INTERNET TOOLS

FOR ADVANCED
NURSING PRACTICE
 Regardless of the search engine used, certain
search methodologies, if applied correctly,
increase the efficiency of retrieval if needed
information. The three strategies are: name
precisely the information being sought, use search
strings rather than single words, and enhance
search strings by using Boolean or natural
language methods.
1. Name precisely the information being sought.
If the search terns used precisely chosen, the searcher goes directly
to the desired information.

2. Use a search string (one or more search terms) rather

than a single word to increase the preciseness of a search.

Enter the precise terms in a string, rather than a single term.

3. Enhances search strings by Boolean or natural language

methods.
Use Boolean terms: AND, or, not. The term “AND” is used when
search terms or strings need to be added together. The
term “OR” is used when equivalent terms or synonyms
are used to capture the information.
 This section is divided into the most
basic components of nursing process:
assessment, diagnosis, treatment, and
outcome evaluation. These component
provide the outward structure for
development of a clinical information
database for advanced practice
nursing.
 1. Assessment
Assessment refers to the systemic collection of data
needed to arrive at one or more diagnoses. The tools
included in this section include forms, miscellaneous
screening tools, risk assessment instrument, and
information, and information of the manifestation of
signs and symptoms. These tools represent a sampling
of assessment content available on the internet.
 Nursing assessment is the first step in nursing
process. The following site provides an example
of a comprehensive nursing assessment form:
◦ http://www.hospitalsoup.com/public/nursinggassess20
01.pdf
◦ http://www.niaaa.nih.gov
◦ http://www.state.vt.us/health/abuse.htm
◦ http://www.ctclearinghouse.org/
 2. Diagnosis
◦ Treatment is diagnostic specific. Hence,
diagnosis and treatment information categories are
frequently not discreet.
◦ The etymology of the word “diagnosis” is based
in its Greek roots. “Dia” means “through,” and
“gnosis” means knowledge base of the person
diagnosing.
◦ The section diagnosis is divided into following
sections: new threats to health, disease/ condition
directories, examples of specific disease
information, easy diagnosis tools, standardized
diagnosis terminologies, and the unified medical
language system (UMLS)
 New Threats to health. New threats to health include mass trauma,
biological and biochemical warfare agents, and emerging infectious
disease. Primary care and emergency department practitioners need
readily accessible information to facilitate diagnosis. The CDC’s
emergency Preparedness and Response web page is excellent
source: http://www.bt.cdc.gov/

 Mass Trauma Preparedness Response. Mass trauma hyperlinks,

featured on CDC Emergency Preparedness and Response webpages
include coping with a traumatic event, a primer for clinicians on dealing
with explosions and blast injuries, fact sheets for injuries and mass
trauma; possible research studies; and rapid assessment of injuries.

 Bioterrorism Agents/ Diseases. The CDC emergency preparedness and

response webpages present information on approximately 30 diseases.
When a particular hyperlink, is activated, the information is available for
everyone, specific groups, and diagnostic testing, infection control, and
other s specialized information for health professionals. Photographic
images and/ or video presentations facilitate clinical decision-making
related to infectious agents that may be used for bioterrorism purposes.
 Clinical Agents. The CDC Emergency Preparedness and
Responsiveness webpages hyperlink information to more than
70 chemical agents. Some of the hyperlinks represent
categories of agents. When these categories are activated,
listings of within category agents are provided.

 Recent Outbreaks and Incidents. The Emergency

preparedness and response page also includes information
on outbreaks. Detailed information is provided on each.

 Bioterrorism Information Available through Academic Health

Science Center. Several academic health science centers have
received federal funding to move biodefense research and
education forward.
 Disease diagnoses – the most familiar disease terminology is the ICD
(World Health Organization, 1992). For use in united states, Who has
authorized the Department of health and Human Services National
Center for Health Statistics to develop, in keeping with WHO ICD
conventions, ICD-10-CM, where CM refers to clinical modification. A
prerelease version is available for review at the national center for
health Statistics
(http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.html ) and
preview books are available for sale at bookstores.

