PURPOSE. The aim of this study was to describe the use of nursing terminologies in the care plans made for patients in a cardiology rehabilitation unit.
METHODS. We retrospectively examined the clinical documentation for all patients admitted to a cardiology program in a small hospital in the northeast of Italy in 2008.
FINDINGS. The sample included 76 patients (87% male) with an average age of 60 years. Care plans included 21 NANDA-I nursing diagnoses and three collaborative problems, 45 Nursing Outcomes Classifications (NOC) and 46 Nursing Intervention Classifications (NIC). The most frequent diagnoses were the following: decreased cardiac output, activity intolerance, and risk for or presence of imbalanced nutrition (more than body requirements). The prevalent outcomes were related to cardiopulmonary physiological health and knowledge about cardiac disease management and diet. The most frequent nursing interventions were the following: exercise promotion, energy management, weight management, medication management, cardiac precautions, cardiac care (rehabilitative), teaching (prescribed activity/exercise and diet), and vital signs monitoring.
CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE. Nurses in rehabilitative cardiology care are aware of patients' problems, but projects can improve the coherence between concepts, the attention to psychological problems, and self-care.
SCOPO. Lo scopo di questo studio era descrivere l'uso di terminologie infermieristiche nei piani di assistenza prodotti per i pazienti assistiti un un'unità operativa di cardiologia riabilitativa.
METODI. Sono state esaminate in modo retrospettivo le cartelle cliniche di tutti i pazienti trattati in un programma di cardiologia, in un piccolo ospedale del Nord-Est dell'Italia nel 2008.
RISULTATI. Il campione includeva 76 pazienti (87% maschi) con età media di 60 anni. I piani di assistenza includevano 21 diagnosi infermieristiche NANDA e tre problemi collaborativi, 45 esiti NOC e 46 interventi NIC. Le diagnosi più frequenti erano le seguenti: riduzione della gittata cardiaca, intolleranza all'attività e rischio di/nutrizione superiore al fabbisogno. Gli esiti prevalenti erano correlate alla salute fisiologica cardiopolmonare e alle conoscenze sulla gestione della malattia cardiaca e della dieta. I più frequenti interventi infermieristici erano i seguenti: promozione dell'attività fisica, gestione dell'energia, gestione del peso, gestione dei farmaci, precauzioni cardiache, assistenza cardiaca: riabilitazione, insegnamento: attività/esercizi prescritti e dieta e monitoraggio dei parametri vitali.
CONCLUSION E IMPLICAZIONI PER LA PRATICA INFERMIERISTICA. Gli infermieri che operano in cardiologia riabilitativa sono consapevoli dei problemi dei pazienti, ma i piani di assistenza possono essere migliorati in termini di coerenza tra i concetti, e garantendo una maggiore attenzione ai problemi psicologici e alla cura di sé.
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