Session
Health Insurance Portability and Accountability Act of 1966 (Pub. L. No. 104-191).
Virginia K. Saba, EdD, RN, FAAN, FACMI
Georgetown University
Washington, DC
Additional Questions for NCVHS Bearing on Coding and Classification Systems # 6:
For presenters recommending a particular coding or classification system, what is the market acceptance for the system and current scope of use? What are mechanisms for low cost distribution?
INTRODUCTION
This paper highlights a presentation to the National Committee on Vital and Health Statistics discussion on medical/clinical coding classification in connection with the requirements of the Health Insurance Portability and Accountability Act of 1966 (Pub. L. No. 104-191).
We believe that the Home Health Care Classification (HHCC) of Nursing Diagnoses and Nursing Interventions represents home health clinical nursing practice and should be considered for the proposed electronic patient record. Traditionally, home health care is based on a medical model which does not represent and/or depict home health patient care. Therefore, we are recommending that home health care be based on a nursing model. We propose that HHCC nursing diagnoses be identified and HHCC nursing interventions performed by the nurses and other professional providers become the basis for reimbursement.
OVERVIEW
The Home Health Care Classification (HHCC) of Nursing Diagnoses and Nursing Interventions is a standardized vocabulary and/or nomenclature designed for home health care. The HHCC nomenclature was developed not only to code, index, and classify home health care; but, also, to document, track, and analyze the clinical care process over time, across settings, and geographic locations.
The HHCC nomenclature consists of two data dictionaries: the HHCC of Nursing Diagnoses with 145 nursing diagnosis / patient problem labels; and the HHCC of Nursing Interventions with 160 nursing intervention /services labels. Both of these two data dictionaries are coded, and classified according to 20 care components. Both are also expanded using a modifier/qualifier as follows: the nursing diagnosis is modified using one of three qualifiers to predict the outcome identification goal; and the nursing intervention is modified using one to four qualifiers to identify type of intervention action.
The HHCC nomenclature has been "recognized" by the American Nurses Association (ANA) as a valid and useful nursing language that can be used to classify nursing practice. Additionally, the HHCC nomenclature has been incorporated in the Metathesaurus developed by National Library of Medicine for its Unified Medical Language System (UMLS).
There are numerous reasons why the HHCC of Nursing Diagnoses and Nursing Interventions nomenclature should be included in the electronic patient record to depict home health patient care described in this testimony. A summary of the reasons follows:
Today, home health care is viewed as a cost effective alternative to institutional care. With the growth of managed care, patients are being discharged "sicker and quicker" from in-hospital stays, increasing the demand for acute, complex, home health services. As a result, the number of home health agencies (HHAs) are increasing in number and size resulting in over 9,000 certified Medicare/Medicaid HHAs in 1996 (NAHC).
Home health care refers to all services provided and products used to restore, maintain, and promote physical, mental, and emotional health to patients in their homes. The services are planned, coordinated, and made available by primarily professional nurse providers organized for the delivery of home care (Spradley & Dorsey, 1985). Home health care also refers to the continuity of care for patients experiencing health problems, from the hospital to the home, requiring various levels of care throughout the continuum of care leading to recovery, rehabilitation, or death.
The current method of reimbursement for home health services to Medicare and Medicaid beneficiaries, as regulated by the Health Care Financing Administration (HCFA), are specifically limited to approximately 30 nursing treatments as well as a limited list of services provided by other health providers identified for a specific medical diagnosis. This list does not address the broad scope of clinical nursing practice; and therefore, the quality and outcomes of care (OBRA, 1987), required as "conditions of participation" cannot be evaluated and/or measured. However, the HHCC nomenclature has expanded this list not only to include other valid interventions/services, but also nursing diagnoses/problems that represent the field of home health nursing.
