scholarly journals Mapping nursing goals of an Intensive Care Unit to the Nursing Outcomes Classification

2012 ◽  
Vol 20 (5) ◽  
pp. 854-862 ◽  
Author(s):  
Tânia Couto Machado Chianca ◽  
Patrícia de Oliveira Salgado ◽  
Juliana Peixoto Albuquerque ◽  
Camila Claudia Campos ◽  
Meire Chucre Tannure ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Descriptive Study ◽  
Nursing Process ◽  
Nursing Outcomes ◽  
Nursing Outcomes Classification ◽  
Mapping Process ◽  
Nursing Diagnoses

AIM: to analyze whether nursing goals formulated for nursing diagnoses can be mapped to nursing outcomes classification and to identify the scales most appropriate to the outcomes mapped. METHOD: a descriptive study was developed in an intensive care unit. Data collection involved extraction of goals in 44 medical records, content standardization, cross-mapping to the outcomes, identification of appropriated scales and validation. Descriptive analysis and agreement with the cross-mapping process were performed. RESULTS: nursing goals (59) were mapped to (28) different outcomes, with agreement of 83% in the mapping process. All goals were mapped to outcomes, which allows to affirm that these outcomes contemplates the goals elaborated to patient care. CONCLUSION: these results favor the inclusion of outcomes and scales validated in the planning and evaluation phases of the nursing process of a software in construction.

scholarly journals A HOSPITALIZAÇÃO DO ADOLESCENTE NA ÓTICA DOS PROFISSIONAIS DE ENFERMAGEM

2018 ◽  
Vol 9 (2) ◽  
Author(s):  
Nathália Da Silva Pimentel Reis ◽  
Maria Fabiane Galdino Dos Santos ◽  
Inez Silva De Almeida ◽  
Helena Ferraz Gomes ◽  
Dayana Carvalho Leite ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Nursing Care ◽  
Medical Records ◽  
Rio De Janeiro ◽  
Descriptive Study ◽  
Tertiary Hospital ◽  
Legal Aspects ◽  
Quantitative Approach ◽  
Patient Identification

Objetivo: Compreender a ótica dos profissionais de enfermagem sobre a hospitalização de adolescentes. Metodologia: Pesquisa qualitativa, descritiva, utilizando entrevista com perguntas semi-estruturadas, realizada em uma enfermaria especializada em saúde do adolescente no Rio de Janeiro, no período de fevereiro a abril de 2016, com 15 profissionais de enfermagem. Resultados: A partir da análise de conteúdo de Bardin, definiram-se três categorias: a inexperiência no cuidado de enfermagem ao adolescente como um desafio, especificidades da adolescência, e sentimentos gerados pela hospitalização do adolescente no profissional de enfermagem. Conclusão: Conclui-se que os profissionais de enfermagem se colocaram inexperientes em cuidar desse público e declararam que o cuidado a essa população é um desafio para a equipe.Descritores: Adolescente, Enfermagem, Hospitalização.THE ADOLESCENT’S HOSPITALIZATION IN THE OPTICS OF NURSING PROFESSIONALSObjective: Analyze the contents of nursing notes in patients’ records in an intensive care unit (ICU) of a public tertiary hospital in Fortaleza, CE. It is a descriptive study with quantitative approach that analyzed 151 medical records of patients admitted to an ICU, from September 2014 to February 2015, whose 48 hour and discharge notes were evaluated. Data revealed notes with poor content, which did not express the patients’ situation, nor the nursing care provided. Data concerning date, time, and patient identification were adequate. However, the COREN number and the professional’s signature raised concern given the high percentage of non-compliance regarding ethical and legal aspects. Nursing notes did not reflect the severity of patients, nor the dynamics in the ICUDescriptors: Adolescent, Nursing, HospitalizationADOLESCENTE EN PERSPECTIVA DE LOS PROFESIONALES DE ENFERMERÍAComprender la óptico del profesional de enfermería de hospitalización de los adolescentes. Metodología: cualitativos, investigación descriptiva, utilizando entrevistas con preguntas semi-estructuradas en una sala especializada para la salud de los adolescentes en Río de Janeiro, en el período de febrero a abril 2016 con 15 profesionales de enfermería. Resultados: A partir del análisis de contenido de Bardin, definido tres categorías: la falta de experiencia en la atención de enfermería a la adolescente como un desafío, características de los adolescentes y los sentimientos generados por la hospitalización de los adolescentes en profesionales de enfermería. Conclusión: Se concluye que los profesionales de enfermería se colocaron inexpertos en cuidar de ese público y declararon que el cuidado a esa población es un desafío para el equipo.Descriptores: Adolescente, Enfermería, Hospitalización

scholarly journals ANÁLISE DOS REGISTROS DE ENFERMAGEM APÓS COLETA DE SECREÇÃO TRAQUEOBRÔNQUICA PARA CULTURA: IMPORTÂNCIA ÉTICA E LEGAL

