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Redalyc.NANDA International Nursing Diagnoses in Patients Admitted to A Revista da Rede de Enfermagem do Nordeste ISSN: 1517-3852 [email protected] Universidade Federal do Ceará Brasil Ubaldo, Isabela; Matos, Eliane; Chiodelli Salum, Nádia; Balbinot Reis Girondi, Juliana; Brito Shiroma, Lícia NANDA International nursing diagnoses in patients admitted to a medical clinic unit Revista da Rede de Enfermagem do Nordeste, vol. 18, núm. 1, enero-febrero, 2017, pp. 68-75 Universidade Federal do Ceará Fortaleza, Brasil Available in: http://www.redalyc.org/articulo.oa?id=324049855010 How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative DOI: 10.15253/2175-6783.2017000100010 Original Article www.revistarene.ufc.br NANDA International nursing diagnoses in patients admitted to a medical clinic unit Diagnósticos de enfermagem da NANDA Internacional em pacientes internados em unidade de clínica médica Isabela Ubaldo1, Eliane Matos1, Nádia Chiodelli Salum1, Juliana Balbinot Reis Girondi1, Lícia Brito Shiroma1 Objective: Methods: a quantitative study that used as a to identify nursing diagnoses, their defining characteristics and related factors, according to the NANDA-International diagnostic classification (2012-2014). Results: the most prevalent nursing diagnoses are in the areas of sample 134 medical records of patients admitted to a university hospital. The analysis was based on descriptive statistics: frequency and percentage. coping/stress tolerance, safety/protection and comfort. The following are the diagnoses of: risk of infection (93.8%), impaired skin integrity risk (60.4%) and anxiety (60.4%). There was a significant variation in the Conclusion: interpretation of the same diagnosis in relation to the defining characteristics and related factors identified. diagnoses presented in the research are among the most frequent in hospitalized patients with Descriptors: clinical intercurrences. Nursing Diagnosis; Nursing Records; Nursing. Objetivo: Métodos: estudo quantitativo que identificar os diagnósticos de enfermagem, suas características definidoras e fatores relacionados, segundo a classificação diagnóstica da NANDA-Internacional (2012-2014). Resultados: os diagnósticos de enfermagem mais utilizou como amostra 134 prontuários de pacientes internados em um hospital universitário. A análise se deu mediante estatística descritiva: frequência e percentual. prevalentes encontram-se nos domínios enfrentamento/tolerância ao estresse, segurança/proteção e conforto. Destacam-se os diagnósticos de: Risco de infecção (93,8%), Risco de integridade da pele prejudicada (60,4%) Conclusão: diagnósticos apresentados na e Ansiedade (60,4%). Houve significativa variação de interpretação de um mesmo diagnóstico em relação às características definidoras e fatores relacionados identificados. Descritores: pesquisa estão entre os mais frequentes em pacientes internados com intercorrências clínicas. Diagnóstico de Enfermagem; Registros de Enfermagem; Enfermagem. 1 CorrespondingUniversidade Federal author :de Eliane Santa Matos Catarina. Florianópolis, SC, Brazil. Rua Prof. Ayrton Roberto Oliveira, 20, apto 302A. CEP: 88034050 – Itacorubi. Florianópolis, SC, Brazil. E-mail: [email protected] 68 Received: Sept. 13rd 2016; Accepted: Dec. 13rd 2016. Rev Rene. 2017 Jan-Feb; 18(1):68-75. NANDA International nursing diagnoses in patients admitted to a medical clinic unit Introduction human responses to potential and real health proble- ms (5) . The Systematization of Nursing Care became Known worldwide, NANDA International , and is un- - mandatory in Brazil as of 2009, through Resolution (NANDA-I) has been used in Brazil,(6) associated to the derstood as the use of method and strategy(1) of scienti- der study, Nursing Care Systematization is based, sin- 358/2009 of the Federal Nursing Council theory of Basic Human Needs . In the institution un support Nursing care and contribute to the promotion, Needs - fic work to identify situations of health/illness, which ce 1980,(6-7) on the reference framework of Basic Human prevention, recovery and rehabilitation of patient, fa- cess the stage of nursing diagnosis, stopping to regis- . However, it does not incorporate in the pro - mily and community health. ter the patient’s problems for the planning of care. The of the diagnostic stage for nursing care planning and The Nursing Assistance Systematization orga present study is justified considering the importance - the diversity of pathologies of patients admitted to the nizes the professional work on the method, personnel - and instruments, making possible the operationali - zation of the Nursing process, which is structured in medical units of the studied institution, which