Health care, health-care, or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, midwifery, nursing, medicine, optometry, audiology, pharmacy, psychology, occupational therapy, physical therapy and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice compared to dependent interventions driven by physician's orders. Nursing diagnoses are developed based on data obtained during the nursing assessment. An problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health and/or life processes and/or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis.
Medical Subject Headings (MeSH) is a comprehensive controlled vocabulary for the purpose of indexing journal articles and books in the life sciences. It serves as a thesaurus that facilitates searching. Created and updated by the United States National Library of Medicine (NLM), it is used by the MEDLINE/PubMed article database and by NLM's catalog of book holdings. MeSH is also used by ClinicalTrials.gov registry to classify which diseases are studied by trials registered in ClinicalTrials.
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding.
MedDRA or Medical Dictionary for Regulatory Activities is a clinically validated international medical terminology dictionary used by regulatory authorities in the pharmaceutical industry during the regulatory process, from pre-marketing to post-marketing activities, and for safety information data entry, retrieval, evaluation, and presentation. In addition, it is the adverse event classification dictionary endorsed by the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).
Readiness for enhanced therapeutic regimen management is a NANDA approved nursing diagnosis which is defined as "A pattern of regulating and integrating into daily living a program(s) for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengthened." It was introduced at the 15th NANDA conference in 2002. Purpose: This book is devoted to a discussion of nursing diagnoses, outcomes, and interventions for older persons. As such, the diagnoses selected for the volume are not exhaustive, but represent a severely underdeveloped knowledge base. We have chosen diagnoses that are most prevalent, most difficult to treat, and/or most in need of further development to inform practicing nurses and nursing students and to improve the quality of life of older persons.
A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
NCLEX is a nationwide examination for the licensing of nurses in the United States and Canada since 1982 and 2015, respectively. There are two types, the NCLEX-RN and the NCLEX-PN. After graduation from a school of nursing, one takes the NCLEX exam to receive a nursing license. A nursing license gives an individual the permission to practice nursing, granted by the state where they met the requirements.
Home health nursing is a nursing specialty in which nurses provide multidimensional home care to patients of all ages. Home health care is a cost efficient way to deliver quality care in the convenience of the client's home. Home health nurses create care plans to achieve goals based on the client's diagnosis. These plans can include preventative, therapeutic, and rehabilitative actions. Home health nurses also supervise certified nursing assistants. The professional nursing organization for home health nurses is the Home Healthcare Nurses Association (HHNA). Home health care is intended for clients that are well enough to be discharged home, but still require skilled nursing personnel to assess, initiate and oversee nursing interventions.
A clinical nurse specialist (CNS) is an advanced practice nurse who can provide expert advice related to specific conditions or treatment pathways. According to the International Council of Nurses (ICN), an Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. Clinical Nurse Specialists are registered nurses, who have graduate level nursing preparation at the master's or doctoral level as a CNS. They are clinical experts in evidence-based nursing practice within a specialty area, treating and managing the health concerns of patients and populations. The CNS specialty may be focused on individuals, populations, settings, type of care, type of problem, or diagnostic systems subspecialty. CNSs practice autonomously and integrate knowledge of disease and medical treatments into the assessment, diagnosis, and treatment of patients' illnesses. These nurses design, implement, and evaluate both patient–specific and population-based programs of care. CNSs provide leadership in the advanced practice of nursing to achieve quality and cost-effective patient outcomes as well as provide leadership of multidisciplinary groups in designing and implementing innovative alternative solutions that address system problems and/or patient care issues. In many jurisdictions, CNSs, as direct care providers, perform comprehensive health assessments, develop differential diagnoses, and may have prescriptive authority. Prescriptive authority allows them to provide pharmacologic and nonpharmacologic treatments and order diagnostic and laboratory tests in addressing and managing specialty health problems of patients and populations. CNSs serve as patient advocates, consultants, and researchers in various settings [American Nurses Association (ANA) Scope and Standards of Practice (2004), p. 15].
MEDCIN, a system of standardized medical terminology, is a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.
Neonatal nursing is a sub-specialty of nursing care for newborn infants up to 28 days after birth. The term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". Neonatal nursing requires a high degree of skill, dedication and emotional strength as the nurses care for newborn infants with a range of problems, varying between prematurity, birth defects, infection, cardiac malformations and surgical problems. Neonatal nurses are a vital part of the neonatal care team and are required to know basic newborn resuscitation, be able to control the newborn's temperature and know how to initiate cardiopulmonary and pulse oximetry monitoring. Most neonatal nurses care for infants from the time of birth until they are discharged from the hospital.
The Omaha System is a standardized health care terminology consisting of an assessment component, a care plan/services component, and an evaluation component. Approximately 22,000 health care practitioners, educators, and researchers use Omaha System to improve clinical practice, structure documentation, and analyze secondary data. Omaha System users from Canada, China, The Czech Republic, Estonia, Hong Kong, Japan, Mexico, New Zealand, The Netherlands, Turkey, the United States, and Wales, have presented at Omaha System International Conferences.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, and one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.