2018 ◽  
Vol 9 (1) ◽  
Author(s):  
Josi Andrade Da Silva ◽  
Vládia Teles Moreira ◽  
Rita Neuma Dantas Cavalcante De Abreu ◽  
Tatiana De Medeiros Colletti Cavalcante ◽  
Rubens Nunes Veras Filho ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Pseudomonas Aeruginosa ◽  
Intensive Care ◽  
Nursing Care ◽  
Medical Records ◽  
Tracheal Aspirate ◽  
Descriptive Study ◽  
Quantitative Approach ◽  
Terapia Intensiva

Conhecer os principais micro-organismos obtidos por meio da cultura de secreção traqueobrônquica e analisar os prontuários quanto aos registros de enfermagem sobre a descrição das características do material obtido durante a aspiração de secreção traqueobrônquica para cultura. Metodologia: trata-se de um estudo documental, descritivo com abordagem quantitativa, realizado com uma amostra de 85 registros nos prontuários dos pacientes internados na Unidade de Terapia Intensiva (UTI). Resultados: o estudo apontou que 60% das culturas do aspirado traqueal foi negativa. Dentre as culturas positivas, Pseudomonas aeruginosa foi o micro-organismo mais prevalente. Quantos aos registros de enfermagem sobre o procedimento realizado pelo enfermeiro foram observados registros curtos deste procedimento. Conclusão: este estudo destaca um maior percentual de culturas negativas nas amostras colhidas; carência dos registros detalhados dos procedimentos de enfermagem conforme recomendações do conselho de classe.Descritores: cuidados de enfermagem, sucção, cuidados críticos.ANALYSIS OF NURSING RECORDS AFTER COLLECTION OF TRACHEOBRONCHIAL SECRETION FOR CULTURE: ETHICAL AND LEGAL IMPORTANCEObjectives: To know the main microorganisms obtained by means of the culture of tracheobronchial secretion and to analyze the charts on the nursing records on the description of the characteristics of the material obtained during the aspiration of tracheobronchial secretion for culture. Methodology: This is a descriptive, descriptive study with a quantitative approach, carried out with a sample of 85 records in the medical records of patients admitted to the Intensive Care Unit (ICU). Results: the study indicated that 60% of tracheal aspirate cultures were negative. Among the positive cultures, Pseudomonas aeruginosa was the most prevalent microorganism. How many of the nursing records about the procedure performed by the nurse were observed short records of this procedure. Conclusion: this study highlights a higher percentage of negative cultures in the samples collected; Lack of detailed records of nursing procedures as recommended by the class council.Descripitors: nursing care, suction, critical care.ANÁLISIS DE LOS REGISTROS DE ENFERMERÍA DESPUÉS DE LA RECOGIDA DE SECRECIONES TRAQUEOBRONQUIALES PARA LA CULTURA: IMPORTANCIA ÉTICA Y LEGALObjetivos: Conocer los principales microorganismos obtenidos por medio de la cultura de secreción traqueobronquica y analizar los prontuarios en cuanto a los registros de enfermería sobre la descripción de las características del material obtenido durante la aspiración de secreción traqueobronquial para cultivo. Metodología: Se trata de un documental, estudio descriptivo con un enfoque cuantitativo, realizado con una muestra de 85 registros en las historias clínicas de los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI). Resultados: El estudio encontró que el 60% de los cultivos de aspirado endotraqueal fue negativo. Entre los cultivos positivos, Pseudomonas aeruginosa fue el microorganismo más prevalente. Como los registros de enfermería en el procedimiento realizado por las enfermeras se observaron registros cortos de este procedimiento. Conclusión: Este estudio pone de manifiesto un mayor porcentaje de cultivos negativos en las muestras; la falta de un registro detallado de los procedimientos de enfermería según lo recomendado por el consejo de clase.Descriptores: cuidados de enfermería, chupar, cuidados críticos

scholarly journals Nursing process: from literature to practice. What are we actually doing?