can be five stages: nursing history, nursing diagnosis, nursing nefit from quality and individualized care, made pos - Understanding that nursing diagnosis is an planning, implementation and evaluation of nursing. sible by the nursing diagnosis. thodological instrument guiding nursing care and do- important part of care systematization, the study ai- The nursing process, in turn, is understood as the me cumentation of professional practice As part of the nursing process,(1) the nursing characteristics and related factors, according to the . med at identifying nursing diagnoses, their defining diagnosis is an important nursing research topic in terms of nursing assessment quality, interventions NANDA-I diagnostic classification (2012-2014). Methods and continuity of care and results, as well as facilitating communication in the planning of nursing(2) care or prescription and - . This is a fundamental step - servational study carried out in a medical clinic unit of This is a non-probabilistic, cross-sectional, ob Identification of the patient’s actual or potential he the Nursing Care Systematization, according to the Ba- alth problems with their particular characteristics, ie, the University Hospital of southern Brazil, which uses (3) for the planning of care of in an individualized way, using scientific reasoning . (6) The nursing diagnosis is the basis for the selection of sic Human Needs model In this institution, Nursing Care Systematiza- nursing interventions, in order to reach the expected the hospitalized patients. (4) - tion is developed based on the nursing history carried results with nursing care . - The use of the term nursing diagnosis is still re cent, both in Brazil and in the international context. out during the first 24 hours of the patient’s hospita - The first conference was created in 1973 with the aim lization, in which nursing problems are identified. For nursing prescription has been performed, in the daily of creating a diagnostic classification system com these problems, nursing care is prescribed. Once the conference that nurses from Canada and the United evolution of nursing, the evaluation of the clinical con- patible with computer science; And it was from this - dition of the patient and the response of the patient States created the National Group for the Classifica - tion of Nursing Diagnosis in 1982 named then North to the nursing care are made. The prescription is then (4)- American Nursing Diagnosis Association (NANDA) . updated according to the patient’s condition. The nur sing as a science capable of diagnosing and treating of the problems/needs and to the establishment of the In 1980 the American Nurses Association defines nur sing diagnosis stage corresponds to the identification Rev Rene. 2017 Jan-Feb; 18(1):68-75. 69 Ubaldo I, Matos E, Salum NC, Girondi JBR, Shiroma LB degree of dependence of the patient ; this step is not (6) - data, the simple frequencies of identification of each adopted in the institution. diagnosis were observed, these being tabulated throu participants in the collection to identify the Nursing Eight nurses from the medical clinic unit were gh absolute frequency and percentage. - The medical records of all patients hospitalized performed by the nurses during the history of the pa- - Diagnostics. The identification of the diagnoses was during the study period were analyzed, i.e., 134 pa tients (medical records), of which in 129 nursing diag in each of the medical records, and the same medical tient and afterwards, they were reassessed, modified, noses were identified. Daily records were considered maintained or added with new diagnoses in the daily performance of the nursing evolution. record was evaluated more than once, depending on - - Data collection took place for 60 days, in June the length of hospital stay. ments contained in the national and international and July 2012, during which 134 patients with va The study complied with the formal require - regulatory standards for research involving human rious pathologies were admitted to the study unit. The nurses performed 1223 nursing processes invol ving these patients. In 994 of the evaluated processes beings. Results the Nursing Diagnosis was included as part of it. At the beginning of the research the nurses chose to work with 8 diagnoses that they understood to be the most frequent in the reality to be studied. At the beginning The results indicate an important nursing need to include three other diagnoses, therefore, 11 is performed daily for each of the patients hospitali- of the research process, however, they realized the adhesion to the Nursing Care Systematization, which - - - sing history, prescription and nursing
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