 There are several disease directories with A-Z lists,that are Internet
available. Example include:
◦ a. Centers for Disease Control and Prevention (CDC), disease and
conditions. The hyperlink is available in the left hand margin of the CDC
homepage ( www.cdc.gov )or may be accessed directly
at http://www.cdc.gov/node.do/id/0900f3ec8000e035 .

◦ b. A-Z list of cancers from the National Cancer Institute

( www.nci.nih.gov )

◦ c. The Karolinska Institute University Library in Sweden

(http://www.mic.ki.se/Disease/ )
 For disease definitions, online medical
dictionaries are useful. One example is the on-
line Medical Dictionary published by the
University of Newcastle upon Tyne Department of
Oncology ( http://cancer-
web.ncl.ac.uk/omd ). Its listing, which is not
limited to oncology-related diseases, is a readily
accessible, comprehensive dictionary.
 New York online Access to health ( www.noah-
health.org ). The latter site has an A-Z Index,
which is especially useful for providing
laypersons with information on uncommon
illness, for example: lupus erythematosus,
Marfan’s syndrome.
 Many internet sites provide clinical information
on tools useful in the diagnosis of specific
diseases.
 Human Response to Illness/ Health Diagnoses- the
internet tools presented in this section are infrastructure
tools, because much of work that need s to be
accomplished in the field in nursing diagnosis is at the
infrastructure level. It is imperative that nurse
informaticists continue to engage in this work, if the
profession is to advance scientifically.
◦ Terminologies designed for or listing nursing diagnoses
include NANDA Diagnoses and classification, Home Health Care
Classifications, The Omaha System and the perioperative nursing
data set ( http://www.aorn.org/research/pnds.htm )

 Methods of Contributing to Terminology Revision and

Development- Clinician, informaticists, researchers,
educators, and students may contribute to this process.
Revision and new diagnosis submission forms and
instructions are available at NANDA Web site
( www.nanda.org ) and the network for language in
Nursing Knowledge Systems Concept Analysis Center
( http://nlinks.org/cac_introduction.phtml ).
 The International Classification Functioning,
Disability, and Health (ICF)- standardized nursing
diagnosis terminologies do not encompass the
entire field. As a result, subsets from the ICD are
used, especially in the provision of primary care
services by advanced practice nurses. Another
terminology of interest to nursing practice is ICF.
The ICF consists of four domains: body functions,
body structures, activity and participation, and
environmental factors. Of these, the body
functions, activity and participation, and
environmental factors contains subsets with term
applicable to or capable of being developed as
nursing diagnosis.
3. Treatment
The term “treatment” is used in lieu of interventions and nursing actions,
because it expresses more precisely the broad clinical management focus
of this section.

 Nursing treatment
Several Internet sites are available for those who desire more information
on Saba’s framework/structure examples, a NIC intervention example,
Omaha System case studies, and PNS examples and outcomes.
They are:

◦ Home Health Care Classification ( Saba,2003, www.sabacare.com )

◦ Nursing Intervention Classifications (NIC)-
http://www.nursing.uiowa.edu/centers/cncce/nic/index.htm
◦ Omaha System(Martin, Elfrink, and Monson,
2001, http://www.omahasystem.org/ )
◦ Perioperative nursing data set ( http://www.aorn.org/research/pnds.htm )
 Drug Management- there is no shortage of information available
on pharmacotherapeutics and pharmacologic management of
patients. The federal government provides wealth of information.
1. Drug Enforcement Agency (www.dea.gov ), excellent information on
drugs and chemicals of concern
(http://www.deadiversion.usdoj.gov/drugs_concern/index.html ).
2. Food and Drug Administration (www.fda.gov ), with outstanding
search capability Clinicians need to remember that herbal products,
even thought pharmacologically active, are listed under “FOODS” and
not under “DRUGS.” Within the FDA Web site, the following are
especially useful pages.

