scholarly journals Unsatisfactory completeness of nurses’ records in the medical records of users with tuberculosis

2022 ◽  
Vol 75 (3) ◽  
Author(s):  
José Nildo de Barros Silva Júnior ◽  
Haline Costa dos Santos Guedes ◽  
Dilyane Cabral Januário ◽  
Ana Cristina de Oliveira e Silva ◽  
Pedro Fredemir Palha ◽  
...  
Keyword(s):  
Medical Records ◽  
Family Health ◽  
Descriptive Statistics ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Nursing Assessment ◽  
Tuberculosis Patients ◽  
Nursing Diagnosis ◽  
Evaluation Strategies

ABSTRACT Objectives: to evaluate the completeness of nurses’ records on the execution of the nursing process in assistance of tuberculosis patients at Primary Care. Methods: this was a retrospective documental study, with 190 records in Family Health Units of a city in the state of Paraíba. The data were analyzed according to descriptive statistics, Pareto Diagram, and trend analysis. Results: the overall mean incompleteness of records was 53.01% (DP=26.13). Therefore, the results presented very poor completeness classification related to nursing diagnosis (88.9%), nursing assessment (66.8%), data collection (60.5%), while nursing interventions were classified as regular (11.1%). The nursing diagnosis was the only variable with a decreasing trend of non-completeness. Conclusions: incompleteness of nurses’ records in the medical records of users with tuberculosis. Evaluation strategies, permanent and continuing education are indispensable in the quality of nurses’ documentation, directly implying the Systematization of Quality in Nursing Care.

A importância do vínculo com o cliente cirúrgico para a realização dos diagnósticos de enfermagem psicossociais: estudo de caso

2009 ◽  
Vol 3 (2) ◽  
pp. 324
Author(s):  
Shimmenes Kamacael Pereira ◽  
Magali Rezende de Carvalho ◽  
Rosimere Ferreira Santana
Keyword(s):  
Nursing Intervention ◽  
Structured Interview ◽  
Nursing Process ◽  
Nursing Assessment ◽  
Nursing Outcomes ◽  
Nursing Diagnosis ◽  
Nursing Outcomes Classification ◽  
Before And After ◽  
Integrity Risk ◽  
Two Phases

Objectives: to apply the nursing process using the language of classification and to show the effectiveness of care systematization. Methodology: report of clinical case conducted with a female patient of 26 years old, admitted in a General Hospital at the city of Niteroi, Rio de Janeiro, during the period from March to April 2008. We used the technique of semi-structured interview based on Carpenito and the documentary survey of medical records analysis. The analysis proceeded second clinical reasoning of Risner. Results: nursing diagnosis were identified according to North American Nursing Diagnosis Association-NANDA, the main are: denial ineffective; hypothermia, acute pain, impared skin integrity, risk for infection, risk for fluid volume deficit, risk for situational low self-steem. Then was built a plan of care with the interventions proposed by Nursing Intervention Classification-NIC and the results were evaluated by Nursing Outcomes Classification-NOC. And to allow evaluation of nursing actions the results of the NOC were described in two phases, before and after intervention. Conclusion: we concluded that the nursing care based on NANDA, NIC and NOC is effective and transparent to the team of professionals. Descriptors: Nursing process; Nursing assessment; Perioperative care.

scholarly journals DIAGNÓSTICOS DE ENFERMAGEM EM PACIENTES SUBMETIDOS À COLOSTOMIA

2017 ◽  
Vol 8 (2) ◽  
Author(s):  
Marília De Sousa Leite ◽  
Lia Cardoso De Aguiar
Keyword(s):  
Gastrointestinal Motility ◽  
Self Esteem ◽  
Quantitative Approach ◽  
Nursing Process ◽  
Human Needs ◽  
Nursing Diagnosis ◽  
Reference Hospital ◽  
Basic Human Needs ◽  
Descriptive Survey

