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The α-dicarbonyl compounds glyoxal (CHOCHO) and methyl glyoxal (CH3C(O)CHO) are produced in the atmosphere by the oxidation of hydrocarbons and emitted directly from pyrogenic sources. Measurements of ambient concentrations inform about the rate of hydrocarbon oxidation, oxidative capacity, and secondary organic aerosol (SOA) formation. We present results from a comprehensive instrument comparison effort at two simulation chamber facilities in the US and Europe that included nine instruments, and seven different measurement techniques: broadband cavity enhanced absorption spectroscopy (BBCEAS), cavity-enhanced differential optical absorption spectroscopy (CE-DOAS), white-cell DOAS, Fourier transform infrared spectroscopy (FTIR, two separate instruments), laser-induced phosphorescence (LIP), solid-phase micro extraction (SPME), and proton transfer reaction mass spectrometry (PTR-ToF-MS, two separate instruments; for methyl glyoxal only because no significant response was observed for glyoxal). Experiments at the National Center for Atmospheric Research (NCAR) compare three independent sources of calibration as a function of temperature (293-330 K). Calibrations from absorption cross-section spectra at UV-visible and IR wavelengths are found to agree within 2% for glyoxal, and 4% for methyl glyoxal at all temperatures; further calibrations based on ion-molecule rate constant calculations agreed within 5% for methyl glyoxal at all temperatures. At the European Photoreactor (EUPHORE) all measurements are calibrated from the same UV-visible spectra (either directly or indirectly), thus minimizing potential systematic bias. We find excellent linearity under idealizedconditions (pure glyoxal or methyl glyoxal, R2 > 0:96), and in complex gas mixtures characteristic of dry photochemical smog systems (o-xylene/NOx and isoprene/NOx, R2 > 0:95; R2 ∼ 0:65 for offline SPME measurements of methyl glyoxal). The correlations are more variable in humid ambient air mixtures (RH>45 %) for methyl glyoxal (0:58 < R2 < 0:68) than for glyoxal (0:79 < R2 < 0:99). The intercepts of correlations were insignificant for the most part (below the instruments' experimentally determined detection limits); slopes further varied by less than 5% for instruments that could also simultaneously measure NO2. For glyoxal and methyl glyoxal the slopes varied by less than 12 and 17% (both 3-σ) between direct absorption techniques (i.e., calibration from knowledge of the absorption cross section). We find a larger variability among in situ techniques that employ external calibration sources (75-90 %, 3-σ), and/or techniques that employ offline analysis. Our intercomparison reveals existing differences in reports about precision and detection limits in the literature, and enables comparison on a common basis by observing a common air mass. Finally, we evaluate the influence of interfering species (e.g., NO2, O3 and H2O) of relevance in field and laboratory applications. Techniques now exist to conduct fast and accurate measurements of glyoxal at ambient concentrations, and methyl glyoxal under simulated conditions. However, techniques to measure methyl glyoxal at ambient concentrations remain a challenge, and would be desirable.

Organic peroxy (RO2) and hydroperoxy (HO2) radicals are key intermediates in the photochemical processes that generate ozone, secondary organic aerosol and reactive nitrogen reservoirs throughout the troposphere. In regions with ample biogenic hydrocarbons, the richness and complexity of peroxy radical chemistry presents a significant challenge to current-generation models, especially given the scarcity of measurements in such environments. We present peroxy radical observations acquired within a ponderosa pine forest during the summer 2010 Bio-hydro-atmosphere interactions of Energy, Aerosols, Carbon, H2O, Organics and Nitrogen-Rocky Mountain Organic Carbon Study (BEACHON-ROCS). Total peroxy radical mixing ratios reach as high as 180 pptv (parts per trillion by volume) and are among the highest yet recorded. Using the comprehensive measurement suite to constrain a near-explicit 0-D box model, we investigate the sources, sinks and distribution of peroxy radicals below the forest canopy. The base chemical mechanism underestimates total peroxy radicals by as much as a factor of 3. Since primary reaction partners for peroxy radicals are either measured (NO) or underpredicted (HO2 and RO2, i.e., self-reaction), missing sources are the most likely explanation for this result. A close comparison of model output with observations reveals at least two distinct source signatures. The first missing source, characterized by a sharp midday maximum and a strong dependence on solar radiation, is consistent with photolytic production of HO2. The diel profile of the second missing source peaks in the afternoon and suggests a process that generates RO2 independently of sun-driven photochemistry, such as ozonolysis of reactive hydrocarbons. The maximum magnitudes of these missing sources (∼120 and 50 pptv minĝ1, respectively) are consistent with previous observations alluding to unexpectedly intense oxidation within forests. We conclude that a similar mechanism may underlie many such observations. © 2014 Aothor(s).