Further, the "conditions of participation" also require that the every patient have a record (paper or electronic) that conforms to professional standards. This condition implies that the clinical nursing practice standards, outlined by the American Nurses Association (ANA) (1991), should be an integral part of the electronic home health patient records and another reason for the acceptance of the HHCC for the proposed legislative mandate.
The HHCC was developed by Saba et al., (Saba, 1992a: 1992b; Saba & Zuckerman, 1992) from research conducted at Georgetown University School of Nursing (1988-1991). The Home Care project was funded by HCFA (Cooperative Agreement # 170C-98983/3)(1991) to develop a method to assess and classify home health Medicare patients in order to predict their need for nursing and other home care services as well as their outcomes of care. A national sample of 646 HHAs randomly stratified by size, type of ownership, and geographic location participated in the study. The HHAs collected retrospective data on 8, 961 newly discharged cases for the entire episode of home health care, from admission to discharge. This landmark study which represents the largest sample of home health agency data in the United States provided new knowledge for the home health care industry.
The Home Care Project also produced other materials; namely, the HHCC of Nursing Diagnoses and Nursing Interventions nomenclature. The HHCC nomenclature was created empirically from computer processing of approximately 40,000 textual phrases representing nursing diagnoses and/or patient problems and 72,000 phrases depicting patient care services and/or actions collected on the study cases. The textual phrases were computer processed using key 'word sorts' from which the standardized labels were developed. The labels were grouped into 20 care components providing the framework for classifying, coding, and indexing the textual phrases for the nomenclature's two data dictionaries..
The HHCC of Nursing Diagnoses consists of 145 Home Health Nursing Diagnoses (50 major categories and 95 subcategories) (Appendix Table 2). Each diagnosis can be modified with one of three qualifiers: improved, maintained and/or deteriorated. Whereas, the HHCC of Nursing Interventions consists of 160 Home Health Nursing Interventions (60) two digit major categories and 100 three-digit subcategories). Each intervention can be modified with any of the following four qualifiers: assess, care, teach. and/or manage. These services are mapped and linked to the nursing diagnoses for which they address. (Appendix Table 3.)
The 20 Care Components were also designed to provide a framework for each of the two complementary home health care classification nomenclature of nursing diagnoses and nursing interventions. The framework is similar to the framework of the clinical modifications of the International Classification of Diseases and Health Related Health Problems (ICD-10-CM) and the ICD-10-CM Health Care for Inpatient Procedures called ICD-10-CM-PCS. The 20 Care Components are similar to the chapters used in ICD-10-CM and the framework for the HHCC of Nursing Diagnoses of patient care diagnostic categories and labels. The 20 Care Components are also used as the framework for the HHCC of Nursing Interventions of patient care service categories and labels (Appendix, Table 1).
The coding framework for the HHCC of Nursing Diagnoses and Nursing Interventions is structured according to 20 Care Components. Each are structured hierarchically and coded according to ICD-10 (WHO, 1992).
They both consist of a five-character alphanumeric code as follows:
1st position: an alphabetic character for the care Component;
2nd & 3rd positions: a two digit code for a core data element (major category), and followed by a decimal point;
4th position: a one digit code for a subcategory (if needed); and
5th & last position is a one digit code for a qualifier.
This structure facilities the design of critical care protocols and/or pathways as well as other applications that make the nomenclature useful. This feature is also critical for the development of decision support and/or expert systems.
The HHCC System uses the HHCC of Nursing Diagnoses and Nursing Interventions nomenclature to document and track the home health nursing care. The HHCC System uses the nursing process based on the standards of clinical nursing practice recommended by American Nurses Association (1991) as its conceptual mode. The nursing process encompasses six steps: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, & Evaluation (Figure 1). This framework makes it possible to track, link and/or map core data with other data elements in the nursing process continuum.
