Representation of Diagnosis and Nursing Interventions in OpenEHR Archetypes

2021 ◽  
Vol 12 (02) ◽  
pp. 340-347
Author(s):  
Denilsen Carvalho Gomes ◽  
Nuno Abreu ◽  
Paulino Sousa ◽  
Claudia Moro ◽  
Deborah Ribeiro Carvalho ◽  
...  
Keyword(s):  
Health Information ◽  
Nursing Care ◽  
Health Information Systems ◽  
Nursing Intervention ◽  
The Other ◽  
Nursing Interventions ◽  
Developmental Study ◽  
Clinical Knowledge ◽  
Nursing Diagnosis ◽  
Knowledge Manager

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

Promoting Success in the Introduction of Health Information Systems

2012 ◽  
pp. 631-641
Author(s):  
Paulo Teixeira ◽  
Patrícia Leite Brandão ◽  
Álvaro Rocha
Keyword(s):  
Organizational Culture ◽  
Information Systems ◽  
Literature Review ◽  
Human Resources ◽  
Health Information ◽  
Health Information Systems ◽  
The Other ◽  
Other Hand ◽  
Number Of Publications

The significant number of publications describing unsuccessful cases in the introduction of health information systems makes it advisable to analyze the factors that may be contributing to such failures. However, the very notion of success is not equally assumed in all publications. Based in a literature review, the authors argue that the introduction of systems must be based in an eclectic combination of knowledge fields, adopting methodologies that strengthen the role of organizational culture and human resources in this project, as a whole. On the other hand, the authors argue that the introduction of systems should be oriented by a previously defined matrix of factors, against which the success can be measured.

Cardiac surgery postperative: diagnosis and nursing interventions

2009 ◽  
Vol 4 (1) ◽  
pp. 391
Author(s):  
Clarissa Garcia Rodrigues ◽  
Roberta Senger ◽  
Laura De Azevedo Guido ◽  
Graciele Fernanda da Costa Linch
Keyword(s):  
Cardiac Surgery ◽  
Postoperative Complications ◽  
Scientific Information ◽  
Descriptive Study ◽  
Nursing Intervention ◽  
Nursing Interventions ◽  
Inclusion Criteria ◽  
Nursing Diagnosis ◽  
Intervention Plan ◽  
Nursing Diagnoses

