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1.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 12: 281-290, jan.-dez. 2020. ilus
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1047745

RESUMO

Objetivo: identificar quais diagnósticos de enfermagem da taxonomia da North American Nursing Diagnosis Association Internacional (NANDA-I) descritos ou indicados nas produções científicas possuem relação com os pacientes em cuidados paliativos e quais são as intervenções de enfermagem mais adequadas segundo a Classificação das Intervenções de Enfermagem (NIC). Método: revisão integrativa da literatura, que consiste na construção de uma análise ampla da literatura tendo como propósito inicial obter entendimento de um determinado fenômeno baseando-se em estudos anteriores. Resultados: realizou-se um levantamento sobre os estudos relacionados ao tema em fontes bibliográficas através de três sistemas informatizados. Dos artigos encontrados, apenas dez tornavam possível a identificação de Diagnósticos de Enfermagem, ou sua inferência. Estes diagnósticos foram contabilizados e relacionados às intervenções mais adequadas de acordo com a literatura. Conclusão: foi identificada uma produção científica pouco expressiva, mas, ainda assim, foi possível identificar diagnósticos e inferências diagnósticas que permitiram determinar quais intervenções de enfermagem seriam as mais adequadas


Objective: to identify which nursing diagnoses of the North American Nursing Diagnosis Association Internacional (NANDA-I) taxonomy described or indicated in the scientific productions are related to patients in palliative care and which are the most appropriate nursing interventions according to the Nursing Interventions Classification (NIC). Method: an integrative review of the literature, which consists of the construction of a comprehensive literature review, with the initial purpose of obtaining an understanding of a given phenomenon based on previous studies. Results: a survey of the studies related to the subject was carried out in bibliographic sources through three computerized systems. Of the articles found, only ten made possible the identification of Nursing Diagnostics, or their inference. These diagnoses were counted and related to the most appropriate interventions according to the literature. Conclusion: little expressive scientific production was identified, but it was still possible to identify diagnoses and diagnostic inferences that allowed to determine which nursing interventions would be the most adequate


Objetivo: identificar qué diagnósticos de enfermería de la taxonomía de la North American Nursing Diagnosis Association Internacional (NANDA-I) descritos o indicados en las producciones científicas, poseen relación con los pacientes en cuidados paliativos y cuáles son las intervenciones de enfermería más adecuadas según la Clasificación de las intervenciones en enfermería (NIC). Método: revisión integrativa de la literatura, que consiste en la construcción de un análisis amplio de la literatura teniendo como propósito inicial obtener entendimiento de un determinado fenómeno basándose en estudios anteriores. Resultados: se realizó un relevamiento sobre los estudios relacionados al tema en fuentes bibliográficas a través de tres sistemas informatizados. De los artículos encontrados, sólo diez hicieron posible la identificación de Diagnósticos de Enfermería, o su inferencia. Estos diagnósticos fueron contabilizados y relacionados con las Intervenciones más adecuadas de acuerdo con la literatura. Conclusión: se identificó una producción científica poco expresiva, pero aún así fue posible identificar diagnósticos e inferencias diagnósticas que permitieron determinar qué intervenciones de enfermería serían las más adecuadas


Assuntos
Humanos , Masculino , Feminino , Cuidados Paliativos/classificação , Diagnóstico de Enfermagem/classificação , Terminologia Padronizada em Enfermagem
2.
Rev Lat Am Enfermagem ; 27: e3153, 2019.
Artigo em Português, Inglês, Espanhol | MEDLINE | ID: mdl-31596405

RESUMO

OBJECTIVE: to identify the predicting factors and sensitivity, specificity, positive and negative related value of nursing diagnosis Ineffective Breathing Pattern among patients of an intensive care unit. METHOD: cross-sectional study. A logistic regression was fitted to assess the simultaneous effects of related factors. RESULTS: among the 120 patients, 67.5% presented Ineffective Breathing Pattern. In the univariate analysis, the related factors were: group of diseases, fatigue, obesity and presence of bronchial secretion, and the defining characteristics were: changes in respiratory depth, auscultation with adventitious sounds, dyspnea, reduced vesicular murmurs, tachypnea, cough and use of the accessory musculature to breathe. The mean age of patients with was higher than those without this diagnosis. The defining characteristics reduced murmurs had high sensitivity (92.6%), specificity (97.4%), negative related value (86.4%) and positive related value (98.7%). The related factors of Ineffective Breathing Pattern were the related factors fatigue, age and group of diseases. CONCLUSION: fatigue, age and patients with a group of diseases were related factors of Ineffective Breathing Pattern in this study. Reduced vesicular murmurs, auscultation with adventitious sounds and cough may be defining characteristics to be added in the international classification, as well as the related factors bronchial secretion and group of diseases.