Objetivo: conhecer os diagnósticos de enfermagem dos pacientes submetidos à colostomia. Metodologia: trata-se de uma pesquisa descritiva, com abordagem quantitativa, realizada nos meses de julho e agosto de 2015. A amostra foi constituída de 15 pacientes colostomizados de um hospital de referência oncológica do estado do Maranhão. Resultados: os diagnósticos de NANDA identificados e mais citados foram padrão de sono prejudicado, baixa autoestima situacional, negação ineficaz, motilidade gastrointestinal disfuncional e padrão de sexualidade ineficaz. Ainda foram identificadas necessidades humanas básicas através da teoria de Wanda Horta. Conclusão: sugere-se promoção de meios que favoreçam a prática do processo de enfermagem, visando uma assistência planejada com métodos que promovam a qualidade do serviço.Descritores: Diagnóstico de Enfermagem, Colostomia, Cuidados de Enfermagem.DIAGNOSIS IN NURSING PATIENTS SUBJECTED TO COLOSTOMYObjective: to know the diagnostic of nursing patients undergoing colostomy Methodology: it is a descriptive survey, quantitative approach conducted in July and August 2015, with 15 colostomy patients of a reference hospital on oncology in the state of Maranhao. Results: as for the diagnoses from NANDA, the most cited were disturbed pattern of sleep, low situational self-esteem, ineffective denial, dysfunctional gastrointestinal motility and ineffective pattern of sexuality. Yet they have identified basic human needs by Wanda Horta’s theory. Conclusion: it is indicated the development of methods that favor the practice of nursing process to a planned tour with methods that promote the quality of service.Descriptors: Nursing Diagnosis, Colostomy, Nursing care.DIAGNÓSTICOS DE ENFERMERÍA EN PACIENTES SOMETIDOS A LA COLOSTAMIAObjetivo: conocer los diagnósticos de enfermería de pacientes sometidos a colostomía. Metodología: Se trata de un estudio descriptivo con un enfoque cuantitativo, llevado a cabo en julio y agosto de 2015, la muestra consistió en 15 pacientes de colostomía un hospital de referencia oncológica en el estado de Maranhao. Resultados: diagnósticos NANDA identificados y más citadas fueron el sueño perturbado estándar, baja autoestima situacional, la negación ineficaz, la motilidad gastrointestinal disfuncional y estándares de sexualidad ineficaces. Sin embargo, se han identificado las necesidades humanas básicas de la teoría de Wanda Horta. Conclusión: se sugiere medios de promoción que favorezcan la práctica del proceso de enfermería a un proyecto de gira con los métodos que promueven la calidad del servicio.nclusión: se sugiere medios de promoción que favorezcan la práctica del proceso de enfermería a la asistencia a los métodos y la calidad de servicio previstas.Descriptors: Diagnóstico de Enfermería, Colostomía, Los Cuidados de Enfermería.

scholarly journals Description and Validation of Nursing Diagnosis Using Electronic Documentation: Study Cases in Mother and Child Hospital Indonesia

2020 ◽  
Vol 14 (1) ◽  
pp. 300-308
Author(s):  
Rr.Tutik Sri Hariyati ◽  
Hanny Handiyani ◽  
Laode Abdul Rahman ◽  
Tuti Afriani
Keyword(s):  
Clinical Judgment ◽  
Medical Records ◽  
Nursing Assessment ◽  
Normal Delivery ◽  
Mapping Model ◽  
Nursing Diagnosis ◽  
Mothers And Children ◽  
Mother And Child ◽  
Child Hospital ◽  
Nursing Diagnoses

Background: A nursing diagnosis is a clinical judgment concerning a human response to a health condition, vulnerability for that response, by an individual, family, group, or community. For the determination of the right nursing diagnosis, a system that guides nurses in implementing care professionally is needed. Objective: To describe the nursing diagnosis in mother and child cases validated by using a management nursing information system. Methods: This case study used secondary data from 5.294 medical records. Medical records were retrieved from the server, analyzed, and validated by using the mapping model in accordance with the most frequent cases in mothers and children in the hospital. Approximately ten million (10.021) nursing diagnoses were performed by nurses and validated by using a mapping model of medical cases and nursing assessment. The selected medical cases were the five most frequent cases, namely normal delivery, cesarean delivery, healthy newborn, fever, and dengue in children. Results: This study yielded the five most frequent nursing diagnoses, namely risk for infection (20.1%), pain (13.37%), anxiety (9.37%), the risk for imbalanced fluid volume (9.36%), and risk for bleeding (9.27%). Conclusion: The electronic nursing documentation could help to determine a nursing diagnosis and had been validated for its appropriateness with assessment and the most common cases in mothers and children. Information and system training development are required to carry out the nursing process comprehensively.

