Pain Management in Clinical Practice Research Using Electronic Health Records.

BACKGROUND: The use of electronic health record (EHR) systems encourages and facilitates the use of data for the development and surveillance of quality indicators, including pain management. AIM: to conduct an integrative review on pain management research using data extracted from EHR in order to synthesize and analyze the following elements: pain management (assessments, interventions, and outcomes) and study results with potential clinical implications, data source, clinical sample characteristics, and method description. DESIGN: An integrative review of the literature was undertaken to identify exemplars of scientific research studies that explore pain management using data from EHR, using Cooper's framework. RESULTS: Our search of 1,061 records from PubMed, Scopus, and Cinahl was narrowed down to 28 eligible articles to be analyzed. CONCLUSION: Results of this integrative review will make a critical contribution, assisting others in developing research proposals and sound research methods, as well as providing an overview of such studies over the past 10 years. Through this review it is therefore possible to guide new research on clinical pain management using EHR.

Quality of Electronic Nursing Records: The Impact of Educational Interventions During a Hospital Accreditation Process.

Hospital accreditation is a strategy for the pursuit of quality of care and safety for patients and professionals. Targeted educational interventions could help support this process. This study aimed to evaluate the quality of electronic nursing records during the hospital accreditation process. A retrospective study comparing 112 nursing records during the hospital accreditation process was conducted. Educational interventions were implemented, and records were evaluated preintervention and postintervention. Mann-Whitney and χ tests were used for data analysis. Results showed that there was a significant improvement in the nursing documentation quality postintervention. When comparing records preintervention and postintervention, results showed a statistically significant difference (P < .001) between the two periods. The comparison between items showed that most scores were significant. Findings indicated that educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices.

Vascular access complications in patients undergoing percutaneous procedures in hemodynamics: a scoping review. / Complicações do acesso vascular em pacientes submetidos a procedimentos percutâneos em hemodinâmica: revisão de escopo.

OBJECTIVE: To map the production of knowledge on vascular access complications in patients undergoing percutaneous procedures in hemodynamic laboratories. METHODS: Scoping review study. The search strategy was developed in three stages, considering the period from July 2005 to July 2015 in the PubMed, CINAHL, Scopus, and LILACS databases. The collected data were analyzed and summarized in a narrative form. RESULTS: One-hundred twenty-eight publications that made it possible to map the contexts of study of complications, occurrence according to access routes, as well as an understanding of diagnosis and clinical management, were included. Three theme categories were identified: complications; predictive factors; and diagnosis/treatment. CONCLUSION: Vascular access site complications range according to the access route used. Knowledge of factors that permeate the occurrence of these events may contribute to early detection, planning, and monitoring of the care implemented.

Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC).

AIMS AND OBJECTIVES: To assess the quality of the advanced nursing process in nursing documentation in two hospitals. BACKGROUND: Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. DESIGN: Cross-sectional study. METHODS: A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. RESULTS: Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. CONCLUSION: The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. RELEVANCE TO CLINICAL PRACTICE: Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.

Risk for adverse reaction to iodinated contrast media: a validation study. / Risco de reação adversa ao meio de contraste iodado: um estudo de validação.

OBJECTIVES: To validate the content of the nursing diagnosis, Risk for adverse reaction to iodinated contrast media, and its nursing interventions and outcomes according to standardized terminologies. METHOD: Fehring's (1987) model of diagnosis content validation was used, with the participation of experts including registered nurses and physicians. RESULTS: Seventy-four experts validated the title and the definition of the diagnosis, and assessed 28 risk factors, five of which were validated as primary, 22 as secondary, and one was discarded. The inclusion of the diagnosis in the NANDA International Taxonomy II was evaluated by 41 registered nurses and validated for Area II - Safety/ Protection and Class 2 - Physical Injury. Sixty-three experts validated seven nursing interventions as primary and one as secondary, and seven nursing outcomes as principal and one as minor. CONCLUSION: The title, definition, and risk factors of the diagnosis were validated, in addition to eight interventions and eight nursing outcomes.