The San Joaquin Valley (SJV) experiences some of the worst ozone air quality in the US, frequently exceeding the California 8 h standard of 70.4 ppb. To improve our understanding of trends in the number of ozone violations in the SJV, we analyze observed relationships between organic reactivity, nitrogen oxides (NOx), and daily maximum temperature in the southern SJV using measurements made as part of California at the Nexus of Air Quality and Climate Change in 2010 (CalNex-SJV). We find the daytime speciated organic reactivity with respect to OH during CalNex-SJV has a temperature-independent portion with molecules typically associated with motor vehicles being the major component. At high temperatures, characteristic of days with high ozone, the largest portion of the total organic reactivity increases exponentially with temperature and is dominated by small, oxygenated organics and molecules that are unidentified. We use this simple temperature classification to consider changes in organic emissions over the last and next decade. With the CalNex-SJV observations as constraints, we examine the sensitivity of ozone production (PO3) to future NOx and organic reactivity controls. We find that PO3 is NOx-limited at all temperatures on weekends and on weekdays when daily maximum temperatures are greater than 29 °C. As a consequence, NOx reductions are the most effective control option for reducing the frequency of future ozone violations in the southern SJV. © 2014 Author(s).

Symptom management for persons living with HIV disease is recognized as an extremely important component of care management. This article reports the validation of a new sign and symptom assessment tool designed to assess the intensity of HIV-related symptoms using two samples (study 1: n=247; study 2: n=686) of people living with HIV disease. Study 1 data were collected between 1994 and 1996 before the initiation of highly active antiretroviral therapy (HAART). Study 2 data were collected between 1997 and 1998 after the wide adoption of HAART therapy. The initial version of the Sign and Symptom Check-List for Persons with HIV Disease (SSC-HIV) included 41 signs and symptoms. This scale was submitted to a principal components factor analysis with a varimax rotation. The final solution reports six factors explaining 68.9% of the variance. The six symptom clusters (factors), the number of items in the factor, and the Cronbach alpha reliability estimates were: malaise/weakness/fatigue (six items, alpha=0.90); confusion/distress (four items, alpha=0.90); fever/chills (four items, alpha=0.85); gastrointestinal discomfort (four items, alpha=0. 81); shortness of breath (three items, alpha=0.79); and nausea/vomiting (three items, alpha=0.77). These six factors have strong reliability estimates and a stable factor structure that supports the construct validity of the 26-item instrument. Additional evidence supports the concurrent validity of the scale as well as its sensitivity to change over time. The final version of the SSC-HIV is a 26-item scale available for use by clinicians and researchers to measure the patient's self-report of HIV-related signs and symptoms. [ABSTRACT FROM AUTHOR]

The naming of nursing phenomena and representing the phenomena in a standardized manner suitable for encoding in computer-based systems is a challenge for the nursing profession at the national and the international level. Considerable progress has been made in the development of classification systems for nursing practice. The focus of this article is on language systems developed to represent nursing judgements in computer-based systems, in particular the electronic health record. A review of two current systems and their proposed revisions (North American Nursing Diagnosis Association, NANDA, Taxonomies I and II, and the International Classification for Nursing Practice, ICNP, Alpha and Beta versions), according to the features suggested by the Computer-based Patient Record Institute (CPRI) for classification systems appropriate for implementation in computer-based systems, suggests that the evolving versions extend the current versions in terms of sufficient granularity (depth and level of detail) and atomic and compositional character. However, it is not clear from the literature available to date whether the characteristics that are most closely related to definition of a formal terminology (i.e. clear and non-redundant representation of concepts, syntax and grammar for logical constructions of compositional terms, synonyms and language independence) will be part of the evolving vocabularies. Formal terminology models and related tools have the potential to complement, extend, and refine existing nursing classification systems. [ABSTRACT FROM AUTHOR]

