Design and Development of a Fully Intelligent Nursing Information System Based on International Standard Nursing Terminology.

OBJECTIVE: Design and develop a Clinical Care Classification (CCC) nursing information system aligned with nursing terminology CCC, emphasizing standard procedures and a responsibility-based nursing model to enhance efficiency and quality of care. METHODS: Conduct thorough investigation into clinical nursing informatics needs, analyze existing system shortcomings, utilize Microsoft.net for development, integrate standard nursing procedures and clinical operating protocols into system functions. Structure database based on bed characteristics, implant CCC Nursing Terminology and clinical nursing knowledge base. RESULTS: Successfully design and develop CCC Nursing Information System featuring patient list, nurse assignment, nursing evaluation, diagnosis, goals, plan, interventions, special care, shift handover, record query, workload statistics, and intelligent guidance based on patient assessment and nursing elements. CONCLUSION: The CCC Nursing Information System advances standard nursing procedures in clinical practice, promoting standardization and responsibility-based holistic care. It harnesses big data to enhance system intelligence.

Cross-Mapping the Portuguese Nursing Ontology with ICNP, SNOMED CT and NANDA-I.

EHR Interoperability is crucial to obtain a set of benefits. This can be achieved by using data standards, like ontologies. The Portuguese Nursing Ontology (NursingOntos) is a reference model describing a set of nursing concepts and their relationships, to represent nursing knowledge in the Electronic Health Records (EHR). The purpose of this work was to define a set of correspondences between Nursing Ontology concepts of NursingOntos and other terminologies, which have the same or similar meaning. In this project, we are using the ISO/TR12300:2016 standard on the principles of mapping between terminological systems. Regarding the domain of "airway clearance", we can say that Portuguese Nursing Ontology has a good level of mapping with other terminologies. In conclusion, we can say that Portuguese Nursing Ontology can be used in EHR with the purpose of a global digitalization of health.

Trial of Converting Nursing Records into Simplified and Structured Information Utilizing ChatGPT-3.5.

In Japan, the excessive length of time required for nursing records has become a social problem. A shift to concise "bulleted" records is needed to apply speech recognition and to work with foreign caregivers. Therefore, using 96,000 descriptively described anonymized nursing records, we identified typical situations for each information source and attempted to convert them to "bulleted" records using ChatGPT-3.5(For return from the operating room, Status on return, Temperature control, Blood drainage, Stoma care, Monitoring, Respiration and Oxygen, Sensation and pain, etc.). The results showed that ChatGPT-3.5 has some usable functionality as a tool for extracting keywords in "bulleted" records. Furthermore, through the process of converting to a "bulleted" record, it became clear that the transition to a standardized nursing record utilizing the "Standard Terminology for Nursing Observation and Action (STerNOA)" would be facilitated.

Representing Nursing Practice in EMR/EHRs.

OBJECTIVE: Review of the ISO 18104 technical standard for a Nursing Categorial structure to best represent nursing practice in EMR/EHRs and digital health ecosystems. METHODS: Application of ISO standard review guidelines in consultation with ISO member stakeholders. RESULTS: Comprehensive views of the nursing practice knowledge domain are presented as mindmaps. Groups of patients can now be identified using the 'type of subject of care' category. The collaborative role of nurses is now recognized. This high level structured information model recognises nursing diagnosis, nursing actions and nurse sensitive outcomes relative to other categories and sub-categories known to influence nursing actions and nurse sensitive outcomes. DISCUSSION: This nursing practice framework reflects the nursing process. It supports conceptual and logical analysis of patient journey related nursing practice. CONCLUSION: This updated categorial structure is a good fit with today's information technologies. Its adoption enables the value of nursing services provided to be demonstrated.

Going Beyond Surface Language: An Exploratory Evaluation of Nursing Ontology Mappings.