scholarly journals Clinical applicability of the terminological subset of palliative care for dignified dying

2021 ◽  
Vol 55 ◽  
Author(s):  
Thais Trybus ◽  
Larissa Sydor Victor ◽  
Rudval Souza da Silva ◽  
Deborah Ribeiro Carvalho ◽  
Marcia Regina Cubas
Keyword(s):  
Palliative Care ◽  
Clinical Practice ◽  
Theoretical Model ◽  
Nursing Practice ◽  
Descriptive Statistics ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Patients With Cancer ◽  
Clinical Applicability ◽  
Nursing Diagnoses

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

scholarly journals Study of Sharing Patient Information by Nurses Between Inpatient and Outpatient Wards in Japan

2021 ◽  
Author(s):  
Natsuko Nishida ◽  
Tomoko Hikita ◽  
Megumi Iida ◽  
Goshiro Yamamoto ◽  
Tomohiro Kuroda
Keyword(s):  
Patient Care ◽  
Information Sharing ◽  
Patient Information ◽  
Medical Records ◽  
Communication Tool ◽  
Nursing Diagnosis ◽  
Quality Of Patient Care ◽  
Hospital Stays ◽  
Communication Needs

Shortening hospital stays increases communication needs between nurses in inpatient and outpatient wards. Smooth information sharing is required to reduce the workload of nurses and improve the quality of patient care. However, electronic medical records (EMR) system does not have sufficient functions to support information sharing between wards, because EMR has been developed mainly for recording. This study led to three improvements; unified communication tool, common patient list linked to EMR, and outpatient nursing diagnosis.

scholarly journals Dor crônica avaliada pela Classificação dos Resultados de Enfermagem

2020 ◽  
Vol 14 ◽  
Author(s):  
Cássia Teixeira Dos Santos ◽  
Claudenilson Da Costa Régis ◽  
Raquel Silveira Einhardt ◽  
Amália De Fátima Lucena
Keyword(s):  
Chronic Pain ◽  
Statistical Significance ◽  
Descriptive Statistics ◽  
Nursing Interventions ◽  
Test Results ◽  
Nursing Process ◽  
Nursing Outcomes ◽  
Nursing Outcomes Classification ◽  
Student Test

Objetivo: analisar resultados e indicadores de enfermagem da Nursing Outcomes Classification/NOC (Classificação dos Resultados de Enfermagem) na avaliação de pacientes com dor crônica em consulta de enfermagem ambulatorial. Método: estudo quantitativo, longitudinal, prospectivo, com nove pacientes, por meio de instrumento contendo resultados e indicadores da NOC. Analisaram-se os dados pela estatística descritiva com uso do teste t-Student. Resultados: foram avaliados nove pacientes com idade média de 56,0 ± 18,2 anos, sexo feminino (88,9 %), brancos (66,7%) e afastados do trabalho (66%) pela Dor Crônica. Cinco resultados e 11 indicadores foram aplicados, o Controle da Dor apresentou dois indicadores com significância estatística. O Nível de Dor apresentou melhora nos escores de dois indicadores, e o Satisfação do Cliente manteve escores altos. Conclusão: os resultados de enfermagem e indicadores demonstraram melhora clínica dos pacientes com dor crônica na avaliação em consulta de enfermagem ambulatorial. Descritores: Avaliação de Resultados (Cuidados em Saúde); Dor crônica; Terminologia Padronizada em Enfermagem; Processo de Enfermagem; Enfermagem; Classificação.AbstractObjective: to analyze nursing results and indicators from the Nursing Outcomes Classification/NOC (Classification of the Results of Nursing Interventions) in the evaluation of patients with chronic pain in an outpatient nursing consultation. Method: a quantitative, longitudinal, prospective study with nine patients, using an instrument containing NOC results and indicators. Data were analyzed using descriptive statistics using the t-Student test. Results: nine patients with a mean age of 56.0 ± 18.2 years, female (88.9%), white (66.7%) on authorized sick leave (66%) due to chronic pain were evaluated. Five results and 11 indicators were applied, the Pain Control presented two indicators with statistical significance. The Pain Level improved in the scores of two indicators, and Customer Satisfaction maintained high scores. Conclusion: the nursing results and indicators showed clinical improvement of patients with chronic pain in the evaluation at an outpatient nursing consultation. Descriptors: Outcome Assessment (Health Care); Chronic pain; Standardized Nursing Terminology; Nursing Process; Nursing; Classification.ResumenObjetivo: analizar los resultados e indicadores de enfermería de la Nursing Outcomes Classification/NOC (Clasificación de los resultados de enfermería) en la evaluación de pacientes con dolor crónico en una consulta de enfermería ambulatoria. Método: estudio cuantitativo, longitudinal, prospectivo con nueve pacientes, utilizando un instrumento que contiene resultados e indicadores de NOC. Los datos se analizaron mediante estadística descriptiva utilizando la prueba t-Student. Resultados: se evaluaron nueve pacientes con una edad media de 56.0 ± 18.2 años, mujeres (88.9%), blancos (66.7%) y fuera del trabajo (66%) debido a dolor crónico. Se aplicaron cinco resultados y 11 indicadores, el Control del Dolor presentó dos indicadores con significación estadística. El nivel de dolor mejoró en los puntajes de dos indicadores, y la satisfacción del cliente mantuvo puntajes altos. Conclusión: los resultados de enfermería e indicadores  mostraron una mejoría clínica de pacientes con dolor crónico en la evaluación en una consulta de enfermería ambulatoria. Descriptores: Evaluación de Resultados (Atención de la Salud); Dolor crónico; Terminología de enfermería estandarizada; Proceso de enfermería; Enfermería; Clasificación.

