scholarly journals Validation of nursing diagnoses, interventions and outcomes in a pediatric clinic

2018 ◽  
Vol 71 (1) ◽  
pp. 80-88 ◽  
Author(s):  
Ana Márcia Nóbrega Dantas ◽  
Kenya de Lima Silva ◽  
Maria Miriam Lima da Nóbrega

ABSTRACT Objectives: To elaborate operational definitions for the Nomenclature nursing diagnoses, interventionsand outcomes of the Pediatric Clinic at a University Hospital and carry out a validation of the content and clinical aspects of this Nomenclature. Method: Methodological research, developed in two stages: documentary study, for the validation of content of the operational definitions of nursing diagnoses; and secondly applied research, via clinical cases, performed with children from 0 to 5 years. Results: The 126 diagnoses were submitted to consensus validation and 55.6% were validated. Six clinical case studies were carried out, using the phases of the nursing process, based on the theory of Basic Human Needs, identifying 24.3% of the validated diagnoses and 54.5% of the nursing interventions listed in the Nomenclature. Conclusion: The study showed the effectiveness of using the Nomenclature in the Pediatric Clinic, in order to optimize the care andquality of health services.

2020 ◽  
Vol 10 (7) ◽  
Author(s):  
Vanda Aparecida Tolari ◽  
Márcia Helena De Souza Freire

Objetivo: Descrever o método de desenvolvimento de uma tecnologia educacional, na modalidade de aplicativo-guia, para o manejo do potencial doador pediátrico, realizada como produto do Mestrado Profissional. Metodologia: relato de um método científico aplicado. Utilizou-se os passos propostos por Echer, com a perspectiva de apresentar o percurso para a produção da Tecnologia Educacional. Resultados: A construção está sustentada na Teoria das Necessidades Humanas Básicas, nos Diagnósticos e Intervenções de Enfermagem. Foi realizado mapeamento cruzado, dos indicadores selecionados, a partir das necessidades humanas básicas, decorrentes das alterações fisiopatológicas e as percebidas na avaliação clínica, com os Diagnósticos de Enfermagem, segundo taxonomia de NANDA-I e Intervenções de enfermagem baseadas nos diagnósticos, sob a ótica da manutenção dos órgãos a serem doados. Conclusão: O Aplicativo-guia subsidiará o Enfermeiro no planejamento da assistência de enfermagem segura e propiciará um impacto social no processo de transplantes em pediatria.Descritores: Morte Encefálica, Métodos, Tecnologia Educacional, Processo de Enfermagem.THE METHOD FOR BUILDING GUIDE APPLICATIONS IN THE NURSING PROFESSIONAL MASTERObjective: To describe the method of development of an educational technology as a guide application for the management of potential pediatric donors, carried out as a product of the Professional Master. Methodology: report of an applied scientific method. The steps proposed by Echer5 were used, with the perspective of presenting the path for the production of Educational Technology. Results: It is supported by the Theory of Basic Human Needs, Nursing Diagnoses and Interventions. Cross-mapping of selected indicators was performed based on basic human needs, resulting from pathophysiological changes and those perceived in clinical evaluation, with Nursing Diagnoses, according to NANDA-I taxonomy and Nursing interventions based on nursing diagnoses, under the optics of the maintenance of the organs to be donated. Conclusion: The Guide application will support the Nurse in the planning of safe nursing care and will provide a social impact on the process of transplantation in pediatrics.Descriptors: Brain Death, Methods, Educational Technology, Nursing Process.EL MÉTODO PARA LA APLICACIÓN DE LA GUÍA DE CONSTRUCCIÓN EN EL MAESTRO PROFESIONAL DE ENFERMERÍAObjetivo: Describir el método de desarrollo de una tecnología educativa como una aplicación de guía para el manejo de posibles donantes pediátricos, realizada como producto del Master Profesional. Metodología: informe de un método científico aplicado. Se utilizaron los pasos propuestos por Echer5, con la perspectiva de presentar el camino para la producción de Tecnología Educativa. Resultados: está respaldado por la Teoría de las necesidades humanas básicas, los diagnósticos e intervenciones de enfermería. El mapeo cruzado de los indicadores seleccionados se realizó con base en las necesidades humanas básicas, como resultado de los cambios fisiopatológicos y los percibidos en la evaluación clínica, con los Diagnósticos de Enfermería, de acuerdo con la taxonomía NANDA-I y las intervenciones de Enfermería basadas en diagnósticos de enfermería, bajo La óptica del mantenimiento de los órganos a donar. Conclusión: La aplicación de la Guía apoyará a la Enfermera en la planificación de la atención de enfermería segura y proporcionará un impacto social en el proceso de trasplante en pediatría.Descriptores: Muerte Cerebral, Métodos, Tecnología Educativa, Proceso de Enfermería.


Author(s):  
Ana Flávia Martinez ◽  
Nayara Tomazi Batista ◽  
Gesiane Cristina Bom ◽  
Cláudia Regina Matiole ◽  
Carmen Silvia Zamboni ◽  
...  

