Nursing documentation related to respiratory process: content analysis of portuguese health records

• Autor(a) principal: Gaspar,Luís
• Data de Publicação: 2023
• Outros Autores: Reis,Neuza, Sousa,Paula, Silva,Abel Paiva e, Pereira,Filipe, Machado,Natália
• Tipo de documento: Artigo
• Idioma: eng
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: http://scielo.pt/scielo.php?script=sci_arttext&pid=S2184-15782023000100073
• topic: nursing diagnosis; nursing process; advanced practice nursing; respiration

Abstract Background: data sharing from clinical practice is crucial to support nurses' decision-making process, improve nursing outcomes, and increase the quality of care. In Portugal, International Classification for Nursing Practice is used to document care being necessary for the standardization of this process preventing information redundancy. Objectives: (1) to identify diagnoses and interventions used by Portuguese nurses related to Respiratory Process, (2) to suggest unified diagnoses and interventions syntaxes. Methodology: qualitative study with a content analysis. The sample included data regarding e-documentation of nursing diagnosis and interventions customized in the nursing public information system until 2019. Results: of the initial sample of 1502 diagnoses aroused 28 and from 2060 interventions emerged 73 as the most relevant. The main findings were: two areas of nursing attention, one related to respiratory function and the other to patient's learning abilities, diversity of diagnoses and interventions to express the same needs resulting from a variety of taxonomic misunderstandings, and lack of standardized language. Conclusions: nursing documentation have two dimensions representing the complexity of nursing care. It also shows that using standardized language does not prevent information redundancy resulting in different diagnoses and interventions to express the same needs.