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 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.

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 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.

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]. Available from: http://datasus.saude.gov.br/informacoes-de-saude/tabnet/assistencia-a-saude Ôunpuu S, Negassa A, Yusuf S. INTER-HEART: A global study of risk factors for acute myocardial infarction. Am. Heart J. 2001; 141(5):711–21. Berwanger O, Guimarães HP, Laranjeira LN, Cavalcanti AB, Kodama AA, Zazula AD, et al. Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: The BRIDGE-ACS randomized trial. 2012; 307(19):2041–9. Saffi MAL, Polanczyk CA, Rabelo-Silva ER. Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial. Eur. J. Cardiovasc. Nurs. 2014; 13(5):436–43. Brasil. Ministerio da Saúde. Diretrizes para o cuidado das pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidado prioritárias [Internet]. Brasília; 2013 [cited: 7 May 2019]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes%20_cuidado_pessoas%20_doencas_cronicas.pdf Gallagher-Lepak S. Fundamentos do diagnóstico de enfermagem. In: Herdman TH, Kamitsuru S O, editor. Diagnósticos de enfermagem da NANDA: Definições e Classificação. 2015. p. 21–30. Santos NA dos, Cavalcante TF, Lopes MV de O, Gomes EB, Oliveira CJ de. Profile of nursing diagnoses in patients with respiratory disorders. Invest. Educ. Enferm. 2015; 33(1):112–8. Sampaio F de C, de Oliveira PP, da Mata LRF, Moraes JT, da Fonseca DF, Vieira VA de S. Profile of nursing diagnoses in people with hypertension and diabetes. Invest. Educ. Enferm. 2017;35(2):139–53. Javier F, Rivas P, Martín-iglesias S, Luis J, Arenas CM, Lagos MB. Effectiveness of Nursing Process Use in Primary Care. Int. J. Nurs. Knowl. 2015; 27(1):43–8. Araújo DD, Carvalho RLR, Chianca TCM. Nursing diagnoses identified in records of hospitalized elderly. Invest. Educ. Enferm. 2014; 31(3):225–35. Menna Barreto LN, Swanson EA, De Abreu Almeida M. Nursing Outcomes for the Diagnosis Impaired Tissue Integrity (00044) in Adults with Pressure Ulcer. Int. J. Nurs. Knowl. 2016; 27(2):104–10. Moreira RP, Guedes NG, Lopes MV de O, Cavalcante TF, Araújo TL de, Moreira RP, et al. Nursing diagnosis of sedentary lifestyle: expert validation. Texto Context - Enferm. 2014; 23(3):547–54. Bowry ADK, Shrank WH, Lee JL, Stedman M, Choudhry NK. A systematic review of adherence to cardiovascular medications in resource-limited settings. J. Gen. Intern. Med. 2011; 26(12):1479–91. Osterberg L, Blaschke T. Adherence to medication. New. Engl. J. Med. 2005; 353(18):1973–4. Vrijens B, De Geest S, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T, et al. A new taxonomy for describing and defining adherence to medications. Br. J. Clin. Pharmacol. 2012; 73(5):691–705. Borges JWP, Moreira TMM, Rodrigues MTP, de Souza ACC, da Silva DB. Content validation of the dimensions constituting non-adherence to treatment of arterial hypertension. Rev. Esc. Enferm. 2013; 47(5):1076–82. Freitas JS de, Silva AEB de C, Minamisava R, Bezerra ALQ, Sousa MRG de. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev. Lat. Am. Enfermagem. 2014; 22(3):454–60. World health Organization. Adherence to long-term therapies: evidence for action [Internet]. Geneve: WHO; 2003 [cited: 7 May 2019]. Available from: https://www.who.int/chp/knowledge/publications/adherence_report/en/

scholarly journals Overview of the Covid-19 Patient Nursing Diagnosis

2020 ◽  
Vol 4 (2) ◽  
pp. 54-59
Author(s):  
Nur Hidayatun ◽  
Abdul Aziz
Keyword(s):  
Medical Records ◽  
Quantitative Methods ◽  
Sampling Technique ◽  
Pain Anxiety ◽  
Consecutive Sampling ◽  
Nursing Diagnosis ◽  
Care Guidelines ◽  
Nutritional Deficits ◽  
Nursing Diagnoses ◽  
Fast Transmission