◦ Center for Drug research and evaluation

(http://www/fda.gov/cder/index.html )
◦ Medwatch: the FDA Safety Information and Adverse Event Reporting
Program ( http://www.fda.gov/medwatch/index.htm )
◦ Medwatch Adverse Event and Product Problem
Forms (http://www.fda.gov/medwatch/get-forms.htm )
◦ Vaccine Adverse Event Reporting
System (http://www.fda.gov.medwatch/safetly/vaers1.pdf )
Evidence-Based Practice Guidelines

Government Sites Practice/ Treatment guidelines are

available at several government sites.
1.CDC ( www.cdc.com )
◦ Disease and Conditions
( http://www.cdc.gov/node.do/id/0900f3ec8000e035 )
◦ Sexually Transmitted Diseases Treatment Guidelines
2002 ( http://ww
w.cdc.gov/std/treatment/ )
◦ Tuberculosis Core Curriculum on Tuberculosis 2000
(http://www.cdc.gov/nchstp/tb/pubs/corecurr/ )
◦ Tuberculosis Treatment per American Thoracic Society, CDC, and
Infectious Disease Society of American (CDC, Morbidity and
Mortality Report,
2003, http://www.cdc.gov/mmwr/PDF/rr/rr5211.pdf )

2. National Guidelines Clearinghouse ( www.mgc.gov )- includes

practice guidelines for the major nursing and medical specialty
organizations as well as those developed by Schools of Nursing
and Schools of Medicine.
3. National Institute of Health. Examples include:

◦ Guidelines for the Diagnosis and Management of Asthma from the

National Heart, Lung, and Blood
Institute, http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.h
tm and 2002 update on selected
topics http://www.nhlbi.nih.gov/guidelines/asthma/index.htm .
◦ Detection, evaluation and treatment of high blood cholesterol in
adults from National Heart, Lung, and Blood institute
( http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm )
◦ Hypertension from the National Heart, Lung, and Blood institute.
◦ Overweight and Obesity Clinical Guildelines from the National
Heart, Lung, and Blood institute
( http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm )
Practice and Treatment Guidelines: Professional
Organization Sites- many of the professional
association or societies include clinical
practice guidelines or recommendations.
They may be evidence-based pr derived from
expert opinion. Examples:
1. American diabetes Association, clinical
recommendation ( http://www.diabetes.org/for-
health-professionals-and-scientists/cpr.jsp )
2. American Academy of Family Physicians, clinical
recommendations ( www.aafp.org/x132.zml )
4. Outcomes
Outcomes measurement is a tradition within nursing practice. Many
categories if patient outcomes are measured today. This section provides
examples of outcome measures within several categories. The categories are
patient safety, nursing outcomes, nursing home and home healthcare setting
outcomes, health plan outcomes, and the short form health survey.
1. Patient safety- is an outcomes issue. There are several patient safety sites, which are prime
importance to advanced practice nurses. They include the following:
a. Agency for Healthcare and Research and Quality web Morbidity and Mortality Rounds, an online
forum for presentation and discussion of medical errors ( www.webmm.ahrq.gov/ )
b. The patient safety page of Medscape.com
c. Institute for Healthcare Improvement ( http://www.ihi.org/ihi )

2. Nursing outcomes- the internet sites presented within this section refer to standardized
nursing-terminologies that either present outcomes in a structured format or data set that may be
used evaluative purposes.
a. Information of Nursing Outcomes Classification may be obtained from the University of Iowa
Center of Classification and Clinical
Effectiveness ( http://www.nursing.uiowa.edu/centers/cncce )
3. Nursing Home and Home Healthcare Setting Outcomes – related nursing outcomes are those
measures that evaluate the quality of care within nursing homes and healthcare settings.
a. Oasis (outcomes assessment information set ) measures are used to evaluate quality within
home, healthcare settings (http://www.cms.hhs.gov/quality/hhqil/HandOut1.pdf ).
3. Nursing Home and Home Healthcare Setting Outcomes – related
nursing outcomes are those measures that evaluate the quality
of care within nursing homes and healthcare settings.
a. Oasis (outcomes assessment information set ) measures are used to
evaluate quality within home, healthcare settings
(http://www.cms.hhs.gov/quality/hhqil/HandOut1.pdf ).