Abstract Objective: To identify the main nursing diagnoses and interventions in children in the immediate postoperative period of palatoplasty. Method: Documentary and retrospective study, developed in a Brazilian public and tertiary hospital, between August and September 2020. Children who underwent only palatoplasty, between January and December 2019, aged between 10 and 24 months, were included. Those with medical syndromes and/or comorbidities were excluded. The Theoretical Framework of Basic Human Needs and the NANDA International and Nursing Interventions Classification Taxonomies were used. Data underwent descriptive statistical analysis. Results: The sample consisted of 126 children. Psychobiological needs such as oxygenation, hydration, nutrition, elimination, cutaneous-mucosal and physical integrity, pain and environmental perception predominated. Based on them, nine nursing diagnoses, with four focusing on the problem and five on risk, as well as 17 interventions, were identified. Conclusion: The use of standardized languages to identify affected human needs and, based on them, diagnoses and interventions, favored clinical reasoning for the construction and organization of clinical nursing practice.


2019 ◽  
Vol 72 (3) ◽  
pp. 584-591
Author(s):  
Daniel Vinícius Alves Silva ◽  
Ingryd Nathany Mendes Sousa ◽  
Carolina Amaral Oliveira Rodrigues ◽  
Fabíola Afonso Fagundes Pereira ◽  
Ricardo Otávio Maia Gusmão ◽  
...  

ABSTRACT Objective: to identify Nursing diagnoses in patients in home care by cross-mapping terms obtained in the anamnesis and clinical examination, with NANDA-I Taxonomy. Method: descriptive exploratory study, transversal type, performed with 131 patients from a home health care program in northern Minas Gerais State. With the aid of an instrument based on the theoretical model of Basic Human Needs, the terms indicators of conditions that required nursing interventions were extracted. The cross-mapping of these terms was also performed with NANDA-I Taxonomy diagnoses. Results: 378 terms and expressions referring to 49 different diagnoses were identified in 11 of the 13 domains of NANDA-I Taxonomy. Conclusion: the profile of identified nursing diagnoses can contribute to care management and organizational processes of nurses who provide care to patients in home care.


2019 ◽  
Vol 72 (2) ◽  
pp. 391-399
Author(s):  
Giselia Santos Tolentino ◽  
Ana Rita de Cássia Bettencourt ◽  
Selma Montosa da Fonseca

ABSTRACT Objective: Construct and validate instrument content for nursing consultation in an adult chemotherapy outpatient clinic. Method: Methodological study composed of two stages: elaboration of the instrument and validation of content. A literary review of the dimensions of customer care was carried out in the light of Theory of Basic Human Needs Theory, culminating in two instruments: one for admission consultation and other for follow-up. The content was validated by the evaluation of listed experts based on the adapted Fehring’s Validation Model. Results: In the first round, two items of the admission instrument and three items of follow-up required reformulation. In the second round, there was an increase in agreement rate: 11% in the instrument of admission and 10% in follow-up. Final Consideration: The instrument represents a guideline for the Nursing Process and future research, but it cannot be seen as a substitute for nurses’ knowledge and clinical reasoning.


2015 ◽  
Vol 4 (3/4) ◽  
pp. 157-160
Author(s):  
Mirella Carneiro Galvão ◽  
Maria Angélica Bezerra Dos Santos ◽  
Marcos Venícios De Oliveira Lopes ◽  
Jaqueline Galdino Albuquerque Perrelli ◽  
Suzana De Oliveira Mangueira

Resumo: Pesquisa descritiva, quantitativa, com a finalidade de identificar diagnósticos de enfermagem e a congruência de sua escrita em relação à NANDA Internacional e correlacioná-los com as necessidades humanas básicas. A partir dos prontuários de 131 alcoolistas internados em uma unidade hospitalar, verificou-se a presença de 72 diagnósticos distintos. O mais frequente foi “Risco de quedas” (12,2%). As necessidades psicobiológicas foram as mais afetadas. Evidenciou-se a falta de registro de diagnósticos em 22,1% dos prontuários, bem como o descompasso de registros com a taxonomia, o que indica a necessidade de capacitação e de educação continuada dos enfermeiros do serviço.Descritores: Alcoolismo; Processos de Enfermagem; Diagnóstico de Enfermagem.Nursing diagnoses of alcoholics admitted in a health unit.Abstract: Descriptive and quantitative research in order to identify nursing diagnoses and the congruence of his writing in relation to NANDA International and to correlate them with basic human needs. From medical records of 131 alcoholic admitted to hospitals, we verified the presence of 72 distinct diagnoses. The most common was “risk for falls” (12.2. The physiological needs were most affected. We observe a lack of registration of diagnoses in 22.1% of records, as well as the mismatch of records with the taxonomy of NANDA-I, which indicates the need for training and continuing education of nurses.Descriptors: Alcoholism; Nursing Process; Nursing Diagnosis.Diagnósticos de enfermería de alcohólicos ingresados en una unidad de saludResumen: Investigación descriptiva y cuantitativa a fin de identificar diagnósticos de enfermería y la congruencia de sus escritos en relación a la NANDA Internacional y correlacionarlos con las necesidades humanas básicas. A partir de los registros médicos de 131 alcohólicos ingresados en hospitales, se verificó la presencia de 72 diagnósticos distintos. El más común fue “riesgo de caídas” (12,2%). Las necesidades fisiológicas son los más afectados. Se evidenció la falta de registro de diagnósticos en un 22,1% de los registros, bien como la falta de coincidencia de registros con la taxonomía de la NANDA-I, lo que indica la necesidad de capacitación y educación continua de los enfermeros de la institución.Descriptores: Alcoholismo; Procesos de Enfermería; Diagnóstico de Enfermería.


