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 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 Nursing process as a strategy in the development of competence for self-care

2012 ◽  
Vol 25 (spe2) ◽  
pp. 96-103 ◽  
Author(s):  
Cynthia de Freitas Sampaio ◽  
Maria Vilani Cavalcante Guedes
Keyword(s):  
Renal Failure ◽  
Nursing Care ◽  
Clinical Care ◽  
Self Care ◽  
Nursing Process ◽  
The North ◽  
Nursing Diagnosis ◽  
Nursing Diagnoses ◽  
Care Demands

OBJECTIVE: To investigate the contribution of clinical care and education of nursing in a hospital context, in the development of competence for self-care for people with chronic renal failure. METHODS: A case study conducted with a patient during hospitalization in Fortaleza, through the nursing process proposed by Orem determining deficiencies and enabling self-care demands satisfaction from him. RESULTS: The requisites of therapeutic self-care d.emands of health deviation sef-care requisites enabled the identification of three nursing diagnoses based on the North American Nursing Diagnosis Association - NANDA for which interventions were defined based on NIC and results according to NOC. CONCLUSION: In the hospital context, clinical and educational nursing care based on the nursing process proposed by Orem contributes as a facilitator for the development of competence for self-care in people with chronic disease.

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 Implementação do processo de enfermagem no paciente queimado: um estudo de caso [Implementing the nursing process for a burn patient: a case study] [Implementación del proceso de enfermería a paciente quemado: un estudio de caso]

2018 ◽  
Vol 26 ◽  
pp. e30962
Author(s):  
Vinicius Lino Souza Neto ◽  
Rayane Teresa Da Silva Costa ◽  
Erlivânia Aparecida de Lucena ◽  
Suellen Cristina da Silva ◽  
Vanessa Mandu Pereira ◽  
...  
Keyword(s):  
Quality Care ◽  
Respiratory Pattern ◽  
Nursing Process ◽  
Clinical Indicators ◽  
Human Needs ◽  
Examination Preparation ◽  
Nursing Diagnoses ◽  
Burn Patient ◽  
Estudio De Caso

Objetivo: implementar o processo de Enfermagem (PE) no contexto do cuidado de um paciente queimado assistido em instituição pública de saúde. Método: estudo de caso, em que as Necessidades Humanas Básicas de Horta (1979) foram adotadas como referencial teórico. A implementação do PE pautou-se nas seguintes etapas: preenchimento do histórico e exame físico, elaboração dos Diagnósticos de Enfermagem (DE), planejamento, além de implementação das atividades definidas a partir das intervenções. Em seguida, foram realizadas avaliações sequenciais do paciente. Resultados: após análise dos indicadores clínicos, elencou-se como prioritários o padrão respiratório ineficaz, risco de infecção e integridade da pele prejudicada. Em seguida foi realizado o planejamento e definição das metas, intervenções e atividades a serem implementadas para posterior avaliação. Conclusão: a implementação do Processo de Enfermagem nos cuidados de um paciente queimado possibilita o desenvolvimento de uma assistência de qualidade, pautada no conhecimento científico.ABSTRACTObjective: to implement the nursing process (NP) in the context of care for a burn patient treated at a public health institution. Method: in this case study, the theoretical frame of reference was given by Horta’s Basic Human Needs (1979). The NP was implemented in the following steps: completion of the case history and physical examination, preparation of Nursing Diagnoses (NDs), planning, and implementation of the activities recommended by the interventions. Sequential patient evaluations were then performed. Results: after analyzing the clinical indicators, the priorities were listed as ineffective respiratory pattern, risk of infection and impaired skin integrity. The goals, interventions and activities to be implemented for further evaluation were then planned and specified. Conclusion: implementation of the NP in care for burn patient made it possible to produce quality care guided by scientific knowledge.RESUMENObjetivo: implementar el Proceso de Enfermería (PE) en el contexto del cuidado de un paciente quemado asistido en institución pública de salud. Método: estudio de caso, en que las Necesidades Humanas Básicas de Wanda Horta (1979) se adoptaron como referencial teórico. La implementación del PE se basó en las siguientes etapas: llenado del historial y examen físico, elaboración de los Diagnósticos de Enfermería (DE), planificación, además de implementación de las actividades definidas a partir de las intervenciones. A continuación, se realizaron evaluaciones secuenciales del paciente. Resultados: después del análisis de los indicadores clínicos, se definió como prioritario el patrón respiratorio ineficaz, el riesgo de infección y la integridad de la piel perjudicada. A continuación se realizó la planificación y definición de las metas, intervenciones y actividades a ser implementadas para posterior evaluación. Conclusión: la implementación del Proceso de Enfermería en el cuidado de un paciente quemado posibilita el desarrollo de un cuidado de calidad, basado en el conocimiento científico.

