ABSTRACT
RESUMO Objetivo: identificar associação entre diagnósticos de enfermagem relacionados à locomoção e ao cuidado corporal com incapacidade funcional em idosos hospitalizados. Método: estudo descritivo, transversal, realizado com 100 idosos em um hospital público, da Paraíba - Brasil, no ano de 2019. Utilizou-se instrumento semiestruturado e Índice de Barthel, sendo elencados diagnósticos a partir da CIPE®. A análise de dados utilizou a estatística descritiva. Resultados: a escala é composta por 17 itens distribuídos em sete domínios: Tratamento Medicamentoso, Assistência Pré-natal, Intervenção Baseada no Senso Comum, Entendimento das Recomendações com Apoio Familiar, Estilo de Vida, Intervenção Dietética e Cuidado de Si. A consistência interna dos domínios pelo alfa de Cronbach variou de 0,527 a 0,597. Conclusão: os diagnósticos identificados fornecem subsídios para planejamento e implementação de cuidados de enfermagem visando menor tempo de hospitalização, prevenindo desfechos desfavoráveis à saúde e garantindo assistência integral e individualizada para a população.
RESUMEN Objetivo: identificar la asociación entre diagnósticos de Enfermería relacionados a la locomoción y al cuidado corporal con incapacidad funcional en adultos mayores hospitalizados. Métodos: estudio descriptivo y transversal, realizado en el año 2019 con 100 adultos mayores en un hospital público de Paraíba - Brasil. Se utilizó un instrumento semiestructurado y el Índice de Barthel, y los diagnósticos se listaron a partir de la clasificación CIPE®. Para el análisis de los dados se utilizó estadística descriptiva. Resultados: la dependencia total se mostró asociada con Capacidad perjudicada para la higiene oral, Capacidad perjudicada para la higiene y Confinado a la cama. La dependencia grave estuvo asociada con Capacidad perjudicada para la higiene oral, Capacidad perjudicada para la higiene, Capacidad perjudicada para vestirse, Movilidad perjudicada y Confinado a la cama. Conclusión: los diagnósticos identificados proporcionan apoyos para planificar e implementar medidas de atención de Enfermería con vistas a reducir los tiempos de hospitalización, previniendo así consecuencias desfavorables para la salud y garantizando asistencia integral e individualizada para la población.
ABSTRACT Objective: to identify the association of Nursing diagnoses related to locomotion and body care with functional disability in hospitalized older adults. Method: a descriptive and cross-sectional study conducted in 2019 with 100 older adults in a public hospital from Paraíba, Brazil. A semi-structured instrument and the Barthel Index were used, with diagnoses being listed from the ICNP©. Descriptive statistics was used for data analysis. Results: total dependence was associated with Impaired ability to perform oral hygiene, Impaired ability to perform hygiene, and Impaired mobility in bed. Severe dependence was associated with Impaired ability to perform oral hygiene, Impaired ability to perform hygiene, Impaired ability to dress, Impaired mobility, and Impaired mobility in bed. Conclusion: the diagnoses identified provide support for planning and implementing Nursing care aimed at shorter hospitalization times, preventing unfavorable health outcomes and ensuring comprehensive and individualized care for the population.
ABSTRACT
OBJECTIVES: The purpose of this study is to explore possibility of information sharing between the medical and nursing domains. METHODS: Narrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts. RESULTS: A total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts. CONCLUSIONS: These mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.
Subject(s)
Humans , Electronic Health Records , Gastrectomy , Hospitalization , Information Dissemination , Information Management , Medical Records , Patient Care , Systematized Nomenclature of Medicine , Vocabulary, ControlledABSTRACT
The purpose of this study was to seek the approach structuring the descriptive nursing documents and using the terminology as controlled vocabula ry in elec tronic nursing r ecord through the analysis of contents re corded in paper-based nursing documentation forms with the International Classification for Nursing Practice(ICNP). Sixty three patients'nursing re cords, corresponding to documents of 395 days of a teaching Hospital in Seoul were used. From the chart review of the 5 nursing record forms; Nurses'note, Deliver y Floor Nur sing Record I, II, Nur sing History Record(Mate rnity), Nur sing Discha rge Plan(Maternity), na rrative da ta and formatted data wer e collecte d and analyzed separately. Na rrative data were broke down semantically into single sentences and classified according to the semantics. Formatted data were summarized by concepts from the nursing forms'items. Fourteen thousand seven hundred twenty-seven statements and sixty-three items were analyzed. In the process of decomposing the narrative data into single statements, a constant pattern of contents like the nursing process and some contextual information, such as the other health professions'behaviors or plans which were not classified in nursing phenomena or actions, were found. The 14,727 statements were represented into 237 unique statements and decomposed into 259 unique concepts. Among those 39.8%(103) were identified as local vocabulary, which represents the concrete concepts in detail in the maternity nursing field. In the analysis of 48 formatted items, 23(47.9%) concepts were local vocabulary. These study findings implied the effective method of structuring the narrative nursing documents and supported the importance of identifying the local vocabulary in terminology of ICNP based approach to improve and complement the expressiveness of clinical practice in detail enough.
ABSTRACT
The purpose of this study was to develop and test the validity of standardized Korean nomenclature of the International Classification for Nursing Practice (ICNP), developed by the International Council of Nursing (ICN). The four phases of the study were: (1) Two professors and 15 graduate students translated who were taking a nursing intervention course, translated nursing phenomena and nursing action of the ICNP into Korean; (2) 12 nurses with various clinical backgrounds reviewed the nomenclature taking into consideration of the definition, and contents for each Korean nursing terminology, and the Delphi method was used to determine the best appropriate nomenclature for each terminology; (3) 20 academic and clinical experts in nursing were given a questionnaire to rate the validity of each Korean nomenclature using a 5 point Likert scale ranging from very inappropriate to very appropriate; (4) five members of the Korean Nurses Association Research Committee reviewed the survey results and determined the most appropriate Korean nomenclature for each nursing phenomena and activity of the ICNP. Most nomenclature of the ICNP had a score of more than 4.0, but four nursing phenomena had a score between 3.5 and 4.0: Unilateral neglect(3.86), Care Giver strain (3.86), Health denial(3.86), Health Adjustment (3.86) and draining(2.63) . In nursing activity 726 items, except for twelve items, had a score of over 4.0: Drainage(2.63) Weaning(3.13), Caring(3.75), Cold Wrapping(3.63), distraction Technique(3.57), drawing(3.88), Establishing Report with(3.5), Heating Wrapping(3.5), Manipulating(3.75), Performing(3.88), Reading material(3.75) and Restricting(3.75).