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Nursing diagnoses focused on universal self-care requisites
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Orientador(es)
Resumo(s)
Aims: (1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to
determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing
diagnoses syntaxes within the scope of universal self-care requisites.
Background/Introduction: Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals’
dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing
diagnoses and interventions.
Methods: A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2.
focus group to explore implicit criteria or insights from content analysis results.
Results: From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites
emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that
emerged after a focus group meeting.
Conclusion: Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or
potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people
with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs.
Implications for nursing practice: Representation of most relevant nursing diagnoses within the scope of universal self-care requisites.
Implications for health policy: Incorporating standardized language into electronic health records is not enough for improving quality
and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in
the backend to meet these requirements.
Descrição
Palavras-chave
Activities of Daily Living Electronic Health Records Focus Groups, Models Nursing Diagnoses
Contexto Educativo
Citação
International Nursing Review.Vol.68, (3) 2021
Editora
International Council of Nurses (ICN)