A range of approaches have been used to develop and evaluate terminology mapping. In seeking to enhance existing methods this exploratory feasibility study examined a small subset of existing equivalency mappings between the International Classification for Nursing Practice and SNOMED CT. To identify potential inconsistencies in allocation, comparisons were made for each concept in each equivalency mapping, through a manual review of a) compositionality and specificity of asserted and inherited relationships, and b) ancestors through to root. There were similarities and several differences across the mappings which were both structural and definitional in nature. In order to demonstrate practical utility, the approach piloted in the present study might benefit from scaling up and a degree of automation. However, the study has demonstrated it is both feasible and potentially useful when evaluating terminology mapping to go beyond the surface language of mapped terms, and to consider the deeper definitional features of the underlying concepts.

Development of a Mapping Table for Nursing Notes Based on Nurses' Concerns in ICU Patients.

This study aimed to develop a mapping table that connects nursing notes with standard terminology, focusing on nurses' concerns for ICU patients. After extracting nursing notes from a publicly accessible database, a research team, including a nursing informatics professor and researchers with ICU experience, developed a mapping table through a four-step process: initially reviewing literature on nurses' concerns, then extracting nursing notes from MIMIC IV and filtering the duplicate notes, subsequently defining and coding these concerns, and finally mapping them according to the CCC. Of 11,430,637 unstructured nursing notes from MIMIC IV, 265 unique notes remained after deduplication, with 208 notes reflecting nurses' concerns and categorized into 15 groups aligned with CCC. This mapping table will be a fundamental tool for predicting clinical deterioration in ICU patients by identifying important lexicons through natural language processing.

Terminology subset for the International Classification of Nursing Practice in Diabetes Mellitus.

OBJECTIVE: to describe the process of developing a terminological subset for the International Classification of Nursing Practice in Diabetes Mellitus, based on Horta's Basic Human Needs Theory and Bandura's Social Cognitive Theory. METHOD: a methodological study based on the identification in the literature of 313 statements of nursing diagnoses pertinent to diabetes care, selected and validated by a consensus of nurses from different states of Brazil, specialists in diabetes, using the nominal group technique. RESULTS: 156 nursing diagnosis/result statements were selected, of which 111 (71.15%) related to psychobiological needs, 42 (26.92%) to psychosocial needs and three (1.92%) to psychospiritual needs. A total of 433 nursing interventions were developed. The diagnostic statements were validated on the basis of a consensus among the experts, with an average content validity index of 0.89: 0.87 for psychobiological needs, 0.93 for psychosocial needs, and 0.77 for psychospiritual needs. CONCLUSION: the study validated the terminological subset for the International Classification of Nursing Practice in Diabetes, favoring clinical reasoning, the qualification of the Nursing Process, and the improvement of self-care practices in diabetes. It has made it possible to use nursing's own language based on a globally recognized classification. (1) Provision of the guiding document for nursing practice in diabetes. (2) Methodological innovation in the development of ICNP® subsets. (3) Advances in knowledge of the basic human needs of people with diabetes. (4) The potential of standardized language for coding and monitoring data. (5) Improving clinical reasoning during nursing consultations.

Nursing terminology for the care of people with respiratory diseases and Covid-19.

OBJECTIVES: To build a specialized nursing terminology for the care of people with respiratory diseases and Covid-19 or who have respiratory diseases after Covid-19, based on ICNP®. METHOD: Methodological study developed in two stages: (1) identification of the relevant concepts for the health priority chosen from the literature; (2) cross-mapping of the identified concepts with the concepts contained in ICNP® version 2019/2020. RESULTS: 9460 terms were extracted from the literature, of which 4065 terms were excluded because they were not related to the object of study and 5395 were submitted to the mapping technique, resulting in 290 constant terms in the ICNP® and 5134 non-constant terms. The constant terms were classified into the following axes: 120 in the Focus axis, 13 in Judgment, 48 in Action, 23 in Location, 38 in Means, eight in Time and one in Client. In addition, 36 nursing diagnoses/outcomes and three nursing interventions were mapped. CONCLUSION: The terminology will support the quality of care provided by the nursing team and the manual and electronic recording of patient data.

Evaluating the validity of the nursing statements algorithmically generated based on the International Classifications of Nursing Practice for respiratory nursing care using large language models.