[Development of the nursing diagnosis risk for pressure ulcer]. / Desenvolvimento do diagnóstico de enfermagem risco de úlcera por pressão.

OBJECTIVE: The study objective was to develop the definition and compile the risk factors for a new Nursing Diagnosis entitled "Risk for pressure ulcer". The process was guided using the research question, "What are the risk factors for development of a PU and what is its definition?" METHOD: An integrative literature review was conducted of articles published in Portuguese, English or Spanish from 2002 to 2012 and indexed on the Lilacs/SCIELO, MEDLINE/PubMed Central and Web of Science databases. The final sample comprised 21 articles that provided answers to the research question. These articles were analyzed and summarized in charts. RESULTS: A definition was constructed and 19 risk factors were selected for the new nursing diagnosis, "Risk for pressure ulcer". CONCLUSIONS: Identification and definition of the components of the new nursing diagnosis should aid nurses to prevent pressure ulcer events.

[Nursing care mapping for patients at risk of falls in the Nursing Interventions Classification]. / Mapeamento de cuidados de enfermagem para pacientes com risco de quedas na Nursing Interventions Classification.

OBJECTIVE: Identifying the prescribed nursing care for hospitalized patients at risk of falls and comparing them with the interventions of the Nursing Interventions Classifications (NIC). METHOD: A cross-sectional study carried out in a university hospital in southern Brazil. It was a retrospective data collection in the nursing records system. The sample consisted of 174 adult patients admitted to medical and surgical units with the Nursing Diagnosis of Risk for falls. The prescribed care were compared with the NIC interventions by the cross-mapping method. RESULTS: The most prevalent care were the following: keeping the bed rails, guiding patients/family regarding the risks and prevention of falls, keeping the bell within reach of patients, and maintaining patients' belongings nearby, mapped in the interventions Environmental Management: safety and Fall Prevention. CONCLUSION: The treatment prescribed in clinical practice was corroborated by the NIC reference.

[Risk factors for falls in hospitalized adult patients: an integrative review]. / Fatores de risco para quedas em pacientes adultos hospitalizados: revisão integrativa.

OBJECTIVE: Identifying risk factors for the occurrence of falls in hospitalized adult patients. METHOD: Integrative review carried out in the databases of LILACS, SciELO, MEDLINE and Web of Science, including articles published between 1989 and 2012. RESULTS: Seventy-one articles were included in the final sample. Risk factors for falls presented in this review were related to patients (intrinsic), the hospital setting and the working process of health professionals, especially in nursing (extrinsic). CONCLUSION: The systematic screening of risk factors for falls was identified as a contributing factor to the reduction of this injury, helping the non-occurrence of this event that, despite being preventable, can have serious consequences including death.

[Nursing outcomes for ineffective breathing patterns and impaired spontaneous ventilation in intensive care]. / Resultados de enfermagem para padrão respiratório ineficaz e ventilação espontånea prejudicada em terapia intensiva.

This study aimed to validate the results of Nursing selected from the link NANDA-I-NOC (Nursing Outcomes Classification--NANDA--International) for diagnosis Ineffective Breathing Pattern and Impaired Spontaneous Ventilation in adult intensive care unit. This is a content validation study conducted in a university hospital in southern Brazil with 15 expert nurses with clinical experience and knowledge of the ratings. The instruments contained five-point Likert scales to rate the importance of each outcome (1st step) and indicator (Step 2) for the diagnoses studied. We calculated weighted averages for each outcome/indicator, considering) 1 = 0. 2 = 0.25, 3 = 0.50 4 = 0.75 and 5 = 1. The outcomes suggested by the NOC with averages above 0.8 were considered validated as well as the indicators. The results Respiratory State--airway permeability (Ineffective Breathing Patterns) and 11 indicators, and Response to mechanical ventilation: adult (Impaired Spontaneous Ventilation) with 26 indicators were validated.

[Translation and cross-cultural adaptation of the Edmonton Symptom Assessment System for use in Palliative Care]. / Tradução e adaptação transcultural do instrumento Edmonton Symptom Assessment System para uso em Cuidados Paliativos.