ABSTRACTObjective: to conduct a survey of the studies regarding the main postoperative complications in cardiac surgery and main nursing diagnoses identified. Methods: this is a descriptive study that to select the papers, the following databases were used: SCIELO, LILACS and MEDLINE. The descriptors were: postoperative, cardiac surgery, nursing diagnoses. The following inclusion criteria have been considered: papers published in Brazil from 1997 to 2007, papers on postoperative complications in cardiac surgery in adults, papers using the diagnoses standardized by NANDA. The selected papers were distributed into categories. Results: the following categories have been defined: category I – Complications in the postoperative in cardiac surgery; and category II – Nursing diagnoses in postoperative in cardiac surgery. The relation among the main postoperative complications has been made – physiology and/or semiology of the complication – nursing diagnoses – nursing interventions, which has been presented through synoptic. Later, a nursing intervention plan has been proposed. Conclusion: in despite of the complexity of the development of a nursing plan, it is highlighted the assistance rendered, the necessity of clinical studies regarding complications and the postoperative scenario, and the logical thinking focused on scientific information contributing for knowledge construction and nursing improvement. Descriptors: postoperative complications; cardiology; nursing diagnosis. RESUMOObjetivo: realizar um levantamento dos estudos referentes às principais complicações em pós-operatório de cirurgia cardíaca e principais diagnósticos de enfermagem identificados. Métodos: estudo descritivo que para a seleção dos artigos optou-se pelas seguintes bases de dados: SCIELO, LILACS e MEDLINE. Os descritores foram: pós-operatório, cirurgia cardíaca; diagnósticos de enfermagem. Consideraram-se os seguintes critérios de inclusão: artigos publicados no Brasil no período de 1997 a 2007; artigos sobre complicações do pós-operatório de cirurgia cardíaca; artigos sobre diagnósticos de enfermagem no pós-operatório de cirurgia cardíaca padronizados pela NANDA. Os artigos selecionados foram distribuídos em categorias. Resultados: foram definidas as seguintes categorias: categoria I - Complicações no pós-operatório em cirurgia cardíaca; e categoria II - Os diagnósticos de enfermagem no pós-operatório em cirurgia cardíaca. Fez-se a relação principais complicações pós-operatórias – fisiologia e/ou semiologia da complicação – diagnósticos de enfermagem – intervenções de enfermagem, a qual foi apresentada em quadros sinópticos. A seguir, propôs um plano de intervenções de enfermagem. Conclusão: Apesar da complexidade do desenvolvimento do plano de enfermagem, ressalta-se a qualidade da assistência prestada, a necessidade de estudos clínicos referentes às complicações e ao cenário pós-operatório e o raciocínio lógico centrado em informações científicas, contribuindo para a construção do conhecimento e engrandecimento da enfermagem. Descritores: complicações pós-operatórias; cardiologia; diagnóstico de enfermagem. RESUMENObjetivo: realizar un levantamiento de los estudios referentes a las principales complicaciones en el pos-operatorio de cirugía cardiaca y principales diagnósticos de enfermería identificados. Métodos: el estudio es descriptivo cuya selección de los artículos se hizo opción por las siguientes bases de datos: SCIELO, LILACS y MEDLINE. Los descriptores fueron: pos-operatorio, cirugía cardiaca, diagnósticos de enfermería. Se consideraron los siguientes criterios de inclusión: artículos publicados en Brasil en el periodo de 1997 a 2007, artículos sobre complicaciones del pos-operatorio de cirugía cardiaca, artículos que utilizan los diagnósticos de enfermería por patrones de NANDA. Los artículos seleccionados fueron distribuidos en categorías. Resultados: fueron definidas las siguientes categorías: categoría I – Complicaciones en el pos-operatorio en cirugía cardiaca; y categoría II – Los diagnósticos de enfermería en el pos-operatorio en cirugía cardiaca. Se hizo la relación de las principales complicaciones pos-operatorias – fisiología y/o semiología de la complicación – diagnósticos de enfermería – intervenciones de enfermería, la que fue presentada a través de cuadros sinópticos. A seguir, se propuso un plan de intervenciones de enfermería. Conclusión: a pesar de la complexidad del desarrollo de un plan de enfermería, se resalta la calidad de la asistencia prestada, la necesidad de estudios clínicos concernientes a las complicaciones y al escenario pos-operatorio y el raciocinio lógico centrado en informaciones científicas, pretendiéndose así la contribución para la construcción del conocimiento y enaltecimiento de la enfermería. Descriptores: complicaciones postoperatorias; cardiología; diagnóstico de enfermería.  

scholarly journals The Implementation Of 3S (SDKI, SIKI, SLKI) to The Quality Of Nursing Care Documentation In Hospital’s Inpatient Rooms

2020 ◽  
Vol 9 (2) ◽  
pp. 1323-1328
Author(s):  
Wiwin Sulistyawati ◽  
Susmiati Susmiati
Keyword(s):  
Nursing Care ◽  
Nursing Intervention ◽  
P Value ◽  
Hospital Inpatient ◽  
Chi Square ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Chi Square Test ◽  
Quality Of Nursing