Covid-19 is a pneumonia caused by coronavirus, very fast transmission. This study aims to descriptions nursing diagnosis in covid-19 patients. This is a descriptive study uses quantitative methods. The sampling technique used is consecutive sampling with total samples are 240 medical records of covid-19 patients undergoing treatment at Fatmawati Hospital, both suspected, probable, and confirmed cases. The results showed that nursing diagnoses that often appeared in Covid-19 patients were the risk of infection (spread), ineffective airway, acut pain, anxiety, and the risk of nutritional deficits. The results of this study can be used for the hospital in making Covid-19 Nursing Care Guidelines, and for nurses in increasing their competences in care covid-19 patients. Keywords: Nursing diagnoses, Covid-19

scholarly journals Visita domiciliar pós-operatória em ortopedia: mapeamento de diagnósticos e intervenções de enfermagem

2018 ◽  
Vol 12 (6) ◽  
pp. 1593
Author(s):  
Vinícius Gonçalves Pires ◽  
Rosimere Ferreira Santana ◽  
Cláudia Mendes De Araújo ◽  
Ilmeire Ramos Rosembach De Vasconcellos ◽  
Luciana De Almeida Marques Oliveira ◽  
...  
Keyword(s):  
Medical Records ◽  
The Elderly ◽  
The Body ◽  
Nursing Interventions ◽  
Geriatric Nursing ◽  
Tissue Integrity ◽  
Nursing Diagnosis ◽  
Descriptive Approach ◽  
Nursing Diagnoses ◽  
Made In

RESUMOObjetivo: identificar os Diagnósticos e Intervenções de Enfermagem segundo as taxonomias da NANDA-I e NIC, no atendimento domiciliar aos idosos em pós-operatório ortopédico. Método: estudo retrospectivo de abordagem descritiva usando o método de mapeamento cruzado. Foram selecionados 51 prontuários de pessoas com idade maior ou igual a 60 anos e que receberam dez ou mais atendimentos domiciliares; a coleta de dados foi feita em formulário semi-estruturado e a análise através de estatística descritiva simples. Resultados: dentre os 24 diagnósticos de enfermagem mapeados, “Integridade tissular prejudicada” foi o mais prevalente (31,01%). Identificaram-se 27 intervenções de enfermagem, dentre as quais se destacou “Cuidados com local de incisão” (37,12%). Conclusão: os diagnósticos e intervenções de enfermagem para idosos submetidos à cirurgia ortopédica estão intimamente relacionados ao suporte do funcionamento físico e homeostático do organismo. Descritores: Enfermagem Ortopédica; Diagnóstico de Enfermagem; Assistência Domiciliar; Cuidados de Enfermagem; Enfermagem Geriátrica; Processo de Enfermagem.ABSTRACTObjective: to identify Nursing Diagnoses and Interventions according to taxonomies of NANDA-I and NIC, in home care to the elderly in post-op orthopedics. Method: a retrospective study of descriptive approach using the method of cross-mapping. There were selected 51 medical records of people aged 60 or over and who have received 10 or more home visits; data collection was made in semi-structured form and analysis through simple descriptive statistics. Results: among the 24 nursing diagnoses mapped, "Impaired tissue integrity" was the most prevalent one (31.01%). There were identified 27 nursing interventions, among which stood out "Incision site care" (37.12%). Conclusion: the diagnoses and nursing interventions for the elderly undergoing orthopedic surgery are closely related to the support of physical functioning and the body homeostatic. Descriptors: Orthopedic Nursing; Nursing Diagnosis; Home Nursing; Nursing Care; Geriatric Nursing; Nursing Process.RESUMENObjetivo: identificar los diagnósticos y las intervenciones de enfermería según las taxonomías de NANDA-I y NIC, en atención domiciliaria a los ancianos en post-operatorio ortopédico. Método: se trata de un estudio retrospectivo de enfoque descriptivo utilizando el método de asignación cruzada. Fueron seleccionados 51 historias clínicas de personas de 60 años o más y que han recibido 10 o más atenciones caseras; la recolección de datos fue hecha en forma semiestructurada y el análisis mediante estadística descriptiva simple. Resultados: entre los 24 diagnósticos de enfermería asignados, “La integridad del tejido deteriorada” fue el más prevalente (31.01%). Identificados 27 intervenciones de enfermería, entre los que destacaron “Cuidados del sitio de incisión" (37,12%). Conclusión: la diagnosis e las intervenciones de enfermería para la tercera edad sometida a cirugía ortopédica están estrechamente relacionadas con el soporte del funcionamiento físico y homeostático del organismo. Descriptores: Enfermería Ortopédica; Diagnóstico de Enfermería; Atención Domiciliaria de Salud; Atención de Enfermería; Enfermería Geriátrica; Proceso de Enfermería.

