Terms used by nurses in the documentation of patient progress. / Termos utilizados por enfermeiros em registros de evolução do paciente.

Objective Describe the terms used in written records of patients' progress by nurses. Methods Descriptive research with a quantitative method that used a software to extract terms related to 148,200 nursing documentations of patient's progress, from 2010 to 2012, in a university hospital in Curitiba - Paraná. The terms were normalized, if appropriate, in spelling, gender, number and tense; then corpus of 2.638 terms was classified for analysis. Results There were problems related to the identification of the records; the use of trade names for designating artifacts used in the nursing practice; unconventional acronyms and abbreviations; and colloquial terms. Records of terms contained in standardized language of nursing diagnoses were found. Conclusion The language used by nurses is heterogeneous. There is a tendency to use terms of specialized language, even when there is no formal terminology standardization in the institution.

Nursing terminology as a work process instrument of nurses in collective health.

OBJECTIVE: To analyze the use of nursing terminology as an instrument of the nursing work process in Collective Health. METHOD: Exploratory case study. For data collection was conducted a group interview with 24 nurses working in health units of a municipality in south central Paraná, Brazil. Data were analyzed in the light of interdependence between the structural, particular and singular dimensions contained in the Theory of Nursing Praxis Intervention in Collective Health. RESULTS: The situations interfering with improper use were the lack of knowledge about the origin and purpose of terminology, lack of training, and non-mandatory use. CONCLUSION: Although the nursing terminology is used as an instrument in the nursing work process in collective health, it requires training to be recognized as a classification system. At the same time, institutional policies should be employed to ensure the effective use of these instruments. OBJETIVO: Analisar a utilização de terminologia de enfermagem como instrumento do processo de trabalho do enfermeiro em Saúde Coletiva. MÉTODO: Estudo de caso exploratório. Para coleta de dados foi realizada entrevista em grupo com 24 enfermeiros que atuam nas unidades de saúde de um município no centro-sul do Paraná, Brasil. Os dados foram analisados à luz da interdependência entre as dimensões estrutural, particular e singular contidas na Teoria da Intervenção Práxica de Enfermagem em Saúde Coletiva. RESULTADOS: As situações que interferiram na utilização inadequada foram o desconhecimento sobre origem e finalidade da terminologia, a falta de treinamento e a não obrigatoriedade de uso. CONCLUSÃO: A terminologia de enfermagem, apesar de utilizada como instrumento no processo de trabalho de enfermeiros em Saúde Coletiva, necessita de capacitação para ser reconhecida como sistema classificatório. Ao mesmo tempo, políticas institucionais devem ser empregadas no intuito de garantir a efetiva utilização destes instrumentos.

[Participation of nurses in the execution of clinical research protocol about technological innovation]. / Participação do enfermeiro na execução de protocolo de pesquisa clínica de inovação tecnológica.

OBJECTIVE: To report the nurse's experience of inclusion in interdisciplinary clinical study about technological innovation, involving people with spinal cord injury. METHOD: Descriptive experience report. The empirical support was based on notes about perspectives and practice of clinical research, with a multi-professional nursing, physical education, physiotherapy and engineering staff. RESULT: The qualification includes the elaboration of the document for the Ethics Committee, familiarization among the members of staff and with the studied topic, and also an immersion into English. The nurse's knowledge gave support to the uptake of participants and time adequacy for data collection, preparation and assistance of the participants during the intervention and after collection. Nursing theories and processes have contributed to reveal risky diagnoses and the plan of care. It was the nurse's role to monitor the risk of overlapping methodological strictness to the human aspect. The skills for the clinical research must be the object of learning, including students in multidisciplinary researches. CONCLUSION: To qualify the nurse for clinical research and to potentialize its caregiver essence, some changes are needed in the educational system, professional behavior, attitude and educational assistance.

Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study.

OBJECTIVE: To reflect on the contributions of representing nursing practice elements in the ISO 18.104:2023 standard. METHOD: This is a theoretical study with standard analysis. Categorical structures were described to represent nursing practice in terminological systems and contributions identified in the parts of the version were analyzed. RESULTS: There is innovation in the inclusion of nurse sensitive outcomes, nursing action, nursing diagnosis explanation as an indicator of nursing service demand and complexity of care, representation of concepts through mental maps and suggestion of use of restriction models for nursing actions. It describes that the Nursing Process is constituted by nursing diagnosis, nursing action and nurse sensitive outcomes. FINAL CONSIDERATIONS: Indicating a nursing diagnosis as an indicator will bring benefits for knowledge production and decision-making. Although care outcomes are not exclusive responses to nursing action, the modifiable attributes of a nursing diagnosis generate knowledge about clinical practice, nursing action effectiveness and subjects of care' health state. There is coherence in understanding the Nursing Process concept evolution.

