Standardized Nursing Languages (SNLs) Basics

By 7th Group Novia Angelina Kaope Dewi Anggraeni Meike Yunita Soputan Siti Rahmi I Made Parwata M. Nasrun

and outcomes related to the documentation of nursing care SNLs-3 elements of nursing care as defined by the Nursing Minimum Data Set (NMDS) Diagnoses of human responses (NDxs) Nursing interventions (NRxs) Nursing-sensitive patient outcomes (NSPOs) . along with the interventions.What is SNLs? Standardized nursing language (SNL) is a commonly-understood set of terms used to describe the clinical judgments involved in assessments (nursing diagnoses).

greater adherence to standards of care.Benefits of Standardized Languages The use of standardized nursing languages has many advantages for the direct care/bedside nurse. . and facilitated assessment of nursing competency. These include: better communication among nurses and other health care providers. enhanced data collection to evaluate nursing care outcomes. improved patient care. increased visibility of nursing interventions.

.Increased Visibility of Nursing Interventions Interventions that should be undertaken to in support nursing judgments and that demonstrate the depth of nursing judgment are built into the standardized nursing languages. before making a judgment about continuing the induction procedure. 2004). This activity guides the nurse to assess the dilatation and effacement of the cervix and presentation of the fetus. one activity listed under labor induction in the NIC language is that of re-evaluating cervical status and verifying presentation before initiating further induction measures (McCloskey-Dochterman & Bulechek. For example.

Nurses identified the chief complaints of the children.Improved Patient Care The use of a standardized nursing language can improve patient care. . the most frequent etiology. the most frequent pain management activities from the NIC. They used the NIC and NOC to determine the interventions and outcomes of children after acute abdomen had been ruled out. Cavendish (2001) surveyed sixty-four members of the National Association of School Nurses to obtain their perceptions of the most frequent complaints for abdominal pain. and the change in NOC outcomes after intervention.

. Patient outcomes are also related to the uniqueness of the individual. and the environment in which the care is provided. the care given by other health care professionals.Enhanced Data Collection to Evaluate Nursing Care Outcomes The use of a standardized language to record nursing care can provide the consistency necessary to compare the quality of outcomes for various nursing interventions across.

Nurse educators can use the knowledge inherent in standardized nursing languages to educate future nurses. standardized language has implications for nursing education. and Administration In addition to enhancing the care provided by direct care nurses. Nurse educators can teach students to use systems such as the CCC and Omaha System when in the community health fields. or the use of the NANDA. Research. NIC. .Implications of Standardized Language for Nursing Education. Such a system can be used to describe the unique roles of the nurse. NOC terminology when in the acute care setting. research. and administration.

Why SNLs? SNLs represent pooled nursing knowledge Use of pooled knowledge helps nurses to plan. intervene and evaluate Sciences seek generally useful vocabularies. ones that produce results Results = quality of care . interpret.

Cost Effectiveness. & Quality Lunney.Effects on Nursing Care of Using SNLs Naming Thoughts Discernment Communication + Cooperation + Action Improved Access. 1999 .

NANDA International (I) Nursing diagnoses are human responses (HRs) to health problems and life processes for which nurses provide interventions Purposes: Name human responses of concern to nurses so accuracy can be addressed and the best NRxs can be selected for positive outcomes .

NANDA I: Examples Pain Death Anxiety Impaired Home Maintenance Readiness for Enhanced Community Coping Hopelessness Ineffective Breathing Pattern Risk for infection Relocation Stress Syndrome Decisional Conflict Acute Confusion Effective Breast Feeding .

outcomes Purposes of naming: Consider appropriateness.NIC (Nursing Interventions Classification [NRxs]) NRxs are treatments performed by nurses based on clinical judgment & knowledge in order to achieve positive pt. communicate with others for continuity. relate to NDxs and NSPOs .

NIC: Examples Acid-Base Management Active Listening Community Disaster Preparedness Coping Enhancement Exercise Promotion Health Education Family Integrity Promotion Health Education Health Policy Monitoring Surveillance Presence Social Support Enhancement .

behaviors or perceptions that are influenced by & sensitive to NRxs and can be measured as variables Purpose of Naming: Determine the quality and effectiveness of nursing care .NOC (Nursing-Sensitive Patient Outcomes [NSPOs] Classification) NSPOs define general pt. states.

NOC: Examples Caregiver Homecare Readiness Knowledge: Illness Care Social Support Mobility level Risk Control: Drug Use Neglect Recovery Activity Tolerance Self Care: Hygiene Dialysis Access Integrity Wound Healing: Primary Intention Acceptance: Health Status Symptom Control .