Evaluation of Nurses’ Perceptions of Nursing Diagnoses and Their Opinions Regarding the Application of Nursing Process

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.

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Integralidade da assistência na visita domiciliar: relato de experiência

Revista Recien - Revista Científica de Enfermagem ◽

10.24276/rrecien2020.10.32.324-331 ◽

2020 ◽

Vol 10 (32) ◽

pp. 324-331

Author(s):

Anna Rebeka Oliveira Ferreira ◽

Wanderson Rocha Oliveira ◽

Brenda Melissa Barros Mota dos Santos ◽

Claudia Regina Marchiori Antunes Araújo

Keyword(s):

Nursing Care ◽

Home Visit ◽

Nursing Process ◽

Health Unit ◽

Unified Health System ◽

Primary Health ◽

History Of ◽

Nursing Diagnoses ◽

Care Nursing

Este relato possui como objetivo realizar a elaboração e aplicação de um instrumento para concretização do Processo de Enfermagem durante as visitas domiciliares. O relato foi realizado em uma Unidade Básica de Saúde de Maringá. Primeiramente foi realizado um aprofundamento teórico e observação da realidade para a construção de roteiros com histórico de enfermagem, diagnósticos e intervenções de acordo com a Classificação Internacional de Práticas em Saúde Coletiva (CIPESC), articulada à Sistematização da Assistência de Enfermagem específica para cada fase do ciclo da vida, para posterior aplicação e avaliação. O instrumento possibilitou a efetivação do princípio da integralidade do Sistema Único de Saúde por parte dos discentes e enfermeiros, o que facilitou a identificação das necessidades do paciente e família de uma forma holística, e contribuiu para uma maior autonomia do enfermeiro durante o processo do cuidar.Descritores: Visita Domiciliar, Educação em Saúde, Atenção Primaria a Saúde, Processo de Enfermagem. Integrality of assistance in home visit: experience reportAbstract: This report aims to carry out the elaboration and application of an instrument for implementation of the Nursing Process during home visits. This report was carried out in a Basic Health Unit at Maringá. First of all, we carried out a theoretical deepening and observation of reality, for the construction of scripts with a history of nursing, diagnoses and interventions according to the International Classification of Public Health Practices (CIPESC) linked to the Systematization of Nursing Care specific to each phase of the life cycle, and later, application and evaluation. The instrument enabled the implementation of the principle of integrality of the Unified Health System by students and nurses, making easier the identification of the needs of patient and family in a holistic way and adding to the greater autonomy of nurses during the care process.Descriptors: Home Visit, Health Education, Primary Health Care, Nursing Process. Integralidad de la asistencia durante las visitas domiciliares: informe de experienciaResumen: Este informe tiene como objetivo llevar a cabo la elaboración y aplicación de un instrumento para implementación del Proceso de Enfermería durante las visitas domiciliarias. Este informe se realizó en una Unidad Básica de Salud en Maringá, en primer realizamos una profundización teórica y observación de la realidad, para la construcción de guiones con antecedentes de enfermería, diagnósticos e intervenciones según la Clasificación Internacional de Prácticas en Salud Colectiva (CIPESC), vinculado a la Sistematización de la Asistencia de Enfermería, específica para cada fase del ciclo de vida, para su posterior aplicación y evaluación. El instrumento permitió la aplicación del principio de integración del Sistema Único de Salud por parte de estudiantes y enfermeros, facilitando la identificación de las necesidades del paciente y la familia de manera integral y contribuyendo a una mayor autonomía de las enfermeras durante el proceso de atención.Descriptores: Visita Domiciliaria, Educación Sanitária, Atención Primaria de Salud, Proceso de Enfermería.

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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]

Revista Enfermagem UERJ ◽

10.12957/reuerj.2018.30962 ◽

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.

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Nursing process applied to a client post-angioplasty: assistential convergent study

Revista de Enfermagem UFPE on line ◽

10.5205/reuol.1262-12560-1-le.0509201120 ◽

2011 ◽

Vol 5 (9) ◽

pp. 2220

Author(s):

Joselany Áfio Caetano ◽

Hérica Alves Vasconcelos ◽

Marli Teresinha Gimeniz Galvão

Keyword(s):