The objective of the study was translation and cross-cultural adaptation into Brazilian Portuguese of the instrument Edmonton Symptom Assessment System (ESAS-r). The ESAS-r is a revised version of the instrument ESAS that assesses nine symptoms in Palliative Care. This is a methodological study based on a benchmark composed of six steps: translation, synthesis, backtranslation, expert committee, pre-test and submission of translated version for consideration of the authors. As a result changes were made to the title, statements and certain terms to ensure adequacy of grammar and vocabulary. In the pre-test the term 'nausea' raised doubts, and an additional explanation on this word was suggested. Standardization of instrument columns and the replacement of the term 'depression' for 'sadness' was also recommended. In this study, the ESAS-r instrument was translated and adapted to Brazilian Portuguese, and the next step will be testing the psychometric properties.

Decreased cardiac output: an integrative review.

OBJECTIVE: to identify, in the scientific literature, the defining characteristics and contributing factors (related factors, associated conditions and populations at risk) for nursing diagnosis decreased cardiac output. METHOD: an integrative literature review, conducted between September and October 2020, with an update in March 2022, in the MEDLINE via PubMed, LILACS, SciELO, CINAHL and EMBASE databases. Using acronym PEO, studies published in the last 10 years in Portuguese, English and Spanish were included. A descriptive analysis was carried out to present the elements mapped in the literature. RESULTS: analysis of 31 articles identified different elements, highlighting 4 new related factors: hyperglycemic stress, prone position, left lateral position, sleep deprivation. Individuals with a history of cardiovascular disease and males were identified as possible populations at risk. FINAL CONSIDERATIONS: the elements for decreased cardiac output, identified in the literature, add evidence that justifies the permanence of this diagnosis in the NANDA-I classification.

[Instrument to collect data for critical patients based on the theory of basic human needs]. / Instrumento de coleta de dados para pacientes críticos fundamentado no modelo das necessidades humanas básicas de horta.

This is an exploratory study based on qualitative approach that aimed to collectively construct an instrument to collect data for patients in the Intensive Care Unit (ICU), based on the Theory of Basic Human Needs (NHB). Data collection was through a focus group with four nurses from the ICU and four residents from the Nursing-Health Integrated Residency (RIS) program in seven meetings in 2009. The discussions produced in each session were analyzed as recommended by Horta. The instrument was divided into seven groups and 17 subgroups of needs. After testing and suggestions from participants, we elaborated the final version of the instrument and a guidance manualfor completing it, according to the need expressed by the group. Validation of the instrument and the manual and inclusion of teaching of the nursing process in the RIS activity program are suggested.

Standardized nursing languages in orthopedics from the perspective of the nursing role effectiveness model.

OBJECTIVE: To analyze the standardized nursing languages in orthopedics from the perspective of the Nursing Role Effectiveness Model. METHOD: Mixed method research carried out in a hospital in southern Brazil between April 2016 and February 2017. Quantitative data were collected from 85 orthopedic patients using the NANDA-International, Nursing Interventions and Outcomes, and submitted to statistical analysis. Qualitative data were collected through interviews with 10 nurses and were analyzed using content analysis. RESULTS: Acute pain (96%) was a prevalent nursing diagnosis. Fall Prevention (33.3%) was the most prescribed intervention. Pain Level, Body Positioning: self-initiated and Mobility showed an increase in outcome scores (p<0.001). In the interviews, nurses indicated that priority diagnoses and nursing interventions contributed to improving mobility outcomes. CONCLUSION: The findings revealed that the focus of Standardized Nursing Languages in orthopedics from the perspective of the Nursing Role Effectiveness Model lies in the context of mobility, but it needs improvements in diagnostic accuracy and electronic health record.

Development of a nursing outcome for a percutaneous procedure.