Assuntos
Diagnóstico de Enfermagem/classificação , Insuficiência Respiratória/enfermagem , Idoso , Estudos Transversais , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Diagnóstico de Enfermagem/normas , Respiração
3.
Rev Bras Enferm ; 72(3): 584-591, 2019 Jun 27.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31269120

RESUMO

OBJECTIVE: to identify Nursing diagnoses in patients in home care by cross-mapping terms obtained in the anamnesis and clinical examination, with NANDA-I Taxonomy. METHOD: descriptive exploratory study, transversal type, performed with 131 patients from a home health care program in northern Minas Gerais State. With the aid of an instrument based on the theoretical model of Basic Human Needs, the terms indicators of conditions that required nursing interventions were extracted. The cross-mapping of these terms was also performed with NANDA-I Taxonomy diagnoses. RESULTS: 378 terms and expressions referring to 49 different diagnoses were identified in 11 of the 13 domains of NANDA-I Taxonomy. CONCLUSION: the profile of identified nursing diagnoses can contribute to care management and organizational processes of nurses who provide care to patients in home care.


Assuntos
Classificação/métodos , Serviços de Assistência Domiciliar/classificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Feminino , Serviços de Assistência Domiciliar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Diagnóstico de Enfermagem/classificação
4.
Rev Bras Enferm ; 72(3): 744-752, 2019 Jun 27.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31269141

RESUMO

OBJECTIVES: To identify useful terms for nursing practice in the care of people with leprosy and to cross-mapp the identified terms with the ICNP® terms. METHOD: A descriptive, documentary study that included publications of the Ministry of Health in the area of leprosy launched between 2002 and 2017. The terms identified in these publications were extracted and underwent a normalization proces and then, were cross-mapped with terms of the ICNP® version 2015 for the identification of constant and non-constant terms in this terminology. RESULTS: In total, were extracted 1,177 terms, of which 26.76% were equal, 4.59% similar, 4.26% were broader, 19.62% were more restricted, and 44.77% were totally different from the ICNP® terms. CONCLUSIONS: The large number of terms identified and not included in the ICNP® show the need for its expansion in order to contemplate the phenomena of clinical practice more effectively and allow better representation of nursing care for people with leprosy.


Assuntos
Hanseníase/classificação , Diagnóstico de Enfermagem/classificação , Humanos , Hanseníase/enfermagem , Cuidados de Enfermagem/métodos , Cuidados de Enfermagem/tendências , Diagnóstico de Enfermagem/estatística & dados numéricos , Terminologia Padronizada em Enfermagem
5.
Rev Bras Enferm ; 72(3): 801-808, 2019 Jun 07.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31269149

RESUMO

OBJECTIVE: to recount the story of the Simpósio Nacional de Diagnóstico de Enfermagem (National Nursing Diagnosis Symposium), from 1991 to 2018, describing the official themes and main recommendations; and reflect on the construction, in this process, of a specific field of knowledge for Nursing. RESULTS: the manuscript became a historical study, using official documents resulting from the thirteen Symposiums conducted in the period from 1991 to 2018 as the primary source of empirical data. The outcomes were divided into two stages, from 1991 to 1992, when the event was linked to Interest Groups in Nursing Diagnosis; and from 1996 to 2018, when ABEn Nacional took over the organization and execution of the event. FINAL CONSIDERATIONS: the socialization and exchange of knowledge about systematization of care, Nursing Process and nursing terminologies, themes focused on SINADEn, contributed decisively to the construction of a fruitful field of knowledge for Nursing.