scholarly journals Transplante de Células-Tronco Hematopoéticas: estudo de caso de um paciente com mucosite severa

2018 ◽  
Vol 86 (24) ◽  
Author(s):  
Ana Cristina da Silva Rangel ◽  
Adriana Gomes da Silva de Freitas ◽  
Alice Andrade Antunes ◽  
Cecilia Ferreira da Silva Borges ◽  
Cláudia Valéria Ramos Ribeiro ◽  
...  
Keyword(s):  
Medical Records ◽  
Scientific Evidence ◽  
Signs And Symptoms ◽  
Nursing Process ◽  
Clinical Practices ◽  
Hematopoietic Stem ◽  
Nursing Diagnosis ◽  
Nursing Diagnoses ◽  
Severe Mucositis

Estima-se que 50% a 80% dos pacientes submetidos ao transplante de células-tronco hematopoéticas (TCTH)desenvolveram mucosite oral com significativa gravidade e acentuada morbidade. As complicações e a complexidadedesta afecção exigem da equipe de enfermagem um contínuo treinamento pautado na atualização de práticas clínicasoriundas de evidências científicas. O objetivo é apresentar um estudo de caso, descrevendo os diagnósticos deenfermagem de um paciente submetido ao transplante de células-tronco hematopoiéticas autólogo que evoluiu parauma mucosite severa. Trata-se de um estudo de caso de um paciente com Linfoma de Hodgkin submetido ao TCTH. Osdados foram coletados no período de outubro a dezembro de 2015, a partir do prontuário do paciente. Foram 51 dias dehospitalização, os principais diagnósticos de enfermagem relacionados à mucosite foram: (1) náusea; (2) risco parainfecção; (3) nutrição desequilibrada; (4) deglutição prejudicada; (5) diarreia; (6) mucosa oral prejudicada; (7) dor aguda;(8) hipertermia e (9) risco de sangramento. A mucosite é uma complicação comumente encontrada nos pacientessubmetidos ao transplante. Logo, é importante que o enfermeiro desenvolva um olhar clínico apurado, a fim de detectarna sutileza dos sinais e sintomas o risco para o agravamento desta afecção.Palavras-chave: Mucosite; Transplante de Células-Tronco Hematopoéticas; Diagnóstico de Enfermagem; Processos deEnfermagem. AbstractIt is estimated that 50% to 80% of patients undergoing hematopoietic stem cells (HSCT) transplantation developed oralmucositis with significant severity and marked morbidity. The complications and complexity of this condition require thenursing team to continue training based on the updating of clinical practices stemming from scientific evidence. The aimis to present a case study, describing the nursing diagnoses of a patient submitted to autologous hematopoietic stem celltransplantation that evolved to a severe mucositis. This is a case study of a patient with Hodgkin's lymphoma undergoingHSCT. Data were collected from October to December 2015, from the patient's medical records. There werehospitalization 51 days, the main nursing diagnoses related to mucositis were: (1) nausea; (2) risk for infection; (3)unbalanced nutrition; (4) impaired swallowing; (5) diarrhea; (6) impaired oral mucosa; (7) acute pain; (8) hyperthermiaand (9) risk of bleeding. Mucositis is a complication commonly found in patients undergoing transplantation. Therefore,it is important that the nurse develops an accurate clinical view to detect in the subtlety of the signs and symptoms therisk for the affection worsening.Keywords: Mucositis; Hematopoietic Stem Cell Transplantation; Nursing Diagnosis; Nursing Process.

