Leenara Bezerra da Silva Cyntia, Lopes de Moura Ericles, Nayara do Nascimento Dantas Thuanny, Matias Karolayne Cabral, Melo de Carvalho Leandro, Vitor Allyne Fortes
Department of Nursing, Federal University of Rio Grande do Norte, Brazil.
Heliyon. 2024 Feb 27;10(5):e27088. doi: 10.1016/j.heliyon.2024.e27088. eCollection 2024 Mar 15.
To identify and analyze the nursing diagnoses listed in the medical records of COVID-19 patients admitted to an intensive care unit using Taxonomy II of NANDA-I. : COVID-19 is a complex disease with heterogeneous behaviors, and the role of intensive care nurses in accurately identifying related signs and symptoms has become even more critical during the pandemic. Nurses rely on classification systems or taxonomies to standardize concepts and language in practice. : This quantitative study employed a descriptive and individual approach, utilizing the cross-mapping method. Data were collected from 57 medical records of critical care patients in a hospital in northeastern Brazil between July 2020 and March 2021. Three researchers analyzed the mapped diagnoses, and agreement was assessed using the Content Validation Index and Fleiss' Kappa. : Among the listed nursing diagnoses, 54.28% were found to be standardized, 45.71% had corresponding nursing diagnoses, and 5.71% did not have an equivalent diagnosis in the reference taxonomy used in the study. Due to the possibility of multiple nursing diagnoses in the same patient, the most frequent diagnoses were Risk of pressure injury in adults (66.66%), Risk of falls in adults (64.91%), and Risk of infection (45.61%). Among the 37 diagnoses mapped, the risk diagnoses were the most prevalent and could be prevented if identified early. : The study highlights the importance of standardized nursing diagnoses in the ICU for COVID-19 patients and the need for accurate identification and prevention of risk diagnoses to enhance patient care and improve outcomes.
使用北美护理诊断协会(NANDA-I)的护理诊断分类系统II,识别并分析入住重症监护病房的新冠肺炎患者病历中列出的护理诊断。:新冠肺炎是一种行为表现多样的复杂疾病,在疫情期间,重症监护护士准确识别相关体征和症状的作用变得更加关键。护士依靠分类系统在实践中规范概念和语言。:这项定量研究采用描述性和个体研究方法,运用交叉映射法。2020年7月至2021年3月期间,从巴西东北部一家医院的57份重症监护患者病历中收集数据。三名研究人员分析映射的诊断,并使用内容效度指数和Fleiss' Kappa评估一致性。:在所列出的护理诊断中,发现54.28%是标准化的,45.71%有相应的护理诊断,5.71%在该研究使用的参考分类系统中没有等效诊断。由于同一患者可能存在多种护理诊断,最常见的诊断是成人压力性损伤风险(66.66%)、成人跌倒风险(64.91%)和感染风险(45.61%)。在映射的37项诊断中,风险诊断最为普遍,如果能早期识别,这些风险是可以预防的。:该研究强调了标准化护理诊断在新冠肺炎患者重症监护病房中的重要性,以及准确识别和预防风险诊断以加强患者护理和改善治疗结果的必要性。