The implementation of 3S (SDKI, SIKI, and SLKI) is a benchmark used as a guideline for the enforcement of nursing diagnosis, nursing intervention, and a nursing outsider to provide safe, effective, and ethical nursing care. This study aims to analyze the implementation of 3S on the quality of documentation in hospital inpatient rooms. Research design correlation analysis with the cross-sectional approach. The research sample of implementing nurses in hospital inpatient rooms who have implemented 3S. Sampling techniques use sampling quotas. Based on Chi-Square test results obtained, p-value = 0.001 < α 0.005 . It means there is a relationship of application of 3S to the quality of nursing care documentation in hospital inpatient rooms. Based on the results of this study, the Head of Nursing is expected to implement 3S to improve the quality of nursing care documentation, which will have an impact on improving the quality of nursing services

Promoting Success in the Introduction of Health Information Systems

2012 ◽  
Vol 8 (1) ◽  
pp. 17-27 ◽  
Author(s):  
Paulo Teixeira ◽  
Patrícia Leite Brandão ◽  
Álvaro Rocha
Keyword(s):  
Organizational Culture ◽  
Information Systems ◽  
Literature Review ◽  
Human Resources ◽  
Health Information ◽  
Health Information Systems ◽  
The Other ◽  
Other Hand ◽  
Number Of Publications

The significant number of publications describing unsuccessful cases in the introduction of health information systems makes it advisable to analyze the factors that may be contributing to such failures. However, the very notion of success is not equally assumed in all publications. Based in a literature review, the authors argue that the introduction of systems must be based in an eclectic combination of knowledge fields, adopting methodologies that strengthen the role of organizational culture and human resources in this project, as a whole. On the other hand, the authors argue that the introduction of systems should be oriented by a previously defined matrix of factors, against which the success can be measured.

Documenting Patterns of Nursing Interventions Using Cluster Analysis

2001 ◽  
Vol 9 (1) ◽  
pp. 73-90 ◽  
Author(s):  
Nancy A. O’Connor ◽  
Trace Kershaw ◽  
Alicia D. Hameister
Keyword(s):  
Cluster Analysis ◽  
Nurse Practitioner ◽  
Nursing Intervention ◽  
Nursing Interventions ◽  
Hierarchical Agglomerative Cluster ◽  
Nursing Diagnosis ◽  
Analysis Strategy ◽  
Nurse Practitioner Students ◽  
Adult Nurse Practitioner ◽  
Using Data

Use of inferential statistics in research applications of the Nursing Intervention Classification has been rare, yet use of these statistical techniques is needed to answer questions related to intervention patterns. Using data from a descriptive study of 3,733 visits documented by 19 adult nurse practitioner students, hierarchical agglomerative cluster analysis was used to determine whether meaningful nursing intervention patterns could be depicted. Eight intervention clusters were derived, replicated, and validated. Clusters of intervention classes differed in the type of nursing and medical diagnosis, amount of time the nurse spent during the visit, cost of visit, and the age of the patient. Clustering supported the utility of standardized nursing diagnosis and intervention typologies to identify actual practice patterns of adult nurse practitioner students. Cluster analysis is a valuable data analysis strategy when analyzing multiple related variables.

scholarly journals Penerapan Massage Abdomen dan Minum Air Putih Hangat untuk Mencegah Konstipasi pada Asuhan Keperawatan dengan Kasus Stroke di RSUD Poso

2019 ◽  
Vol 13 (2) ◽  
pp. 91
Author(s):  
Nirva Rantesigi ◽  
Agusrianto Agusrianto
Keyword(s):  
Nursing Care ◽  
Muscle Tension ◽  
Case Study Research ◽  
District General Hospital ◽  
Abdominal Muscle ◽  
Warm Water ◽  
Nursing Interventions ◽  
Nursing Diagnosis ◽  
Abdominal Massage