Specifically, the HHCC nomenclature is structured according to the 20 Care Components and used to index, code, and classify the six steps of the nursing process (Saba, 1994). Each of the six steps has its own unique data dictionary (Figure 2). They are as follows:
The 20 HHCC Care Components provide the organizing framework for coding, indexing, and classifying the HHCC System nomenclature. The Care Components are used to link and map the six data dictionaries as well as track the nursing care protocols. (See Appendix Table 1.) A Care Component is a cluster of elements that represent a functional, psychological, physiological, and/or health behavioral care pattern (Figure 3).
The HHCC Nursing Diagnoses data dictionary consists of 145 Home Health Nursing Diagnoses (50 two digit major categories and 95 three-digit subcategories), (Appendix Table 2). A Nursing Diagnosis is defined as a "clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for the nursing interventions selected to achieve outcomes for which the nurse is accountable" (Approved at the Ninth NANDA Conference, 1992).
The data dictionary consists of 3 modifiers: (a) Improvement, (b) Stabilization, or (c) Deterioration. Each nursing diagnosis requires an Outcome Identification to predict the Expected Outcome Goals of care being performed as interventions. A modifier/qualifier expands the nursing diagnosis and provides the outcome goal for each diagnosis.
The HHCC Nursing Intervention data dictionary consists of 160 Home Health Nursing Interventions (60) two digit major categories and 100 three-digit subcategories). These services are mapped and linked to the nursing diagnoses for which they address. A Nursing Intervention is defined as a single nursing action (treatment, procedure, or activity) performed to achieve an outcome for a diagnosis (medical or nursing) for which the nurse is accountable.
The type action uses a data dictionary consisting of 4 modifiers/qualifiers: (a) Assess/Monitor, (b) care/perform, (c) teach/instruct, and/or (d) Manage / Coordinate (Figure 4). Each nursing intervention requires one or more type of intervention action to identify the specific type of care that is used to implement it. These four modifiers/qualifiers expand the number of nursing interventions four fold resulting in 640 possible patient interventions and/or services.
The data dictionary consists of 3 modifiers: (a) Improved, (b) Stabilized, or (c) Deteriorated. The Outcome Identification goal for each diagnosis is evaluated on discharge and/or at discrete time periods during an episode of care as an actual outcome of care. The actual outcome for each diagnosis is used to evaluate and measure the outcome of care.
The HHCC nomenclature and system make it possible not only to assess and document, but also code, index, classify, link and map the nursing process according to the 20 Care Components. This innovative nomenclature provides the structure and coding strategy for a computer-based patient record (CPR); identifies a nursing minimum data set; and tracks the nursing care process across time, different settings, and geographic locations. Whereas, the HHCC system facilitates the documentation of patient care by computer, at the point-of-care, instead of the traditional paper-based method. The data once collected can be used many times which allow for better documentation and more efficient analysis.
The HHCC system is a free-standing system that can be integrated into any home health system and linked electronically to any system designed to collect the data required for professional and/or federal home health care reporting. This HHCC systems can be used: (a) to improve the efficiency of assessing and documenting home health nursing care; (b) to develop clinical care protocols and/or pathways; (c) to provide the strategy for evaluating quality and measuring outcomes of care; and (d) to develop a costing method for reimbursement and payment.
American Nurses Association (1991). Standards of Clinical Nursing Practice. Washington, DC: ANA.
Lamberts, H., & Wood, M. (Eds.). (1987). International classification of primary care (ICPC). New York: Oxford University Press.
National Association for Home Care (1996, October). Basic statistics about home care, 1996. Washington, DC: NAHC.
North American Nursing Diagnosis Association (1992). NANDA nursing diagnoses: Definitions and classification 1992-1993. St. Louis, MO: NANDA.
Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987). Homecare: Omnibus Budget Reconciliation Act of 1987. Public Law 100-203. Washington, DC.
Saba, V.K. 1991, Feb.) Home health care classification project. Washington, DC: Georgetown University (NTIS Pub # PB92-177013/AS).
Saba, V.K. (March, 1992a). The classification of home health care nursing diagnoses and interventions. Caring,10(3), 50-57.