scholarly journals THERAPEUTIC TOY IN PRIMARY CARE: CONTRIBUTIONS FOR THE SYSTEMATIZATION OF NURSING CARE

2021 ◽  
Vol 30 ◽  
Author(s):  
Letícia Roberta Pedrinho ◽  
Bianca Machado Cruz Shibukawa ◽  
Gabrieli Patrício Rissi ◽  
Roberta Tognollo Borotta Uema ◽  
Maria de Fátima Garcia Lopes Merino ◽  
...  
Keyword(s):  
Nursing Care ◽  
Multiple Case Study ◽  
The North ◽  
Coping Process ◽  
Nursing Diagnosis ◽  
Multiple Case ◽  
Nursing Diagnoses

ABSTRACT Objective: to analyze the role of the therapeutic toy as a tool for the nursing diagnosis in the setting of care for the child with diabetes. Method: a qualitative multiple-case study conducted with children diagnosed with Type 1 Diabetes mellitus and living in the inland of Paraná. The data were collected in 2018 through interviews, field diary and sessions using the therapeutic toy. Nursing diagnoses were elaborated according to the North American Nursing Diagnosis Association Taxonomy I and a targeted content analysis was performed, resulting in four categories. Results: using the dramatic therapeutic toy allows the child to show their perception of the disease and of the care provided. The sessions with the dramatic therapeutic toy made it possible to identify five nursing diagnoses, which were later worked on by means of an instructional therapeutic toy. Conclusion: systematization of assistance mediated by the use of the toy allows nurses to establish bonds with the child with diabetes and their family, revealing their perceptions of the disease and treatment, thereby stimulating a more active participation of the binomial in the management of this coping process.

scholarly journals The Pathogenesis Characteristics and Symptom of Covid-19 in the Context of Establishing a Nursing Diagnosis

2020 ◽  
Vol 3 (1) ◽  
pp. 21
Author(s):  
Mayusef Sukmana ◽  
Falasifah Ani Yuniarti
Keyword(s):  
Signs And Symptoms ◽  
Ventilator Weaning ◽  
The Body ◽  
Host Cells ◽  
Breathing Patterns ◽  
Literature Study ◽  
Inflammatory Reactions ◽  
Nursing Diagnosis ◽  
Standard Characteristic ◽  
Nursing Diagnoses

Covid-19 is a disease that causes a global health emergency, caused by SAR-CoV2 and transmitted through droplets. Viruses attached to host cells are strongly bound to ACE2 causing excessive inflammatory reactions (Cytokine Storm). The incubation period 1-14 days, causing signs and symptoms of the respiratory syndrome, fever, leukopenia, thrombocytopenia, and in severe conditions multi-organ failure that ends in death. In May 2020 the world mortality rate increased by 15.45%, which previously was March 2020 at 3.4%. The concept of pathogenesis is needed as an effort to provide understanding in handling Covid-19 so that mortality can be controlled. Tracing and understanding the characteristics of Covid-19 pathogenesis that gives rise to various pathological responses of the body becomes an interesting analytical study to establish an appropriate diagnosis, including nursing diagnoses in order to develop a comprehensive nursing plan. This study aims to review the characteristics of covid-19 pathogenesis in the context of establishing a nursing diagnosis according to the Indonesian Nursing Diagnosis Standards.  A literature study is done by analyzing the characteristics of COVID-19 signs and symptoms and comparing the major and minor data groupings that exist in the Indonesian Nursing Diagnosis Standard. Characteristic pathogenesis results from mild, moderate and severe symptoms. Grouping results refer to nursing diagnoses including ineffective airway clearance, ventilator weaning disorders, gas exchange disorders, ineffective breathing patterns, the risk of spontaneous circulatory disorders, hyperthermia and anxiety. Keywords: Nursing diagnosis Covid-19, signs anda symptome covid-19,  pathogenesis Covid-19, SAR-CoV2 

