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.

Mapeamento das ações do enfermeiro de prática avançada em uma instituição de ensino superior / Mapping the actions of advanced practice nurses in a higher education institution

Mapear as ações do Enfermeiro de Prática Avançada nos campos de ensino clínico e estágio curricular supervisionado de um curso de graduação em enfermagem. Métodos: estudo transversal, descritivo, incluindo 21 enfermeiros. A coleta de dados deu-se por questionário sócio-profissiográfico, alinhado às competências do Conselho Internacional de Enfermeiros no tocante à Prática Avançada de Enfermagem. Resultados: Os enfermeiros demonstraram médio conhecimento em Prática Avançada de Enfermagem, e ações de prática avançada mapeadas como prescrição de agentes terapêuticos para lesões, procedimento de catéter central de inserção periférica, solicitação de exames de imagem e swab peri-anal, pareceres em lesão, manejo e consulta de enfermagem no pré-parto, assistência no parto. Competências no domínio do cuidado e no domínio da gestão/educação foram evidenciadas. Conclusão: evidenciou-se potenciais de ação de Prática Avançada na Instituição de Ensino.(AU)

To map the actions of Advanced Practice Nurses in the clinical teaching and supervised curricular internship fields of an undergraduate nursing course. Methods: A cross-sectional, descriptive study including 21 nurses. Data was collected using a socio-professional questionnaire, aligned with the International Council of Nurses' competencies regarding Advanced Nursing Practice. Results: The nurses demonstrated medium knowledge of Advanced Nursing Practice, and mapped advanced practice actions such as prescribing therapeutic agents for injuries, peripherally inserted central catheter procedures, requesting imaging tests and peri-anal swabs, injury opinions, management and nursing consultation in the prepartum period, and assistance in childbirth. Skills in the care domain and the management/education domain were highlighted. Conclusion: There was potential for action in Advanced Practice at the Teaching Institution.(AU)

Mapear las acciones de las Enfermeras de Práctica Avanzada en los campos de la enseñanza clínica y de las prácticas curriculares supervisadas de un curso de enfermería de pregrado. Métodos: Se trató de un estudio transversal, descriptivo, en el que participaron 21 enfermeras. Los datos fueron recogidos a través de un cuestionario socio-profesional, alineado con las competencias del Consejo Internacional de Enfermería en relación a la Práctica Avanzada de Enfermería. Resultados: Las enfermeras demostraron conocimiento medio de la Práctica Avanzada de Enfermería, y mapearon acciones de práctica avanzada como prescripción de agentes terapéuticos para lesiones, procedimientos de catéter central de inserción periférica, solicitud de pruebas de imagen e hisopos perianales, emisión de dictámenes sobre lesiones, manejo y consulta de enfermería en el período preparto, asistencia al parto. Se destacaron las competencias en el ámbito de los cuidados y en el de la gestión/educación. Conclusión: Hubo potencial de actuación en la Práctica Avanzada en la Institución de Enseñanza.(AU)

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.

Acciones del enfermero en la consulta de enfermería de puericultura en la atención primaria / Nurses' actions in childcare Nursing consultations in Primary Care

Introducción: En la Consulta de Enfermería de Puericultura, el enfermero realiza el seguimiento delcrecimiento y desarrollo del niño, práctica fundamental para la promoción y prevención de la salud. Sin embargo, hay fragilidades en la implementación, como vacíos en los registros y fallas en la evaluación preventiva de resultados importantes en la infancia, como obesidad y desnutrición. Objetivo: Identificar las acciones del enfermero en la consulta de enfermería de puericultura en la red de Atención Primaria de un municipio de la región semiárida del Nordeste de Brasil. Método: Estudio cualitativo descriptivo-exploratorio realizado con 9 enfermeros que trabajan en las Estrategias Salud de la Familia de la Atención Primaria de un municipio del estado de Río Grande del Norte, en la región semiárida del nordeste de Brasil. Los datos fueron recolectados a través de entrevistas semiestructuradas entre enero y marzo de 2021 y analizados mediante Análisis de Contenido Temático. Resultados: Surgieron 5 categorías de análisis y discusión: acogida para el vínculo; antropometría y examen físico; seguimiento del desarrollo infantil; educación para la salud: comportamiento para el cuidado; Dificultades para completar la libreta de salud del niño. Conclusión: Se observó que el enfermero es capaz de realizar una evaluación integral de la salud del niño, el vínculo y la acogida y la educación para la salud forman parte de la atención. Se verificó que hay deficiencias en la cumplimentación de la cartilla y que el proceso de enfermería no sigue la estructura esperada, lo que puede comprometer la calidad de la atención (AU)