4. Office Tools: Online Health Record Audit and Patient Satisfaction

Forms- until the electronic health record is universal, the
completeness of the health record or specific aspects of care
need to be evaluated manually. The following links provide
resources on auditing the health record and patient satisfaction.
a. Health Care Record Audit Criteria, adapted from the Santa Barbara
Regional Health Authority
(http://www.sbrba.org/section/ensuring_quality/provider_audit/pdfMedic
al_Record_review_Criteria.pdf )
b. Patients Satisfaction Form (four-point scale)-
http://www.geomedics.com/downloads/pss4.rtf
c. Patients Satisfaction Form (five-point scale)-
http://www.geomedics.com/downloads/pss5.rtf
Outcomes Measurement: Internet-Available Biostatistical and

Analytical Tools- although the biostatical measurement of outcome

variables is not a routine part of clinical practice, it is likely to
assume an important role when new programs or initiatives are
begun. The following sites provide basic biostatistical tool
available online including an AOL listing that includes free
software and software packages available through CDC.
a. Qualitative data creation, management, and analysis software
(CDC, http://www.cdc.gov/hiv/software/ez-text.htm )
b. Qualitative Database Software
(CDC, http://www.cdc.gov/hiv/software/answer/howto.htm )
c. Epidemiologic analysis software
(CDC, http://www.cdc.gov/epiimfo/ )
d. Chi-square calculator (Georgetown
University, http://www.georgetown.edu/faculty/ballc/webtools/w
eb_chi.html )
e. Student’s t-test calculator
(http://www.physics.cbsju.edu/stats/t-test.html )
 A New Definition of Community

Community health is the provision of healthcare

outside the hospital infrastructure. As such, the
public health departments have been viewed as the
major delivery system of healthcare.
 Federal funds were channeled through the Centers
for Disease Control and Prevention (CDC) to the
states in order to strengthen the public health
infrastructure. At the same time, federal funds were
directed to hospitals through the Health Resources
and Services Administration (HRSA).
 Challenges for hospital and public health
1. reporting systems lack stardardization
2. no central place for accessing information

 Informatics Solutions
1. healthcare member in St. Louis developed a
barcode system to track victims
2. East Carolina university tested the in-place
telehealth networks
 Inability to access electronic health data
creates barriers to continuity of care, quality
of care and cost analysis, and vulnerabilties
exposures during bioterrorism events.
 The development of National Health
Information Infrastracture (NHII) will come an
improved Public Health Information Network
(PHIN). At the same time, data sharing has to
be carefully planned in order to stay in
compliance with the HIPPA.
Federal Responsibilities for Healthcare
Providers
Department of Health and Human Services
(DHHS) – is responsible for education of
health care professionals in preparedness for
emergencies, including potential terrorism
 3 units focusing on emergency planning and
response
 1. CDC – Centers for Dse Control and
Prevention
 2. AHRQ – Agency for Healthcare Research
and Quality
 3. HRSA – Health Resources and Services
Administration
 The organization of the new Department of
Homeland Security (DHS) caused some confusion
about whether education for emergency planning
and response of healthcare professionals would
remain within DHHS or move to other first
responder training activities already instituted by
theFederal Emergency Management Agency
(FEMA).
 Typically, first responders are: firemen,
policemen, and emergency technicians who arrive
first on the scene of an event but now healthcare
providers are included.
New Visibility of CDC Promotes Informatics Solutions

