Answer to Question 1
1,2,5
Rationale: Terminologies must be used to support nursing practice reflecting the nursing process. The nursing process data elements include assessment, diagnosis, outcome identification (goal), planning, implementation (interventions), and evaluation. The terminologies have to contain concepts that are clear and unambiguous with a unique identifier. The terminology developer should have an outlined maintenance and submission process.
Answer to Question 2
communication
Rationale : The use of coded standardized terminology for nurses is vital to bedside nursing and to the nursing profession. It is essential because it enables consistent use of terminologies across clinical settings and specialists. The use of standardized nursing terminology will result in better communication to the interdisciplinary team, increase the visibility of nursing interventions, enhance data collection used to evaluate and analyze patient care outcomes, and support greater adherence to standards of care. Further, the use of standardized nursing terminology can be used to assess nursing competency. Health care facilities are required to demonstrate the competency of staff for the Joint Commission. The nursing interventions delineated in standardized terminologies can be used as a means by which to assess nurse competency in the performance of these interventions (Rutherford, 2008).
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Communication and Documentation
Learning Outcome:
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