Assuntos
Congressos como Assunto/história , Diagnóstico de Enfermagem/classificação , Brasil , História do Século XX , História do Século XXI , Humanos , Diagnóstico de Enfermagem/tendências
6.
Rev Bras Enferm ; 72(1): 221-230, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30916289

RESUMO

OBJECTIVE: To identify in the literature the defining characteristics and related factors of the nursing diagnosis "ineffective breathing pattern". METHOD: Integrative review with the steps: problem identification, literature search, evaluation and analysis of data and presentation of results. RESULTS: Twenty articles and two dissertations were included. In children, the most prevalent related factor was bronchial secretion, followed by hyperventilation. The main defining characteristics were dyspnea, tachypnea, cough, use of accessory muscles to breathe, orthopnea and adventitious breath sounds. Bronchial secretion, cough and adventitious breath sounds are not included in the NANDA-International (NANDA-I). For adults and older adults, the related factors were fatigue, pain and obesity and the defining characteristics were dyspnea, orthopnea and tachypnea. CONCLUSION: This diagnosis manifests differently according to the patients' age group. It was observed that some defining characteristics and related factors are not included in the NANDA-I. Their inclusion can improve this nursing diagnosis.


Assuntos
Diagnóstico de Enfermagem/classificação , Insuficiência Respiratória/enfermagem , Fatores Etários , Humanos , Diagnóstico de Enfermagem/métodos , Insuficiência Respiratória/classificação
7.
Rev Lat Am Enfermagem ; 26: e3092, 2018 Nov 29.
Artigo em Inglês, Português, Espanhol | MEDLINE | ID: mdl-30517580

RESUMO

OBJECTIVE: to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. METHOD: case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. RESULTS: variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). CONCLUSION: such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Circulação Extracorpórea/efeitos adversos , Diagnóstico de Enfermagem , Hemorragia Pós-Operatória/diagnóstico , Idoso , Índice de Massa Corporal , Estudos de Casos e Controles , Feminino , Humanos , Período Intraoperatório , Masculino , Diagnóstico de Enfermagem/classificação , Hemorragia Pós-Operatória/etiologia , Fatores de Risco
8.
Rev Bras Enferm ; 71(6): 2860-2868, 2018.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30517386

RESUMO

OBJECTIVE: To describe the scientific production of the International Classification for Nursing Practice throughout dissertations and theses published by nurses in Brazil from 1996 to 2016. METHOD: A bibliometric, descriptive, quantitative documentary study, carried out from October/2015 to July/2016 on the sites of the Center of Studies and Research in Nursing (CEPEn), at the thesis and dissertation banks of the Coordination of Improvement of Higher Education Personnel and of the Plataforma Sucupira (Sucupira Platform). RESULTS: There were 108 productions, 30 theses and 78 dissertations. In 2014, there was the largest number of publications (19). The Graduate Program in Nursing of the Universidade Federal da Paraíba had the highest number of productions (23). Regarding the theme, the use in clinical practice was highlighted (69), followed by the elaboration of terminology subsets (17). CONCLUSION: The Brazilian scientific production setting on ICNP® is expressive, evidencing this system as a tool that allows the provision of systematic care.


Assuntos
Diagnóstico de Enfermagem/normas , Bibliometria , Brasil , Humanos , Cuidados de Enfermagem/métodos , Cuidados de Enfermagem/normas , Diagnóstico de Enfermagem/classificação
9.
Rev Bras Enferm ; 71(suppl 3): 1435-1444, 2018.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29972545

RESUMO

OBJECTIVE: Classify the diagnoses in the conceptual framework of vulnerability of Ayres and in the Orem's self-care theory; Elaborate operational definitions of nursing diagnoses for elderly women vulnerable to HIV/AIDS. METHOD: A descriptive exploratory study, developed from March to December 2016 in the stages: 1. Classification of diagnoses in the conceptual framework of vulnerability of Ayres and in the Orem's self-care theory; 2. Operational definition of nursing diagnoses. RESULTS: 70 nursing diagnoses were classified in the conceptual framework of vulnerability of Ayres and Orem's self-care theory, and their operational definitions were constructed, where 75.7% of these were validated. FINAL CONSIDERATION: Diagnoses represent conditions that make older women vulnerable to HIV/AIDS and are linked to their self-care practices. Operational definitions contribute to a systematic approach to care and greater clarity in its implementation.