2009 ◽  
Vol 17 (3) ◽  
pp. 302-307 ◽  
Author(s):  
Simoni Pokorski ◽  
Maria Antonieta Moraes ◽  
Régis Chiarelli ◽  
Angelita Paganin Costanzi ◽  
Eneida Rejane Rabelo
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Retrospective Study ◽  
Medical Records ◽  
Daily Routine ◽  
Nursing Process ◽  
Porto Alegre ◽  
Cross Sectional ◽  
Research Institution ◽  
Nursing Diagnosis

OBJECTIVES: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. RESULTS: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

scholarly journals Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit

2008 ◽  
Vol 16 (4) ◽  
pp. 700-706 ◽  
Author(s):  
Emilia Campos de Carvalho ◽  
Fernanda Titareli Merizio Martins ◽  
Maria Célia Barcellos Dalri ◽  
Silvia Rita Marin da Silva Canini ◽  
Ana Maria Laus ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Retrospective Study ◽  
Data Collection ◽  
Teaching Hospital ◽  
Medical Records ◽  
Adult Patients ◽  
Large Teaching Hospital ◽  
Nursing Data ◽  
Nursing Diagnoses

This descriptive, retrospective study aimed to analyze the relation between nursing data collection, diagnoses and prescriptions for 26 adult patients who were hospitalized at the intense care unit of a large teaching hospital for at least 24 hours. Through the analysis of medical records, 135 diagnoses and 421 nursing prescriptions were established, and 24 different diagnosis categories and 20 different items for prescriptions were identified. The most frequent diagnosis risk was that for infection, present in the medical records of 22 (84.60%) patients, with 175 prescriptions (42%) related to this diagnosis. The data the nurses collected were sufficient to establish the nursing diagnoses, and the majority of prescriptions (87.9%) were related to the diagnoses.

scholarly journals Identification and mapping of the nursing diagnoses and actions in an Intensive Care Unit

2011 ◽  
Vol 19 (4) ◽  
pp. 928-935 ◽  
Author(s):  
Patrícia de Oliveira Salgado ◽  
Tânia Couto Machado Chianca
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Descriptive Study ◽  
Nursing Interventions ◽  
Psychosocial Needs ◽  
Validation Process ◽  
Adult Intensive Care Unit ◽  
Clinical Records ◽  
Nursing Diagnoses

This is a descriptive study with the aim of examining the nursing diagnoses labels and actions prescribed by nurses in the clinical records of patients hospitalized in an Adult Intensive Care Unit. A sample of 44 clinical records was obtained and a total of 1087 nursing diagnoses and 2260 nursing actions were identified. After exclusion of repetitions 28 different nursing diagnoses labels and 124 different nursing actions were found. Twenty-five nursing diagnoses labels were related to human psychobiological needs and three to psychosocial needs. All the nursing actions were mapped to the physiological needs and also to interventions of the Nursing Interventions Classification-NIC. Concordance of 100% was obtained between the experts in the validation process of the mapping performed, both for the nursing diagnoses labels and actions. Similar studies should be conducted for the identification and development of nursing diagnoses and actions.

scholarly journals Validation of nursing outcome indicators of the nursing outcomes classification: dry eye severity

2020 ◽  
Vol 73 (suppl 5) ◽  
Author(s):  
Mércio Gabriel de Araújo ◽  
Allyne Fortes Vitor ◽  
Amanda Barbosa da Silva ◽  
Leandro Melo de Carvalho ◽  
Dase Luyza Barbosa de Sousa Alves ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Dry Eye ◽  
Content Validity ◽  
Statistical Significance ◽  
Binomial Test ◽  
Outcome Indicators ◽  
Nursing Outcomes ◽  
Nursing Outcomes Classification ◽  
Two Stages

ABSTRACT Objective: To validate the content of the indicators of the nursing outcome Dry eye severity, of the Nursing Outcomes Classification, in adult patients admitted to the intensive care unit. Methods: Methodological study of content validity, developed in two stages: the first, consisting of 23 specialists; and the second, of a consensus group formed by ten nurses. For analyzing the data in the first stage, we used the content validity index and binomial test for each indicator; in the second stage, the discussions of each meeting were transcripted, and the indicators that achieved 100% consensus were validated. Results: Of the 14 indicators evaluated by the specialists, 7 presented a cut-off point below 0.80, but did not show statistical significance in the binomial test. In the consensus group’s validation, six indicators were reformulated. Conclusion: This study considered the 14 indicators valid for evaluating patients admitted to the intensive care unit.

scholarly journals Riscos para o desenvolvimento de úlceras por pressão em idosos utilizando as subescalas de Braden

2019 ◽  
Vol 77 (15) ◽  
Author(s):  
Belarmino Santos de Sousa Júnior ◽  
Ana Elza Oliveira de Mendonça ◽  
Fernando Hiago da Silva Duarte ◽  
Cíntia de Carvalho Silva
Keyword(s):  
Health Care ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
High Risk ◽  
Nursing Care ◽  
Medical Records ◽  
Descriptive Study ◽  
Ethics Committee ◽  
Terapia Intensiva ◽  
Very High