The phenomena of interest in nursing informatics are nursing data, nursing information and nursing knowledge. The current state of knowledge related to these phenomena suggests four implications for the development of systems to support nursing. First, research has provided evidence that knowledge and experience is related to the quality of nursing assessment, diagnosis or clinical inference, and planning of nursing care, and also that knowledge is task-specific. Information technology can provide access to a variety of information resources, such as knowledge bases and decision support systems, to increase the level of knowledge of the nurse decision-maker. Second, structured patient assessment forms with linkages to knowledge bases of diagnoses have the potential to improve the quality of the patient assessment and the accuracy of the diagnosis or clinical inference. Third, studies on planning care have demonstrated the complexity of the task when a number of options are potentially appropriate. Model-based decision support applications such as decision analysis and multi-attribute utility theory can assist the clinicians and patients to analyse and compare the treatment alternatives in a systematic manner. Fourth, there is modest support for demonstrating the relationship between the process and outcomes of clinical decision making. Large databases built upon nursing data are needed to further examine this relationship. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe the problems of HIV-infected patients, hospitalized for Pneumocystis carinii pneumonia (PCP), as documented in the nursing care plan and to examine differences in the number and type of activated patient problems and patient outcomes between manually generated, computer-supported, and standardized care planning systems. Of the sample, 22% had no care plan. In the computer-supported care planning system the fewest number of care plans were completed. The total number of problems generated for the 89 patients having care plans was 199. The problems were categorized as PCP-related (37%), AIDS-related (16%), psychosocial (23%), knowledge deficit (14%), and other (10%). There was significant differences among the three groups in the total number of problems, PCP-related problems, and knowledge deficit problems. There were no statistically significant differences in patient outcomes, as measured by HIV-QAM scale scores and patient self-rating of physical condition approximately 1 week after admission, and length of stay among the three care planning systems. Future research is needed to examine the effect of type of care planning system on the quality of patient care. [ABSTRACT FROM AUTHOR]

Examination of four standardized nursing care plans for people with AIDS (PWAs) from four agencies with extensive experience with caring for PWAs revealed that there is little agreement about the nursing care problems of PWAs. Differences in language, conceptual clarity, and level of complexity related to problem identification have implications for nursing practice, quality assurance and research. Without consensus about patient problems, it is impossible to communicate effectively about nursing care problems for PWAs. Research is needed to validate patient problems that can serve as the basis for standards of care and provide guidance for nurses inexperienced in caring for PWAs. [ABSTRACT FROM AUTHOR]

Our premise is that from the perspective of maximum flexibility of data usage by computer-based record (CPR) systems, existing nursing classification systems are necessary, but not sufficient, for representing important aspects of "what nurses do." In particular, we have focused our attention on those classification systems that represent nurses' clinical activities through the abstraction of activities into categories of nursing interventions. In this theoretical paper, we argue that taxonomic, combinatorial vocabularies capable of coding atomic-level nursing activities are required to effectively capture in a reproducible and reversible manner the clinical decisions and actions of nurses, and that, without such vocabularies and associated grammars, potentially important clinical process data is lost during the encoding process. Existing nursing intervention classification systems do not fulfill these criteria. As background to our argument, we first present an overview of the content, methods, and evaluation criteria used in previous studies whose focus has been to evaluate the effectiveness of existing coding and classification systems. Next, using the Ingenerf typology of taxonomic vocabularies, we categorize the formal type and structure of three existing nursing intervention classification system--Nursing Interventions Classification, Omaha System, and Home Health Care Classification. Third, we use records from home care patients to show examples of lossy data transformation, the loss of potentially significant atomic data, resulting from encoding using each of the three systems. Last, we provide an example of the application of a formal representation methodology (conceptual graphs) which we believe could be used as a model to build the required combinatorial, taxonomic vocabulary for representing nursing interventions. [ABSTRACT FROM AUTHOR]

In recent decades there have been major advances in the creation and implementation of information technologies and in the development of measures of health care quality. The premise of this article is that informatics provides essential infrastructure for quality assessment and improvement in nursing. In this context, the term quality assessment and improvement comprises both short-term processes such as continuous quality improvement (CQI) and long-term outcomes management. This premise is supported by 1) presentation of a historical perspective on quality assessment and improvement; 2) delineation of the types of data required for quality assessment and improvement; and 3) description of the current and potential uses of information technology in the acquisition, storage, transformation, and presentation of quality data, information, and knowledge. [ABSTRACT FROM AUTHOR]

Objective: To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms.Design: Prospective research design with manual matching of terms to the SNOMED III vocabulary.Measurements: The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms.Results: Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms. [ABSTRACT FROM AUTHOR]

The purpose of this secondary analysis was to test empirically the influence of biological and physiological variables, symptom status, functional status, general health perceptions, characteristics of the individual and characteristics of the environment on overall quality of life in persons living with HIV disease. Path analysis, using multiple linear regression, was used to examine the fit between a health-related quality of life (HRQOL) theoretical model and data from a sample of 142 persons with an AIDS diagnosis. Thirty-two per cent of the variance in overall quality of life was explained by the HRQOL model with symptom status having the greatest influence (beta = -0.237, R2(Y x 2) = 5%). This analysis suggests that symptom status, functional status and general health perceptions are key dimensions of HRQOL. With a focus on prevention, health promotion, symptom management, and the alleviation of acute and chronic illness effects, HRQOL may be appropriate for capturing the outcomes of nursing interventions. [ABSTRACT FROM AUTHOR]