Assuntos
Infecções por HIV/enfermagem , Diagnóstico de Enfermagem/classificação , Populações Vulneráveis/classificação , Idoso , Feminino , Humanos , Teoria de Enfermagem , Autocuidado
10.
Nurse Educ Today ; 67: 114-117, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29857304

RESUMO

PURPOSE: To determine nursing students' perception of nursing diagnosis and the effect of 'nursing terminologies and classifications' course on this perception. METHODS: This study was carried out as a quasi-experimental, two group design. Data were collected through the Nursing Diagnosis Survey. FINDINGS: The overall Perceptions of Nursing Diagnosis Survey score for this study was found 2.44 ±â€¯0.44. Perceptions of Nursing Diagnosis Survey mean scores of nursing students who took 'Nursing Terminologies and Classifications' course were found more positive than the nursing students who did not take the course. CONCLUSIONS: Positive perceptions about the use of nursing diagnosis have beneficial effects on the identification of patient problems and planning of these; and improves the quality of the patient care.


Assuntos
Diagnóstico de Enfermagem , Terminologia Padronizada em Enfermagem , Estudantes de Enfermagem/psicologia , Feminino , Humanos , Masculino , Diagnóstico de Enfermagem/classificação , Diagnóstico de Enfermagem/normas , Inquéritos e Questionários , Adulto Jovem
11.
Rev Bras Enferm ; 71(suppl 1): 467-474, 2018.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29562000

RESUMO

OBJECTIVE: To construct nursing diagnosis statements based on the International Classification for Nursing Practice (ICNP®) for people with metabolic syndrome, settled on the theoretical framework of Basic Human Needs. METHOD: Descriptive study developed in four stages: 1) Identification and validation of terms relevant to care with health priority; 2) Cross-mapping of the terms identified with ICNP® terms; 3) Construction of the nursing diagnosis statements; and 4) Cross-mapping of constructed statements with the ones in ICNP®. RESULTS: Regarding terms extracted, 370 were validated based on the consensus (100%) among specialists, subsidizing the elaboration of 52 nursing diagnosis statements from ICNP® version 2015, distributed among the Basic Human Needs proposed by theoretical framework. CONCLUSION: It was possible to construct nursing diagnoses for people with metabolic syndrome based on the terms extracted from the literature, with a predominance of the need for "Health education and learning".


Assuntos
Síndrome Metabólica/diagnóstico , Diagnóstico de Enfermagem/classificação , Dissertações Acadêmicas como Assunto , Brasil , Educação de Pós-Graduação em Enfermagem/métodos , Humanos , Terminologia Padronizada em Enfermagem
12.
Int J Nurs Knowl ; 29(1): 66-78, 2018 01.
Artigo em Inglês, Português | MEDLINE | ID: mdl-27059109

RESUMO

The accurate identification of the nursing diagnoses and the corresponding measurement of their indicators will depend on the elements in the standardized language systems. OBJECTIVE: To analyze the correspondence between elements of four NANDA-I nursing diagnoses and outcomes suggested by the nursing outcomes classification (NOC) for the resolution of these diagnoses. METHOD: A methodological study consisting of cross-mapping was performed in the first stage between definitions, defining characteristics (DCs), and related factors (RFs) of impaired oral mucous membrane, impaired tissue integrity, spiritual distress, and delayed surgical recovery and outcome definitions and indicators to measure results of diagnoses resolution and an analysis of its relevance by experts in the second stage. RESULTS: It found partial correspondence between outcome indicators, DCs, RFs, and definitions. CONCLUSION: The data evidence the relevance of this review for a reliable application of these taxonomies and demonstrated partial correspondence between concepts analyzed. A identificação precisa dos diagnósticos de enfermagem e a medida correspondente dos seus indicadores dependerá dos elementos nos sistemas de linguagem padronizados.


Assuntos
Diagnóstico de Enfermagem/classificação , Terminologia Padronizada em Enfermagem , Resultado do Tratamento , Convalescença , Humanos , Mucosa Bucal/fisiopatologia , Alta do Paciente , Cuidados Pós-Operatórios/enfermagem
13.
Rev. latinoam. enferm. (Online) ; 26: e3092, 2018. tab, graf
Artigo em Inglês | LILACS | ID: biblio-978604

RESUMO

ABSTRACT Objective: to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. Method: case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. Results: variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). Conclusion: such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.