Non-pharmacological actions that can prevent and treat constipation are abdominal massage and therapy to drink 500 cc of warm water in the morning.  Doing massage can help encourage faeces and reduce abdominal muscle tension.  The purpose of this study is the application of nursing care in stroke cases.  This research is a type of case study research by applying comprehensive nursing care to patients.  The results showed data of patients who have not defecated for 4 days, the stomach feels full, there is a desire to defecate but it is difficult to get out, bowel sounds 6 times / minute.  The goal of nursing care is to prevent and overcome constipation, from moderate to mild constipation.  Nursing diagnosis of constipation is related to decreased gastrointestinal.  Nursing interventions Management constipation / impication.  Implementation of nursing doing abdominal massage and therapy to drink 500 cc of warm water in the morning.  Evaluation after 5 times giving patient intervention can defecate.  Conclusion: The application of abdominal massage and 500 cc warm water drinking therapy can prevent and overcome constipation in stroke patients in Poso District General Hospital.

scholarly journals Análise sobre estudos de validação de intervenções de enfermagem

2020 ◽  
Vol 14 ◽  
Author(s):  
Erika Christiane Marocco Duran ◽  
Larissa Costa Figueiredo ◽  
Ráisa Camilo Ferreira
Keyword(s):  
Literature Review ◽  
Nursing Care ◽  
Validation Studies ◽  
Time Frame ◽  
Scientific Production ◽  
Integrative Review ◽  
Nursing Interventions ◽  
Nursing Diagnosis ◽  
Nursing Processes ◽  
Diagnosis Classification

Objetivo: analisar a produção científica sobre a validação de intervenções de enfermagem. Método: trata-se de um estudo bibliográfico, descritivo, tipo revisão integrativa de literatura, no recorte temporal de 2007 a 2016, na MEDLINE, CINAHL e Bibliotecas Virtual de Saúde e COCHRANE. Organizaram-se os estudos, categorizando-os e os analisando de modo descritivo. Resultados: encontraram-se 147 artigos e, após a leitura dos resumos e dos textos na íntegra, foram incluídos oito artigos. Conclusão: identificou-se, por meio da revisão integrativa, a produção científica referente à validação de intervenções de enfermagem na literatura, evidenciando um aumento da produção desses estudos, o que contribui para a prática de Enfermagem no Brasil. Descritores: Cuidados de Enfermagem; Estudos de Validação; Processo de Enfermagem; Diagnóstico de Enfermagem; Classificação; Enfermagem.AbstractObjective: to analyze the scientific production on the validation of nursing interventions. Method: this is a bibliographic, descriptive, integrative literature review, in the time frame from 2007 to 2016, in MEDLINE, CINAHL and Virtual Health Libraries and COCHRANE. The studies were organized, categorized, and analyzed in a perspective descriptive. Results: 147 articles were researched and, after reading the abstracts and texts in full, eight articles were included. Conclusion: it was identified, through the integrative review, the scientific production referring to the validation of nursing interventions in the literature, showing an increase in the production of these studies, which contributes to the practice of Nursing in Brazil. Descriptors: Nursing Care; Validation Studies; Nursing Processes; Nursing Diagnosis; Classification; Nursing.ResumenObjetivo: analizar la producción científica sobre la validación de las intervenciones de enfermería. Método: se trata de una revisión bibliográfica, descriptiva, integradora de la literatura, en el período de 2007 a 2016, en MEDLINE, CINAHL y Bibliotecas Virtuales de Salud y COCHRANE. Se organizaron los estudios, categorizándolos y analizándolos de manera descriptiva. Resultados: se encontraron 147 artículos y, después de leer los resúmenes y textos completos, se incluyeron ocho artículos. Conclusión: a través de la revisión integradora, se identificó la producción científica relacionada con la validación de las intervenciones de enfermería en la literatura, mostrando un aumento en la producción de estos estudios, lo que contribuye a la práctica de Enfermería en Brasil. Descriptores: Atención de Enfermería; Estudios de Validación; Proceso de Enfermería; Diagnóstico de Enfermería; Clasificación; Enfermería.

scholarly journals Diagnosis identification and nursing intervention proposal for a patient with deep venous thrombosis