OBJECTIVE: This study aims to facilitate the creation of quality standardized nursing statements in South Korea's hospitals using algorithmic generation based on the International Classifications of Nursing Practice (ICNP) and evaluation through Large Language Models. MATERIALS AND METHODS: We algorithmically generated 15 972 statements related to acute respiratory care using 117 concepts and concept composition models of ICNP. Human reviewers, Generative Pre-trained Transformers 4.0 (GPT-4.0), and Bio_Clinical Bidirectional Encoder Representations from Transformers (BERT) evaluated the generated statements for validity. The evaluation by GPT-4.0 and Bio_ClinicalBERT was conducted with and without contextual information and training. RESULTS: Of the generated statements, 2207 were deemed valid by expert reviewers. GPT-4.0 showed a zero-shot  AUC of 0.857, which aggravated with contextual information. Bio_ClinicalBERT, after training, significantly improved, reaching an AUC of 0.998. CONCLUSION: Bio_ClinicalBERT effectively validates auto-generated nursing statements, offering a promising solution to enhance and streamline healthcare documentation processes.

Clinical validation of the terminological subset for people with chronic kidney disease undergoing conservative treatment.

OBJECTIVE: To clinically validate a terminological subset of the International Classification for Nursing Practice (ICNP®) to care for people with chronic kidney disease undergoing conservative treatment. METHOD: Prospective study of clinical validation assessment of 117 nursing diagnoses/outcomes statements and 199 nursing intervention statements. It was operationalized through the following steps: implementation of the Nursing Process in an outpatient clinic in Southeast Brazil; preparation of case studies; analysis of agreement between specialist nurses. The Kappa. Kruskal-Wallis coefficient of agreement and intraclass correlation coefficient (ICC) were used. RESULTS: The sample consisted of 50 people with chronic kidney disease. Diagnoses/outcomes and interventions were evaluated with almost perfect/perfect agreement and excellent ICC. The Kruskal-Wallis test showed that there was no significant difference between the assessments. The study allowed the clinical validation of a subset with 110 nursing diagnoses/outcomes and 195 nursing interventions. CONCLUSION: Care for people with chronic kidney disease undergoing conservative treatment based on the proposed subset has become applicable to clinical practice.

ICNP® terminological subset for preventing falls in the elderly in primary care.

OBJECTIVE: Build and validate a terminological subset of ICNP® for the prevention of falls in the elderly in the context of primary health care, in light of the Self-Care Deficit Theory. METHOD: Methodological study developed in accordance with ICN recommendations and the Brazilian method for constructing terminological subsets, in two stages: 1) construction of ICNP® statements of nursing diagnoses, outcomes, and interventions; 2) content validation of statements by specialist nurses. RESULTS: A total of 182 diagnoses/outcomes and 321 nursing interventions were constructed, which were subjected to content validation by 28 experts, being validated with a Content Validity Index ≥ 0.80. After validation, the statements were organized according to self-care requirements and the majority of diagnoses/outcomes (51.6%) and interventions (52.7%) were classified under health deviation requirements. CONCLUSION: It was possible to construct and validate a terminological subset of ICNP® with a predominance of statements related to health deviation requirements, standing out for being the first terminological subset for the prevention of falls in the elderly in the context of primary care.

Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study.

AIM: To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams. DESIGN: Retrospective descriptive study of electronic record review. METHODS: Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020. RESULTS: Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051). CONCLUSION: Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting. IMPACT: What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care. REPORTING METHOD: STROBE checklist has been used as a reporting method. NO PATIENT OR PUBLIC CONTRIBUTION: Only patients' records were reviewed without further involvement.

Standardizing nursing data extracted from electronic health records for integration into a statewide clinical data research network.