RESUMO Objetivo: identificar os fatores de risco associados aos casos de sangramento excessivo em pacientes submetidos à cirurgia cardíaca com circulação extracorpórea. Método: estudo de caso-controle dos fatores de risco de sangramento com análise de dados de prontuários de 216 pacientes submetidos à cirurgia cardíaca com circulação extracorpórea de caráter eletivo durante o período de três anos. Resultados: foram analisadas variáveis comumente associadas ao sangramento excessivo em estudos na área, sendo considerados como fatores de risco para o diagnóstico de enfermagem "risco de sangramento" (00206) em cirurgia cardíaca com circulação extracorpórea: Índice de massa corporal menor que 26,35kg/m² (Odds ratio = 3,64); Circulação extracorpórea maior que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidose metabólica (Odds ratio = 3,50) e Tempo de tromboplastina parcial ativada maior que 40 segundos (Odds ratio = 2,55). Conclusão: tais variáveis podem ser indicadores clínicos de natureza operacional para melhor caracterização do fator de risco "regime de tratamento" e de um refinamento do conhecimento relacionado à coagulopatia induzida pela circulação extracorpórea, provavelmente hoje incorporada na categoria de "regime de tratamento" da classificação diagnóstica de enfermagem da NANDA International, Inc.


RESUMEN Objetivo: identificar los factores de riesgo asociados a casos de hemorragia excesiva en pacientes sometidos a cirugía cardíaca con circulación extracorpórea. Método: estudio de caso control de los factores de riesgo de hemorragia con análisis de datos de fichas médicas de 216 pacientes, sometidos a cirugía cardíaca, con circulación extracorpórea, de carácter electivo durante el período de tres años. Resultados: fueron analizadas variables comúnmente asociadas a hemorragia excesiva, en estudios en esta área, siendo considerados como factores de riesgo para el diagnóstico de enfermería "riesgo de hemorragia" (00206) en cirugía cardíaca con circulación extracorpórea, los siguientes: Índice de masa corporal <26,35 Kg/m² (Odds ratio= 3,64); Circulación extracorpórea mayor que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidosis metabólica (Odds ratio = 3,50); y Tiempo de tromboplastina parcial activada mayor que 40 segundos (Odds ratio = 2,55). Conclusión: esas variables pueden ser indicadores clínicos de naturaleza operacional para caracterizar mejor el factor de riesgo "régimen de tratamiento" y para perfeccionar el conocimiento relacionado a la coagulopatía inducida por la circulación extracorpórea; probablemente, actualmente incorporada a la categoría de "régimen de tratamiento" de la clasificación diagnóstica de enfermería de la NANDA International Inc.


Assuntos
Humanos , Masculino , Feminino , Idoso , Diagnóstico de Enfermagem/classificação , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/etiologia , Circulação Extracorpórea/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Índice de Massa Corporal , Estudos de Casos e Controles , Fatores de Risco , Período Intraoperatório
14.
Belo Horizonte; s.n; 2018. 319 p. ilus, tab.
Tese em Português | LILACS, BDENF - Enfermagem | ID: biblio-948314