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 The Most Commonly Determined Nursing Diagnoses According to NANDA-I Taxonomy and Difficulties Using the Nursing Process in COVID-19 Outbreak

2021 ◽  
pp. 105477382110515
Author(s):  
Hale Tosun ◽  
Ayşe Tosun ◽  
Birgül Ödül Özkaya ◽  
Asiye Gül
Keyword(s):  
High School ◽  
Nursing Care ◽  
High School Graduates ◽  
Cross Sectional Study ◽  
Nursing Process ◽  
Sectional Study ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Acute Confusion ◽  
Nursing Diagnoses

The study was planned to determine the most common nursing diagnoses according to NANDA International (NANDA-I) taxonomy and difficulties experienced in using of nursing process in COVID-19 outbreak. The sample of the descriptive cross-sectional study consisted of nurses cared for patients with COVID-19 ( n = 114). Average age of nurses is 26.86 ± 6.68. Commonly determined nursing diagnoses according to NANDA-I taxonomy in patients with COVID-19 were imbalanced nutrition (66.7%), impaired gas exchange (40.4%), insomnia (21.1%), acute confusion (31.6%), hopelessness (96.5%), difficulty playing caregiver (84.2%), anxiety (38.6%) willingness to strengthen religious bond (71.9%), risk for infection (64.9%), nausea (49.1%). Twenty-four-years old and younger, high school graduates, caring for intubated patients, and those who stated that they did not use nursing diagnosis had more difficulty in using nursing process (<0.05). The use of nursing diagnoses and process for patients with COVID-19 is extremely important in ensuring individual and qualified nursing care.

scholarly journals Studi Kasus: Asuhan Keperawatan pada Orang dengan Gangguan Jiwa dengan Perilaku Kekerasan

2021 ◽  
Vol 1 (01) ◽  
Author(s):  
Nurul Ainul Shifa ◽  
Aisyah Safitri
Keyword(s):  
Nursing Care ◽  
Violent Behavior ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Process Approach ◽  
Nursing Interventions ◽  
Nursing Process ◽  
The Family ◽  
Nursing Diagnoses

Introduction: Perilaku kekerasan adalah suatu keadaan seseorang melakukan tindakan yang dapat membahayakan secara fisik baik terhadap diri sendiri, orang lain dan lingkungan. Dampak atau perubahan yang terjadi dapat berupa perasaan tidak sabar, cepat marah, dari segi sosial kasar, menarik diri, dan agresif. Objectives: The purpose of this study was to determine the appropriate nursing care and intervention in patients with a diagnosis of violent behavior. Method: The design in this study is a case study design using a nursing process approach. The sample in this study was Mr. J. The sampling technique used was simple random sampling. The research was conducted at X Hospital in April 2021. Data was collected by means of interviews, observations, and documentation studies. The research instrument is using the mental nursing care format and the SOP on Implementation Strategy (SP). The nursing process approach carried out by researchers includes the following stages: Assessment Researchers collect data, both from respondents/patients. Nursing diagnoses, make nursing interventions, carry out implementation and then carry out nursing evaluations. Result: The client was escorted by his family on the grounds of fighting with his friends, feeling humiliated for not working, drugs being hidden and not being taken, being angry at home, speaking rudely and throwing tantrums, having trouble sleeping, the patient dropped out of medicine for approximately 4 weeks Mr. J had previously been admitted to the hospital with the same case, namely violent behavior. There are no families with mental disorders, the patient's communication pattern is closed with the family and the parenting pattern of the client's family is authoritarian. Conclusion: The main nursing problem is violent behavior

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