OBJECTIVES: To develop a nursing outcome, consistent with the standardized format of outcomes within the nursing Outcomes Classification (NOC). This outcome will include an outcome label, an outcome definition, and clinical indicators. The proposed use for this outcome is to evaluate the access site of a percutaneous procedure. METHODS: Concept analysis with a scoping review. Initially, content experts were recruited to validate the indicators of the proposed outcome in order to complete a consensus validation. After consensus validation, a review of the proposed outcome and its indicators was completed by two of the editors of the NOC team to confirm that the outcome label, definition, and indicators were consistent with the NOC taxonomy. During this review, edits were made on the label name and definition. FINDINGS: After a series of reviews, the initial outcome of Vascular Status: Percutaneous Procedure Access was changed to Tissue Injury Severity: Percutaneous Procedure. In addition, the original definition of the condition of an access site for percutaneous procedure by venous or arterial puncture and health of surrounding tissues was edited to: Severity of complications from a needle-puncture access through the skin and into deeper tissues. The outcome has 11 indicators to be used to formulate a target rating for use in the clinical setting. The indicators were not edited over the course of the reviews. CONCLUSION: The proposed outcome will assist nurses in evaluating the access site of percutaneous procedures and in identifying possible complications. IMPLICATIONS FOR THE NURSING PRACTICE: This research contributes to the refinement of the NOC taxonomy by having a new outcome that meets clinical practice needs.

OBJETIVOS: Desenvolver um resultado de enfermagem, consistente com o formato padronizado de resultados da Classificação dos Resultados de Enfermagem (NOC). Este resultado incluirá um título de resultado, uma definição de resultado e indicadores clínicos. O uso proposto para esse resultado é avaliar o local de acesso de um procedimento percutâneo. MÉTODOS: Análise de conceito com revisão de escopo. Inicialmente, especialistas de conteúdo foram utilizados para validar os indicadores do resultado proposto em uma validação por consenso. Após a validação por consenso, uma revisão do resultado proposto e de seus indicadores foi realizada por dois editores da equipe da Classificação dos Resultados de Enfermagem para confirmar o título do resultado, definição e indicadores para serem consistentes com a taxonomia NOC. Durante esta revisão, foram feitas edições no título e na definição. RESULTADOS: Após uma série de revisões, o resultado denominado inicialmente de Estado Vascular: Acesso Procedimento Percutâneo foi alterado para Gravidade da Lesão Tecidual: Procedimento Percutâneo. Além disso, a definição original de condição de um local de acesso de procedimento percutâneo por punção venosa ou arterial e saúde dos tecidos adjacentes foi editada para - Gravidade das complicações de um acesso por punção com agulha através da pele e em tecidos mais profundos. O resultado tem 11 indicadores a serem usados para formular uma classificação-alvo para uso no ambiente clínico. Os indicadores não foram editados ao longo das revisões. CONCLUSÃO: O resultado proposto auxiliará o enfermeiro a avaliar o local de acesso dos procedimentos percutâneos e identificar possíveis complicações. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Esta pesquisa contribui para o refinamento da taxonomia NOC por ter um novo resultado que atende às necessidades da prática clínica.

Cross-cultural adaptation and validation of instrument to measure nursing care dependency.

OBJECTIVE: To cross-culturally adapt and validate the INICIARE instrument for use in Brazil. METHOD: methodological study divided into two phases: cross-cultural adaptation and validation. The first phase took place in six stages: translation, synthesis, back-translation, expert review, pre-test and submission to the author. The second, carried out with 130 patients, took place at a private hospital in Porto Alegre, Rio Grande do Sul, Brazil, between May and July 2019. The study was approved by the Research Ethics Committee. Data were analyzed for stability, equivalence and internal consistency. RESULTS: In the cross-cultural adaptation, the expert committee adjusted the translated version, validating the content. At validation, most patients were women (64.6%) with a mean age of 59 ± 15.3. The reliability index was 0.744. CONCLUSION: The version of the instrument adapted for Brazil proved to be adequate and reflects the reality of daily nursing practice.

Nursing Process in the Brazilian context: reflection on its concept and legislation.