Diagnósticos de enfermagem em gestantes atendidas em Unidade de Saúde da Família

2009 ◽  
Vol 3 (2) ◽  
pp. 292 ◽  
Author(s):  
Maria Clerya Alvino Leite ◽  
Maria Mirtes da Nobrega ◽  
Maria Miriam Lima da Nobrega
Keyword(s):  
Pregnant Women ◽  
Demographic Data ◽  
Descriptive Statistics ◽  
Nursing Interventions ◽  
Health Unit ◽  
Related Factors ◽  
Sharp Pain ◽  
Nursing Diagnosis ◽  
Las Mujeres ◽  
Nursing Diagnoses

ABSTRACTObjective: to elaborate the profile of nursing diagnoses in pregnant women assisted in a Family’s Health Unit based on NANDA-I’s Taxonomy II. Method: this is about a retrospective study, analytic descriptive, regards to analysis from 20 pregnant women handbooks registered in the prenatal program from a family’s health unit. Data were collected in July 2008, with a form composed of three parts: partner-demographic data, obstetric data and referring data to defining characteristics and related factors (of risk) of the nursing diagnoses. Diagnoses were analyzed based on the descriptive statistics and discussed according to obstetrics references. Results: 13 nursing diagnoses were elaborated: risk for infection of the genital tract, ineffective maintenance of the health, risk for infection of the urinary tract, prejudiced urinary elimination, nauseas, sharp pain (head, pelvis and lumbar), fatigues, insomnia, sexual dysfunction, risk of paternity or prejudiced maternity, volume of excessive liquid, constipation, anxiety. Conclusion: the objective of the study was researched and we hope from the nursing diagnoses elaborated, some nursing interventions specific be addressed to the problems identified in the pregnant women during the prenatal consultations. Descriptors: nursing diagnosis; nursing assistance; assistance pré-natal; pregnancy.RESUMOObjetivo: elaborar o perfil de diagnósticos de enfermagem em gestantes atendidas em Unidade de Saúde da Família com base na Taxonomia II da NANDA-I. Método: trata-se de um estudo retrospectivo, analítico descritivo, com dados colhidos em prontuários das 20 gestantes cadastradas no programa de pré-natal de uma unidade de saúde da família. Os dados foram coletados no mês de julho de 2008 em formulário composto de três partes: dados sócio-demográficos, dados obstétricos e dados referentes a características definidoras e fatores relacionados (de risco) dos diagnósticos de enfermagem. Os diagnósticos foram analisados levando-se em consideração a estatística descritiva e discutidos à luz de referenciais da obstetrícia. Resultados: foram elaborados 13 diagnósticos de enfermagem: risco para infecção do trato genital, manutenção ineficaz da saúde, risco para infecção do trato urinário, eliminação urinária prejudicada, náusea, dor aguda (cabeça, pelve e lombar), fadiga, insônia, disfunção sexual, risco de paternidade ou maternidade prejudicada, volume de líquido excessivo, constipação, ansiedade. Conclusão: o objetivo do estudo foi atendido e espera-se que a partir dos diagnósticos de enfermagem elaborados, possam ser direcionadas intervenções de enfermagem específicas aos problemas detectados nas gestantes durante as consultas de pré-natal. Descritores: diagnóstico de enfermagem; assistência de enfermagem; assistência pré-natal; gestação. RESUMENObjetivo: elaborar el perfil de los diagnósticos de enfermería en las mujeres embarazadas ayudado en Unidad de Salud de la Familia con base en el Taxonomia II del NANDA-I. Método: trata-se del estudio retrospectivo, analítico descriptivo, con dados colectados en prontuarios de 20 mujeres embarazadas registró en el programa de prenatal de unidad de salud de la familia. Los datos eran reunidos no mes de julio de 2008 en formulario compuesta de tres partes: los datos compañero-demográficos, datos obstétricos y datos refiriéndose a los definidoras de las características y los factores relacionados (de riesgo) de los diagnósticos de enfermería. La colección de datos de los archivos era cumplida por el mes de julio de 2008. Los diagnósticos se analizaron ser alojado la consideración las estadísticas descriptivas y discutieron a la luz de referenciales de la obstetricia. Resultados: se elaboraron 13 diagnósticos de la enfermería: riesgo para la infección del tracto genital, mantenimiento ineficaz de la salud, el riesgo para la infección del tracto urinario, la eliminación urinario prejuiciada, la náusea, el dolor afilado (la cabeza, pelvis y lumbar), fatiga, insomnio, el trastorno sexual, el riesgo de paternidad o la maternidad prejuiciada, el volumen de líquido excesivo, el estreñimiento, la ansiedad. Conclusión: el objetivo del estudio forra alcanzado y ha esperado que de los diagnósticos de enfermería elaborada, puedan diseccionar intervenciones de enfermería específica a los problemas identificados en las mujeres embarazadas durante las consultaciones de prenatal. Descriptores: diagnósticos de enfermería. asistencia de enfermería. asistencia prenatal. gestación.