Research traditionally has focused on the development of symptoms in those who experienced trauma directly but overlooked the impact of trauma on the families of victims. In recent years, researchers and clinicians have begun to examine how individual exposure to traumatic events affects the spouses/partners, children, and professional helpers of trauma survivors. The current study reports data from a larger mixed-methodology study that includes qualitative interview data from 17 individuals, coded to identify the mechanisms that may affect the couple's interpersonal functioning when there is a history of trauma exposure in one or both partners. The following primary themes were identified: role in the relationship, boundary issues, intimacy problems, triggers, and coping mechanisms. Areas for future research and clinical implications also are identified., (© 2011 American Association for Marriage and Family Therapy.)

Research has traditionally focused on the development of symptoms in those who experienced trauma directly but has overlooked the impact of trauma on victims' families. In recent years, researchers and clinicians have begun to examine how individual exposure to traumatic events affects the spouses or partners, children, and professional helpers of trauma survivors. The current study examines qualitative interview data from 17 individuals, analyzed using a retroductive methodology to identify how intimate relationships are affected when there is a history of trauma exposure. The following primary themes were identified: increased communication, decreased communication, increased cohesion/connection, decreased cohesion/connection, increased understanding, decreased understanding, sexual intimacy problems, symptoms of relationship distress, support from partner, and relationship resources. Areas for future research and clinical implications are identified., ((c) 2007 APA, all rights reserved)

The relationships among the biological and physiological indicators of cytopenias in AIDS and measures of quality of life are not well characterized. The purpose of this secondary analysis was to determine the relationships among anemia, neutropenia and thrombocytopenia and characteristics of the individual, physiological markers, symptoms, functional status, general health perceptions, and well-being in people with AIDS. The five dimensions of the Wilson and Cleary model of health-related quality of life provided the conceptual model for this study. In addition to descriptive statistics, logistic regression was used to analyze clusters of variables. The sample of 146 hospitalized patients with AIDS had an 85% prevalence of anemia, a 53% prevalence neutropenia and a 33% prevalence of thrombocytopenia. The mean age was 38 years old, 19% were female, 35% were white, 27% had a history of injection drug use and the mean T-helper cell count was 74 mm3. The five dimensions of the Wilson and Cleary model offered significant predictability for anemia only. Patients with higher symptom scores were more likely to have treatable anemia, defined as a hematocrit of < 30%. Treatable anemia was also associated with lower self-care scores and lower T-helper cells. Fifty-four percent of the cohort were candidates for colony stimulating factors, while only 17% of those eligible received them. These data suggest suboptimal treatment of anemia and neutropenia in this cohort of AIDS patients.

This article describes the Client Adherence Profiling-Intervention Tailoring (CAP-IT) intervention designed to enhance adherence to HIV/AIDS medications and reports the results of a pilot study aimed at assessing the feasibility of CAP-IT. Initially, CAP-IT was designed to be implemented by nurse case managers during regularly scheduled home visits; it is currently under revision for use in an outpatient, ambulatory care setting. CAP-IT is an innovative, structured nursing assessment and care-planning activity that allows a standardized assessment of client needs and tailored highly active antiretroviral therapy adherence intervention strategies. CAP-IT is significantly different from the current standard nursing case management practice. Pilot study results in a sample of 10 home care patients suggests that clients have knowledge and skill deficits related to adherence and in the management of the side effects of medications. In addition, the pilot study supported the acceptability of the protocol to clients and the feasibility of integrating CAP-IT into nurse case manager practice. The pilot study results also provided evidence for the efficacy of CAP-IT. The next steps include testing CAP-IT in a randomized clinical trial to determine its effectiveness.

A case control design was used to examine quality of life and self-care management strategies in persons living with AIDS (PLWAs) with chronic diarrhea. PLWAs without chronic diarrhea (n = 20) as compared to those with chronic diarrhea (n = 20) reported significantly higher general health perceptions (p = .028). In contrast, comparisons on symptom status scores revealed that PLWAs without chronic diarrhea reported greater fatigue (p = .05), greater psychological distress (p = .005), and greater gastrointestinal discomfort (p = .01). Although the intensity of chronic diarrhea was reported as moderate to severe by 85% of the sample, no single category of self-care management strategies was used by more than 65% of respondents. The number of categories of self-care management activities was significantly correlated with general health perceptions. The study findings support the need to test nursing interventions aimed at improving symptom management in chronic diarrhea and facilitating self-care behaviors including those focused on increasing adherence to prescribed therapeutic regimens.

