International Journal of Nursing Knowledge

PURPOSE.  To analyze the degree to which standardized nursing language was used by baccalaureate nursing students completing Outcome-Present State-Test (OPT) model worksheets in a clinical practicum.

METHODS.  A scoring instrument was developed and 100 worksheets were retrospectively analyzed.

FINDINGS.  NANDA nursing diagnoses were correctly stated in 92% of the OPT models. Nursing Outcomes Classification (NOC) outcomes were explicitly stated in 22%, and implied in 72%. Interventions matched appropriate Nursing Interventions Classification (NIC) activities in 61%.

CONCLUSIONS.  NANDA, NIC, and NOC (NNN) language was used inconsistently by students in this sample.

IMPLICATIONS FOR PRACTICE.  If NNN language is to advance nursing knowledge, its promotion, representation in curriculum development, and active use is necessary. Educational research is needed on the facilitators and barriers to NNN language use.

PURPOSE.  To identify the nursing diagnoses and their most frequent related factors or risk factors in patients admitted to an intensive care unit (ICU).

METHOD.  Descriptive cross-sectional study with information from 991 admissions to an ICU during a 6-month period.

FINDINGS.  Sixteen nursing diagnoses resulting from hospitalization were most frequently identified; six had percentages greater than 40% with 29 related/risk factors. The resulting averages were 6.9 diagnoses per hospitalization and 1.2 related/risk factors per nursing diagnoses.

CONCLUSIONS.  The nursing diagnoses identified seemed to be common to the clinical practice of nursing and their fundamental related/risk factors to precise clinical judgment, thus providing a basis for interventions for a desired outcome.

PRACTICE IMPLICATIONS.  The findings have contributed to the development of the standardized nursing language usage in Brazilian nursing practices.

Diagnósticos de Enfermagem em uma Unidade de Terapia Intensiva Brasileira

OBJETIVO.  Identificar os diagnósticos de enfermagem e os seus fatores relacionados/risco mais freqüentemente estabelecidos aos pacientes internados numa unidade de terapia intensiva (UTI).

MÉTODO.  Estudo descritivo, transversal, com informações de 991 admissões numa UTI, durante seis meses.

RESULTADOS.  Dezesseis diagnósticos de enfermagem foram mais freqüentes, seis deles com percentuais acima de 40% por internação e com 29 fatores relacionados ou de risco. As médias foram de 6,9 diagnósticos de enfermagem por internação e 1,2 fatores relacionados ou de risco por diagnóstico de enfermagem.

CONCLUSÕES.  Os diagnósticos de enfermagem identificados parecem ser comuns à prática clínica de enfermagem e os seus fatores relacionados ou de risco fundamentais ao julgamento clínico preciso, que subsidia à escolha da intervenção para um resultado esperado.

IMPLICAÇÕES PARA A PRÁTICA.  Os resultados têm colaborado para o desenvolvimento do uso da linguagem padronizada de enfermagem no Brasil.