scholarly journals CARACTERIZAÇÃO SOCIODEMOGRÁFICACLÍNICA E DIAGNÓSTICOS DE ENFERMAGEM NA ENFERMARIA PEDIÁTRICA

2020 ◽  
Vol 10 (7) ◽  
Author(s):  
Suelen Reiniack ◽  
Jamile Pascoal Franco Gonçalves ◽  
Alexandre Sousa da Silva ◽  
Teresa Tonini
Keyword(s):  
Medical Records ◽  
Intermediate Care ◽  
Patient Classification ◽  
Quality And Safety ◽  
Nursing Process ◽  
Nursing Diagnosis ◽  
Level Of Significance ◽  
Nursing Diagnoses ◽  
Patient Classification System

Objetivo: caracterizar o perfil de pacientes internados na enfermaria de pediatria e identificar os Diagnósticos de Enfermagem mais prevalentes, de acordo com a taxonomia NANDA-I. Metodologia: estudo descritivo realizado a partir de prontuários de 100 pacientes. Foram consideradas variáveis como: idade, gênero, sistema de classificação de pacientes, diagnóstico clínico e de enfermagem. Utilizou-se o programa Rcommander® para realização da análise exploratória e testes de hipóteses nãoparamétricos, sendo considerado nível de significância de 5%. Resultado: predominância do sexo masculino (71%), idade média de 7,32 anos, o Cuidado Intermediário (49%) foi o mais frequente, Pediatria foi a clínica com maior número de internações (39%), encontrados 44 diagnósticos médicos e 46 diagnósticos de enfermagem, sendo 27 considerados preponderantes. Conclusão: a realização do diagnóstico situacional possibilita um caráter norteador para as demais etapas do Processo de Enfermagem e direciona as ações de cuidado, contribuindo para a melhora contínua da qualidade e segurança dos cuidados.Descritores: Processo de Enfermagem, Diagnósticos de Enfermagem, Enfermagem Pediátrica.CLINICAL SOCIODEMOGRAPHICAL AND DIAGNOSTIC CHARACTERIZATION OF NURSING IN PEDIATRIC NURSINGOjective: to characterize the profile of hospitalized patients in the pediatric ward and to identify the most prevalent Nursing Diagnoses, according to the NANDA-I taxonomy. Methodology: descriptive study based on medical records of 100 patients. Variables such as: age, gender, patient classification system, clinical and nursing diagnosis were considered. The Rcommander® program was used to perform the exploratory analysis and tests of non-parametric hypotheses, being considered level of significance of 5%. Results: predominance of males (71%), mean age of 7.32 years, Intermediate Care (49%) was the most frequent, Pediatrics was the clinic with the greatest number of hospitalizations (39%), 44 medical and 46 nursing diagnoses, of which 27 were considered as preponderant. Conclusion: the accomplishment of the situational diagnosis allows a guiding character for the other stages of the Nursing Process and directs care actions, contributing to the continuous improvement of quality and safety of care.Descriptors: Nursing Process; Nursing Diagnostics; Pediatric Nursing.CARACTERIZACIÓN SOCIODEMOGRÁFICA Y DIAGNÓSTICA CLÍNICA DE ENFERMERÍA EN ENFERMERÍA PEDIÁTRICAObjetivo: caracterizar el perfil de pacientes internados en la enfermería de pediatría e identificar los Diagnósticos de Enfermería más prevalentes, de acuerdo con la taxonomía NANDA-I. Metodología: estudio descriptivo realizado a partir de prontuarios de 100 pacientes. Se consideraron variables como: edad, género, sistema de clasificación de pacientes, diagnóstico clínico y de enfermería. Se utilizó el programa Rcommander® para realizar el análisis exploratorio y pruebas de hipótesis no paramétricas, siendo considerado nivel de significancia del 5%. Resultado: En la mayoría de los casos, el cuidado intermedio (49%) fue el más frecuente, la Pediatría fue la clínica con mayor número de internaciones (39%), encontrados 44 diagnósticos médicos y, 46 diagnósticos de enfermería, siendo 27 considerados preponderantes. Conclusión: la realización del diagnóstico situacional posibilita un carácter orientador para las demás etapas del proceso de enfermería y dirige las acciones de cuidado, contribuyendo a la mejora continua de la calidad y seguridad del cuidado.Descriptores: Proceso de Enfermería; Diagnósticos de Enfermería; Enfermería Pediátrica.