This study examined the relationships between the five dimensions of the Wilson and Cleary model of health-related quality of life and three self-reported adherence measures in persons living with HIV using a descriptive survey design. Data collection occurred in seven cities across the United States, including university-based AIDS clinics, private practices, public and for-profit hospitals, residential and day-care facilities, community-based organizations, and home care. The three dependent adherence measures studied were "medication nonadherence," "follows provider advice," and "missed appointments." The sample included 420 persons living with HIV disease with a mean age of 39 years of which 20% were women and 51% were white; subjects had a mean CD4 count of 321 mm3. HIV-positive clients with higher symptom scores, particularly depression, were more likely to be nonadherent to medication, not to follow provider advice, and to miss appointments. Participants who reported having a meaningful life, feeling comfortable and well cared for, using their time wisely, and taking time for important things were both more adherent to their medications and more likely to follow provider's advice. No evidence was found demonstrating any relationship between adherence and age, gender, ethnicity, or history of injection drug use. These findings support the need to treat symptoms, particularly depression, and to understand clients' perceptions of their environment as strategies to enhance adherence. A limitation of this study was that adherence was measured only by self-report; however, the study did expand the concept of adherence in HIV care beyond medication adherence to include following instructions and keeping appointments.

Efforts to develop an International Classification for Nursing Practice (ICNP) were initiated nearly a decade ago. To update nurses on progress, below is a critical review of the ICNP using the Computer-based Patient Record Institute (CPRI) Features Framework and a discussion of its relevance to current US efforts: 1) the activities of the American Nurses' Association (ANA) Steering Committee on Databases To Support Clinical Nursing Practice; 2) implementation of formal approaches for representing nursing concepts and 3) Health Level 7 standards.

Building on the work of previous authors, the Computer-based Patient Record Institute (CPRI) Work Group on Codes and Structures has described features of a classification scheme for implementation within a computer-based patient record. The authors of the current study reviewed the evaluation literature related to six major nursing vocabularies (the North American Nursing Diagnosis Association Taxonomy 1, the Nursing Interventions Classification, the Nursing Outcomes Classification, the Home Health Care Classification, the Omaha System, and the International Classification for Nursing Practice) to determine the extent to which the vocabularies include the CPRI features. None of the vocabularies met all criteria. The Omaha System, Home Health Care Classification, and International Classification for Nursing Practice each included five features. Criteria not fully met by any systems were clear and non-redundant representation of concepts, administrative cross-references, syntax and grammar, synonyms, uncertainty, context-free identifiers, and language independence.

Practice guidelines are an integral part of evidence-based health care delivery. When the authors decided to install the clinical documentation component of an electronic health record in a nurse practitioner faculty practice, however, they found that they lacked the resources to integrate it immediately with other systems and components that would support the processing of clinical rules. They were thus challenged to devise an initial approach for decision support related to clinical practice guidelines that did not include interfacing with an inference engine and set of decision rules. The authors developed a prototypic application within the WAVE electronic health record that demonstrates the feasibility of representing a guideline as structured encoded text organized into an online patient-encounter template. Although this approach may be more broadly applicable, it is described within the context of the management of diabetes mellitus by nurse practitioners. The advantages of the approach relate primarily to the integration of the guideline recommendations with the encounter form, the online interaction of the clinician with the system, and the ease of creation and modification of the guideline-based encounter form. However, there are several limitations of the current approach as a result of the inability to do inference and the lack of integration with patient-specific data to trigger specific rules.

The nursing profession has developed a number of classification systems. What can HIM professionals learn from the processes and results? This article presents an overview of the major nursing classification systems and examines some of the national efforts to standardize nursing data elements.