Saba, V.K. (May, 1992b). Home health care classification. Caring,(5), 58-60.
Saba, V.K. (July, 1994). Home health care classification (HHCC) of nursing diagnoses and interventions. (Revised). Washington, DC: Author.
Saba, V.K., & Zuckerman, A. E. (October, 1992). A new home health re classification method. Caring, 10(10).
Spradley, B. W., & Dorsey, B. (1985). Home health care. In B. W. Spradley (Ed.)., Community health nursing. Boston, MA: Little, Brown & Co.
World Health Organization (1992). International statistical classification of diseases and related health problems: Tenth Revision. Geneva, Switzerland: WHO
Zielstorff, R. D., Hudgings, C.I., & Grobe, S.J. (1993). Next-Generation nursing formation systems: Essential characteristics for professional practice. Washington, DC: ANA.
A complete description of HHCC of Nursing Diagnoses and Nursing Interventions with the 20 Care Components including their definitions is available on the Internet
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Table 1. Home Health Care Classification - 20 Nursing Components: Alphabetic Index and Codes
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A ACTIVITY COMPONENT
B BOWEL ELIMINATION COMPONENT
C CARDIAC COMPONENT
D COGNITIVE COMPONENT
E COPING COMPONENT
F FLUID VOLUME COMPONENT
G HEALTH BEHAVIOR COMPONENT
H MEDICATION COMPONENT
I METABOLIC COMPONENT
J NUTRITIONAL COMPONENT
K PHYSICAL REGULATION COMPONENT
L RESPIRATORY COMPONENT
M ROLE RELATIONSHIP COMPONENT
N SAFETY COMPONENT
O SELF-CARE COMPONENT
P SELF-CONCEPT COMPONENT
Q SENSORY COMPONENT
R SKIN INTEGRITY COMPONENT
S TISSUE PERFUSION COMPONENT
T URINARY ELIMINATION COMPONENT
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Coding structure for Home Health Care Classification (HHCC) of Nursing Diagnoses and Expected Outcomes/Goals. The coding structure consists of five alphanumeric characters.
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CODING STRUCTURE
HOME HEALTH CARE COMPONENT: 1st Alpha Code A-T
NURSING DIAGNOSIS MAJOR CATEGORY: 2nd / 3rd Digit: 01-50
NURSING DIAGNOSIS SUBCATEGORY: 4th Decimal Digit: 1 to 9
DISCHARGE STATUS/GOAL: 5th Digit: 1-3 (Use Only One)
1=Improved, 2=Stabilized, 3=Deteriorated
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Table 2: Home Health Care Classification of Nursing Diagnoses and Coding Scheme: 50 Major Categories and 95 Subcategories.
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A - ACTIVITY COMPONENT
01 Activity Alteration
01.1 Activity Intolerance
01.2 Activity Intolerance Risk
01.3 Diversional Activity Deficit
01.4 Fatigue
01.5 Physical Mobility Impairment
01.6 Sleep Pattern Disturbance
02 Musculoskeletal Alteration
B - BOWEL ELIMINATION COMPONENT
03 Bowel Elimination Alteration
03.1 Bowel Incontinence
03.2 Colonic Constipation
03.3 Diarrhea
03.4 Fecal Impaction
03.5 Perceived Constipation
03.6 Unspecified Constipation
04 Gastrointestinal Alteration
C - CARDIAC COMPONENT
05 Cardiac Output Alteration
06 Cardiovascular Alteration
06.1 Blood Pressure Alteration
D - COGNITIVE COMPONENT
07 Cerebral Alteration
08 Knowledge Deficit
08.1 Knowledge Deficit of Diagnostic Test
08.2 Knowledge Deficit of Dietary Regimen
08.3 Knowledge Deficit of Disease Process
08.4 Knowledge Deficit of Fluid Volume
08.5 Knowledge Deficit of Medication Regimen
08.6 Knowledge Deficit of Safety Precautions
08.7 Knowledge Deficit of Therapeutic Regimen
09 Thought Processes Alteration
E - COPING COMPONENT
10 Dying Process
11 Family Coping Impairment
11.1 Compromised Family Coping
11.2 Disabled Family Coping
12 Individual Coping Impairment