[Nursing diagnoses and outcomes related to the circulatory-system terms (ICNP®) represented in an ontology]. / Diagnósticos e resultados de enfermagem relacionados aos termos do sistema circulatório - CIPE® representados em uma ontologia.

The aim of the present study was to develop titles of Nursing Diagnoses and Outcomes (ND/NO) through the relationship between the terms of the Focus axis, limited to the Circulatory System Process, and the terms of other ICNP® axes and to integrate these terms into an ontology. Titles were developed linking 17 terms of the focus axis, which were evaluated by expert nurses in five Brazilian cities. Titles whose use concordance was above 0.80 were included in the ontology. In total, 89 titles for ND/NO were supported in the literature, and 19 were not supported; 37 were assessed as eligible for use in healthcare practice and were included in the ontology. The construction of ND/NO titles based on the ICNP® and using a formal representation of knowledge is a task that requires deepening concepts used for nursing and adequate classification revisions. The elaborated titles will facilitate the composition of diagnostics that are more consistent with practice.

Elaboration of a nursing record standard for an Emergency Care Unit.

OBJECTIVE: To develop a registration standard with diagnoses, outcomes and nursing interventions for an Emergency Care Unit. METHOD: This is applied research of technological development developed in three steps: elaboration of diagnoses/outcomes and interventions statements following the International Classification for Nursing Practice; assessment of diagnosis/outcome relevance; organization of diagnosis/outcome and interventions statements according to health needs described in TIPESC. RESULTS: A total of 185 diagnoses were prepared, of which 124 (67%) were constant in the classification, and 61 had no correspondence. Of the 185 diagnoses, 143 (77%) were rated as relevant by 32 experienced emergency room nurses, and 495 nursing interventions were correlated to diagnoses/outcomes. CONCLUSION: It was possible to build a record standard for the Emergency Care Unit following standardized terminology, containing diagnostic statements/outcomes and relevant interventions for nursing practice assessed by nurses with practice in emergency.

[International Classification of Public Health Nursing Practices - CIPESC®: a pedagogical tool for epidemiological studies]. / Classificação Internacional das Práticas de Enfermagem em Saúde Coletiva - CIPESC®: instrumento pedagógico de investigação epidemiológica.

The CIPESC® is a tool that informs the work of nurses in Public Health and assists in prioritizing their care in practice, management and research. It is also a powerful pedagogical instrument for the qualification of nurses within the Brazilian healthcare system. In the teaching of infectious diseases, using the CIPESC® assists in analyzing the interventions by encouraging clinical and epidemiological thinking regarding the health-illness process. With the purpose in mind of developing resources for teaching undergraduate nursing students and encouraging reflection regarding the process of nursing work, this article presents an experimental application of CIPESC®, using meningococcal meningitis as an example.

Use of the International Classification for Nursing Practice in the construction of a care protocol.

OBJECTIVES: to describe the use of the International Classification for Nursing Practice (ICNP®) in the construction of a nursing care protocol for children undergoing hematopoietic stem cell transplantation. METHODS: experience report. RESULTS: nursing problems were defined based on complications identified in a previous study; later, the ICNP® enabled the organization and systematization of childcare. The care protocol consists of 40 nursing problems, with their human needs affected, diagnoses and nursing interventions. The axes Focus, Judgment, Location, Action, Means, Time, and Client were used in the elaboration of diagnoses and interventions proposed in the protocol. Final Considerations: the use of the classification allowed the establishment of nursing interventions compatible with the needs of the child undergoing transplantation, providing support for the care protocol. It made it possible to encourage the use of classification in this context, contribute to patient safety and strengthen professional practice.

Construction of a nursing care protocol for children in post-hematopoietic stem cell transplantation.

