice.
science, and computer science to
manage and process nursing data, 2 Data Sets are recognized: Nursing
information and knowledge to Minimum Data Set and Nursing
facilitate the delivery of healthcare. Management Minimum Data Set

Metathesaurus
NURSING
TERMINOLOGY
CHALLENGES
2 Major Challenges
The existence of multiple, specialized
terminologies has resulted in areas of
overlapping content, areas for which
there was no content and large number of
different codes and terms
Existing Terminologies most often were
developed to provide set pf terms and
definitions of concept human
interpretation, with computer
interpretation only a secondary goal
ADVANCE
TERMINOLOGY
SYSTEM IN
NURSING
FORMAL
TERMINOLOGIES
Advance terminology system such as ICNP and
SNOMED-CT are a focus of today’s harmonizing
efforts.
Both terminologies facilitated two important
facets of knowledge representation for HIT and
EHR system that supports clinical care:
describing concept
manipulating and reasoning
 FORMAL
TERMINOLOGIES
Advantages resulting from first facet includes
a.) non ambigous representation of concepts
b.) facilitation of data abstraction or de-
absrtraction without loss of original meaning
c.) non ambigous mapping among terminologies
d.) data reuse in different context
e.) data interoperability across settings
FORMAL
TERMINOLOGIES
Advantages resulting from second facet includes
a.) auditing the terminology system
b.) automated classification of new concepts
c.) an ability to support multiple inheritance of
defining characteristics
CHARACTERISTIC OF
ADVANCE
TERMINOLOGIES
Concept Oriented
Domain Completeness
Polyhierarchical organizations
Atomic level
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non ambiguity
concept permanence
compositionality
synonym
CONCEPT
ORIENTATION
Semiotic Triangle
MODEL
STRUCTURES
Schemata and Type Definitions
Schemata incorporate domain-specific knowledge about
the typing constellation of entities, attributes and events in
the real world and, as such, reflect plausible combination
of concept for naming a nursing diagnosis or problem.
REFERENCE
TERMINOLOGY MODELS
FOR NURSING
DEVELOPMENT OF
ISO 18104:2003
intendended to be “consistent with the goals
and objectives of other specific health
terminology models in order to provide a more
unified reference health model.
ONTOLOGIES

represent classes (also refereed to as

concepts, categories, or types) and their
properties (also referred to as relations,
slots, roles, or attributes).
Also facilitate reasoning about the concept
OWL
REPRESENTATION
OF ICNP
intended for use where applications, rather
than humans, process information. As such, it
should be able to meet the requirements of
advance terminology systems the support
contemporary healthcare.
ICNP AS A
TERMINOLOGY

The primary motivation for an international

nursing terminology involves sharing and
comparing data across settings, countries,
and languages
SNOMED-CT
considered to be the most comprehensive,
multilingual clinical healthcare terminology in
the world and integrates, through external
mappings, concepts from many nursing
terminologies.
NURSING MINIMUM
DATA SET (NMDS)

identifies essential, common, and core data

elements to be collected for all patients/ clients
receiving nursing care includes three
categories of elements:
a. ) nursing care
b.) patient or client demographics
c.) service elements
NURSING MINIMUM
DATA SET (NMDS)
NURSING MINIMUM
MANAGEMENT DATA SET
(NMMDS)

The 18 NMMDS elements are organized into

three categories: environment, nursing care
resources, and financial resources
most appropriately focuses on the nursing
delivery unit/service/center of excellence
level across the settings
provides the structure for the collection of
uniform information that influences quality
of patient care, directly and indirectly.
NURSING MINIMUM
MANAGEMENT DATA SET
(NMMDS)
INTERNATIONAL
NURSING MINIMUM DATA
SET (I-NMDS)
Intended to build on and support data set work
already underway in individual countries.
i-NMDS project focuses on coordinating ongoing
national-level efforts
i-NMDS includes the core, internationally
relevant, essential, minimum data elements to be
collected in the course of providing nursing care
These data can provide information to describe,
compare, and examin nursing practice around
the globe.
END