RESUMO

Introdução: A neurorreabilitação é identificada, como um importante componente no processo saúde-doença de pessoas com deficiência, condição cada vez mais complexa e diversificada. O Processo de Enfermagem é uma ferramenta metodológica que deve ser utilizada para direcionar os cuidados prestados a essa população e para utilizá-la é recomendado o uso de uma terminologia unificada, capaz de possibilitar, aos enfermeiros codificar, armazenar e recuperar a informação em um formato que possa ser útil e aplicável na assistência ao paciente. Objetivo: construir um Catálogo de conceitos da Classificação Internacional para a Prática de Enfermagem (CIPE®) na neurorreabilitação de adultos. Método: Trata-se de um estudo metodológico desenvolvido em quatro etapas: composição dos enunciados de diagnósticos / resultados e intervenções de enfermagem; construção de definições operacionais para os enunciados dos diagnósticos / resultados de enfermagem; validação de conteúdo dos enunciados e das definições operacionais dos diagnósticos/resultados de enfermagem e dos enunciados das intervenções de enfermagem junto a enfermeiros especialistas na área; organização do Catálogo de acordo com o Modelo de Adaptação de Roy. Resultados: Foram construídos 1490 enunciados, sendo 394 diagnósticos/resultados de enfermagem e 1090 intervenções de enfermagem. Validou-se quanto ao conteúdo 266 diagnósticos/resultados de enfermagem e 540 intervenções. Os enunciados foram alocados nos modos do Modelo de Adaptação de Roy, sendo 20 diagnósticos/resultados e as intervenções de enfermagem no modo desempenho de papel, 10 diagnósticos/resultados e suas intervenções de enfermagem no modo interdependência; 52 no modo autoconceito e, 184 no modo fisiológico. Conclusão: desenvolveu-se um Catálogo CIPE® para Adultos em processo de neurorreabilitação à luz do modelo teórico de adaptação de Roy. Diagnósticos / resultados e intervenções de enfermagem foram propostos e validados e para ajudar o raciocínio clínico do enfermeiro. Este foi julgado como refletindo as demandas que a população pode apresentar durante o processo de neurorreabilitação e seu uso dará suporte à documentação sistemática do cuidado clínico de enfermagem, usando a CIPE® como terminologia de referência. A CIPE® tem sido considerada uma classificação versátil pois se adapta às muitas realidades e singularidades da prática de enfermagem. Neste sentido, acredita-se que esse Catálogo possa ser usado por enfermeiros reabilitadores na sua prática, padronizando a linguagem empregada e contribuindo com o processo de tomada de decisão clínica.(AU)


Introduction: Neurorehabilitation is identified as an important component in the healthdisease process of people with disabilities, an increasingly complex and diversified condition. The Nursing Process is a methodological tool that should be used to direct the care provided to this population and to use it, it is recommended to use a unified terminology, capable of enabling nurses to code, store and retrieve information in a format which may be useful and applicable in patient care. Objective: to construct a Catalog of concepts of the International Classification for Nursing Practice (CIPE®) in adult neuro-rehabilitation. Method: It is a methodological study developed in four stages: composition of the statements of diagnoses / results and nursing interventions; construction of operational definitions for statements of nursing diagnoses / results; validation of contents of statements and operational definitions of nursing diagnoses / results and statements of nursing interventions with specialist nurses in the area; organization of the Catalog according to Roy's Adaptation Model. Results: A total of 1490 statements were constructed, being 394 nursing diagnoses / results and 1096 nursing interventions. 266 nursing diagnoses / results and 540 interventions were validated. The statements were allocated in the Roy Adaptation Model modes, with 20 diagnoses / results and the nursing interventions in paper performance mode, 10 diagnoses / results and their nursing interventions in the interdependence mode; 52 in the self-concept mode, and 184 in the physiological mode. Conclusions: a CIPE® Catalog for Adults in the process of neurorehabilitation was developed in light of Roy's theoretical model of adaptation. Diagnoses / outcomes and nursing interventions were proposed and validated and should enhance the nurses' clinical reasoning. This was judged as reflecting the demands that the population may present during the neuro-rehabilitation process and its use will support the systematic documentation of clinical nursing care, using CIPE® as a reference terminology. CIPE® has been considered a versatile classification because it adapts to the many realities and singularities of nursing practice. In this sense, it is believed that this Catalog can be used by rehabilitation nurses in their practice, standardizing the language used and contributing to the clinical decision-making process.(AU)


Assuntos
Humanos , Diagnóstico de Enfermagem/classificação , Enfermagem em Reabilitação/classificação , Terminologia , Inquéritos e Questionários , Modelos de Enfermagem , Dissertação Acadêmica , Reabilitação Neurológica , Processo de Enfermagem/classificação
16.
Rev. calid. asist ; 32(3): 127-134, mayo-jun. 2017. tab, ilus, graf
Artigo em Espanhol | IBECS | ID: ibc-162450