Introdução: Na Consulta de Enfermagem em puericultura, o enfermeiro realiza a vigilância do crescimento e desenvolvimento da criança, prática essencial para promoção e prevenção da saúde. Entretanto, evidencia-se fragilidades na sua implementação como lacunas de registros e debilidades na avaliação preventiva de desfechos importantes na infância, como obesidade e desnutrição. Objetivo: Identificar as ações do enfermeiro na consulta de enfermagem em puericultura na rede de Atenção Básica de um município do Semiárido Nordestino brasileiro.Métodos: Estudo qualitativo descritivo-exploratório realizado com 9 enfermeiros atuantes nas Estratégias de Saúde da Família da Atenção Básica de um município do Estado do Rio Grande do Norte, interior do semiárido nordestino brasileiro. Os dados foram coletados por entrevista semiestruturada entre janeiro e março de 2021 e analisados por Análise de Conteúdo do tipo Temática. Resultados: Emergiram 5 categorias de análise e discussão: acolhimento para o vínculo; antropometria e exame físico; vigilância do desenvolvimento infantil; educação em saúde: atitude de cuidado; dificuldades no preenchimento da caderneta de saúde da criança. Conclusão: Percebeu-se queos enfermeiros conseguem realizar ampla avaliação de saúde das crianças, perpassando o cuidado pelo vínculo e acolhimento e pela educação em saúde. Evidencia-se que as deficiências no preenchimento da caderneta existem e que o processo de enfermagem não obedece a estrutura prevista, podendo comprometer com a qualidade da assistência (AU)

Introduction: In Childcare Nursing Consultations, nurses monitor children's growth and development, an essential practice for health promotion and prevention. However, there are weaknesses in their implementation, such as gaps in records and deficits in the preventive assessment of important outcomes in childhood, such as obesity and malnutrition. Objective: To identify nurses' actions in childcare Nursing consultations in the Primary Care network of a municipality in the semi-arid region of northeastern Brazil. Methods: A qualitative and descriptive-exploratory study carried out with 9 nurses working in the Family Health Strategies of Primary Care in a municipality from the state of Rio Grande do Norte, in the inland of the semi-arid region of northeastern Brazil. The data were collected through semi-structured interviews between January and March 2021 and analyzed using Thematic Content Analysis. Results: A total of 5 analysis and discussion categories emerged: welcoming for the bond; anthropometry and physical examination; child development surveillance; health education: caring attitude; and difficulties completing the children's health booklets. Conclusion: It was noticed that nurses are able to carry out a comprehensive assessment of children's health, permeating care through bonding, welcoming and health education. It is evidenced that there are deficiencies in completing the booklets and that the Nursing Process does not follow the expected structure, which may compromise care quality (AU)

Psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version / Evaluación psicométrica del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil / Avaliação psicométrica do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada

Objective: to test the factorial structure, reliability and convergent validity of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Method: this was a psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Seven hundred and seventeen participants answered the data collection instrument consisting of two parts. Part I included a structured questionnaire to collect sociodemographic data and the participants' perceptions and satisfaction with their current health status. Part II consisted of the tool being tested. The internal structure was assessed using Confirmatory Factor Analysis. Convergent validity was evaluated by the correlation of the tool scores with the rates corresponding to self-perception and satisfaction with current health status. Reliability was assessed using Cronbach's alpha. Results: the Confirmatory Factor Analysis confirmed a three-factor solution. The factor loadings were significant and varied from 0.16 to 0.75; the fit indices suggested moderate fit of the model. Internal consistency for all three components varied between 0.779 and 0.919. Conclusion: the findings suggest that the tool is valid and reliable to be used in the Brazilian population, although caution is recommended when interpreting the results due to the moderate fit of the model.