BACKGROUND: Care plans documented by nurses in electronic health records (EHR) are a rich source of data to generate knowledge and measure the impact of nursing care. Unfortunately, there is a lack of integration of these data in clinical data research networks (CDRN) data trusts, due in large part to nursing care being documented with local vocabulary, resulting in non-standardized data. The absence of high-quality nursing care plan data in data trusts limits the investigation of interdisciplinary care aimed at improving patient outcomes. OBJECTIVE: To map local nursing care plan terms for patients' problems and goals in the EHR of one large health system to the standardized nursing terminologies (SNTs), NANDA International (NANDA-I), and Nursing Outcomes Classification (NOC). METHODS: We extracted local problems and goals used by nurses to document care plans from two hospitals. After removing duplicates, the terms were independently mapped to NANDA-I and NOC by five mappers. Four nurses who regularly use the local vocabulary validated the mapping. RESULTS: 83% of local problem terms were mapped to NANDA-I labels and 93% of local goal terms were mapped to NOC labels. The nurses agreed with 95% of the mapping. Local terms not mapped to labels were mapped to the domains or classes of the respective terminologies. CONCLUSION: Mapping local vocabularies used by nurses in EHRs to SNTs is a foundational step to making interoperable nursing data available for research and other secondary purposes in large data trusts. This study is the first phase of a larger project building, for the first time, a pipeline to standardize, harmonize, and integrate nursing care plan data from multiple Florida hospitals into the statewide CDRN OneFlorida+ Clinical Research Network data trust.

Identification of North American Nursing Diagnosis Association-Nursing Interventions Classification-Nursing Outcomes Classification of nursing home residents using on-time data by android smartphone application by registered nurses.

PURPOSE: We aimed to investigate the nursing process linkages formed by Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) according to the primary NANDA-I diagnoses by registered nurses (RNs), customized to nursing home (NH) residents in Korea, using a developed smartphone application for NH RNs. METHODS: This is a retrospective descriptive study. Applying quota sampling, a total of 51 NHs from all operating 686 NHs hiring RNs participated in this study. Data were collected from June 21 to July 30, 2022. Data on NANDA-I, NIC, NOC (NNN) of nurses applied to the NH residents were collected through a developed smartphone application. The application consists of general organization and residents' characteristics, NANDA-I, NIC, and NOC. RNs selected randomly up to 10 residents and NANDA-I with risk factors and related factors over the past 7 days, followed by all applied interventions out of 82 NIC. RNs then evaluated residents through 79 selected NOC. RESULTS: We found the frequently used NANDA-I diagnoses, Nursing Interventions Classifications and Nursing Outcomes and Classifications applied for NH residents by RNs and developed the top five NOC linkages used to build care plan. CONCLUSION: It is time to pursue high-level evidence and reply to the questions raised in NH practice using NNN with high technology. The outcomes for patients and nursing staff are improved by the continuity of care made possible by uniform language. IMPLICATIONS FOR NURSING PRACTICE: NNN linkages should be used to construct and utilize the coding system of electronic health records or electronic medical records in Korean long-term care facilities.

Creating Subsets of International Classification for Nursing Practice Precoordinated Concepts: Diagnoses/Outcomes and Interventions Categorized Into Areas of Nursing Practice.

The International Classification for Nursing Practice is a comprehensive terminology representing the domain of nursing practice. A categorization of the diagnoses/outcomes and interventions may further increase the usefulness of the terminology in clinical practice. The aim of this study was to categorize the precoordinated concepts of the International Classification for Nursing Practice into subsets for nursing diagnoses/outcomes and interventions using the structure of an established documentation model. The aim was also to investigate the distribution of the precoordinated concepts of the International Classification for Nursing Practice across the different areas of nursing practice. The method was a descriptive content analysis using a deductive approach. The VIPS model was used as a theoretical framework for categorization. The results showed that all the precoordinated concepts of the International Classification for Nursing Practice could be categorized according to the keywords in the VIPS model. It also revealed the parts of nursing practice covered by the concepts of the International Classification for Nursing Practice as well as the parts that needed to be added to the International Classification for Nursing Practice. This has not been identified in earlier subsets as they covered only one specific area of nursing.

Exploring Nursing Care for Patients With COVID-19 Using International Classification for Nursing Practice-Based Nursing Records.

This study explored nursing care topics for patients with the coronavirus disease 2019 admitted to the wards and intensive care units using International Classification for Nursing Practice-based nursing narratives. A total of 256630 nursing statements from 555 adult patients admitted from December 2019 to June 2022 were extracted from the clinical data warehouse. The International Classification for Nursing Practice concepts mapped to 301 unique nursing statements that accounted for the top 90% of all cumulative nursing narratives were used for analysis. The standardized number of nursing statements for each concept was calculated according to the types of nursing care and compared between the two groups. The most documented topics were related to infection; physical symptoms such as sputum, cough, dyspnea, and shivering; and vital signs including blood oxygen saturation and body temperature. Nurses in the intensive care units frequently documented concepts related to the directly monitored and assessed physical signs such as consciousness, pupil reflex, and skin integrity, whereas nurses in wards documented more concepts related to symptoms patients complained. This study showed that the International Classification for Nursing Practice-based nursing records can be used as source of information to identify nursing care for patients with coronavirus disease 19.