2011 ◽  
Vol 5 (9) ◽  
pp. 2254
Author(s):  
Cleise Querino Carneiro de Santana ◽  
Carmem Lúcia Oliveira dos Santos
Keyword(s):  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
North American ◽  
Tissue Perfusion ◽  
Nursing Intervention ◽  
Clinical State ◽  
Liquid Volume ◽  
Nursing Interventions ◽  
Nursing Diagnosis ◽  
Health Council

ABSTRACTObjective: to identify the nursing diagnosis, according to the Taxonomy II of the North American Nursing Diagnosis Association (Nanda), in a patient with deep venous thrombosis (DVT), allowing the planning of nursing assistance. Methodology: this is a case study, carried out within the period from February 19 2009 to February 26 2009. Data were collected through the information available in the medical record and the nursing consultation carried out having the patient’s interview and physical examination as a basis. The study observed the ethical aspects established in Resolution 196/96 from the National Health Council. Results: the data were presented as a nursing history and the diagnosis, results, and nursing interventions were presented in figures. The information allowed the planning of nursing assistance, with the identification of the following nursing diagnoses: ineffective peripheral tissue perfusion, excessive liquid volume, risk for impaired skin integrity, impaired physical mobility, acute pain, unbalanced nutrition ― less than body requirements ―, and fatigue, establishing the nursing interventions implemented and assessed. Conclusion: the planning of nursing assistance allowed the prevention of complications from DVT and a better general clinical state of the female patient, highlighting the importance of planning the care provided to the patient with this disease. Descriptors: venous thrombosis; nursing diagnosis; patient care planning.RESUMOObjetivo: identificar o diagnóstico de enfermagem, segundo a Taxonomia II da Associação Norte-Americana de Diagnóstico de Enfermagem (North American Nursing Diagnosis Association ― Nanda), em paciente com trombose venosa profunda (TVP), possibilitando a elaboração da assistência de enfermagem. Metodologia: trata-se de um estudo de caso, realizado no período de 19 de fevereiro a 26 de fevereiro de 2009. Os dados foram coletados por meio das informações disponíveis no prontuário e da realização da consulta de enfermagem a partir da entrevista e exame físico do paciente. O estudo obedeceu aos aspectos éticos estabelecidos na Resolução n. 196/96 do Conselho Nacional de Saúde. Resultados: os dados foram apresentados na forma de histórico de enfermagem e em figuras, os diagnósticos, resultados e intervenções de enfermagem. As informações possibilitaram a elaboração da assistência de enfermagem, identificando-se os seguintes diagnósticos de enfermagem: perfusão tissular periférica ineficaz, volume de líquidos excessivo, risco para integridade da pele prejudicada, mobilidade física prejudicada, dor aguda, nutrição desequilibrada ― menos do que as necessidades corporais ― e fadiga, estabelecendo-se as intervenções de enfermagem que foram implementadas e avaliadas. Conclusão: a elaboração da assistência de enfermagem possibilitou a prevenção de complicações decorrentes da TVP e melhora do estado clínico geral da paciente, evidenciando a importância da realização do plano de cuidados ao paciente com essa enfermidade. Descritores: trombose venosa; diagnóstico de enfermagem; planejamento de assistência ao paciente.RESUMENObjetivo: identificar el diagnóstico de enfermería, según la Taxonomía II de la Asociación Norteamericana de Diagnóstico de Enfermería (North American Nursing Diagnosis Association ― Nanda), en paciente con trombosis venosa profunda (TVP), posibilitando la elaboración de la asistencia de enfermería. Metodología: esto es un estudio de caso, realizado en el período de 19 de febrero a 26 de febrero de 2009. Los datos fueron recolectados por medio de las informaciones disponibles en el prontuario y de la realización de la consulta de enfermería basada en la entrevista y en el examen físico del paciente. El estudio obedeció a los aspectos éticos establecidos en la Resolución 196/96 del Consejo Nacional de Salud. Resultados: los datos fueron presentados como histórico de enfermería y en figuras tenemos los diagnósticos, resultados y intervenciones de enfermería. Las informaciones posibilitaron la elaboración de la asistencia de enfermería, identificándose los siguientes diagnósticos de enfermería: perfusión tisular periférica inefectiva, volumen excesivo de líquido, riesgo para integridad de la piel perjudicada, mobilidad física perjudicada, dolor aguda, nutrición desequilibrada ― menos que las necesidades corporales ― y fatiga, estableciéndose las intervenciones de enfermería que fueron implementadas y evaluadas. Conclusión: la elaboración de la asistencia de enfermería posibilitó la prevención de complicaciones derivadas de la TVP y la mejora del estado clínico general de la paciente, evidenciando la importancia de la realización del plan de cuidados al paciente con esa enfermedad. Descriptores: trombosis de la vena; diagnóstico de enfermería; planificación de atención al paciente. 