Objetivo: someter a prueba la estructura factorial, confiabilidad y validez convergente del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil. Método: evaluación psicométrica del instrumento Functional Health Pattern Assessment Screening Tool - Versión modificada para Brasil. Setecientos diecisiete participantes respondieron el instrumento de recolección de datos, compuesto por dos partes. La Parte I incluyó un cuestionario estructurado para recopilar datos sociodemográficos y las percepciones y el nivel de satisfacción de los participantes con respecto a su estado de salud actual. La Parte II consistió en la herramienta sometida a prueba. La estructura interna se evaluó empleando Análisis Factorial Confirmatorio. La validez interna se evaluó por medio de la correlación entre las puntuaciones obtenidas en la herramienta y los índices correspondientes a los niveles de autopercepción y satisfacción con respecto al estado de salud actual. La confiabilidad se evaluó utilizando el coeficiente alfa de Cronbach. Resultados: el Análisis Factorial Confirmatorio confirmó una solución con tres factores. Las cargas factoriales fueron significativas y variaron entre 0,16 y 0.75; los índices de ajuste sugirieron ajuste moderado del modelo. La consistencia interna correspondiente a los tres componentes varió entre 0,779 y 0,919. Conclusión: los hallazgos sugieren que la herramienta es válida y confiable para ser usada en la población de Brasil, aunque se recomienda interpretar los resultados con precaución debido al moderado ajuste del modelo.

Objetivo: testar a estrutura fatorial, a confiabilidade e a validade convergente do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada. Método: avaliação psicométrica do Functional Health Pattern Assessment Screening Tool - Versão Brasileira Modificada. Setecentos e dezessete participantes responderam os itens do instrumento de coleta de dados composto por duas partes. A Parte I incluiu um questionário estruturado contendo dados sociodemográficos e a percepção e satisfação dos participantes com seu estado de saúde atual. A Parte II consistiu no instrumento testado. A estrutura interna foi avaliada por meio de Análise Fatorial Confirmatória. A validade convergente foi avaliada pela correlação dos escores do instrumento com os índices correspondentes à autopercepção e à satisfação com o estado de saúde atual. A confiabilidade foi avaliada pelo alfa de Cronbach. Resultados: a Análise Fatorial Confirmatória confirmou uma solução de três fatores. As cargas fatoriais foram significativas e variaram de 0,16 a 0,75; os índices de ajuste sugeriram ajuste moderado do modelo. A consistência interna dos três componentes variou entre 0,779 e 0,919. Conclusión: os achados sugerem que o instrumento é válido e confiável para ser utilizado na população brasileira, embora seja recomendada cautela na interpretação dos resultados devido ao ajuste moderado do modelo.

Design and implementation of an automatic nursing assessment system based on CDSS technology.

BACKGROUND: Various quantitative and quality assessment tools are currently used in nursing to evaluate a patient's physiological, psychological, and socioeconomic status. The results play important roles in evaluating the efficiency of healthcare, improving the treatment plans, and lowing relevant clinical risks. However, the manual process of the assessment imposes a substantial burden and can lead to errors in digitalization. To fill these gaps, we proposed an automatic nursing assessment system based on clinical decision support system (CDSS). The framework underlying the CDSS included experts, evaluation criteria, and voting roles for selecting electronic assessment sheets over paper ones. METHODS: We developed the framework based on an expert voting flow to choose electronic assessment sheets. The CDSS was constructed based on a nursing process workflow model. A multilayer architecture with independent modules was used. The performance of the proposed system was evaluated by comparing the adverse events' incidence and the average time for regular daily assessment before and after the implementation. RESULTS: After implementation of the system, the adverse nursing events' incidence decreased significantly from 0.43 % to 0.37 % in the first year and further to 0.27 % in the second year (p-value: 0.04). Meanwhile, the median time for regular daily assessments further decreased from 63 s to 51 s. CONCLUSIONS: The automatic assessment system helps to reduce nurses' workload and the incidence of adverse nursing events.

Diagnósticos e Intervenções de Enfermagem em Pacientes Com Ferida Crônica na Atenção Primária e Secundária / Nursing Diagnoses and Interventions in Patients With Chronic Wound in Primary and Secondary Care / Diagnósticos e Intervenciones de Enfermería en Pacientes con Heridas Crónicas en Atención Primaria y Secundaria

