Abstract
PURPOSE
To demonstrate the use of standardized nursing language for a client with a severe traumatic brain injury, from the time of admission to the emergency center to the client's admission to the rehabilitation unit.
BACKGROUND
A client with increased intracranial pressure based on pertinent assessment data was followed.
MAIN CONTENT POINTS
Although the client's outcomes remained consistent, the indicators reflected the client's recovery and decreased risk of increased intracranial pressure. The nursing activities were individualized as the client moved from the emergency center, to the intensive care unit, to the acute care unit, and eventually to the rehabilitation unit.
CONCLUSIONS
Challenges to the use of standardized nursing languages include development of software for computer documentation and retrieval. Legend-code charting rather than text-based charting must be used. Nurses need to understand the value of taxonomies and standardized nursing languages, and that NOC outcomes and NIC activities are easily individualized for specific client populations.
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