 The CDC is recognized as the lead federal agency for protecting

the health and safety of people – at home and abroad, providing
credible information to enhance health decisions and promoting
health through strong partnerships.
 The National Electronic Disease Surveillance System (NEDSS) - to
detect outbreaks rapidly and to monitor the health of the nation;
facilitate the electronic transfer of appropriate information for
clinical information systems in the healthcare system to public
health departments; reduce provider burden in the provision of
information; and enhance both the timeliness and quality of
information provided.
 The CDC established the Laboratory and Response Network
(LRN) which outlined national antiterrorism policies and assigned
specific missions to federal departments and agencies. Its
objective was to ensure an effective laboratory response to
bioterrorism by helping to improve the nation’s public health
laboratory infrastructure, which had limited ability to respond to
bioterrorism.
 Roles of AHRQ in Stimulating New Informatics
Solutions
 DECISION SUPPORT SYSTEMS

AHRQ’s Intergrated Delivery System Research Network

(IDSRN) is to develop a computer simulation model for
citywide response planning for mass prophylaxis and
vaccination during bioterrorist attacks and other public
health emergencies.
 SYNDROMIC SURVEILLANCE
It is a detection of a disease outbreak before the actual
disease or mechanism of transmission is identified. Real-
time outbreak and disease Surveillance (RODS) system is a
system that provides early warning of possible infectious
disease outbreaks caused by bioterrorism or other public
health emergencies.
 HELPING CLINICIANS RESPOND
Provider training and education are also critical elements of
a comprehensive plan for bioterrorism and public health
preparedness in general.
Roles of Health Resource & Services Administration
(HRSA) in Promoting Informatics Educational
Solutions
 The Hospital Bioterrorism Preparedness Program
and the Bioterrorism Training and Curriculum
Development Program (BTCD) are 2 grant
management programs that exist under the
management of the HRSA.
◦ National Bioterrorism Hospital Preparedness Program -
is to aid state, territory, and care system, including
hospitals, emergency departments, outpatient facilities,
emergency medical services systems, and poison control
centers.
◦ BTCD program - provides practicing healthcare
providers and current students. The developed materials
are designed to equip a healthcare workforce to
recognize indications of a terrorist event or other public
health emergency
 presents the current trends, issues, obstacles,
and opportunities facing the nursing
profession with regard to utilization of HCIT.
 Current Trends Toward Prime Vendors, EHRs, and Systems Integration
There are a wide variety of software products offered by an array of
diverse vendors that nurses use to plan, document, manage, and evaluate patient
care.
· “NICHE” applications focus on a discrete set of nursing functions such as care
planning.
· “DEPARTMENTAL” systems address a more comprehensive set of functions. This
is either of the three: for a single point of service such as labor and delivery; or
department such as cardiology; or closely aligned group of departments such as
the perioperative suite. These departmental systems are more targeted and robust
than comparable modules of EHR solutions since departmental systems focus on
one or a few specialties and points of service. Thus, Departmental Systems
continue to be sought by many organizations, particularly in academic medical
centers and for high acuity, specialized care departments.

 New Technologies
New and emerging hardware and software technologies such as handheld devices
are increasingly being incorporated in nursing applications. Key goals are to
improve quality of care, mobility of caregivers and collaboration among the care
team. Currently, strong emphasis is being placed on delivering technology at the
point of care via bedside terminals and wireless devices such as PDAs and
Laptops. These bedside terminal accesses can facilitate real-time charting,
increase nursing time at the bedside, and eliminate “batch” end of shift charting.
 Historical Perspective

Historically, nurse executives have not widely

embraced it as a strategic business tool. The nursing
profession has been largely underserved by HCIT
vendors, even though Nursing is one large
beneficiaries of IT. There are a variety of reasons why
Nursing is not highly provided by these vendors. In
most national and local healthcare debates, nursing
has been essentially invisible, partly because this is
the only profession that does not charge for services
rendered. However, currently there is a new breed of
registered nurses that are engaging into the field of
informatics.
Current Situation

 Today, the majority of nursing-related patient care applications are acquired as part of
EHR decisions. But some of the products released are poorly designed and user-
unfriendly for nurses, basically because of the following factors:

·Nursing is an untapped and underserved resource in provider organizations.