Objetivo:Identificar os diagnósticos e as intervenções de enfermagem relacionados a pacientes com ferida crônica produzidos por um sistema específico na atenção primária e secundária. Método: Estudo descritivo, quantitativo, realizado entre julho e outubro de 2022. Utilizaram-se os dados do sistema Sistematização da Assistência de Enfermagem em Feridas ­ gerencial (SAEFg). O estudo foi aprovado pelo Comitê de Ética em Pesquisa sob Parecer nº 4.329.008/2020. Resultados: No total, foram 314 registros de diagnósticos e 1.300 de intervenções de enfermagem. Os principais diagnósticos de enfermagem foram: úlcera venosa (17,6%), cicatrização da ferida prejudicada e ansiedade (7,6%), risco de queda (7,1%), risco de infecção (6,7%) e prurido (6,4%). As intervenções foram: prescrever/orientar a elevação das pernas (9,3%), orientar não coçar ou usar produtos abrasivos (8,3%), examinar condições da pele (7%), descrever/documentar as características da ferida (5,5%). Conclusão: Os principais diagnósticos e intervenções de enfermagem versaram sobre os aspectos tegumentares, emocionais e de riscos como queda e infecção. A maior ocorrência de registros foi na atenção secundária.

Objective:To identify nursing diagnoses and interventions related to patients with chronic wound produced by a specific system in primary and secondary care. Method: Descriptive study conducted between July and October 2022. We used data from the Systematization of Nursing Care in Wounds­anagerial (SAEFg) system. The study was approved by the Ethics and Research Committee, under Opinion no. 4.329.008/2020. Results: There were 314 records of diagnoses and 1,300 of nursing interventions. The main nursing diagnoses were: venous ulcer (17.6%), impaired wound healing and anxiety (7.6%), risk of falling (7.1%), risk of infection (6.7%), and pruritus (6.4%). The interventions were: prescribe/guide leg elevation (9.3%), guide not to scratch or use abrasive products (8.3%), examine skin conditions (7%), and describe/document wound characteristics (5.5%). Conclusion: The main nursing diagnoses and interventions were about tegumentary, emotional and risk aspects such as fall and infection. The highest occurrence of records was in secondary care.

Objetivo:Identificar los diagnósticos de enfermería y las intervenciones relacionadas con los pacientes con herida crónica producidas por un sistema específico en Atención Primaria y Secundaria. Método: Estudo descritivo, realizado entre julho e outubro de 2022. Se utilizaron los datos del Sistema "Sistematización de la Asistencia de Enfermería en Ferias - gerencial (SAEFg)". El estudio fue aprobado por el Comité de Ética e Investigación con el Dictamen nº 4.329.008/2020. Resultados: Hubo un total de 314 registros de diagnósticos y 1.300 de intervenciones de enfermería. Los principales diagnósticos de enfermería fueron: úlcera venosa (17,6%), deterioro de la cicatrización y ansiedad (7,6%), riesgo de caídas (7,1%), riesgo de infección (6,7%) y prurito (6,4%). Las intervenciones fueron: prescribir/guiar la elevación de las piernas (9,3%), guiar para no rascarse ni utilizar productos abrasivos (8,3%), examinar las condiciones de la piel (7%), describir/documentar las características de la herida (5,5%). Conclusión: Los principales diagnósticos e intervenciones de enfermería fueron sobre aspectos tegumentarios, emocionales y de riesgo como caídas e infecciones. El mayor número de registros se produjo en la atención secundaria.

Diagnostic concordance among nursing clinical decision support system users: a pilot study.

OBJECTIVE: To analyze the nursing diagnostic concordance among users of a clinical decision support system (CDSS), The Electronic Documentation System of the Nursing Process of the University of São Paulo (PROCEnf-USP®), structured according to the Nanda International, Nursing Intervention Classification and Nursing Outcome Classification (NNN) Taxonomy. MATERIALS AND METHODS: This pilot, exploratory-descriptive study was conducted from September 2017 to January 2018. Participants were nurses, nurse residents, and nursing undergraduates. Two previously validated written clinical case studies provided participants with comprehensive initial assessment clinical data to be registered in PROCEnf-USP®. After having registered the clinical data in PROCEnf-USP®, participants could either select diagnostic hypotheses offered by the system or add diagnoses not suggested by the system. A list of nursing diagnoses documented by the participants was extracted from the system. The concordance was analyzed by Light's Kappa (K). RESULTS: The research study included 37 participants, which were 14 nurses, 10 nurse residents, and 13 nursing undergraduates. Of the 43 documented nursing diagnoses, there was poor concordance (K = 0.224) for the diagnosis "Ineffective airway clearance" (00031), moderate (K = 0.591) for "Chronic pain" (00133), and elevated (K = 0.655) for "Risk for unstable blood glucose level" (00179). The other nursing diagnoses had poor or no concordance. DISCUSSION: Clinical reasoning skills are essential for the meaningful use of the CDSS. CONCLUSIONS: There was concordance for only 3 nursing diagnoses related to biological needs. The low level of concordance might be related to the clinical judgment skills of the participants, the written cases, and the sample size.