Introdução: O avanço tecnológico e científi co vem possibilitando o aperfeiçoamento dos serviços e cuidados desaúde, no entanto, o surgimento de Úlceras por Pressão (UP), em pacientes hospitalizados permanece elevado,principalmente em idosos que necessitam de cuidados intensivos. Objetivo: Analisar os riscos no desenvolvimentode UP em pacientes idosos, admitidos em uma Unidade de Terapia Intensiva (UTI), utilizando as subescalas deBraden. Método: Trata-se de um estudo descritivo, com abordagem quantitativa; a população consistiu de 20pacientes idosos acamados, de ambos os sexos. Para a coleta de dados utilizou-se de um instrumento estruturado ea análise dos prontuários, após aprovação do Comitê de Ética em Pesquisa. Resultados: A Escala de Braden (EB) foiaplicada durante o exame físico, e demonstrou risco muito elevado em 95% dos pacientes estudados e evidencioua presença de UP em 95% destes pacientes. Conclusões: A EB é de fácil aplicação na prática clínica do enfermeiro emostrou-se útil na avaliação de predição do risco de UP no grupo estudado.Palavras-chave: Unidades de terapia intensiva; Úlcera por pressão; Cuidados de enfermagem. ABSTRACTIntroduction: technological and scientifi c advancement has enabled the improvement of services and health care,however, the emergence of Pressure Ulcers (PU) in hospitalized patients remains high, especially in the elderlywho need intensive care. Objective: To analyze the risks in the development of PU in elderly patients admitted toan Intensive Care Unit (ICU) using the subscales Braden. Method: This is a descriptive study with a quantitativeapproach; population consisted of 20 elderly bedridden patients, of both sexes. For data collection was used astructured instrument and analysis of medical records, after approval by the Research Ethics Committee. Results:Braden Scale (SB) was applied during the physical examination, and demonstrated very high risk in 95% ofpatients studied and showed the presence of PU in 95% of patients. Conclusions: SB is easy to apply in clinicalnursing practice and proved useful in PU risk prediction assessment in this group.Keywords: Intensive care units; Pressure ulcer; Nursing care.

scholarly journals Multidimensional model of successful aging and nursing terminologies: similarities for use in the clinical practice

2020 ◽  
Vol 41 (spe) ◽  
Author(s):  
Amália de Fátima Lucena ◽  
Carla Argenta ◽  
Melissa de Freitas Luzia ◽  
Miriam de Abreu Almeida ◽  
Luciana Nabinger Menna Barreto ◽  
...  
Keyword(s):  
Successful Aging ◽  
Elderly Care ◽  
The Elderly ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Multidimensional Model ◽  
Nursing Outcomes ◽  
Nursing Outcomes Classification ◽  
Mapping Process ◽  
Two Stages

ABSTRACT Aim: To compare the domains of the Multidimensional Model of Successful Aging (MMSA) with the nursing terminologies, such as, NANDA International (NANDA-I), Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC), in order to find similarities among them. Method: Cross-mapping between MMSA and nursing terminologies in two stages: individual analysis and comparison between the MMSA and the nursing terminologies, based on the mapping process rules; consensus among researchers to validate the results. Results: All NOC and NIC domains were mapped with similarity in the MMSA domains, and 12 of the 13 NANDA-I domains showed similarity to the MMSA domains. In addition, similarity was identified between MMSA and most classes of the three classifications. Conclusions: The similarity between MMSA, NANDA-I, NIC and NOC supported the idea that the MMSA framework can be used in the nursing process to qualify the nursing practice in the elderly care.

scholarly journals Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane: a retrospective descriptive study

2021 ◽  
pp. bmjmilitary-2021-001876
Author(s):  
Thibault Martinez ◽  
K Simon ◽  
L Lely ◽  
C Nguyen Dac ◽  
M Lefevre ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Acute Respiratory Distress Syndrome ◽  
Intensive Care ◽  
Respiratory Distress Syndrome ◽  
Selection Criteria ◽  
Distress Syndrome ◽  
Descriptive Study ◽  
Military Aircraft ◽  
Life Threatening ◽  
The Military

After the appearance of the COVID-19 pandemic in France, MEROPE system was created to transform the military tactical ATLAS A400M aircraft into a flying intensive care unit. Collective aeromedical evacuations (aero-MEDEVAC) of patients suffering from SARS-CoV-2-related acute respiratory distress syndrome was performed from June to December 2020. A total of 22 patients were transported during seven missions. All aero-MEDEVAC was performed in safe conditions for patients and crew. No life-threatening conditions occurred during flight. Biohazard controls were applied according to French guidelines and prevented crew contamination. Thanks to rigorous selection criteria and continuous in-flight medical care, the safe transportation of these patients was possible. To the best of our knowledge, this is the first description of collective aero-MEDEVAC of these kinds of patients using a tactical military aircraft. We here describe the patient’s characteristics and the flight’s challenges.

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