A retrospective descriptive study of NANDA-I nursing diagnoses used by midwives working in obstetrics and gynecologic service: An example from south-eastern Turkey.

PURPOSE: This study aims to identify NANDA-I nursing diagnoses that midwives working in obstetrics and gynecologic service use while managing the electronic nursing care process. METHODS: This retrospective study was conducted in a descriptive way to evaluate electronic care plan records of 3025 patients staying in obstetrics and gynecologic service between April 1, 2020. and April 1, 2021. Diagnoses in the records of the electronic care process were digitalized by two faculty members. Then, NANDA-I nursing diagnoses used by midwives were identified. NANDA-I nursing diagnoses used by midwives were identified. FINDINGS: It was determined that diagnoses in care plans documented from the system within the 1-year period fell into eight domains and 10 classes, and 5819 diagnoses were given in total. The most frequent diagnoses given in obstetrics and gynecologic service were "acute pain" and "risk for bleeding." CONCLUSION: Findings of this study revealed that nursing care records in obstetrics and gynecologic service did not have a large number of diagnoses and interventions. IMPLICATIONS FOR NURSING PRACTICE: Care plans directly reflect the contribution of the care to the patient. Consequently, midwives being aware of and recording nursing diagnoses while giving care will ensure a standardized language and visibility in care. More coverage of midwifery-related diagnoses in the midwifery curriculum will make NANDA-I nursing diagnoses more visible in midwifery as well.

Terminology subset for the International Classification of Nursing Practice in Diabetes Mellitus / Subconjunto terminológico para la Clasificación Internacional para la Práctica de Enfermería en Diabetes Mellitus / Subconjunto terminológico para la Clasificación Internacional para la Práctica de Enfermería en Diabetes Mellitus

Objective: to describe the process of developing a terminological subset for the International Classification of Nursing Practice in Diabetes Mellitus, based on Horta's Basic Human Needs Theory and Bandura's Social Cognitive Theory. Method: a methodological study based on the identification in the literature of 313 statements of nursing diagnoses pertinent to diabetes care, selected and validated by a consensus of nurses from different states of Brazil, specialists in diabetes, using the nominal group technique. Results: 156 nursing diagnosis/result statements were selected, of which 111 (71.15%) related to psychobiological needs, 42 (26.92%) to psychosocial needs and three (1.92%) to psychospiritual needs. A total of 433 nursing interventions were developed. The diagnostic statements were validated on the basis of a consensus among the experts, with an average content validity index of 0.89: 0.87 for psychobiological needs, 0.93 for psychosocial needs, and 0.77 for psychospiritual needs. Conclusion: the study validated the terminological subset for the International Classification of Nursing Practice in Diabetes, favoring clinical reasoning, the qualification of the Nursing Process, and the improvement of self-care practices in diabetes. It has made it possible to use nursing's own language based on a globally recognized classification.

Objetivo: describir el proceso de elaboración de un subconjunto terminológico para la Clasificación Internacional para la Práctica de Enfermería en Diabetes Mellitus , basado en la Teoría de las Necesidades Humanas Básicas de Horta y en la Teoría Social Cognitiva de Bandura. Método: estudio metodológico realizado a partir de la identificación en la literatura de 313 enunciados de diagnósticos de Enfermería pertinentes al cuidado en diabetes, seleccionados y validados por consenso de enfermeras especializadas en diabetes, provenientes de diferentes estados de Brasil, utilizando la técnica de grupo nominal. Resultados: fueron seleccionados 156 enunciados diagnósticos/resultados de Enfermería, así relacionados: 111 (71,15%) con las necesidades psicobiológicas; 42 (26,92%) con las psicosociales y tres (1,92%) con las psicoespirituales. Fueron construidas 433 intervenciones de Enfermería. Los enunciados diagnósticos fueron validados a partir del consenso entre las especialistas con índice de validez de contenido medio de 0,89; siendo: 0,87 para las necesidades psicobiológicas; 0,93 para las psicosociales y 0,77 para las psicoespirituales. Conclusión: el estudio validó los enunciados del subconjunto terminológico para la Clasificación Internacional para la Práctica de Enfermería en diabetes, favoreciendo el raciocinio clínico, la calificación del Proceso de Enfermería y la mejora de las prácticas de autocuidado en diabetes. También, posibilitó la utilización de lenguaje propio de la Enfermería basado en una clasificación reconocida mundialmente.