RESUMO

Objetivo. Describir el proceso de implantación del Plan de Cuidados Individualizado Enfermero en la Historia Clínica Electrónica y su impacto en el Hospital Universitario Fundación Alcorcón. Metodología. Grupos de trabajo de enfermeras asistenciales que analizaron inicialmente las actividades enfermeras que realizaban habitualmente para crear el catálogo de diagnósticos, resultados e intervenciones. Se creó un grupo de referentes que depuró el catálogo para hacerlo manejable. Se diseñaron un plan de formación, los formularios de valoración enfermera y el Informe de Cuidados Enfermeros al alta. Resultados. En febrero de 2016 se implementó la nueva metodología en las unidades de hospitalización de adultos. Al 74,86-88,18% de los pacientes se les realizó un plan de cuidados con la nueva metodología. Entre un 69,41 y un 76,25% de los pacientes son dados de alta con un Informe de Cuidados Enfermeros conforme a la normativa. Se observó un aumento del 24,13% de los pacientes con Informe de Cuidados Enfermeros tras la implantación (p=0,000; RR 1,46; IC 95% 1,36-1,56). Se ha formado a un total de 116 enfermeras. Conclusiones. En las condiciones del estudio, la utilización de taxonomías enfermeras ha generado capacidad de reflexión y ha permitido emitir juicios enfermeros, aportar calidad de cuidados y aplicar intervenciones con unos resultados planificados. La taxonomía enfermera y el plan de cuidados en la historia clínica electrónica han permitido aumentar la comunicación interprofesional para mejorar la continuidad asistencial, a través de la mejora del Informe de Cuidados Enfermeros (AU)


Aim. To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. Methodology. Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. Results. In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. Conclusions. In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report (AU)


Assuntos
Humanos , Processo de Enfermagem/organização & administração , Registros Eletrônicos de Saúde/organização & administração , Registros de Enfermagem , Hospitais Universitários/organização & administração , Diagnóstico de Enfermagem/classificação , Planejamento de Assistência ao Paciente/classificação , Sumários de Alta do Paciente Hospitalar/classificação , Relações Interprofissionais
17.
Gerokomos (Madr., Ed. impr.) ; 28(1): 19-24, mar. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-162349

RESUMO

Objetivo: El envejecimiento conlleva la aparición de procesos crónicos que aumentan la morbilidad, la pérdida de funcionalidad y el consumo de recursos. En la evaluación del estado de salud se han explorado indicadores distintos a los clásicos parámetros biológicos, y la calidad de vida relacionada con la salud (CVRS) es un indicador de resultado útil como herramienta clínica y de gestión. El objetivo de este trabajo ha sido seleccionar, de manera no exhaustiva, con base en la taxonomía NOC (Nursing Outcomes Classification), unos resultados sobre unas variables con una doble característica: tener un impacto negativo demostrado en la CVRS del anciano y ser sensibles a la actuación enfermera. Metodología: Búsqueda bibliográfica. Priorización de variables según el método de Hanlon. Selección de códigos NOC, tanto en relación con las variables priorizadas como con la autopercepción de salud de las personas. Resultados: Se seleccionaron 6 variables. De ellas, las tres primeras priorizadas fueron úlceras por presión, pérdida de autonomía y caídas. Se seleccionaron 37 códigos NOC, relacionados con estas tres variables y con la salud autopercibida. Conclusiones: El logro de NOC relacionado con variables con un fuerte impacto negativo en la CVRS del anciano puede suponer una mejora en su percepción de salud. La revisión de la bibliografía y las técnicas de priorización son herramientas útiles que complementan la metodología NOC, mejorando la efectividad y eficiencia de nuestras actuaciones


Objective: One of the consequences of ageing is the appearance of chronic diseases that increase morbidity, loss of functional ability and the use of healthcare resources. New indicators have been developed to evaluate health status, beyond the classical biological parameters. Health-related Quality of Life (HRQoL), an output indicator closely related to patient´s perceptions, has shown to be useful for clinicians and for management purposes. The aim was to select, according to Nursing Outcomes Classification (NOC) taxonomy, some results related to factors with a double characteristic: having a substantial negative impact on HRQol in the elderly and being sensitive to nursing practice. Methods: Bibliographic research. Prioritization of variables according to Hanlon method. Selection of NOC codes, with regard to the prioritized list and to the self-perception of health. Results: 6 variables were selected. The first three prioritized factors were pressure ulcers, loss of functional ability and falls. 37 NOC codes were finally set up, related to these 3 variables and to the selfperception of health. Conclusions: Achieving the NOC related to variables that are associated with a strong negative impact on HRQOL in the elderly people can lead to an improvement in perceived health of individuals. Bibliographic research and prioritization techniques are useful tools that complement the NOC methodology, improving the effectiveness and efficiency of nursing cares