Nursing Care ◽

Goal Attainment ◽

Self Care ◽

Nursing Process ◽

Nursing Theory ◽

Adequate Diet ◽

Disturbed Sleep ◽

Implementation Time ◽

Care Deficit ◽

Nursing Diagnoses

ABSTRACT Objective: to apply nursing care systemization to a client submitted to angioplasty with placement of coronary stents in the light of King’s Theory of Goal Attainment. Method: convergent care research, carried out at the patient’s home. The following Nursing Diagnoses were elaborated and the interventions are proposed according to the connection between NANDA, NIC and NOC. The project was previously approved by the Research Ethics committee from University Federal do Ceará, under no protocol 61/08. Results: the nursing diagnoses: imbalanced nutrition: less than body requirements, impaired physical mobility, activity intolerance, chronic sadness, disturbed sleep patterns, self-care deficit control and ineffective family therapeutic regimen. the goals were: To obtain an adequate diet and fluid intake; Perform physical exercise safely and social interaction activities; Try and decrease dependence on the medication and adjust sleep times; Facilitate the accomplishment of self-care activities. The nursing plan attained a majority of the established goals, even if partially, which was expected in view of the proposed goals and implementation time. Conclusion: the use of Nursing Diagnoses is a technology needed for daily nursing care, as it permits comprehensive care and is relevant in home treatment, with an emphasis on health promotion.Descriptors: nursing process; nursing theory; coronary disease; care.RESUMO Objetivo: implementar a sistematização da assistência de enfermagem a um cliente submetido à angioplastia com colocação de stents coronarianos à luz da Teoria de Alcance de Metas de King. Método: pesquisa convergente-assistencial, realizada em um domicílio de Fortaleza, em 2010. Elaboraram-se os Diagnósticos de Enfermagem e propôs intervenções, segundo a ligação entre NANDA, NIC e NOC. O projeto foi previamente aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal do Ceará, sob nº de protocolo 61/08. Resultados: os diagnósticos de enfermagem: nutrição desequilibrada: menos do que as necessidades corporais, mobilidade física prejudicada, intolerância à atividade, tristeza crônica, padrão do sono perturbado, déficit no autocuidado e controle familiar ineficaz do regime terapêutico. As metas foram: Obter dieta e ingesta hídrica adequada; Realizar as atividades físicas e atividades de interação social; Tentar diminuir a dependência do medicamento e ajustar os horários de sono; Facilitar a realização das atividades de autocuidado. O plano de enfermagem alcançou a maioria das metas estabelecidas, mesmo que de forma parcial, fato esperado diante das metas propostas e o tempo de implementação. Conclusão: o uso dos Diagnósticos de Enfermagem é tecnologia necessária ao cotidiano de enfermagem, pois possibilita o cuidado integral e se mostra relevante no tratamento domiciliar, com ênfase na promoção da saúde. Descritores: processo de enfermagem; teoria de enfermagem; coronariopatia; cuidado.RESUMEN Objetivo: implementar la sistematización de la asistencia de enfermería a un cliente sometido a la angioplastia con la colocación de stents coronarianos a la luz de la Teoría de Alcance de Metas de King. Método: investigación convergente asistencial, realizada en un domicilio de Fortaleza, en 2010. Se elaboraron los Diagnósticos de Enfermería y se propuso intervenciones, según la conexión entre NANDA, NIC y NOC. El proyecto fue previamente aprobado por el Comité de Ética en Investigación de la Universidad Federal do Ceará, bajo protocolo 61/08. Resultados: los diagnósticos de enfermería: nutrición desequilibrada: menos que las necesidades corporales, movilidad física perjudicada, intolerancia a la actividad, tristeza crónica, trastornos del sueño, déficit en el autocuidado y control familiar ineficaz del régimen terapéutico. Las metas fueron: Obtener una dieta e ingesta hídrica adecuada; Realizar las actividades físicas y actividades de interacción social; Intentar disminuir la dependencia del medicamento y ajustar los horarios de sueño; Facilitar la realización de las actividades de autocuidado. El plan de enfermería alcanzó la mayoría de las metas establecidas, aunque de forma parcial, hecho esperado delante de las metas propuestas y el tiempo de implementación. Conclusión: el uso del Diagnóstico de Enfermería es tecnología necesaria al cotidiano de enfermería, pues posibilita el cuidado integral y se muestra relevante en el tratamiento domiciliario, con énfasis en la promoción de la salud. Descriptores: proceso de enfermería; teoría de enfermería; coronariopatía; cuidado.

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

Revista da Escola de Enfermagem da USP ◽

10.1590/1980-220x-reeusp-2021-0126 ◽

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.

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

Clinical Nursing Research ◽

10.1177/10547738211051565 ◽

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.

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

Revista Enfermagem Atual In Derme ◽

10.31011/reaid-2018-v.86-n.24-art.87 ◽

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.

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Knowledge-based clinical decision support engine for psychiatric nursing process: design and evaluation (Preprint)

10.2196/preprints.12889 ◽

2018 ◽

Author(s):

Kuei-Fang Ho ◽

Po-Hsiang Chou ◽

Jane C.-J. Chao ◽

Chien-Yeh Hsu ◽

Min-Huey Chung

Keyword(s):