OBJECTIVE: To construct a nursing care protocol for children in post-hematopoietic stem cell transplantation. METHOD: Methodological research carried out from January to September 2019, in three steps: (a) integrative review (nursing care was identified); (b) theoretical structuring and organization of healthcare based on the Theory of Basic Human Needs and on the International Classification for Nursing Practice (supplementing the review data); and (c) development of a protocol in the three previously mentioned stages. Analysis of the understanding of the protocol's items/care was performed by three specialist nurses. RESULTS: The care protocol consists of 40 nursing problems and is organized in accordance with the psychobiological, psychosocial, and psycho-spiritual needs of children undergoing transplantation, integrating practical and guidance care. CONCLUSION: The care protocol is an important technology for nursing care to transplanted children, aimed to prevent and manage transplantation complications.

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.

Challenges for nursing at the reach of primary health care goals. / Desafios para a enfermagem no alcance das metas da atenção primária.

The debate is based on the contextualization of the goals presented by the National Primary Health Care Plan (Plano Nacional de Atenção Básica), which despite having improved the quality and attempted to solve inequities and vulnerabilities, still has contradictions to overcome. The plan discusses that nursing, in this setting, is included as a member of the family health team and in the coordination of community health agents. The analysis of the challenges to be overcome was divided into three blocks: undergraduate teaching, the working process, and continuous training. The first block presents a panorama of undergraduates studies in Brazil and how the primary health care issues are addressed in the curricula and understood by faculty and students; the second examines the views that primary health care nurses have about their working process and the guidelines of the Brazilian National Health System; finally, the third block points to the challenges related to the different knowledge and practices that must be developed in nursing, in this specific area of practice.

[Nursing practice in view of adverse events following vaccination]. / A prática da enfermagem frente aos eventos adversos pós-vacinação.

The objectives of this article are to identify the adverse events following vaccination, the focus if nursing practice, using the Post-Vaccination Adverse Events Information System database, and discuss on the nurses' practice on the surveillance for those events. Secondary data were those regarding the vaccines applied in the Brazilian public health system, in the period from 1999 to 2008, totaling 65,442 registers, 59,899 of which were confirmed and 1,403 were associated with another vaccine. The 16 nursing practice events totaled 21,727 registers. Although they account for 35.4% of the registers, the data do not reflect the reality, because their reliability depends on the knowledge network that comprises diagnosis, notification and inclusion in the system. Discussions were made on interventions for the most prevalent events: fever and local events. Most interventions established in the adverse events manual was in agreement with the literature, though there were differences in the content between conducts for the same event due to different vaccines.

[International scientific output on the International Classification for Nursing Practice]. / Uma visão da produção científica internacional sobre a Classificação Internacional para a Prática de Enfermagem.

The International Classification for Nursing Practice (ICNP) is a classification system that aims at an universal standardized language for nursing. This article aims to discuss the results of studies addressing ICNP. This is a review of the literature in the database of the Virtual Health Library, by the term "ICNP" with coverage until 2009. 124 articles were found; 65 were analyzed and their contents were grouped in nine categories: general approaches; applicability in practice; assessment ratings; experiments with computational resources; development and inclusion of terms; approach to classification systems; use to anchor the building of nursing statements; translations; and others. It was found that few studies present projects or evaluate the practical applications of ICNP. The majority discusses conceptual issues or compare ICNP with other classification systems. Several studies conclude about the appropriateness and relevance of ICNP, despite pointing a need for improvement.

[Breastfeeding: nurses' practice under the perspective of the International Classification of Collective Health Nursing Practices]. / Amamentação: a prática do enfermeiro na perspectiva da Classificação Internacional de Práticas de Enfermagem em Saúde Coletiva.

This descriptive and exploratory study aimed to describe nursing diagnoses and interventions under the International Nursing Practice Classification in Collective Health--CIPESC®--in Women's Health Care, sub-theme Pre-Natal and Puerperium, correlating them to nurses' competences at Curitiba's Mother Program. Data used were diagnoses and interventions during nursing consultation from April to July/ 2005. Basic Statistics was used for data treatment. Proper Breastfeeding was the most frequent diagnosis and most interventions are related to strengthening the user to face the health-disease process (68.9%). In spite of nurses' practice during puerperium, such a competence is not part of the Program Protocol. In conclusion, minor adjustments are necessary in the analyzed diagnoses and the Protocol should be reviewed to entail nurses' competences that are developed in their practice in health services according to CIPESC' s registers.

Domestic violence: a Rodger's evolutionist conceptual analysis.