12.1 Adjustment Impairment
12.2 Decisional Conflict
12.3 Defensive Coping
12.4 Denial
13 Post-Trauma Response
13.1 Rape Trauma Syndrome
14 Spiritual State Alteration
14.1 Spiritual Distress
F - FLUID VOLUME COMPONENT
15 Fluid Volume Alteration
15.1 Fluid Volume Deficit
15.2 Fluid Volume Deficit Risk
15.3 Fluid Volume Excess
15.4 Fluid Volume Excess Risk
G - HEALTH BEHAVIOR COMPONENT
16 Growth and Development Alteration
17 Health Maintenance Alteration
18 Health Seeking Behavior Alteration
19 Home Maintenance Alteration
20 Noncompliance
20.1 Noncompliance of Diagnostic Test
20.2 Noncompliance of Dietary Regimen
20.3 Noncompliance of Fluid Volume
20.4 Noncompliance of Medication Regimen
20.5 Noncompliance of Safety Precautions
20.6 Noncompliance of Therapeutic Regimen
H - MEDICATION COMPONENT
21 Medication Risk
21.1 Polypharmacy
I - METABOLIC COMPONENT
22 Endocrine Alteration
23 Immunologic Alteration
23.1 Protection Alteration
J - NUTRITIONAL COMPONENT
24 Nutrition Alteration
24.1 Body Nutrition Deficit
24.2 Body Nutrition Deficit Risk
24.3 Body Nutrition Excess
24.4 Body Nutrition Excess Risk
K - PHYSICAL REGULATION COMPONENT
25 Physical Regulation Alteration
25.1 Dysreflexia
25.2 Hyperthermia
25.3 Hypothermia
25.4 Thermoregulation Impairment
25.5 Infection Risk
25.6 Infection Unspecified
L - RESPIRATORY COMPONENT
26 Respiration Alteration
26.1 Airway Clearance Impairment
26.2 Breathing Pattern Impairment
26.3 Gas Exchange Impairment
M - ROLE RELATIONSHIP COMPONENT
27 Role Performance Alteration
27.1 Parental Role Conflict
27.2 Parenting Alteration
27.3 Sexual Dysfunction
28 Communication Impairment
28.1 Verbal Impairment
29 Family Processes Alteration
30 Grieving
30.1 Anticipatory Grieving
30.2 Dysfunctional Grieving
31 Sexuality Patterns Alteration
32 Socialization Alteration
32.1 Social Interaction Alteration
32.2 Social Isolation
N - SAFETY COMPONENT
33 Injury Risk
33.1 Aspiration Risk
33.2 Disuse Syndrome
33.3 Poisoning Risk
33.4 Suffocation Risk
33.5 Trauma Risk
34 Violence Risk
O - SELF-CARE COMPONENT
35 Bathing/Hygiene Deficit
36 Dressing/Grooming Deficit
37 Feeding Deficit
37.1 Breastfeeding Impairment
37.2 Swallowing Impairment
38 Self Care Deficit
38.1 Activities of Daily Living (ADLs) Alteration
38.2 Instrumental Activities of Daily Living (IADLs)Alteration
39 Toileting Deficit
P - SELF-CONCEPT COMPONENT
40 Anxiety
41 Fear
42 Meaningfulness Alteration
42.1 Hopelessness
42.2 Powerlessness
43 Self Concept Alteration
43.1 Body Image Disturbance
43.2 Personal Identity Disturbance
43.3 Chronic Low Self-Esteem Disturbance
43.4 Situational Self-Esteem Disturbance
Q - SENSORY COMPONENT
44 Sensory Perceptual Alteration
44.1 Auditory Alteration
44.2 Gustatory Alteration
44.3 Kinesthetic Alteration
44.4 Olfactory Alteration
44.5 Tactile Alteration
44.6 Unilateral Neglect
44.7 Visual Alteration
45 Comfort Alteration
45.1 Acute Pain
45.2 Chronic Pain
45.3 Unspecified Pain
R - SKIN INTEGRITY COMPONENT
46 Skin Integrity Alteration
46.1 Oral Mucous Membranes Impairment
46.2 Skin Integrity Impairment
46.3 Skin Integrity Impairment Risk
46.4 Skin Incision
47 Peripheral Alteration
S - TISSUE PERFUSION COMPONENT
48 Tissue Perfusion Alteration
T - URINARY ELIMINATION COMPONENT
49 Urinary Elimination Alteration
49.1 Functional Urinary Incontinence
49.2 Reflex Urinary Incontinence
49.3 Stress Urinary Incontinence
49.4 Total Urinary Incontinence
49.5 Urge Urinary Incontinence
49.6 Urinary Retention
50 Renal Alteration
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1 Adapted from NANDA: Taxonomy I: Revised 1990.