Clinical decision-making and the nursing process in digital health systems: An integrated systematic review.

AIMS: To identify how the nursing process (assessment, planning, intervention and outcome evaluation) has been incorporated into digital health systems (electronic medical records, electronic care plans and clinical decision support systems) to gain an understanding of known benefits and challenges posed to nurses' decision-making processes. BACKGROUND: Nursing terminologies, including the International Classification for Nursing Practice (ICNP), and Nursing Minimum Data Set's (NMDS), have been developed to improve standardised language integration of components of nursing care into digital systems. However, there is limited evidence regarding whether the complete nursing process is effectively being incorporated into digital health systems. METHODS: An integrative systematic review following PRISMA guidelines. A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, SCOPUS and Web of Science Core Collection. Articles were limited to English language and published January 2007-March 2022 and assessed using a pre-determined eligibility criteria. Quality assessment and a narrative synthesis were conducted. RESULTS: A total of 3321 articles were identified, and 27 studies included. There were (n = 10) qualitative, (n = 4) quantitative non-randomised controlled trials, (n = 3) quantitative descriptive studies and (n = 10) mixed methods. Nurse assessment and planning components were the most comprehensive phases incorporated into digital health systems, and interventions and outcome evaluation were scarcely reported. CONCLUSIONS: Inadequate capture of nursing work is a problem unresolved by digital health systems. This omission may be hindering nurse clinical decision-making for patient care and limiting the visibility of the nursing role in health care interventions and the associated impact on patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Further research is needed on how digital systems can support nurses to apply the full nursing process and to further evaluate patient outcomes. Digital systems can support health-service level evaluation through capturing missed nursing care and the consequences on patients utilising nurse-sensitive-outcomes; however, this is not yet being realised.

Utilizing standardized nursing terminologies in implementing an AI-powered fall-prevention tool to improve patient outcomes: a multihospital study.

OBJECTIVES: Standardized nursing terminologies (SNTs) are necessary to ensure consistent knowledge expression and compare the effectiveness of nursing practice across settings. This study investigated whether SNTs can support semantic interoperability and outcoming tracking over time by implementing an AI-powered CDS tool for fall prevention across multiple EMR systems. MATERIALS AND METHODS: The study involved 3 tertiary academic hospitals and 1 public hospital with different EMR systems and nursing terms, and employed an AI-powered CDS tool that determines the fall risk within the next hour (prediction model) and recommends tailored care plans (CDS functions; represented by SNTs). The prediction model was mapped to local data elements and optimized using local data sets. The local nursing statements in CDS functions were mapped using an ICNP-based inpatient fall-prevention catalog. Four implementation models were compared, and patient outcomes and nursing activities were observed longitudinally at one site. RESULTS: The postimplementation approach was practical for disseminating the AI-powered CDS tool for nursing. The 4 hospitals successfully implemented prediction models with little performance variation; the AUROCs were 0.8051-0.9581. The nursing process data contributed markedly to fall-risk predictions. The local nursing statements on preventing falls covered 48.0%-86.7% of statements. There was no significant longitudinal decrease in the fall rate (P = .160, 95% CI = -1.21 to 0.21 per 1000 hospital days), but rates of interventions provided by nurses were notably increased. CONCLUSION: SNTs contributed to achieving semantic interoperability among multiple EMR systems to disseminate AI-powered CDS tools and automatically track nursing and patient outcomes.

Child vaccination in animated infographic: technology for permanent education about the nursing process.

OBJECTIVE: To develop and validate an animated infographic about the nursing process in childhood vaccination. METHOD: Methodological study for the development and validation of educational technology, an animated infographic, on childhood vaccination. First, contents from the Ministry of Health that should compose the infographic were selected. Then, a script was prepared and a storyboard used to guide the production of the animated infographic. Once finalized, the technology went through the content and appearance validation process with nursing experts in the study area. RESULTS: Sixty-nine screens of storyboard were done and the infographic lasted five minutes and 52 seconds. Forty-five nurses were selected and, of these, 21 agreed to participate in the study. The infographic was evaluated according to its objectives, structure, presentation, and relevance, resulting in an overall CVI of 97%. CONCLUSION: The animated infographic produced was validated by experts and, once adapted following the judges' suggestions, it became a valid educational tool to be used by students and nursing professionals.