Objetivo: descrever o processo de elaboração de um subconjunto terminológico para a Classificação Internacional para a Prática de Enfermagem em Diabetes Mellitus , baseado na Teoria das Necessidades Humanas Básicas de Horta e na Teoria Social Cognitiva de Bandura. Método: estudo metodológico realizado a partir da identificação na literatura de 313 enunciados de diagnósticos de Enfermagem pertinentes ao cuidado em diabetes, selecionados e validados por consenso de enfermeiras especialistas em diabetes, provenientes de diferentes estados do Brasil, utilizando a técnica de grupo nominal. Resultados: foram selecionados 156 enunciados diagnósticos/resultados de Enfermagem, sendo relacionados: 111 (71,15%) às necessidades psicobiológicas; 42 (26,92%) às psicossociais e três (1,92%) às psicoespirituais. Foram construídas 433 intervenções de Enfermagem. Os enunciados diagnósticos foram validados a partir do consenso entre os especialistas com índice de validade de conteúdo médio de 0,89, sendo: 0,87 para as necessidades psicobiológicas; 0,93 para as psicossociais e 0,77 para as psicoespirituais. Conclusão: o estudo validou os enunciados do subconjunto terminológico para a Classificação Internacional para a Prática de Enfermagem em diabetes, favorecendo o raciocínio clínico, a qualificação do Processo de Enfermagem e a melhoria das práticas de autocuidado em diabetes. Possibilitou a utilização de linguagem própria da Enfermagem com base em uma classificação reconhecida mundialmente.

Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study / Contribuições da representação dos elementos da prática de enfermagem na norma ISO 18.104:2023: estudo teórico / Aportes de la representación de los elementos de la práctica de enfermería en la norma ISO 18.104:2023: estudio teórico

ABSTRACT 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.

RESUMO Objetivo: Refletir sobre as contribuições da representação dos elementos da prática de enfermagem na norma ISO 18.104:2023. Método: Estudo teórico com análise da norma. Foram descritas estruturas categoriais para representação da prática da enfermagem nos sistemas terminológicos e analisadas as contribuições identificadas nas partes da versão. Resultados: Há inovação na inclusão do resultado sensível à ação da enfermeira, explicitação do diagnóstico de enfermagem como indicador da demanda de serviços e complexidade de assistência, representação dos conceitos por mapas mentais e sugestão do uso de modelos de restrição para ações de enfermagem. Descreve que o Processo de Enfermagem é constituído pelo diagnóstico, ação e resultado sensível à ação da enfermeira. Considerações finais: A indicação do diagnóstico de enfermagem como um indicador trará benefícios para produção de conhecimento e tomada de decisão. Embora os resultados do cuidado não sejam respostas exclusivas a uma ação da enfermeira, os atributos modificáveis de um diagnóstico de enfermagem geram conhecimentos sobre a prática clínica, a eficácia das ações de enfermagem e o estado de saúde dos sujeitos de cuidado. Há coerência na compreensão da evolução do conceito de Processo de Enfermagem.

