Nursing diagnoses of newborns in rooming-in care using ICNP®

Abstract

Objectives: to create nursing diagnosis definitions for newborns in rooming-in care, using the International Classification for Nursing Practice (ICNP). Methods: methodological study following the steps for the identification and validation of relevant terms to care for clients; cross-mapping of the terms identified with the terms of the ICNP® 2019; elaboration and validation of the nursing diagnostic definitions of ICNP® and later classification according with the Basic Human Needs described by Wanda Horta. Results: from the terms extracted, 168 were validated through specialist consensus, subsidizing the elaboration of 27 diagnosis definitions. Conclusions: the most common diagnoses for the clients studied were: “Effective Feeding Behaviour”, “Effective Urination”, “Normal Respiration Rhythm”, “Effective Swallowing”, “Effective Peripheral Intravenous Access”, and “Effective Parent Child Attachment”. It was confirmed that the records of psychobiological needs are mainly made by nurses, which were responsible for 23 of the diagnoses in this study.

Nursing documentation of newborns with birth weight under 1500g in an Italian Neonatal Intensive Care Unit: a cross-mapping study to develop an ICNp® subset

“…Nutrition and Hydration, with the 19.4%, represents the third need of ICNP terms in nurses' notes. Even in a study regarding the ICNP nursing diagnoses of newborns in rooming-in care, Nutrition and Elimination needs were among the most cited [19].…”

“…Besides, two Intervention terms concerned actions regarding the evaluation of respiratory status. Some of higher risks related to preterm newborns involve these of apparatus functions, for example feeding difficulty, hypoglycemia, respiratory complications, apnoea, and necrotizing enterocolitis [1,2,19 Nursing documentation of newborns with birth weight under 1500g in an Italian Neonatal Intensive Care Unit: a cross-mapping study... Some nursing phenomena are poorly described in nursing notes.…”

“…Th e ICNP pre-coordinate diagnoses and interventions are not suffi cient to describe all nursing practices in NICU newborns and infants [19,23]. It was necessary to use the ICNP syntax with Seven Axis Model to create terms that describe diagnoses or interventions.…”

“…Documentations were analyzed by cross-mapping method, used to analyze data, comparing existing information in the records of the patients and the reference classifications for nursing practice [18]. Some studies used this method in different clinical context to build nursing terminology with the ICNP, or to develop an ICNP terminology subset, or to validate terms identified in nursing registers, mapping them to the ICNP [19][20][21]. In this study, the recovered sample of nursing documentation was analyzed, and every term and short sentence that described nursing phenomena were collected in a database.…”