How to cite this article:Oliveira FP, Oliveira BGRB, Santana RF, Silva BP, Candido JSC. Nursing interventions and outcomes classifi cations in patients with wounds: cross-mapping. Rev Gaúcha Enferm. 2016 jun;37 (2) ABSTRACTObjective: Cross-mapping of terms referring to nursing interventions and outcomes in the medical records of patients with wounds compared to nursing interventions and nursing outcomes classifi cations. Method: An observational retrospective study based on cross-mapping. The sample consisted of 81 outpatients treated in a university hospital in Rio de Janeiro. Data was collected from medical records between May and July of 2013. The analysis was done in four steps: search for phrases used to describe interventions and outcomes; setting the frequency of occurrence of phrases; grouping synonyms; comparison of terms with taxonomies. Results: 13 interventions were mapped and the most frequent was "Care with wounds" (47.23%). Also, 6 results were mapped and the priority was "Wound healing: secondary intention" (45%). Conclusions:The use of cross-mapping of terms referring to interventions and nursing outcomes in patients with wounds suggested additions to the taxonomies for adaptation to outpatient care.
RESUMO:Objetivo: realizar o mapeamento cruzado dos termos identificados nos prontuários de pacientes com feridas de acordo com a Classificação de Diagnósticos de Enfermagem da NANDA Internacional (I) Método: pesquisa observacional retrospectiva, de mapeamento cruzado. Amostra composta por 81 prontuários e 405 evoluções de enfermagem de pacientes acompanhados em um ambulatório especializado no tratamento de feridas. Pesquisa desenvolvida em 2013, em duas etapas: mapeamento dos termos descritivos de diagnósticos de enfermagem para o cruzamento com a NANDA-I e, análise de concordância entre especialistas. Resultados: foram mapeados 309 termos descritivos correspondentes a 19 diagnósticos da NANDA-I (3,7±0,2), presentes em sete domínios da terminologia. Os mais frequentes foram Integridade da pele prejudicada (20,4%) e Risco de integridade da pele prejudicada (16,1%). Conclusão: o mapeamento cruzado permitiu identificar os principais diagnósticos de enfermagem em pacientes com feridas, indicando a possibilidade de elaboração de um protocolo clínico, que contribuirá para uma prática avançada em enfermagem. Palavras-chave: Úlcera; cicatrização de feridas; processos de enfermagem; cuidados de enfermagem. ABSTRACT:Objective: cross-mapping of terms identified in wound patient medical records, by NANDA International (I) Classification nursing diagnosis. Method: this retrospective observational study, using cross-mapping in a sample of 81 records and 405 nursing progress reports on patients treated at a specialized wound clinic, was conducted in 2013 in two steps: descriptive terms in nursing diagnoses were mapped to the intersection with NANDA-I and related expert agreement was analyzed. Results: 309 descriptive terms corresponding to 19 NANDA-I diagnoses (3.7 0.2), in seven areas of terminology, were mapped. The most common were Impaired skin integrity (20.4%) and Risk of impaired skin integrity (16.1%). Conclusion: cross-mapping identified the main nursing diagnoses in wound patients, indicating that it is possible to draft a clinical protocol to contribute to advanced nursing practice.
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