Cardoso Patrícia Cristina, Gussatschenko Caballero Larissa, Brasil Ruschel Karen, Pereira de Moraes Maria Antonieta, Rabelo da Silva Eneida Rejane
Clinical Hospital of Porto Alegre, Brazil,
Institute for Health Technology Assessment, Federal University of Rio Grande do Sul, Brazil,
Invest Educ Enferm. 2019 May;37(2). doi: 10.17533/udea.iee.v37n2e08.
To identify the nursing diagnoses through reports in the medical records of patients monitored in a specialized ischemic heart disease outpatient clinic.
Cross-sectional study with retrospective data collection in the medical records. From the data collected, the nursing diagnoses were proposed by the researchers and submitted for validation by specialist cardiology nurses.
A total of 13 nursing diagnoses were evaluated from the medical records of 50 outpatients with the following validation agreements among the specialists: Ineffective health management (100%), Noncompliance (100%), Sedentary lifestyle (100%), Activity intolerance (100%), Decreased cardiac output (88%), Risk of decreased cardiac tissue perfusion (65%), Risk of intolerance to activity (65%), Acute pain (76%), Ineffective health maintenance (65%), Risk-prone health behavior (65%), Risk for decreased cardiac output (65%), Risk for intolerance to activity (65%), Ineffective respiratory pattern (53%), Impaired memory (29%).
In this study, the nursing diagnoses validated for stable heart disease patients were linked to adherence to treatment and to the cardiovascular responses of the patients, reinforcing the importance of early intervention. These results allow the multidisciplinary team to individualize the goals and interventions proposed for ischemic heart disease patients.
通过在一家专门的缺血性心脏病门诊监测的患者病历报告来确定护理诊断。
采用横断面研究,对病历进行回顾性数据收集。研究人员根据收集的数据提出护理诊断,并提交给心脏病专科护士进行验证。
从50名门诊患者的病历中总共评估了13项护理诊断,专家之间的验证一致性如下:健康管理无效(100%)、不依从(100%)、久坐不动的生活方式(100%)、活动不耐受(100%)、心输出量减少(88%)、心脏组织灌注减少风险(65%)、活动不耐受风险(65%)、急性疼痛(76%)、健康维持无效(65%)、易发生健康行为风险(65%)、心输出量减少风险(65%)、活动不耐受风险(65%)、呼吸模式无效(53%)、记忆受损(29%)。
在本研究中,经验证的稳定型心脏病患者护理诊断与治疗依从性和患者的心血管反应相关,强化了早期干预的重要性。这些结果使多学科团队能够针对缺血性心脏病患者提出的目标和干预措施实现个体化。