·Workflow inefficiencies are not well addressed by existing solutions
·Automation is not highly priority for nursing in their organizations
·Vendors are out of sync with nursing needs
·Some new tools and technologies have complicated rather than simplified nursing
practice, at times decreasing productivity and introducing an element of increased risk
to patients.

 Root causes of poorly designed nursing applications include:

·Vendor product design processes driven by non-nurse professionals

·Insufficient nursing representatives on vendor executive and development teams
·Then HCIT industry’s overall woeful lack of adequate requirements definition,
functional specifications, and process analysis
·Early focus on automation of the paper chart without a full understanding of
underlying nursing process, workflows, anf ergonomic challenges
 Vendor Response
In response to market demand, HCIT vendors are
delivering more robust and tightly integrated clinical
solutions that better address the needs of all health care
providers for more coordinated, streamlined patient care
delivery. While some vendors offer clearly superior nursing
applications, no solutions; each has different strengths
and limitations.
 Care Flow Diagram
The care flow diagram is a conceptual model that
represents a patient-centric, interdisciplinary, inpatient-
oriented view of a clinical information system that
supports a fully integrated HER. The model assumes direct
physician use of the HER and represents a multidisciplinary
team approach reflecting emerging care delivery models.
Key Clinical System Nursing and Multidisciplinary Care
Concepts
Patient Access
The patient record is initiated in the admission, discharge and transfer [ADT]
system or administrative portion of EHR.
Admission assessments
Nurses and allied health professionals perform initial patient assessment and
intakes.
Diagnosis/Problem
The concept of “Nursing Diagnosis” has been somewhat controversial.
A “Problem list” is a common set of patient specific problems that are
maintained by the MD and care team.
Nursing and Multidisciplinary Orders and Plans of Care
Physicians can enter medical orders directly online (CPOE) or via authorized
designees such as RNs and Clerks.
Integrated Plans of Care
An Integrated Plan of Care includes all orders for all services to be provided for
a patient, including physician, nursing, ang multidisciplinary pathways, and orders and
patient care plans.
Kardex
A Kardex is patient management tools used by nurses to collect, organize,
and display summary patient information.
Workplans – Tasklists
EHRs support generation of work plans, known as task lists, as an automatic
byproduct of orders and plans of care. These task list help nurses organize, document,
and manage patient care activities for individual or groups of assigned patients.
Results
In an HER, Results data (e.g Laboratory values, chest x-rays) can be
viewed overtime in tabular formats and graphed for display of trends.
Clinical Documentation
Physicians and all care providers document care in progress notes and
ongoing assessments. This is the major method by which diverse care providers
collaborate across multiple points of service.
Discharge summaries
The discharge summary is an increasingly important component of care
with inpatient stays shortening and postdischarge care often provided by diverse
providers in multiple venues of care across the community.
Summary Reports
Patient summaries can be support rounding, initial patient
assessment by consulting physicians, end of shift reporting by nurses, and other
patient-care-related activities.
Outcome Variance Reports
Virtually all HCOs are focused on improving patient safety and quality
care. For organizations to thrive, clinicians must be committed to continual
performance improvement.
StandardTerminology Provided with Clinical Applications

 Expectation of the marketplace

Despite the lack of a national consensus regarding one standard
nursing terminology or data set, HCOs expect their HER vendor to
deliver a Standards-based set of nursing content for charting and
planning care.

 Current Status
Responding to this market demand, most of the major HCIT vendors
now deliver at least basic starter set of terminology. An increase
number of these vendors are including standards-based terminology
with their clinical documentation application as well as evidence-
based standards of care with their care planning and clinical
pathway applications, and some are using standard terminologies
that map tp SNOMED[Systematized Nomenclature of Medicine].