ICNP® terminology subset for the care of people with heart failure

ABSTRACT Objective: to develop an ICNP® terminology subset for the care of people with heart failure. Methods: this is a methodological study, which used the theoretical framework of the Mid-Range Nursing Theory for Cardiovascular Rehabilitation, with the steps: Construction of nursing diagnoses/outcomes and interventions statements and Cross-mapping of statements constructed. Results: forty-two diagnosis/outcome statements and 179 nursing intervention statements were constructed, organized based on five theory concepts, with a higher prevalence of statements related to “Rehabilitative care”, “Psychosocial support for patients and families” and “Supervised cardiovascular rehabilitation program”. Final considerations: it was possible to build nursing diagnosis/outcome and intervention statements for developing a terminology subset for the care of people with heart failure, based on the chosen theory.

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

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.

Nursing diagnosis after hematopoietic stem cell transplant due to Fanconi anemia

ABSTRACT Objectives: to identify nursing diagnoses in patients who underwent hematopoietic stem-cell transplants due to Fanconi anemia, according to the NANDA-I taxonomy. Methods: exploratory study using a retrospective analysis of 85 records from patients who underwent hematopoietic stem-cell transplants due to Fanconi anemia, developed in a specialize transplant center in the South of Brazil. The results were analyzed using descriptive statistics. Results: 73 different diagnoses were found in 9 out of the 13 domains from the NANDA-I taxonomy. From these, 22 were in 50% or more of the patients investigated, and most of them are related to the domain Safety/Protection. Conclusions: it was possible to identify the nursing diagnosis in the patients who underwent hematopoietic stem cell transplants due to Fanconi anemia, contributing to design a plan for the care of these patients. The same was true for those with other syndromes of chromosomal instability that need to undergo this transplant.

Self-care deficit versus the potential to improve self-care: explanation of the nurse's clinical judgments

Background: people who become functionally dependent due to serious illness and/or the worsening of a chronic illness have different recovery paths. The attribution of the nursing diagnosis of self-care deficit versus potential to improve self-care requires, on the part of the nurse, a rigorous clinical judgment, for which a set of diagnostic activities is necessary. Objectives: the present study sought to identify the assumptions used by expert nurses when formulating the clinical judgment of self-care deficit versus the potential to improve self-care Methodology: qualitative design. Data were generated in two focus group meetings that included eleven nurses experienced in caring for persons with functional dependence and self-care defict. Previously prepared structured questions were used to facilitate discussion. The focus group meetings were recorded in audio and transcribed. Inductive content analysis was used to identify emerging themes. The checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was also used. Results: nurses` decision-making depends: the factors of influencing the potential to improve self-care abilities of a person with functional dependence, the domain of influence of these factors, and three fundamental aspects to consider when evaluating a person with functional dependence. Conclusions: the absence of recovery potential can rarely be deduced. People without cognitive impairment or with mild cognitive impairment present highest potential for recovery.

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

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

Development and Implementation of Pediatric Nursing-Clinical Decision Support System for Hyperthermia: A Pre- and Post-Test

Firstly, we form the Pediatric Nursing-Knowledge Base for Hyperthermia, which combines publicly clinical practice guidelines and nursing routines of hyperthermia management. Then, following the nursing process framework, the system is developed by clinical decision support technology. Finally, a pre- and post-test is adopted to examine the effectiveness, usability and feasibility before and after using the system. Its effectiveness is examined by nursing records quality including completeness of nursing assessment, timeliness of nursing diagnosis, individualization of nursing interventions, and timeliness of nursing evaluation. Its usability and feasibility are assessed using the Clinical Nursing Information System Effectiveness Evaluation Scale. There is a significant difference between the two groups in effectiveness, usability and feasibility. Although the system is developed specifically for our hospital workflow and processes, the Pediatric Nursing-Knowledge Base for Hyperthermia and workflow for hyperthermia management in this study can be used as a reference to other hospitals.