Although the prevalence and complexity of pain management in HIV/AIDS has been described in the literature, little is known about the management of pain from the patient perspective. This study used a set of standardized instruments, a medication chart audit, and a semistructured interview to elicit patients' self-reports of pain and patients' perceptions of nursing and self-care pain management strategies and examined potential physiological and psychosocial correlates of pain. The sample of 249 AIDS patients from three types of care settings (hospital, home care, skilled nursing facility) reported a modest overall current pain intensity (M = .14, range = 0-1). They reported experiencing pain in all body parts as measured by a body outline and characterized their pain with an average of 8.96 words from a list of 67 words. A lower pain rating was correlated with higher ratings on quality of life and perceived psychological support. An audit of the medication record revealed that the study sample received the following medications: narcotic analgesics (49%), nonnarcotic analgesics (47%), and antidepressants (22%). In a semistructured interview, medications were rated as effective by 80% of patients experiencing pain who stated that their health care providers included pain medications as part of the patient's pain management plan. Patients reported few nonpharmacologic self-care or health care provider interventions to manage their pain, and the effectiveness ratings of the interventions demonstrated wide variability. The study findings suggest that because pain was related to quality of life ratings and the pain management strategies reported by patients were not completely effective, further work is needed to examine pain management strategies that incorporate both pharmacologic and nonpharmacologic interventions with particular attention to self-care interventions. In addition, the data suggest that nursing assessments should include questions aimed at eliciting potentially harmful (e.g., street drugs, self-prescribed medications) strategies that patients may be using to manage their pain.

Background: Because of the difficulty of implementing clinical outcomes-focused quality improvement (QI) projects, most organizations' efforts and comparative quality report cards have centered on structure and process indicators or on outcomes captured in administrative data systems. Ultimately, however, health care is intended to improve health. Health status is now frequently included in the set of quality of care information requested by purchasers of health care, accrediting and governmental agencies, and consumer groups. Subsequently, users of electronic health record (EHR) systems are demanding that the EHR support the collection and comparative analysis of health status information over time and by clinical population and provider., Approach: As opposed to the current practice in most organizations of collecting health status data via an annual mail survey, the approach discussed in this article utilizes standardized coding and classification (SCC) systems and standardized surveys to capture health status information in the EHR during the routine course of care delivery through the use of templates built on structured text. This method is illustrated with examples from the WAVE EHR. The EHR-based structured text and template approach facilitates the incorporation of health status measurement into the documentation of the patient-provider encounter, builds on recognized SCC systems and standardized surveys, and enables information retrieval for a variety of analyses, including those focused on QI., Conclusions: Health status outcomes are an essential component of an information set focused on health care quality. To routinely capture and analyze health status variables, SCC systems and standardized health status surveys are necessary.

Objectives: The purpose of this article is to review the evidence linking variations in care delivery system with achievement of appropriate self-care., Methods: This synthetic review of the research literature used the Outcomes Model for Health Care Research. The concept of self-care was reviewed from several theoretical perspectives, as was the quality of instruments used to measure aspects of self-care. Finally, studies examining the linkage between care delivery system and self-care were critically analyzed., Results: Reliable and valid instruments exist to measure self-care agency and self-care performance, and these data elements are collected routinely in many care settings. Only a few studies, however, have examined the relation between achievement of self-care and variations in delivery systems., Conclusions: Achievement of appropriate self-care may be an outcome measure better suited to nonacute care settings or across the continuum of care. Additionally, work is needed in applying risk-adjustment strategies to the measurement of achievement of appropriate self-care.

The purpose of this study is to evaluate the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. The data set comprised 5,844 problem terms and 20,055 interventions terms. All terms could be categorized using the Nursing Components and Major Categories for Nursing Diagnoses and Interventions. A total of 1,767 (30.2%) patients problem terms could be placed into Major Nursing Diagnosis categories, but not subcategories even though there were subcategories related to the major category. All intervention terms whether they were classified at the Intervention Category or Subcategory could be coded according to Type of Nursing Action. These findings demonstrate that the Home Health Care Classification, at the level of Nursing Components and Major Categories, was domain complete for the data set. The fact that not all terms could be classified according to the existing subcategories suggests some areas for future development, but is also a reflection of the level of detail expressed in the data set itself. The results suggest that the Home Care Classification will be adequate and appropriate for categorizing problems and interventions across setting for the next phases of the research project.

Developers of healthcare information systems are challenged by the difficulty of meeting the simultaneous goals of 1) capturing and electronically representing the broad array of data related to healthcare with sufficient expressibility to provide adequate documentation of the patient encounter, and 2) utilizing standardized coding and classification systems to facilitate linkages among computer-based systems. The evaluation studies to date have primarily focused on matching actual clinical data with terms in the recognized classification systems. These studies have provided evidence that the classification systems are relatively domain complete for categorizing patient problems and nursing interventions. Although several of the published criteria for evaluation relate to structure, it is noteworthy that this has not yet been a major focus of study in nursing. There are several areas of critical need that must be addressed. First, additional work is needed to develop and refine a standardized set of atomic-level terms relevant to nursing, including those for assessments, problems, and activities. Second, knowledge representations must be developed to support the building of complex concepts from atomic-level data.