Necessidades humanas básicas afetadas e diagnósticos de enfermagem da nanda-i para pacientes graves com covid-19 / Necesidades humanas básicas afectadas y diagnósticos de enfermería de nanda-i para pacientes graves con covid-19 / Basic human needs affected and nanda-i nursing diagnoses for severe patients with covid-19

Objetivo: Identificar as Necessidades Humanas Básicas Psicobiológicas e os Diagnósticos de Enfermagem da NANDA-I para pacientes com covid-19 internados em unidade de terapia intensiva. Método: estudo descritivo, documental, transversal e quantitativo, realizado em uma unidade de terapia intensiva para pacientes com diagnóstico de covid-19, utilizando como fonte de dados o prontuário eletrônico do paciente. Para análise dos dados utilizou-se estatística descritiva, sendo avaliado frequência absoluta e relativa, média e desvio padrão. Resultados: foram identificadas sete Necessidades Humanas Básicas Psicobiológicas e 15 Diagnósticos de Enfermagem mais frequentes. Conclusão: o uso da Sistematização da Assistência de Enfermagem e a operacionalização do Processo de Enfermagem auxilia no planejamento individualizado do cuidado voltado à pacientes críticos com covid-19 internados em unidades de terapia intensiva. A identificação dessas necessidades contribui para o gerenciamento do cuidado e melhora a qualidade da assistência de enfermagem.

Objective: Identify Psychobiological Basic Human Needs and NANDA-I Nursing Diagnoses for patients with COVID-19 admitted to an intensive care unit. Method: descriptive, documentary, cross-sectional and quantitative study, carried out in an intensive care unit for patients diagnosed with COVID-19, using the patient's electronic medical record as a data source. Descriptive statistics were used for data analysis, with absolute and relative frequency, mean and standard deviation being evaluated. Results: seven Psychobiological Basic Human Needs and 15 most frequent Nursing Diagnoses were identified. Conclusion: the use of the Systematization of Nursing Care and the operationalization of the Nursing Process helps in the individualized planning of care aimed at critical patients with COVID-19 hospitalized in intensive care units. Identifying these needs contributes to the management of care and improves the quality of nursing care.

Objetivo: Identificar las Necesidades Humanas Básicas psicobiológicas y los Diagnósticos de Enfermería de NANDA-I para pacientes con covid-19 que ingresaron en una unidad de cuidados intensivos. Método: estudio descriptivo, documental, transversal y cuantitativo realizado en una unidad de cuidados intensivos para pacientes con diagnóstico de covid-19, utilizando como fuente de datos la historia clínica electrónica del paciente. Para el análisis de los datos se utilizó estadística descriptiva, que evaluó la frecuencia absoluta y relativa, la media y la desviación estándar. Resultados: se identificaron siete Necesidades Humanas Básicas Psicobiológicas y 15 Diagnósticos de Enfermería más frecuentes. Conclusión: el uso de la Sistematización de la Atención de Enfermería y la puesta en marcha del Proceso de Enfermería ayuda en la planificación individualizada de la atención dirigida a pacientes críticos con covid-19 hospitalizados en las unidades de cuidados intensivos. La identificación de esas necesidades contribuye a la gestión del cuidado y la mejora de la calidad de la atención de enfermería.

Holistic Digitalization of the Nursing Internship Process in the Federal State of Salzburg with Strong User Involvement.

BACKGROUND: In the federal state of Salzburg, the harmonization of nursing internship took place from 2014-2019 as a joint effort of educational and internship providers. Currently the handling of these mostly paper pencil-based documents involves a manual process through different institutions and people. OBJECTIVES: The project provides the basis for the implementation of the "internship platform". In the future, this is to be the digital, state-of-the-art one-stop shop for the state-wide practical nursing training (in the form of immanent internships) at all training levels. METHODS: The process is influenced by modern requirements engineering techniques: As-is analysis of the internship process and related documents, contextual inquires in different internship providers, iterative focus group discussions focusing first on user stories, then on interface designs, and final user testing. RESULTS: Standardized workflow and authorization concept for all user groups, mandatory requirements for the software system, tested user interfaces, tender documents for EU-wide tender procedure. CONCLUSION: Positive feedback from all involved user groups on project goal, results and involvement in the process.

Electronic Health Records as Information Source in Assessment of the Effectiveness of Delivered Care - A Pilot Study.