scholarly journals Análise das evoluções de enfermagem contextualizadas no processo de enfermagem

2018 ◽  
Vol 12 (11) ◽  
pp. 2952
Author(s):  
Leticia Bottcher Dias ◽  
Erika Christiane Marocco Duran
Keyword(s):  
Quality Care ◽  
Care Plan ◽  
Nursing Process ◽  
Nursing Assessment ◽  
Nursing Diagnosis ◽  
Provide Quality Care ◽  
Terapia Intensiva ◽  
Nursing Diagnoses ◽  
Identifiable Data ◽  
Process Method

RESUMOObjetivo: avaliar os registros das evoluções de Enfermagem da unidade de internação em Cardiologia e Unidade de Terapia Intensiva Coronariana contextualizadas no processo de Enfermagem. Método: trata-se de estudo quantitativo, exploratório e descritivo, por meio de uma leitura sistematizada de prontuários. Leram-se 150 evoluções de Enfermagem utilizando-se roteiro digital para a tabulação, e posterior análise estatística dos dados. Apresentaram-se os dados por meio de estatística descritiva Resultados: ressalta-se que, dentre os diagnósticos de Enfermagem identificados, 42,45% não foram apresentados sob a forma de dados identificáveis nas evoluções de Enfermagem; a evolução do diagnóstico de Enfermagem manteve-se inalterada em 87,83% dos casos e o diagnóstico mais utilizado foi o de risco de infecção. Conclusão: conclui-se que as evoluções de Enfermagem não têm sido realizadas de maneira coerente com a escolha e a evolução do diagnóstico de Enfermagem e o plano de cuidados. Considera-se que os enfermeiros devem se apropriar dos diagnósticos de Enfermagem utilizando-os, em sua prática, a fim de proporcionar a assistência de qualidade e não apenas cumprir a legislação. Descritores: Pesquisa em Enfermagem; Processo de Enfermagem; Avaliação em Enfermagem; Diagnóstico de Enfermagem; Registros de Enfermagem; Cuidados de Enfermagem. ABSTRACT Objective: to evaluate the records of the Nursing evolutions of the hospitalization unit in Cardiology and Coronary Intensive Care Unit contextualized in the Nursing process. Method: this is a quantitative, exploratory and descriptive study, through a systematized reading of medical records. 150 Nursing evolutions were read using a digital script for tabulation, and later statistical analysis of the data. The data were presented through descriptive statistics. Results: it is noteworthy that among the Nursing diagnoses identified, 42.45% were not presented as identifiable data in Nursing evolutions; the evolution of the nursing diagnosis remained unchanged in 87.83% of the cases and the most used diagnosis was the risk of infection. Conclusion: it is concluded that the Nursing evolutions have not been carried out in a manner consistent with the choice and evolution of the Nursing diagnosis and the care plan. It is considered that nurses should appropriate nursing diagnoses using them in their practice in order to provide quality care and not just comply with legislation. Descritores: Nursing Research; Nursing Process; Nursing Assessment; Nursing Diagnosis; Nursing Records; Nursing Care.RESUMEN Objetivo: evaluar los registros de las evoluciones de Enfermería de la unidad de internación en Cardiología y Unidad de Terapia Intensiva Coronaria contextualizadas en el proceso de Enfermería. Método: se trata de estudio cuantitativo, exploratorio y descriptivo, por medio de una lectura sistematizada de prontuarios. Se le dieron 150 evoluciones de Enfermería utilizando guion digital para la tabulación, y posterior análisis estadístico de los datos. Se presentaron los datos por medio de estadística descriptiva. Resultados: se resalta que, entre los diagnósticos de Enfermería identificados, el 42,45% no fueron presentados bajo la forma de datos identificables en las evoluciones de Enfermería; la evolución del diagnóstico de Enfermería se mantuvo inalterada en el 87,83% de los casos y el diagnóstico más utilizado fue el de riesgo de infección. Conclusión: se concluye que las evoluciones de Enfermería no se han realizado de manera coherente con la elección y la evolución del diagnóstico de Enfermería y el plan de cuidados. Se considera que los enfermeros deben apropiarse de los diagnósticos de enfermería utilizando en su práctica, a fin de proporcionar la asistencia de calidad y no sólo cumplir la legislación. Descritores: Investigación en Enfermería; Proceso de Enfermería; Evaluación en Enfermería; Diagnóstico de Enfermería; Registros de Enfermería; Atención de Enfermería.                                                              