scholarly journals Profile of the nursing diagnoses in stable heart disease patients

2019 ◽  
Vol 37 (2) ◽  
Author(s):  
Patrícia Cristina Cardoso ◽  
Larissa Gussatschenko Caballero ◽  
Karen Brasil Ruschel ◽  
Maria Antonieta Pereira de Moraes ◽  
Eneida Rejane Rabello da Silva
Keyword(s):  
Heart Disease ◽  
Medical Records ◽  
Sedentary Lifestyle ◽  
World Health ◽  
Nursing Process ◽  
Adherence To Treatment ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Health Organization ◽  
Nursing Diagnoses

Abstract Objective. To identify the nursing diagnoses through reports in the medical records of patients monitored in a specialized ischemic heart disease outpatient clinic.Methods. Cross-sectional study with retrospective data collection in the medical records. From the data collected, the nursing diagnoses were proposed by the researchers and submitted for validation by specialist cardiology nurses.Results. A total of 13 nursing diagnoses were evaluated from the medical records of 50 outpatients with the following validation agreements among the specialists: Ineffective health management (100%), Noncompliance (100%), Sedentary lifestyle (100%), Activity intolerance (100%), Decreased cardiac output (88%), Risk of decreased cardiac tissue perfusion (65%), Risk of intolerance to activity (65%), Acute pain (76%), Ineffective health maintenance (65%), Risk-prone health behavior (65%), Risk for decreased cardiac output (65%), Risk for intolerance to activity (65%), Ineffective respiratory pattern (53%), Impaired memory (29%).Conclusion. In this study, the nursing diagnoses validated for stable heart disease patients were linked to adherence to treatment and to the cardiovascular responses of the patients, reinforcing the importance of early intervention. These results allow the multidisciplinary team to individualize the goals and interventions proposed for ischemic heart disease patients.Descriptors: ambulatory care; cross-sectional studies; nursing diagnosis; outpatients; nursing process; myocardial ischemia.How to cite this article: Cardoso PC, Caballero LG, Ruschel KB, Moraes MAP, Silva ERR. Profile of the nursing diagnoses in stable heart disease patients. Invest. Educ. Enferm. 2019; 37(2):e08.ReferencesWorld Health Organization. World Health Statistics 2018: monitoring health for the SDGs, sustainable development goals [Internet]. Geneva: WHO; 2018 [cited: 7 May 2019]. Available from: https://www.who.int/gho/publications/world_health_statistics/2018/en/ Ministério da Saúde. Informações de Saúde (TABNET) - Assistência à Saúde. DATASUS. Departamento de Informatica a Serviço do SUS [Internet]. 2016 [cited: 7 May 2019]. 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