Effectiveness is a key element of high quality health services. The aim of this pilot study was to explore the potential of electronic health records (EHR) as an information source for assessing the effectiveness of nursing care by investigating the appearance of nursing processes in the documentation of care. Deductive and inductive content analysis were used in a manual annotation of ten patients' EHRs. The analysis resulted in the identification of 229 documented nursing processes. The results indicate that EHRs can be used in decision support systems for assessing effectiveness of nursing care, however, future work is needed to verify these findings in a larger data set and extend to other dimensions related to care quality.

Avalia TIS SPF: protótipo de software para avaliação clínica de enfermeiros em penitenciária federal de segurança máxima / Evaluates TIS SPF: software prototype for clinical assessment of nurses in maximum security federal penitentiary

Resumo: Objetivou-se desenvolver o protótipo de um software para avaliação clínica de enfermeiros, no serviço de saúde da penitenciária federal de segurança máxima de Porto Velho, Brasil. Como método, seguiram-se os moldes da pesquisa metodológica de produção tecnológica, que teve como cenário uma penitenciária federal, e foi desenvolvida em duas fases: fase 1, denominada fase exploratória, que incluiu três etapas: a) revisão de literatura; b) informações obtidas dos participantes sobre o conhecimento da avaliação clínica; c) análise dos dados; fase 2, denominada de fase de desenvolvimento do modelo de prototipação, o qual seguiu o ciclo de vida de desenvolvimento de sistema, dividido em três etapas: análise e especificação; desenvolvimento; e manutenção, propostas por Pressman (2011). Como produto, obteve-se o protótipo do software intitulado AVALIA TIS - SPF, com características dinâmicas que inclui módulos de cadastro e login do usuário; identificação do paciente; histórico/anamnese e avaliação clínica. Conclui-se que esta ferramenta tem potencial para instrumentalizar o enfermeiro na execução e documentação da primeira etapa do processo de enfermagem, contribuindo na valorização e sustentação da prática profissional, colaborando para a assistência integral da população carcerária. É viável a replicabilidade para outras unidades prisionais, temas e outras áreas do conhecimento. Tem potencial para impacto social, mantendo a população de pessoas privadas de liberdade, com melhor qualidade de vida durante o período do cumprimento de pena; impacto econômico, com possibilidade de identificação precoce de problemas de saúde e, consequentemente, menor número de complicações que exigem utilização de serviços de saúde de atenção secundária ou terciária. O teor inovador encontra-se no fato de implementar um sistema de informação segura dos dados dos custodiados, com possibilidade de ampliação de todas as penitenciárias de segurança máxima brasileiras.

Abstract: This study aimed to develop a software prototype to clinically evaluate nurses in the health service of the maximum-security federal penitentiary in Porto Velho. We followed the methodological research of technological production using a federal penitentiary as a scenario. The study consisted of two phases: Phase 1, the exploratory phase, which included three stages: a) literature review; b) the information obtained from participants regarding their knowledge of clinical evaluation; and c) data analysis; Phase 2, the prototyping model development phase, which followed the system development life cycle, divided into three stages: a) analysis and specification; b) development; and maintenance, proposed by Pressman (2011). The final product is a software prototype entitled AVALIA TIS - SPF, with dynamic characteristics that include user registration and login modules, patient identification, history/anamnesis, and clinical evaluation. In conclusion, this tool has the potential to equip nurses in the execution and documentation of the first stage of the nursing process, contributing to the appreciation and support of professional practice and collaborating for the integral assistance of the prison population. Replicability for other prison units, themes, and other areas of knowledge is feasible. It has the potential for social impact, giving a better quality of life to the freedom-deprived population while serving their sentence, and economic impact, with the possibility of early identification of health problems and, consequently, fewer complications that require secondary or tertiary health care services. The innovative content is because it implements a secure information system for the data of those in custody, with the possibility of expanding all Brazilian maximum security penitentiaries.

Adaptação dos processos de trabalho da enfermagem na implementação do Acesso Avançado (AA) em Unidades Básicas de Saúde

A Implementação do Acesso Avançado (AA) em UBS envolve uma série de questões, dentre elas, a adaptação dos processos de enfermagem levando-se em conta a complexidade e atribuições profissionais que vão da assistência direta ao usuário ao gerenciamento de programas. No modelo Acesso Avançado utilizado nas UBS, adaptado do modelo criado por Mark Murray (2000), o usuário acessa o serviço conforme sua necessidade, não havendo a necessidade de agendamento prévio, partindo-se da premissa "fazer hoje o serviço de hoje''.