RESUMEN Objetivo: Reflexionar sobre los aportes de representar los elementos de la práctica de enfermería en la norma ISO 18.104:2023. Método: Estudio teórico con análisis de la norma. Se describieron estructuras categóricas para representar la práctica de enfermería en sistemas terminológicos y se analizaron las contribuciones identificadas en las partes de la versión. Resultados: Hay innovación en la inclusión del resultado sensible a la acción del enfermero, explicación del diagnóstico de enfermería como indicador de demanda de servicios y complejidad del cuidado, representación de conceptos a través de mapas mentales y sugerencia del uso de modelos de restricción para las acciones de enfermería. Describe que el Proceso de Enfermería está constituido por el diagnóstico, la acción y el resultado sensible a la acción del enfermero. Consideraciones finales: La indicación del diagnóstico de enfermería como indicador traerá beneficios para la producción de conocimiento y la toma de decisiones. Aunque los resultados del cuidado no son respuestas exclusivas a la acción del enfermero, los atributos modificables de un diagnóstico de enfermería generan conocimiento sobre la práctica clínica, la efectividad de las acciones de enfermería y el estado de salud de los sujetos del cuidado. Hay coherencia en la comprensión de la evolución del concepto de Proceso de Enfermería.

Content analysis of NOC outcomes related to mechanical ventilation in people with COVID-19 / Análisis de contenido de los resultados NOC relacionados con la ventilación mecánica en personas con COVID-19 / Análise de conteúdo de resultados NOC relacionados à ventilação mecânica em pessoas com COVID-19

ABSTRACT Objective: To analyze the evidence of content validity of the Nursing Outcomes "Mechanical Ventilation Response: Adult" and "Mechanical Ventilation Weaning Response: Adult", for patients with severe COVID-19. Method: Methodological study developed in two stages: literature review to construct the definitions of the indicators and analysis of the evidence of content validity of the nursing outcomes by a focus group. Results: All the conceptual and operational definitions developed for the 56 indicators were considered clear and precise. However, 17 indicators were excluded because they were deemed not to be relevant. The definitions of the magnitudes for 17 indicators of the Nursing Outcome "Mechanical Ventilation Response: Adult" and 22 indicators "Mechanical Ventilation Weaning Response: Adult" were thus constructed. Conclusion: The development of definitions and validation by experts makes the use of these outcomes and their indicators more understandable and precise, favoring their use in clinical practice and providing greater detail in assessment and recording.

RESUMEN Objetivo: Analizar la evidencia de validez de contenido de los resultados de enfermería "Respuesta a la ventilación mecánica: Adulto" y "Respuesta al destete de la ventilación mecánica: Adulto", para pacientes adultos con COVID-19 grave. Método: Estudio metodológico desarrollado en dos etapas: revisión bibliográfica para construir las definiciones de los indicadores y análisis de la evidencia de validez de contenido de los resultados de enfermería mediante un grupo focal. Resultados: Todas las definiciones conceptuales y operativas elaboradas para los 56 indicadores se consideraron claras y precisas. Sin embargo, se excluyeron 17 indicadores porque se consideró que no eran pertinentes. Se construyeron así las definiciones de las magnitudes para 17 indicadores del resultado de enfermería "Respuesta a la ventilación mecánica: adulto" y 22 indicadores "Respuesta al destete de la ventilación mecánica: adulto". Conclusiones: La elaboración de definiciones y validación por expertos hace más comprensible y preciso el uso de estos resultados y sus indicadores, favoreciendo su uso en la práctica clínica y aportando mayor detalle en la valoración y registro.

RESUMO Objetivo: Analisar as evidências de validade de conteúdo dos Resultados de Enfermagem "Resposta à ventilação mecânica: adulto" e "Resposta ao Desmame da Ventilação Mecânica: adulto", para pacientes adultos com COVID-19 grave. Método: Estudo metodológico desenvolvido em duas etapas: revisão da literatura para construção das definições dos indicadores e análise das evidências de validade de conteúdo dos resultados de enfermagem por um grupo focal. Resultados: Todas as definições conceituais e operacionais elaboradas para os 56 indicadores foram consideradas claras e precisas. Entretanto, 17 indicadores foram excluídos por serem julgados pouco relevantes. Desse modo foram construídas as definições das magnitudes para 17 indicadores do Resultados de Enfermagem "Resposta a ventilação mecânica: adulto" e de 22 indicadores "Resposta ao desmame da ventilação mecânica: adulto". Conclusão: A elaboração das definições e a validação por especialistas tornam o uso desses Resultados e seus indicadores mais compreensível e preciso, favorecendo o uso na prática clínica, proporcionando maior detalhamento da avaliação e dos registros.