Purpose: To compare the frequency with which nursing activity terms could be categorized using Nursing Interventions Classification (NIC) and Current Procedural Terminology (CPT) codes., Design: Descriptive. The sample was 201 patients with AIDS hospitalized 1989-1992 for pneumocystis carinii pneumonia in three US medical centers., Methods: Nursing activity terms (n = 21,366) were collected from patient interviews, nurse interviews, intershift reports, and patient records, then were categorized using NIC and CPT codes., Results: Nursing activity terms were categorized into 80 NIC interventions across 22 classes and into 15 CPT codes. All terms in the data set were classifiable using the NIC system and the majority (60%) of the terms were classified into 14 NIC intervention categories; 6% of the terms were classifiable by CPT codes. The most frequently used CPT code was "pulse oximetry." Significantly (p < .0001) greater numbers of nursing activity terms could be categorized in the NIC system compared to the CPT system., Conclusions: Findings provide evidence that NIC is superior to CPT for categorizing nursing activities in this study's population. The findings support the importance of discipline-specific classifications for categorization of health care interventions. Nursing-specific intervention classification systems such as NIC, the Omaha System, and the Home Health Care Classification are essential to defining the contribution of nursing to both quality and cost outcomes.

This descriptive, correlational study was designed to determine the sensitivity of a generic health status instrument to patient population and to time. The study sample included adult patients undergoing total joint replacement (TJR), adult patients in acute congestive heart failure (CHF), and pediatric patients receiving chemotherapy (PediOnc). A 2 x 3 (population x time) ANOVA for TJR and CHF demonstrated a significant main effect of time (F = 8.0, p = .0006) and a significant interaction effect between time and population (F = 14.4, p < .0001) for functional status. In the PediOnc subsample (HSOD child version), the highest scores for all HSOD factors with the exception of functional status were at Time 3. There was also a significant main effect of time on health care involvement, on the caregiver factor, and the family factor. These results support the sensitivity of the HSOD to patient population and to time.

The purpose of this study was to examine the relationships between the patient's health status at hospital admission and the initial care planned by the nurse. Functional status, engagement in care, and psychosocial well-being were measured by the Health Status Outcome Dimensions(HSOD) instrument. The HSOD is the foundation for developing a computer-based infrastructure for the analysis of health related outcomes. The consecutive, convenience sample of 308 subjects was drawn from five acute clinical populations: pulmonary; cerebrovascular, cardiac; gastrointestinal; and infection. Logistic and multiple regression analyses were used to test the relationships between control (patient and setting) variables, health status, and the dependent variables of type of problem identified, number of problems identified, and the time required to implement interventions ordered for the patient. In seven of ten models, control variables of facility, age, and/or severity of illness contributed to a model at p < .01. In six of ten models, at least one health status measure significantly explained variation beyond the control variables, at p < .01. Study results support using data gathered during the course of care, to evaluate the process of that care. Further work is needed to understand the effects of setting and provider variables on the use of health status data in care planning. Computer-based outcomes infrastructures are essential to support the collection and analysis of health status over time.

A variety of strategies for knowledge representation have been applied to the texts from a number of medical domains. Many of the techniques rely on the well-defined ways in which medical terms are used within a given domain, a phenomenon referred to as 'sublanguage.' Because much of nursing documentation involves the use of 'everyday' language, the viable application of sublanguage-based approaches to knowledge representation of nursing documentation is not a forgone conclusion. We propose an approach utilizing semantic markup of nursing notes as a strategy for determining whether the documentation of 'what nurses do' is a sublanguage Results of an initial feasibility study utilizing the approach are presented.

Given an appropriate conceptual model, such as the Wilson and Cleary model for linking clinical variables with health-related quality of life, ambulatory care information systems have the potential to facilitate holistic care for persons infected with the human immunodeficiency virus. Four examples of the manner in which an ambulatory care system can support the provision of holistic care are the contextualization of care through inclusion of the patient's voice, improved coordination of care and knowledge-harvesting through systems integration, timely application of agency-specific information and domain information and knowledge to an individual patient, and blurring of the boundaries of ambulatory care.

The American Nurses Association Steering Committee on Databases to Support Nursing Practice has recognized three standardized nursing intervention classification systems. Because each of these classifications systems focuses on encoding informational abstractions of nursing actions, rather than providing a controlled vocabulary and compositional grammar from which informational concepts and abstractions can be constructed, the systems are necessary, but not sufficient, for representing what nurses do. In particular, computer based patient record systems focused on process understanding and process improvement will require atomic-level representations of nursing actions suitable for transformation into a variety of information abstractions, including, but not limited to, the abstractions contained in the three existing classification systems.