Diagnóstico situacional da Sistematização da Assistência de Enfermagem em unidades de Estratégia Saúde da Família

Relatório apresentado à Secretaria Municipal de Saúde de Itajubá – MG, como produto técnico da dissertação de mestrado do Programa de Pós Graduação Mestrado Profissional em Atenção Primária à Saúde no Sistema Único de Saúde da Escola de Enfermagem da Universidade de São Paulo, com o título: Diagnóstico situacional da Sistematização da Assistência de Enfermagem em unidades de Estratégia Saúde da Família de um município do estado de Minas Gerais.

Guide for Systematization of Care and Nursing Process: educational technology for professional practice.

OBJECTIVE: to elaborate and validate the content of a digital guide educational technology on Systematization of Nursing Care and Nursing Process. METHODS: applied research of technological development, developed between 2020 and 2021, in three steps. First, a scoping review was carried out to elaborate the content. In the second step, the content was validated with 46 nurse judges selected for convenience. The minimum criterion of agreement among judges was 80%. The third step consisted of content organization and layout. RESULTS: the guide content was elaborated from the Federal Nursing Council legislation, scientific articles and textbooks. Content was considered appropriate, relevant and organized by judges. FINAL CONSIDERATIONS: the digital guide is an alternative that can contribute to the NP execution and implementation, supporting the planning and implementation of actions for quality of care.

Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system.

OBJECTIVE: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. METHOD: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. RESULTS: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. CONCLUSION: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.

Uso de tecnologias para o processo de enfermagem: revisão integrativa / Uso de tecnologías para el proceso de enfermería: revisión integrativa / Use of technologies for the nursing process: integrative review

Objetivo: avaliar as evidências sobre o que tem sido produzido cientificamente a respeito do uso de tecnologias para implementação do processo de enfermagem. Método: revisão integrativa da literatura com busca nas bases de dados Web of Science, SCOPUS e Medical Literature Analysis and Retrieval System Online, com os descritores: "Nursing Process" e "Technology ". Incluídos artigos publicados na íntegra entre 2015 e 2020, em português, inglês ou espanhol, e que respondessem à questão norteadora. Resultados: incluídos 20 artigos, publicados a partir de 2015, com maior concentração em 2019. As análises foram divididas em três eixos temáticos: Taxonomias empregadas para a implementação do Processo de Enfermagem; Tecnologias como ferramentas de educação para implementação; Desenvolvimento e análise do uso de tecnologias no contexto da Sistematização da Assistência de Enfermagem. Conclusão: necessidade de aproximação entre as áreas de tecnologia e saúde para implementar e manter a execução do processo de enfermagem.

Objective: evaluate evidence on what has been scientifically produced regarding the use of technologies to implement the nursing process. Method: integrative literature review with search in the Web of Science, SCOPUS and Medical Literature Analysis and Retrieval System Online databases, with the descriptors: "Nursing Process" and "Technology". Articles published in full between 2015 and 2020, in Portuguese, English or Spanish, and that answered the guiding question, were included. Results: 20 articles were included, published from 2015, with the highest concentration in 2019. The analyzes were divided into three thematic axes: Taxonomies used to implement the Nursing Process; Technologies as educational tools for implementation; Development and analysis of the use of technologies in the context of Systematization of Nursing Care. Conclusion: need for closer ties between the areas of technology and health to implement and maintain the execution of the nursing process.

Objetivo: evaluar evidencias sobre lo producido científicamente sobre el uso de tecnologías para implementar el proceso de enfermería. Método: revisión integrativa de la literatura con búsqueda en las bases de datos Web of Science, SCOPUS y Medical Literature Analysis and Retrieval System Online, con los descriptores: "Proceso de enfermería" y "Tecnología". Se incluyeron artículos publicados íntegramente entre 2015 y 2020, en portugués, inglés o español, y que respondieran a la pregunta orientadora. Resultados: se incluyeron 20 artículos, publicados desde 2015, con mayor concentración en 2019. Los análisis se dividieron en tres ejes temáticos: Taxonomías utilizadas para implementar el Proceso de Enfermería; Tecnologías como herramientas educativas para la implementación; Desarrollo y análisis del uso de tecnologías en el contexto de la Sistematización de la Atención de Enfermería. Conclusión: existe la necesidad de estrechar lazos entre las áreas de tecnología y salud para implementar y mantener la ejecución del proceso de enfermería.