Coding structure for the Home Health Care Classification of Nursing Interventions and Type Intervention Action. The coding structure consists of five alphanumeric characters.
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HOME HEALTH CARE COMPONENT: 1st Alpha Code A-T
NURSING INTERVENTION MAJOR CATEGORY : 2nd / 3rd Digit: 01-60
NURSING INTERVENTION SUBCATEGORY: 4th Decimal Digit: 1-9
TYPE INTERVENTION ACTION: 5th Digit: 1-4 (Use all that Apply)
1=Assess, 2=Care, 3=Teach, 4=Manage
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Table 3: Home Health Care Classification of Nursing Interventions and Coding Scheme: 60 Major Categories & 100 Subcategories.
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A - ACTIVITY COMPONENT
01 Activity Care
01.1 Cardiac Rehabilitation
01.2 Energy Conservation
02 Fracture Care
02.1 Cast Care
02.2 Immobilizer Care
03 Mobility Therapy
03.1 Ambulation Therapy
03.2 Assistive Device Therapy
03.3 Transfer Care
04 Sleep Pattern Control
05 Rehabilitation Care
05.1 Range of Motion
05.2 Rehabilitation Exercise
B - BOWEL ELIMINATION COMPONENT
06 Bowel Care
06.1 Bowel Training
06.2 Disimpaction
06.3 Enema
07 Ostomy Care
07.1 Ostomy Irrigation
C - CARDIAC COMPONENT
08 Cardiac Care
09 Pacemaker Care
D - COGNITIVE COMPONENT
10 Behavior Care
11 Reality Orientation
E - COPING COMPONENT
12 Counseling Service
12.1 Coping Support
12.2 Stress Control
13 Emotional Support
13.1 Spiritual Comfort
14 Terminal Care
14.1 Bereavement Support
14.2 Dying/Death Measures
14.3 Funeral Arrangements
F - FLUID VOLUME COMPONENT
15 Fluid Therapy
15.1 Hydration Status
15.2 Intake/Output
16 Infusion Care
16.1 Intravenous Care
16.2 Venous Catheter Care
G - HEALTH BEHAVIOR COMPONENT
17 Community Special Programs
17.1 Adult Day Center
17.2 Hospice
17.3 Meals-on-Wheels
17.4 Other Community Special Program
18 Compliance Care
18.1 Compliance with Diet
18.2 Compliance with Fluid Volume
18.3 Compliance with Medical Regime
18.4 Compliance with Medication Regime
18.5 Compliance with Safety Precautions
18.6 Compliance with Therapeutic Regime
19 Nursing Contact
19.1 Bill of Rights
19.2 Nursing Care Coordination
19.3 Nursing Status Report
20 Physician Contact
20.1 Medical Regime Orders
20.2 Physician Status Report
21 Professional/Ancillary Services
21.1 Home Health Aide Service
21.2 Medical Social Worker Service
21.3 Nurse Specialist Service
21.4 Occupational Therapist Service
21.5 Physical Therapist Service
21.6 Speech Therapist Service
21.7 Other Ancillary Service
21.8 Other Professional Service
H - MEDICATION COMPONENT
22 Chemotherapy Care
23 Injection Administration