Decision Support ◽

Sensitivity And Specificity ◽

Clinical Decision Support ◽

Support System ◽

Clinical Decision Making ◽

Clinical Decision ◽

Psychiatric Nursing ◽

Nursing Process ◽

Knowledge Based ◽

Nursing Diagnoses

BACKGROUND Nursing assessments used in the psychiatry department considerably differ from those used in other departments. OBJECTIVE We developed a psychiatric knowledge-based clinical decision support system (Psy-KBCDSS) to help nurses in assessing patients’ problems. In addition, we evaluated the sensitivity and specificity of the Psy-KBCDSS and determined whether the Psy-KBCDSS can accurately formulate nursing diagnoses to assist nurses in providing care for psychiatric patients. METHODS Visual Studio 2005 was adopted as the primary software development tool. C# was used as the main development language, and a graphical concept was applied to develop the interface. We established a clinical diagnostic validity inference engine (CDVIE) to calculate the actual nursing assessment scores of nurses engaging in clinical tasks and to compute the nursing diagnosis data registered in the psychiatric nursing process system (Psy-NPS). The sensitivity and specificity of the nursing diagnoses formulated by the senior nurses and junior nurses regarding the same patient were extracted from the Psy-NPS and Psy-KBCDSS databases to conduct effectiveness assessment. RESULTS This study involved 22 nursing diagnoses commonly encountered in psychiatric wards. Of these diagnoses, the top 8 most common diagnoses formulated by the participants were altered thought processes, ineffective coping, sensory and perceptual alterations, insomnia, risk for other-directed violence, anxiety, impaired social interaction, and risk for suicide in Psy-NPS and Psy-KBCDSS. However, the diagnoses that showed significant increase in sensitivity between the Psy-NPS and Psy-KBCDSS were sensory and perceptual alterations, ineffective coping, and insomnia. The specificity of ineffective coping also increased considerably. CONCLUSIONS The Psy-KBCDSS is an empirical patient-oriented nursing clinical decision-making support system that may be used in patients’ individual assessment and helps nurses in formulating appropriate nursing diagnoses according to the nursing process.

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Processo de enfermagem fundamentado na teoria do autocuidado de Orem a um paciente submetido à cirurgia bariátrica

Revista de Enfermagem UFPE on line ◽

10.5205/reuol.581-3802-1-rv.0304200904 ◽

2009 ◽

Vol 3 (4) ◽

pp. 814 ◽

Cited By ~ 1

Author(s):

Lidiany Galdino Felix ◽

Maria Miriam Lima da Nóbrega ◽

Maria Júlia Guimarães de Oliveira Soares

Keyword(s):

Bariatric Surgery ◽

Nursing Care ◽

Clinical Case ◽

Self Care ◽

Nursing Interventions ◽

Nursing Process ◽

Qualified Individual ◽

Case Type ◽

Nursing Diagnoses

Objective: to apply the nursing process fundament on the Theory of Orem’ Self-care, through the conduct of a report of clinical case, with a patient submitted to bariatric surgery. Methods: this is about a descriptive study, from qualitative approach, report of clinical case type, performed in a patient with morbid obesity, included in Bariatric Surgery Group of a teaching hospital in João Pessoa-PB city. For data collection was used a script adapted to Theory of Orem’ Self-care, which led to the identification of deficits of self-care and therefore to nursing diagnoses. It was then developed the plan of nursing care, with the determination of goals, objectives, method of assistance, type of system and nursing interventions. This study has been approved by the Research Ethics Committee of the Hospital of the Federal University of Paraiba (054/07). Results: from the identification of nursing diagnoses was established and implemented the plan of nursing care with the aim of restoring the patient to prevent postoperative complications, promote recovery and prepare you for the self-care. Conclusion: it is considered that the application of the nursing process, based on Theory of Orem’ Self-care, enabled the provision of assistance and qualified individual, encouraging the patient to participate actively in their treatment, but also to increase their responsibility in the outcome of care. Descriptors: nursing; nursing process; self care; bariatric surgery.

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Computerized nursing process: development of a mobile technology for use with neonates

Revista Brasileira de Enfermagem ◽

10.1590/0034-7167-2017-0267 ◽

2018 ◽

Vol 71 (suppl 3) ◽

pp. 1273-1280 ◽

Cited By ~ 5

Author(s):

José Janailton de Lima ◽

Larissa Gabrielle Dias Vieira ◽

Marília Mendes Nunes

Keyword(s):

Data Collection ◽

Mobile Technology ◽

Process Development ◽

Clinical Signs ◽

Diagnostic Reasoning ◽

Nursing Process ◽

Human Needs ◽

Bibliographical Survey ◽

Nursing Diagnoses ◽

Ruby On Rails

ABSTRACT Objective: to build a mobile technology to assist nurses during data collection, diagnostic reasoning, and identification of interventions in neonates. Method: methodological study with a qualitative approach. The development was carried out in three phases, namely: bibliographical survey, construction of a database of diagnosis/interventions, and development of the software. We used the development tools Ruby on Rails, IONIC 2, PostgresSQL, and Amazon EC2. Results: The developed technology received the name Natus, able to contribute to the development of the nursing process applied to patients of neonatal units. Its requirements are: to define human needs, select nursing diagnoses, select interventions, define time periods, and issue printed files. Final considerations: the technology built is a computerized tool that allows for the development of the nursing process, facilitating data collection, diagnostic reasoning, and identification and grouping of the clinical signs presented by the newborn in neonatal units.

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