OBJECTIVES: to reflect on the global understanding of the Nursing Process concept, with emphasis on the Brazilian context. METHODS: a reflection article, aligned with the vision and expertise of researchers who are members of the Nursing Process Research Network. RESULTS: the reflection is presented in two main topics: The evolution of Systematization of Nursing Care X Nursing Process concepts and its consonance with national and international practices, and Brazilian legislation; The Nursing Process concept realignment in Brazilian legislation in line with current care, teaching and research practices. Final Considerations: the reflections were oriented to the Nursing Process' conceptual, normative and legal issues, including elements of its historical evolution, and, with that, pointed to the need to modify the Brazilian regulation on the Nursing Process.

[Characterization of bed falls sustained by inpatients in a university hospital]. / Caracterização das quedas do leito sofridas por pacientes internados em um hospital universitário.

This is a descriptive study which aimed to characterize the profile, risk factors, and Nursing Diagnoses (NDs) of adult patients who have fallen from bed during hospitalization. We analyzed 53 reports of bed falls, during the period from December 2009 to May 2010, in a big hospital. Results showed higher occurrence in male patients. Greater prevalence occurred in patients age 60 and above, during the night shift and the clinical unit. Only 13% presented the "Risk for falls" ND, although they had on average of 11 risk factors for it. Findings resemble what is described in world literature, reinforcing the need to install preventive measures for falls and to mitigate risks.

Clinical evidence of the nursing diagnosis Adult pressure injury.

OBJECTIVE: To identify clinical evidence of the nursing diagnosis Adult pressure injury. METHOD: Cross-sectional study with 138 adult patients, with community-acquired or hospital-acquired pressure injuries, admitted to clinical, surgical, and intensive care units. Data collected from Electronic health records (EHR) and from the clinical assessment of patients at the bedside, analyzed through descriptive statistics. RESULTS: The partial thickness loss of dermis presenting as a shallow open ulcer, intact or open/ruptured blister, consistent with a stage II pressure injury, was the significant defining characteristic. Significant related factors were pressure on bony prominence, friction surface, shear forces, and incontinence. The population at significant risk was that at age extremes (≥60 years). Significant associated conditions were pharmacological agent, physical immobilization, anemia, decreased tissue perfusion, and impaired circulation. CONCLUSION: The clinical indicators assessed in the patients showed evidence of the nursing diagnosis Adult pressure Injury, with significant lesions consistent with stage II, resulting from pressure, especially in elderly individuals, and in those on various medications.

Development of a nursing diagnosis educational software program.

INTRODUCTION: The human-computer interaction is essential in simulated electronic systems associated with teaching-learning activities. Interactive clinical cases reinforce the diagnostic reasoning ability, a stage of the advanced Nursing Process. PURPOSE: To build educational software, based on NANDA International, to improve the accuracy of nursing diagnoses. METHOD: Methodological study in three stages: preparation and validation of case studies; construction; homologation and evaluation. Held between January / 2012 and December / 2013, in a university hospital in southern Brazil. Teachers, nurses, undergraduate students and graduate students in nursing and information technology participated. Approved by the Research Ethics Committee (130035). RESULTS: Construction of five case studies and two versions of the software: one simulates the reasoning process for establishing the diagnosis; another, aimed at teachers, makes it possible to edit/create cases. CONCLUSION: The software helps in the teaching-learning process, generating accurate diagnoses, supporting more appropriate interventions.

[Competencies in the education of nursing technicians to implement the nursing care systematization]. / Competências na formação de Técnicos de Enfermagem para implementar a Sistematizaçao da Assistência de Enfermagem.

This is a qualitative, exploratory and descriptive study whose general objective was to learn, considering the perspective of the nursing technician who works in school hospitals, the competencies developed during their educational process to implement the Nursing Care Systematization (NCS). Data collection and analysis were carried out through a focal group, with content analysis and nursing technicians. Two thematic categories emerged: The participation of the nursing technician in the NCS and The competencies in the education of the nursing technician. Each one received two subcategories: Conception of the NCS and (De)valuation of the NCS, Technical-scientific competency and Competency in the interpersonal relationship, respectively. It was observed that the NCS must be shared, discussed and made public among nursing professionals, so that they may acknowledge themselves as the leading actors of their methodology and be aware that their practices determine the results.