Assuntos
Humanos , Idoso , Idoso de 80 Anos ou mais , Nível de Saúde , Autoimagem , Diagnóstico de Enfermagem/classificação , Planejamento de Assistência ao Paciente/organização & administração , Qualidade de Vida , Doença Crônica/epidemiologia , Envelhecimento
18.
Enferm. glob ; 16(45): 457-473, ene. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-159338

RESUMO

Introducción: Una familia es saludable cuando se logra un equilibrio entre el control, crecimiento, la estabilidad y la espiritualidad de cada uno de sus integrantes con el entorno que los rodea (2). Objetivo: Diseñar un instrumento validado que permita la valoración familiar por el Modelo de Dominios de la Taxonomía II de NANDA. Metodología: Diseño cuantitativo, de tipo tecnológica psicométrica con análisis de datos descriptivos. La muestra para la validación del instrumento fue de 8 profesionales en enfermería; además, se realizó una prueba piloto en donde participaron 40 familias pertenecientes a las ciudades de Bucaramanga y Santa Marta, Colombia, 20 para cada ciudad. Para la validación de contenido, se tuvo en cuenta el Modelo de Lawshe Modificado. Resultados: Existió un consenso general entre los jueces evaluadores en la validación de contenido del Instrumento, el Coeficiente Alpha de Cronbach fue de 0.847, la correlación no paramétrica Rho de Spearman, arrojó una buena correlación entre los ítems contemplados en el instrumento, con un valor de r mayor de 0.5 y un nivel de significancia < de 0.05, con un valor de p de cero. Conclusiones: Se encontró consenso entre los jueces evaluadores, una fiabilidad por medio del Alpha de Cronbach superior a 0.7 y correlaciones no paramétrica Rho de Spearman significativas entre algunos ítems del instrumento (AU)


Introduction: A family is healthy when a balance among the control, growth, stability and spirituality of each of its members is achieved with the surrounding environment (2). Objective: To design a validated instrument that permits family assessment based on the North American Nursing Diagnosis Association (NANDA) Taxonomy II domains model. Methodology: A quantitative design, of the psychometric technological type with descriptive data analysis. The sample for the validation of the instrument comprised eight nursing professionals. In addition, a pilot test was conducted; 40 families from the cities of Bucaramanga and Santa Marta, Colombia, including 20 from each city, participated. For the content validation, the Modified Lawshe’s Model was considered. Results: There was a general consensus among the evaluating judges regarding the validation of the content of the instrument. Cronbach’s alpha was 0.847. Regarding Spearman’s rho nonparametric correlation, there was a good correlation among the items considered by the instrument, with a value of r greater than 0.5, a significance level of <0.05 and a p-value of zero. Conclusions: A bibliographical review was performed, according to the context of family. The Family Assessment Instrument, based on the NANDA Taxonomy II Domains Model and consisting of 45 items, was designed. Consensus among the evaluating judges, a reliability by means of Cronbach's alpha value greater than 0.7 and significant Spearman’s rho nonparametric correlations among some items of the instrument were found (AU)


Assuntos
Humanos , Masculino , Feminino , Família/psicologia , Características da Família , Saúde da Família/classificação , Saúde da Família/educação , Psicometria/métodos , Psicometria/tendências , Estudos de Validação como Assunto , Classificação/métodos , Análise de Dados/métodos , Diagnóstico de Enfermagem/classificação , Diagnóstico de Enfermagem/normas
19.
J Clin Nurs ; 26(3-4): 379-387, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27192041

RESUMO

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


Assuntos
Diagnóstico de Enfermagem/normas , Processo de Enfermagem/normas , Registros de Enfermagem/normas , Qualidade da Assistência à Saúde , Terminologia Padronizada em Enfermagem , Prática Avançada de Enfermagem , Estudos Transversais , Humanos , Enfermeiras e Enfermeiros , Diagnóstico de Enfermagem/classificação , Pesquisa em Avaliação de Enfermagem , Processo de Enfermagem/classificação , Vocabulário Controlado
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