scholarly journals Nursing intervention assessment tool fall prevention in elderly people with systemic arterial hypertension

2020 ◽  
Vol 10 (7) ◽  
pp. 60 ◽  
Author(s):  
Paula Cristina Morais Pinheiro ◽  
Glauciano de Oliveira Ferreira ◽  
Francisca Valúzia Guedes Guerra ◽  
Tahissa Frota Cavalcante ◽  
Nirla Gomes Guedes ◽  
...  
Keyword(s):  
Arterial Hypertension ◽  
Elderly People ◽  
Fall Prevention ◽  
Assessment Tool ◽  
Nursing Intervention ◽  
Nursing Interventions ◽  
Final Assessment ◽  
Nursing Diagnosis ◽  
Effective Interventions ◽  
Risk Of Falls

Background and objective: Elderly people are at greater risk for falls and, therefore, need effective interventions to prevent them. The aim of the study was to develop an assessment tool for nursing intervention fall prevention to elderly with arterial hypertension and with nursing diagnosis Risk of falls.Methods: A methodological study, accomplished in four stages: activities selection of the fall Prevention intervention from Nursing Interventions Classification (NIC); 2) construction of constructive definitions and operational for selected activities; 3) expert validation of constructed definitions; 4) pretest of the final assessment tool.Results: The experts selected 50 activities out of 65 presented by NIC. The constitutive and operational definitions of the 50 activities were elaborated. From the focus group, some activities were grouped and the content of others changed. The pretest showed that, although the application of the assessment tool with the definitions take longer, it was more complete and targeted. The final assessment tool contains 28 activities with constitutive definitions and operational.Conclusions: The produced assessment tool has nursing activities with constitutive and operational definitions suitable for clinical nursing practice. It is believed that it can lead the intervention of the nurses in preventing falls in elderly people with SAH and with the nursing diagnosis Risk of falls.

scholarly journals Application of theoretical and methodological components of nursing care

2016 ◽  
Vol 13 (2) ◽  
pp. 107 ◽  
Author(s):  
Rosa Del Socorro Morales-Aguilar ◽  
Alba Cecilia Pardo-Vásquez
Keyword(s):  
Nursing Care ◽  
Nursing Intervention ◽  
Care Process ◽  
Nursing Process ◽  
Nursing Theory ◽  
Florence Nightingale ◽  
Nursing Diagnosis ◽  
Palabras Clave ◽  
El Sistema ◽  
Care Nursing