Analysis of Standardized Nursing Languages Application in the Context of Nursing Diagnosis in Hospital in Indonesia

Background. Documentation of nursing care is important in applying care to patients, in terms of their workload coming into the context of indirect nursing care. The focus of his study is to assess the application of nursing diagnoses in hospitals. The phenomenon that occurs in the order of nursing services was found that nurses only focused on documenting nursing assessments, but formulating nursing diagnoses was not clearly illustrated and there are still different perceptions in relation to writing a nursing diagnosis phrase. Objective. The purpose of this study is to identify the application of Standardized Nursing Languages in the context of nursing diagnoses in hospitals in Indonesia. Method. This study uses a descriptive correlation design using simple random sampling and obtained 132 nurse respondents. Closed questions (with answer choices prepared by the researcher) and open questions (in the form of frequently used diagnostic questions) were used. The instrument was first tested for validity and content validity with a CVI (0.9) and CVR (0.85) value, which means that the instrument is relevant and important to use. Results. It was found that almost half of the respondents (48.49%) nurses did not use a standard diagnosis. Only the level of education has a relationship with the application of the use of standard language nursing in Indonesia (p-value = 0.006) where the higher the education of nursing will have an impact on accuracy in diagnosing. Whereas for other variables such as gender, career ladder level and position in nursing were found no relationship with the ability in the accuracy of writing diagnoses. Conclussion. As the results shows that the use of the standard language of nursing is not fully used by nurses in Indonesia. Standardization and equalization of perception by nursing professional organizations are needed to be a guide for all nurses in carrying out documentation of nursing care

NURSING CARE OF NEONATAL JAUNDICE IN HYPERBILIRUBINEMIA BABIES: A CASE REPORT

Introduction: Jaundice is a condition that is often found in the 24 hours after the birth of the baby due to hyperbilirubinemia. Hyperbilirubinemia can cause various complications and death if not treated properly and immediately. The knowledge and ability of nurses in providing nursing care for neonatal jaundice still need to be improved. This study aims to describe nursing care for neonatal jaundice in hyperbilirubinemia infants. Methods: This study uses a case study approach design through the nursing process with a sample of a hyperbilirubinemia baby with neonatal jaundice nursing problems. Data collection techniques were carried out through interviews, observations, physical examinations and documentation studies. Data analysis in this study uses narrative analysis. Results: The case report found jaundice on the skin, sclera, and mucosa. The nursing diagnosis in this study was neonatal jaundice associated with less than 7 days of age. The intervention provided in the form of phototherapy and breastfeeding education showed the result was not found jaundice on the skin, sclera, and mucosa after three days. Conclusion: The provision of phototherapy and breastfeeding education is effective in solving neonatal jaundice.

FAMILY NURSING CARE IN THE CASE OF DIABETES MELLITUS WITH NURSING PROBLEMS READINESS TO INCREASE FAMILY COUPLING IN THE VILLAGE BANJAREJO, SUKODADI DISTRICT, LAMONGAN REGENCY

Introduction : Family is an important aspect in nursing. Family members need care, supervision, and attention if they suffer from health problems such as Diabetes Mellitus. Families must have effective and competent coping to overcome health problems of family members. Global DM prevalence in 2019 an estimated 9,3% (463 million people). DM patients in Lamongan regency are 1,4% with a total of 4,138 cases per year and are ranked 4th in Java Province. According to an integrated disease surveillance report based on Puskesmas in Lamongan. The percentade of DM in the last 2 years was 12 cases, based on data from Banjarejo village, Sukodadi. District, Lamongan Regency in 2020 as many as 6 patients from 450 patients. Method : Method this research uses a descriptive method in the form of a case study to axplore the problem of family nursing care in the case of Diabetes Mellitus with nursing problems of increasing family coping readiness in Banjarejo village, Sukodadi district, Lamongan regency. The approach used is a nursing care approach that includes assessment, nursing diagnosis, planning,implementation, and evaluation. Result : Patients usually then do things that are not allowed in the treatment process, such as not maintaining a pattern of nutrition, activity, and wound care. Discussion: The role of the family is needed because it has a duty in health so that they understand the health problems of family members with each other so that they can have a positive impact.