Diagnósticos de enfermagem na assistência ambulatorial a pacientes com lesões tissulares: mapeamento cruzado

2013 
Introduction: The treatment of patients with wounds, whatever their etiologies are, is a specific role of nursing and requires interventions based on scientific evidence. Within this context, it becomes important that the nurse performs the systematization of nursing care for patients with wounds, thereby contributing to a skilled nursing care, facilitating the recovery of the patient. General Objective: To compare terms from the medical records with the nursing diagnoses proposed by NANDA-I. Specific Objectives: To characterize patients with tissue damage in relation to the gender, age, co-morbidities, length and type of treatment; Identify the terms recorded by nursing staff; Analyze nursing diagnoses most frequently observed in patients with lesions according to the taxonomy NANDA Method: A retrospective and observational study, with a quantitative approach, that employed cross mapping as a methodological tool. The study setting: Wound Repair Ambulatory of HUAP. The sample is of 81 patients with lesions of any etiology, of both genders. The study of the terms occurred using a form for data collection. For data analysis, were extracted terms that indicated nursing problems. These terms were combined with the NANDA-I taxonomy. It was used the simple descriptive statistics. The research appears adequate to ethical principles (FM/ UFF/ HU no 219.752/08-03-2013). Results: The average age of patients was 59.98 years, the treatment time of approximately two years and three months. There is a high prevalence of cardiovascular disease 87 (47.3%) and Diabetes Mellitus 23 (12.5%). The venous ulcer is the type of injury most commonly found in the population attended at the wound care ambulatory, with a frequency of 65.4% (53). Was found a total of 24 nursing diagnoses distributed in 8 domains: Domain 1 - Health Promotion: Ineffective Self control of Health (4.94%); Domain 2 – Nutrition: Unbalanced nutrition: less than body requirements (1.23%), Risk of Unstable Glycemia (9.88%), fluid volume deficit (32.09%) and excessive fluid volume (20.99%); Domain 4 – Activity/Rest: Willingness to improved sleep (1.23%), impaired sleep pattern (1.23%), impaired Deambulation (45.68%), impaired physical mobility (8.64%), Ineffective peripheral tissue perfusion (13.58%), bathing self-care deficit (1.23%); Domain 5 - Perception / cognition: Acute Confusion (3.70%), chronic Confusion (1.23%), impaired memory (1.23%); Domain 9 - Confronting / stress tolerance: Anxiety (6.17%); Domain 10 – Principles of life: Lack of adherence (9.88%); Domain 11 – Security/Protection: Impaired skin integrity (85.18%), risk of impaired skin integrity (11.11%), impaired tissue integrity (14.81%), contamination (7.41%), risk of allergic response (14.81 %); Domain 12 - Comfort: Acute pain (12.34%), chronic pain (27.16%). Conclusion: Through the cross-mapping method of a non-standard language with a standardized language it is possible to identify the nursing diagnoses of clients in treatment of injuries. The proposed study later with data validation by experts disclosed will enable the standardization of nursing care in a classification known internationally, allowing the inclusion of nursing data in computerized information systems for optimization and improvement of quality of care.
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