ABSTRACTIntroduction: the theoretical and methodological components are the proper expertise in nursing, and it refers to models, theories, care process, taxonomy of nursing diagnoses, system of nursing intervention classification, and system of outcomes classification, which base nursing care into professional practice. Methodology: research was performed on Google Scholar, reviewing the databases of Scielo, Ciberindex, Index Enfermería, Dialnet, Redalyc, Medline, identifying 70 published articles between 2005-2015, and selecting 52 of them. The keywords used were: nurse care, nursing diagnostic, classification, nursing theory, in spanish and portuguese. Results: training students, receive knowledge in the nursing process, NANDA International, classification of the interventions, nurse results and theoretical components. The Dorothea Orem, Callista Roy, Nola Pender, Virginia Henderson, Florence Nightingale, and Betty Neuman theories are applied. The application of the nursing process is limited and low familiarity with the international taxonomy by nurse professionals in the assistance area is noticed. Conclusions: the challenge of nursing is to continue to solidify the scientific knowledge and to undo the gap between theory and practice.KEY WORDS: nursing care, nursing diagnosis, classification, nursing theory.Aplicación de los elementos teóricos y metodológicos del cuidado de enfermeríaRESUMENIntroducción: los elementos teóricos y metodológicos son conocimientos propios de enfermería y se refieren a modelos, teorías, proceso de atención, taxonomía de diagnósticos de enfermería, el sistema de clasificación de intervenciones de enfermería, y el sistema de clasificación de resultados, los cuales fundamentan el cuidado de enfermería en la práctica profesional. Metodología: se realizó búsqueda en Google Chrome,  revisando las bases de datos de Scielo, Ciberindex, Index Enfermería, Dialnet, Redalyc y Medline, identificando 70 artículos publicados entre 2005-2015, seleccionándose 52. Las palabras clave utilizadas fueron: cuidado de enfermería, diagnóstico de enfermería, clasificación, teoría de enfermería, , en idiomas español y portugués. Resultados: los estudiantes en formación reciben conocimientos en el proceso de enfermería, NANDA Internacional, clasificación de las intervenciones, resultados enfermeros y elementos teóricos. Las teóricas aplicadas fueron Dorotea Orem, Callista Roy, Nola Pender, Virginia Henderson, Florence Nigthingale y Betty Neuman. La aplicación del proceso de enfermería es limitada y hay escasa familiaridad con la taxonomía internacional por parte de los profesionales de enfermería en el área asistencial. Conclusiones: el reto de enfermería es continuar dando solidez al cuerpo de conocimiento científico y deshacer la brecha entre la teoría y la práctica. PALABRAS CLAVE: cuidado de enfermería, diagnóstico de enfermería, clasificación, teoría de enfermería. Aplicação de elementos teóricos e metodológicos dos cuidados de enfermagem RESUMOIntrodução: os elementos teóricos e metodológicos são os conhecimentos próprios em enfermagem, e se referem a modelos, teorias, processos de atendimento, taxonomia de diagnósticos de enfermagem, o sistema de classificação de intervenções de enfermagem, e o sistema de classificação de resultados, os quais fundamentam os cuidados de enfermagem na prática professional. Materiais e métodos: realizou-se busca em Google Acadêmico, revisando as bases de dados de Scielo, Ciberindex, Index Enfermagem, Dialnet, Redalyc, Medline, identificando 70 artigos publicados entre 2005-2015, selecionando-se 52. As palavras-chave utilizadas foram cuidados de enfermagem , diagnóstico de enfermagem , classificação, teoria de enfermagem, processo de atendimento, intervenção e resultados de enfermagem, nas línguas espanhol e português. Resultados: os estudantes em formação, recebem conhecimentos no processo de enfermagem, NANDA Internacional, classificação das intervenções, resultados enfermeiros e elementos teóricos. Se aplicam as teorias de Dorotea Orem, Callista Roy, Nola Pender, Virginia Henderson, Florence Nigthingale e Betty Neuman. A aplicação do processo de enfermagem é limitado e é percebida falta de familiaridade com a taxonomia internacional, principalmente pelos professionais de enfermagem na área assistencial. Conclusão: o desafio da enfermagem é de continuar a solidificar ao corpo de conhecimento científico e desfazer a lacuna entre a teoria e prática. PALAVRAS-CHAVE: cuidados de enfermagem , diagnóstico de enfermagem, classificação, teoria de enfermagem.

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