23.1 Insulin Injection
23.2 Vitamin B12 Injection
24 Medication Administration
24.1 Medication Actions
24.2 Medication Prefill Preparation
24.3 Medication Side Effects
25 Radiation Therapy Care
I - METABOLIC COMPONENT
26 Allergic Reaction Care
27 Diabetic Care
J - NUTRITIONAL COMPONENT
28 Gastrostomy/Nasogastric Tube Care
28.1 Gastrostomy/Nasogastric Tube Insertion
28.2 Gastrostomy/Nasogastric Tube Irrigation
29 Nutrition Care
29.1 Enteral/Parenteral Feeding
29.2 Feeding Technique
29.3 Regular Diet
29.4 Special Diet
K - PHYSICAL REGULATION COMPONENT
30 Infection Control
30.1 Universal Precautions
31 Physical Health Care
31.1 Health History
31.2 Health Promotion
31.3 Physical Examination
31.4 Physical Measurements
32 Specimen Analysis
32.1 Blood Specimen Analysis
32.2 Stool Specimen Analysis
32.3 Urine Specimen Analysis
32.4 Other Specimen Analysis
33 Vital Signs
33.1 Blood Pressure
33.2 Temperature
33.3 Pulse
33.4 Respiration
34 Weight Control
L - RESPIRATORY COMPONENT
35 Oxygen Therapy Care
36 Respiratory Care
36.1 Breathing Exercises
36.2 Chest Physiotherapy
36.3 Inhalation Therapy
36.4 Ventilator Care
37 Tracheostomy Care
M - ROLE RELATIONSHIP COMPONENT
38 Communication Care
39 Psychosocial Analysis
39.1 Home Situation Analysis
39.2 Interpersonal Dynamics Analysis
N - SAFETY COMPONENT
40 Abuse Control
41 Emergency Care
42 Safety Precautions
42.1 Environmental Safety
42.2 Equipment Safety
42.3 Individual Safety
O - SELF-CARE COMPONENT
43 Personal Care
43.1 Activities of Daily Living (ADLs)
43.2 Instrumental Activities of Daily Living (IADLs)
44 Bedbound Care
44.1 Positioning Therapy
P - SELF-CONCEPT COMPONENT
45 Mental Health Care
45.1 Mental Health History
45.2 Mental Health Promotion
45.3 Mental Health Screening
45.4 Mental Health Treatment
46 Violence Control
Q - SENSORY COMPONENT
47 Pain Control
48 Comfort Care
49 Ear Care
49.1 Hearing Aid Care
49.2 Wax Removal
50 Eye Care
50.1 Cataract Care
R - SKIN INTEGRITY COMPONENT
51 Decubitus Care
51.1 Decubitus Stage 1
51.2 Decubitus Stage 2
51.3 Decubitus Stage 3
51.4 Decubitus Stage 4
52 Edema Control
53 Mouth Care
53.1 Denture Care
54 Skin Care
54.1 Skin Breakdown Control
55 Wound Care
55.1 Drainage Tube Care
55.2 Dressing Change
55.3 Incision Care
S - TISSUE PERFUSION COMPONENT
56 Foot Care
57 Perineal Care
T - URINARY ELIMINATION COMPONENT
58 Bladder Care
58.1 Bladder Instillation
58.2 Bladder Training
59 Dialysis Care
60 Urinary Catheter Care
60.1 Urinary Catheter Insertion
60.2 Urinary Catheter Irrigation ______________________________________________________________________________