Author(s):  
Cássio Baliza Santos ◽  
Deíze Carvalho Pereira ◽  
Ricardo Bruno Santos Ferreira ◽  
Elaine de Oliveira Souza Fonseca

Introduction: Accidental tetanus is an infectious disease with systemic repercussions and high lethality. Due to the complexity surrounding the care for these patients, nursing care must be conducted in a systematic, scientific and individualized way. Objective: To report the experience of systematization of nursing care to a patient affected by accidental tetanus in the light of the Basic Human Needs theory. Outline: This is a descriptive study, an experience report, developed in March 2019 after nursing care for a patient diagnosed with accidental tetanus, admitted to an intensive care unit (ICU) of a public hospital. Results: The elaboration of the care plan included information about the risk diagnosis and real diagnosis, nursing interventions and expected results, associated with the affected basic human need. Implications: It is well known that the provision of qualified care in the admission of patients with suspected accidental tetanus as well as their proper referral to the ICU contributes to a better prognosis.


Author(s):  
Harlon França de Menezes ◽  
Jéssica Lima Moura ◽  
Sylvia Silva de Oliveira ◽  
Michelle Carneiro Fonseca ◽  
Paulino Artur Ferreira de Sousa ◽  
...  

ABSTRACT Objective: To develop and validate a terminological subset of the International Classification for Nursing Practice for COVID-19 patients in critical care. Method: This is a methodological study, which followed the guidelines of the Brazilian method, using the Basic Human Needs as a theoretical model. Content validation was performed by 25 specialist nurses using the Delphi technique. Results: A total of 73 diagnoses and their respective nursing results were prepared. Of these, 62 statements had a Content Validity Index ≥ 0.80, with the need for oxygenation having the highest number of statements. Of the 210 nursing interventions developed, and after suggestions from experts, 150 interventions reached an index ≥ 0.80 and comprised the terminological subset. Conclusion: The terminological subset developed showed statements that were validated by specialist nurses and, therefore, are relevant to the nurse's clinic in the critical care scenario associated with Covid-19.


2021 ◽  
Vol 74 (2) ◽  
Author(s):  
Ludimila Paiva Zamprogno Silva ◽  
Cândida Caniçali Primo ◽  
Thiago Nascimento do Prado

ABSTRACT Objectives: to develop an ICNP® terminology subset to care for people with tuberculosis. Methods: a methodological research that followed the following steps: identification and validation of empirical indicators of altered needs relevant to people with tuberculosis based on literature; cross-mapping of the empirical indicators of altered needs identified with ICNP® 2017 terms; construction of nursing diagnoses/outcomes and interventions; assessment of relevance of nursing diagnoses /outcomes and interventions and ICNP® terminology subset structuring. Results: an ICNP® terminology subset was developed to care for people with tuberculosis with 51 diagnoses/outcomes and 264 nursing interventions, assessed by nurses from Primary Health Care and structured according to Wanda Horta’s Theory of Basic Human Needs. Final Considerations: the subset is a technological instrument through which it is possible to identify the elements of nursing practice from the affected human needs.


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 ◽  
...  

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.


2018 ◽  
Vol 71 (5) ◽  
pp. 2535-2542 ◽  
Author(s):  
Richardson Augusto Rosendo da Silva ◽  
Romanniny Hévillyn Silva Costa ◽  
Laísi Catharina da Silva Barbalho Braz ◽  
Indira de Araújo Lucena ◽  
Kalyane da Silva Ferreira ◽  
...  

ABSTRACT Objective: To analyze the association between nursing diagnoses and sociodemographic and clinical characteristics in people living with AIDS. Method: Cross-sectional study with 100 people living with AIDS in a University Hospital. Data collection took place between January and July 2015, using an interview script and physical examination. The association occurred through Pearson's Chi-Square Test and Fisher's Exact Test. Results: The most prevalent nursing diagnoses were: ineffective protection, poor knowledge, lack of adherence and sexual dysfunction. Significant associations were observed among nursing diagnoses with the following sociodemographic and clinical characteristics: marital status, place of residence, level of schooling, family income, modes of transmission of acquired immunodeficiency virus, current opportunistic infection, abandonment of treatment, difficulty of access to health services and use of alcohol and illicit drugs. Conclusion: The diagnoses presented significant associations with sociodemographic and clinical aspects.


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