In the three decades since the installation of the first bedside computer in the "shock ward" at the University of California and Los Angeles County Hospital, both computer technology and critical care practice have evolved rapidly. The premise of this article is that critical care information systems are an essential infrastructure for critical care nursing practice. This premise is described in terms of the critical care environment, clinical decision making in critical care, increasing demands for information about quality and costs, and national initiatives for the sharing of health care information.

The authors of this prospective study describe the problems of persons living with HIV/AIDS hospitalized for Pneumocystis carinii pneumonia (PCP) (N = 90) and examine how the problems change over time. Data were obtained from four sources and were classified into major problem categories. The largest mean number of problems were reported in the category of PCP. Specific psychosocial problems were more likely to be reported in the patient and nurse interviews than in the chart and intershift report. The study findings validate the physical symptoms addressed in the published care plans and guidelines for caring for patients with PCP. The study identified the limitation of using the patient record as the only data source in determining nursing care needs and emphasized the importance of the patients perspective.

Using a sample of 201 patients hospitalized for Pneumocystis carinii pneumonia, this study describes problem lists generated by physicians and examines the overlap among problem lists generated by physicians, nurses, and patients. The findings indicate that the majority of patients in this sample had at least one problem that occurred in more than one problem list. Problems that most frequently appeared in more than one problem list were those related to the medical diagnosis of Pneumocystis carinii pneumonia and its associated physiological symptoms. Problems which occurred uniquely in the nurse problem list were knowledge deficit and potential for injury. Thirty-four percent of the patients identified at least one psychosocial problem that did not occur in either the physician- or nurse-generated problem lists. The study findings demonstrate that while there is overlap among the problem lists in problems related to the principal medical diagnoses, the nurse- and patient-generated problem lists include unique problems which provide additional significant information related to patient status that has the potential to impact patient outcomes. These findings suggest that a unified, nonredundant, multidisciplinary problem list is warranted in order to provide a comprehensive view of the patient for computer-based patient record (CPR) systems. Appropriate data models and comprehensive controlled vocabularies are needed to support the multiple uses of the problem list for CPR systems.

The purpose of this study was twofold: 1) to compare the ability of terms from the nursing intervention classification and from the current procedural terminology to represent the clinical terms used by nurses and patients to describe nursing interventions during hospitalization; and 2) to identify the strengths and weaknesses of the two classification systems for representing nursing systems. More NIC than CPT codes matched the concepts in the clinical terms used by nurses and patients to describe nursing interventions demonstrating, not unexpectedly, that NIC represents a broader scope of nursing practice. The major difficulty encountered using NIC was the lack of mutual exclusiveness of the nursing activities within the interventions. CPT codes were easy to apply to the clinical terms, but were limited in scope for nursing practice. The findings of this study demonstrate the necessity of using a nursing-specific classification system for the representation of nursing interventions. This is of particular importance for databases that will be used to examine the effectiveness of healthcare interventions and for databases related to reimbursement for healthcare interventions.

1. RESEARCH OBJECTIVES AND METHODS. Because of a need for a standard classification and coding system to encode data for HIV infected patients in the AIDS Program clinic at San Francisco General Hospital, we have begun a subset of clinical terms commonly used in the care of patients with HIV disease, and we have sought to represent these terms using terminology from the SNOMED International classification system. We selected a sample of key findings for AIDS primary care for the AIDS Registry database. The areas of chest x-ray findings, psychological problems, and patient symptoms were chosen because they were representative of a number of SNOMED International axes, including diagnoses, morphology, topography, and function. They also included modifiers representing the concepts of laterality, time, severity, and certainty. 2. RESULTS. As shown by the sample terms in the table below, the findings suggest that SNOMED is a good starting point for a standard classification and coding system to support the clinical care of patients with HIV disease. The next phase of the research will focus on the evaluation of the adequacy and acceptability of the SNOMED representation to clinicians in the AIDS clinic.

The cost, quality, and outcomes of healthcare services have become the focus of national attention as providers, consumers, and payers of healthcare services grapple with healthcare reform in the United States. Given the importance of patient care data to the activities of all segments of the healthcare spectrum, the development and implementation of computer-based patient records (CPRs) has been recommended as CPRs have the potential to improve healthcare delivery, enhance outcomes research programs, and increase hospital efficiency [12]. The current paradigm shift in healthcare requires the active involvement of the patient in the delivery and evaluation of care. The patient must be considered as an essential user of CPRs in order to exploit the benefits of information technology for the purposes of outcome assessment. Research and development of the future CPRs must incorporate the needs of the patient. Systems should be designed to meet these needs in order to capture the patient's perceptions in CPRs.