Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit

Carvalho, Emı́lia Campos de; Martins, Fernanda Titareli Merízio; Dalrí, Maria Célia Barcellos; Canini, Sílvia Rita Marin da Silva; Laüs, Ana Maria; Bachion, Maria Márcia; Rossi, Lídia Aparecida

doi:10.1590/s0104-11692008000400008

Cited by 14 publications

(20 citation statements)

References 16 publications

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“…The most frequent NDs identified among ICU patients are also prevalent in other studies (7)(8)14) . This information reinforces the relevance of identifying nursing interventions necessary for appropriate care for these patients, since they are common in clinical nursing practice.…”

Section: Discussionsupporting

confidence: 67%

“…It reflects the high percentage of patients in the ICU with nursing diagnoses associated with damage in the respiratory tract (18) , which requires several interventions to improve or solve vital problems. Interventions in this class are also frequently used for critical patients in other studies (7)(8)17) .…”

Section: Discussionmentioning

confidence: 99%

“…Comparatively analyzing the 57 interventions The results obtained in this study are focused on interventions used in the clinical practice of ICUs and aggregate knowledge from recent publications of this periodical concerning the nursing process (5,8,20) .…”

Section: Discussionmentioning

confidence: 99%

“…There is also a scarcity of studies carried out in ICUs settings (7)(8) ,which also suggests the need for further investigation in order to deepen understanding of this subject in this nursing field.…”

Section: Introductionmentioning

confidence: 99%

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Nursing Interventions in the Clinical Practice of an Intensive Care Unit

Lucena

Gutiérrez

Echer

et al. 2010

Rev. Latino-Am. Enfermagem

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This cross-sectional study was carried out at a university hospital to describe the nursing interventions most frequently performed in the clinical practice of an intensive care unit, based on nursing care prescriptions, and to investigate their similarity to the Nursing Interventions Classification (NIC). The sample consisted of 991 hospitalizations of patients.Data were retrospectively collected from the computer database and analyzed through descriptive statistics and cross-mapping. A total of 57 different NIC interventions frequently used in the unit were identified; most of them in the complex (42%) and basic physiological (37%) domains, in the classes 'respiratory management' and 'self-care facilitation'. Similarity between the nursing care prescribed and nursing interventions/NIC was found in 97.2% of the cases. The conclusion is that the interventions/NIC used in the clinical practice of this intensive care unit reflects the level of complexity of nursing care, which is mainly directed at the regulation of the body's physical and homeostatic functioning. Descriptors Intervenciones de enfermería utilizadas en la práctica clínica de una unidad de terapia intensivaSe trata de un estudio descriptivo, transversal realizado en un hospital universitario con los objetivos de describir las intervenciones de enfermería más utilizadas en la práctica clínica de una unidad de terapia intensiva, con base en las prescripciones de enfermería y, analizar si son similares a las Nursing Interventions Clasification (NIC).La muestra constó de 991 internaciones de pacientes. Los datos fueron recolectados retrospectivamente, en base informatizada, y analizados por la estadística descriptiva y diseño cruzado. Se identificó 57 diferentes intervenciones/NIC frecuentemente utilizadas en la unidad; siendo la mayoría en el dominio fisiológico complejo (42%) y fisiológico básico (37%), en las clases de control respiratorio y facilitación del autocuidado. En 97,2% de los casos se encontraron similares entre las prescripciones de enfermería de la unidad y las intervenciones/NIC. Se concluye que las intervenciones/NIC utilizadas en la práctica clínica de la unidad de terapia intensiva reflejan el nivel de complejidad del cuidado de enfermería en esta unidad, destinándose, principalmente, a regular el funcionamiento físico y homeostático del organismo.

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Section: Discussionsupporting

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Nursing Interventions in the Clinical Practice of an Intensive Care Unit

Lucena

Gutiérrez

Echer

et al. 2010

Rev. Latino-Am. Enfermagem

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“…Record analysis of nursing diagnoses in the charts can contribute to identify permanent education needs, as well as to estimate the participation of nurses in the outcomes reached by patients (9) and to generate useful data to the management and administration sectors (10) . It is also relevant to the identification of specific diagnoses of a certain unit and because of that it will enhance the process of preparing diagnoses, improving their accuracy and, above all, contributing to the planning of more accurate and adequate interventions to the profile of the clientele cared for (11) .…”

Section: Introductionmentioning

confidence: 99%

Diagnósticos de enfermagem de pacientes internados em enfermaria de Moléstias Infecciosas

et al. 2010

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Objectives: To identify nursing diagnoses of admitted patients into a Unit of Infectious and Parasitic Diseases (ID) at a university hospital; and to analyze: the denomination, the related factors and the diagnoses' defining characteristics and its compatibility with the NANDA Taxonomy 2008. Methods: It was a descriptive, cross-sectional and retrospective study, covering 50 medical records of patients admitted in July 2008. The diagnoses were compared to those proposed by the NANDA Taxonomy 2008. Results: Were found 105 real diagnoses and 18 of risk; 12 diagnoses (10%) corresponded fully with the Nanda taxonomy. The more frequently denominations were "Risk of infection"(100%) and "Anxiety"(32%). In the real diagnosis the denominations, the related factors and the defining characteristics, were in accordance with Nanda taxonomy in 76%, 27% and 23% respectively; in the diagnosis of risk the denominations and risk factors were adequate in 83% and 72%. Conclusions: The main difficulty encountered during the construction of nursing diagnoses was the appropriate choice of related factors and defining characteristics. The authors suggest discussion of concepts and review the practice adopted in the unit. Keywords: Nursing diagnosis; Inpatients; Nursing assessment RESUMO Objetivos: Identificar os diagnósticos de enfermagem de pacientes internados na Unidade de Moléstias Infecciosas e Parasitárias (MI) de um hospital universitário; e analisar título, fator relacionado e características definidoras dos diagnósticos e sua adequação à Taxonomia NANDA 2008. Métodos: Estudo descritivo, transversal e retrospectivo abrangendo 50 prontuários de pacientes internados em julho de 2008. Os diagnósticos foram comparados aos propostos pela Taxonomia NANDA 2008. Resultados: Foram encontrados 105 diagnósticos reais e 18 de risco; 12 diagnósticos (10%) correspondiam totalmente à taxonomia. Os títulos atribuídos com mais frequência foram: "Risco de infecção" (100%) e "Ansiedade" (32%). Títulos, fatores relacionados e características definidoras estavam, de acordo com a taxonomia em, respectivamente, 76%, 27% e 23% dos diagnósticos reais; títulos e fatores de risco eram adequados em 83% e 72% dos diagnósticos de risco. Conclusão: A principal dificuldade observada na construção dos diagnósticos de enfermagem foi a escolha apropriada de fatores relacionados e características definidoras. Os autores sugerem discussão dos conceitos e revisão da prática adotada na unidade. Descritores: Diagnóstico de Enfermagem; Pacientes internados; Avaliação em Enfermagem RESUMEN Objetivos: Identificar los diagnósticos de enfermería de pacientes ingresados en la Unidad de Enfermedades Infecciosas y Parasitarias (EI) en un hospital universitario; y, examinar la denominación, los factores relacionados y las características que definen los diagnósticos, y su adecuación a la nomenclatura de la taxonomía NANDA 2008. Métodos: Se trata de un estudio descriptivo, transversal y retrospectivo que abarca 50 historias clínicas de pacientes ingresados en julio de ...

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