Salgado Patrícia de Oliveira, Chianca Tânia Couto Machado
Hospital Municipal Odilon Behrens, Belo Horizonte, MG, Brazil.
Rev Lat Am Enfermagem. 2011 Jul-Aug;19(4):928-35. doi: 10.1590/s0104-11692011000400011.
This is a descriptive study with the aim of examining the nursing diagnoses labels and actions prescribed by nurses in the clinical records of patients hospitalized in an Adult Intensive Care Unit. A sample of 44 clinical records was obtained and a total of 1087 nursing diagnoses and 2260 nursing actions were identified. After exclusion of repetitions 28 different nursing diagnoses labels and 124 different nursing actions were found. Twenty-five nursing diagnoses labels were related to human psychobiological needs and three to psychosocial needs. All the nursing actions were mapped to the physiological needs and also to interventions of the Nursing Interventions Classification-NIC. Concordance of 100% was obtained between the experts in the validation process of the mapping performed, both for the nursing diagnoses labels and actions. Similar studies should be conducted for the identification and development of nursing diagnoses and actions.
这是一项描述性研究，旨在检查成人重症监护病房住院患者临床记录中护士开出的护理诊断标签和护理措施。获取了44份临床记录样本，共识别出1087项护理诊断和2260项护理措施。排除重复项后，发现了28种不同的护理诊断标签和124种不同的护理措施。25种护理诊断标签与人类心理生物学需求相关，3种与心理社会需求相关。所有护理措施都对应于生理需求以及护理干预分类系统（NIC）的干预措施。在护理诊断标签和护理措施的映射验证过程中，专家之间的一致性达到了100%。应开展类似研究以识别和制定护理诊断及护理措施。
