Hospital de Magalhães Lemos (Oporto), Porto, Portugal.
Escola Superior de Enfermagem do Porto (Oporto Nursing School), Porto, Portugal.
Int Nurs Rev. 2019 Jun;66(2):199-208. doi: 10.1111/inr.12493. Epub 2018 Oct 17.
To identify the diagnoses documented by nurses in Portugal to describe the nursing needs within the scope of mental health nursing and the main problems in documenting these needs.
BACKGROUND/INTRODUCTION: The diagnosis process is an essential step in nursing care planning. This process should be carried out by nurses in a rigorous and standardized manner, in order to ensure quality practices and to obtain indicators that can increase the visibility of nursing care.
The 2014 initial diagnosis records were systematized into 78 final diagnostic categories, which may represent the most relevant diagnoses in the field of mental health nursing in Portugal. The main problems found in the diagnostic identification by nurses included lack of a standardized language; confusion between nursing diagnoses and focus areas and identification of incongruent clinical judgements.
DISCUSSION/CONCLUSION: The changes observed in the fields of behaviour, emotions and psychological process correspond to the largest concentration of nursing diagnoses and challenges in Portugal. This study revealed the lack of standardized language used by nurses in defining diagnoses. The problems identified in the diagnoses documentation suggest that more training in this area is needed.
This study provides information on the most relevant diagnoses in the area of mental health nursing in Portugal and may offer an important contribution towards improving nursing informatics systems and care to patients by means of standardization of language used in diagnosis definitions.
The standardization of language used by mental health nurses may contribute towards producing health indicators that provides evidence to policymakers about the contribution made by nursing care towards improved population health.
确定葡萄牙护士记录的诊断，描述精神科护理范围内的护理需求以及记录这些需求的主要问题。
背景/引言：诊断过程是护理计划的重要步骤。这个过程应该由护士严格、标准化地进行，以确保护理实践的质量，并获得可以增加护理可见度的指标。
一项描述性研究，结合：1. 对在葡萄牙国家卫生服务机构的 39 个精神科部门工作的护士所写的护理诊断记录进行定量内容分析，2. 对 14 名护士进行焦点小组会议，以探讨第一研究阶段的结果。对定性和定量数据进行内容分析。
2014 年最初的诊断记录被系统化为 78 个最终诊断类别，这些类别可能代表了葡萄牙精神科护理领域最相关的诊断。护士在诊断识别中发现的主要问题包括缺乏标准化语言；护理诊断与重点领域之间的混淆以及识别不一致的临床判断。
讨论/结论：观察到的行为、情绪和心理过程领域的变化与葡萄牙最大的护理诊断和挑战相对应。这项研究揭示了护士在定义诊断时缺乏标准化语言。在诊断文件记录中发现的问题表明，在这方面需要更多的培训。
本研究提供了葡萄牙精神科护理领域最相关诊断的信息，并且可以通过标准化诊断定义中使用的语言为改善护理信息学系统和患者护理做出重要贡献。
精神科护士使用的语言标准化可能有助于产生健康指标，为政策制定者提供证据，说明护理对改善人口健康的贡献。