Nursing Diagnosis for Potential Organ Donors: Accuracy Study

2021 ◽  
pp. 105477382110194
Author(s):  
Luciana Nabinger Menna Barreto ◽  
Éder Marques Cabral ◽  
Marina Raffin Buffon ◽  
Juliana Elenice Pereira Mauro ◽  
Lisiane Pruinelli ◽  
...  
Keyword(s):  
Heart Rate ◽  
Diagnostic Accuracy ◽  
Medical Records ◽  
Heart Rhythm ◽  
Organ Donors ◽  
Predictive Capacity ◽  
Nursing Diagnosis ◽  
Accuracy Study ◽  
Altered Blood ◽  
Accuracy Data

The objective was to analyze the diagnostic accuracy of Impaired physiological balance syndrome in potential brain-dead organ donors. It is a study of diagnostic accuracy. Data was retrospectively collected from 145 medical records through the filling out of an instrument containing 25 indicators of the nursing diagnosis (ND). Descriptive and inferential statistics were used. The prevalence of the ND was 77 (53.1%). The indicator with the best measures of accuracy was altered heart rate. Therefore, it has the best predictive capacity for determining the ND. It was identified that the absence of the indicators altered heart rate, hyperglycemia, and altered blood pressure is associated with the absence of the ND, while the presence of the indicators hyperthermia, hypothermia, and altered heart rhythm is associated with the presence of the ND. Accurate indicators will assist in diagnostic inference and the interventions and results will have greater chances of targeting and effectiveness.

PSYCHOLOGICAL BASIS OF CONVICTED WOMEN IN DETENTION PLACES WITH CHILDREN: INTERNATIONAL EXPERIENCE

2021 ◽  
pp. 110-116
Author(s):  
Светлана Станиславовна Пиюкова
Keyword(s):  
Great Britain ◽  
Family Reunification ◽  
Research Data ◽  
Correctional Institution ◽  
Correctional Institutions ◽  
Mothers And Children ◽  
Mother And Child ◽  
The Usa ◽  
The One

Статья посвящена рассмотрению психологических основ совместного пребывания осужденных женщин с детьми в отделениях матери и ребенка пенитенциарных учреждений различных стран. Раскрывается значение регулярных контактов осужденной женщины со своим ребенком на протяжении всего срока ее пребывания в исправительном учреждении. Характеризуется влияние ограничения контактов с матерями, находящимися в местах лишения свободы, на развитие психики их детей. Авторами статьи обосновывается роль поддержания отношений между матерями и детьми как одного из факторов, способствующих увеличению вероятности успешного воссоединения семей после освобождения женщин из мест лишения свободы. Рассматриваются существующие в настоящее время в международной пенитенциарной практике решения по созданию условий для содержания осужденных женщин с детьми в исправительных учреждениях. Характеризуются задачи отделений матери и ребенка, а также приводятся примеры из практики их организации в пенитенциарных системах США, Канады, Великобритании, Новой Зеландии, Германии и других стран. Приводятся данные исследований, свидетельствующие об эффективности работы отделений матери и ребенка. Анализируются аргументы сторонников и противников содержания осужденных женщин с детьми в исправительных учреждениях. Обосновывается тезис о необходимости достижения баланса в удовлетворении потребностей ребенка, с одной стороны, и организации условий для совместного содержания осужденных женщин с детьми в исправительных учреждениях, принимая во внимание вопросы безопасности и серьезность правонарушений со стороны матери. The article is devoted to the examination of the psychological foundations of the joint stay of convicted women with children in the mother and child wards of penitentiary institutions in different countries. The significance of regular contacts between a convicted woman and her child throughout the entire period of her stay in a correctional institution is revealed. The influence of limiting contacts with mothers in prison on the development of the psyche of their children is characterized. The authors of the article substantiate the role of maintaining relations between mothers and children as one of the factors contributing to an increase in the likelihood of successful family reunification after the release of women from prison. The author considers the solutions currently existing in international penitentiary practice to create conditions for the detention of convicted women with children in correctional institutions. The tasks of mother and child departments are characterized, and examples from the practice of their organization in the penitentiary systems of the USA, Canada, Great Britain, New Zealand, Germany and other countries are given. Research data showing the effectiveness of the work of the mother and child departments are presented. The arguments of supporters and opponents of keeping convicted women with children in correctional institutions are analyzed. The thesis is substantiated that it is necessary to achieve a balance in meeting the needs of the child, on the one hand, and to organize conditions for the joint detention of convicted women with children in correctional institutions, taking into account the issues of safety and the seriousness of offenses on the part of the mother.

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