OBJECTIVE: to analyze the concept of domestic violence based on its use in health sciences, humanities, and exact sciences according to Rodgers' evolutionary model. METHODS: this is a concept analysis based on Rodgers' evolutionary conceptual model. Ninety-six articles were included in Portuguese, English, Spanish, and French, which had a definition of domestic violence, having identified the antecedents, attributes and consequences and produced a model case. RESULTS: twenty-two attributes, ten antecedents and eight consequences were identified. FINAL CONSIDERATIONS: from antecedents, attributes and consequences, it was possible to identify the connection between domestic violence and gender issues, especially patriarchal, being seen in a normalized way by society and causing consequences to the victims' physical and psychological health.

Clinical applicability of the terminological subset of palliative care for dignified dying.

OBJECTIVE: To evaluate the clinical applicability of the terminological subset of the international classification for the nursing practice of palliative care for a dignified dying, in oncology. METHOD: Prospective study evaluating the clinical applicability of 33 nursing diagnoses/outcomes and 220 nursing interventions. It used case studies of 20 cancer patients undergoing palliation. The nursing process steps were operated by two nurses. Descriptive statistics was used to present, according to the theoretical model, the nursing diagnoses/outcomes and interventions identified in the patients. All statements identified in patients at some point during care were considered applicable in clinical practice. RESULTS: Twenty-nine nursing diagnoses/outcomes and 197 nursing interventions from the subset were identified. CONCLUSION: In the context of palliative care in patients with cancer, the clinical applicability of 87.8% of the diagnoses/outcomes and 89.5% of the interventions that make up the palliative care terminological subset for dignified dying is affirmed.

Process modeling: technological innovation to control the risk for perioperative positioning injury.

OBJECTIVES: to report the construction of a process model to support the decision making of operating room nurses to control the risk for perioperative positioning injury. METHODS: experience report on a process model that helps nurses with decision making regarding clients at risk for perioperative positioning injury. By following the steps, it was possible to identify intrinsic and extrinsic variables of the literature and of the workflows of teams involved in the positioning of the client for surgery. The Business Process Model and Notation, the Bizagi Modeler software and terms from the International Classification for Nursing Practice were used in the model. RESULTS: the experience allowed the observation of the knowledge integration between different areas, which enabled the process modeling and its validation. CONCLUSIONS: process modeling is an innovative option for the development of support systems for clinical nursing decisions.

Representation of Diagnosis and Nursing Interventions in OpenEHR Archetypes.

OBJECTIVE: The study aimed to represent the content of nursing diagnosis and interventions in the openEHR standard. METHODS: This is a developmental study with the models developed according to ISO 18104: 2014. The Ocean Archetype Editor tool from the openEHR Foundation was used. RESULTS: Two archetypes were created; one to represent the nursing diagnosis concept and the other the nursing intervention concept. Existing archetypes available in the Clinical Knowledge Manager were reused in modeling. CONCLUSION: The representation of nursing diagnosis and interventions based on the openEHR standard contributes to representing nursing care phenomena and needs in health information systems.

Assessing oral health of crack users in Brazil: Perceptions and associated factors, findings from a mixed methods study.

This study explores associated factors and perceptions of oral health among crack users recruited in open drug scenes in Brazil. A mixed methods approach was used. The quantitative component analysed findings from a large (N = 7381), population-based survey. The outcomes under analysis were 'self-perception of oral health' and 'self-reporting of problems affecting the mouth, teeth and gingiva (gums)'. The qualitative component comprised a focus group, with 12 individuals recruited from a drug treatment clinic. Lower self-perception of oral health problems vis-à-vis a higher prevalence of problems affecting the mouth, teeth, and gingiva were found in users who had a lower level of education, used substances daily, had worse self-perception of physical health, did not receive health care and regularly used alcohol and/or tobacco. The results show an association between substance use and decline in oral health, as well as the lack of health services focusing on such issues. Oral health services should be emphasised as a gateway to the health system. So far, the putative cross-referral between services and professionals working in oral health and other health professionals working in the field of drug dependence has not been observed.

The ISO 18.104: 2003 as integrative model of nursing terminologies.

This paper presents the ISO 18.104:2003 as an integrative model of nursing terminology. It describes the standard, studies and experiences with its use and discusses possibilities to develop knowledge in the field. The standard has been shown to be effective in developing reference terminologies, and as a standard method for interoperability and reuse. Studies have internal limitations such as language and notations unknown to nursing. Correspondence of the model with classifications used in health services and practice is incipient, which hinders its applicability and development due to the lack of examples to be analyzed and discussed.