Validación de diagnósticos, resultados e intervenciones de enfermería de la clínica pediátrica

Dantas, Ana Márcia Nóbrega; Silva, Kenya de Lima; Nóbrega, Maria Miriam Lima da

doi:10.1590/0034-7167-2016-0647

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RESEARCH • Rev. Bras. Enferm. 71 (1) • Jan-Feb 2018 • https://doi.org/10.1590/0034-7167-2016-0647 linkcopiar

Validación de diagnósticos, resultados e intervenciones de enfermería de la clínica pediátrica

Autoría SCIMAGO INSTITUTIONS RANKINGS

Objetivos: Elaborar las definiciones operacionales de los diagnósticos de la Nomenclatura de diagnósticos, resultados e intervenciones de enfermería de la Clínica Pediátrica de un Hospital Escuela y realizar la validación de contenido y clínica de la referida Nomenclatura.

Método: Pesquisa metodológica, desarrollada en dos etapas: estudio documental, para la validación de contenido de las definiciones operacionales de los diagnósticos de enfermería; y pesquisa aplicada, del tipo estudio de casos clínicos, realizada con niños de 0 a 5 años.

Resultados: Los 126 diagnósticos fueron sometidos a la validación por consenso y 55,6% fueron validados. Fueron realizados seis estudios de casos clínicos, utilizando las fases del proceso de enfermería, fundamentado en la teoría de las Necesidades Humanas Básicas, identificándose 24,3% de los diagnósticos validados y 54,5% de las intervenciones de enfermería constantes en la Nomenclatura.

Conclusión: El estudio mostró la eficacia del uso de la Nomenclatura en la Clínica Pediátrica, de modo a mejorar, cuidar y permitir la realización de una asistencia de cualidad.

Descriptores:
Enfermería; Procesos de Enfermería; Salud de Niños; Clasificación de la Práctica; Estudios de Validación

Basic human needs	Nursing diagnosis	F	%
Psychobiological Needs
Oxygenation	Impaired respiration	2	33.3
Hydration	Dehydration	3	50.0
Hydration	Edema	1	16.8
Nutrition	Impaired appetite	1	16.8
Nutrition	Alimentary intolerance	1	16.8
Elimination	Diarrhea	2	33.3
Sleep and rest	Impaired Sleep	2	33.3
Sleep and rest	Adequate Sleep	1	16.8
Activity and exercise Physical/mechanical corporal/ motility	Impaired physical mobility	1	16.8
Body care	Impaired oral hygiene	2	33.3
Body care	Appropriate body hygiene	1	16.8
Physical and cutaneo-mucosal integrity	Impaired skin integrity	2	33.3
Thermoregulation	Hyperthermia	1	16.8
Immunological regulation	Risk for infection	4	66.8
Perception	Pain	1	16.8
Psychosocial necessities
Education for health/learning	Lack of knowledge of mother / caregiver about disease and treatment	4	66.8
Recreation, leisure, creativity	Disrupted recreational activities	1	16.8

Nursing diagnosis	Nursing interventions
Risk for infection	Attempt to control the infused volume; Evaluate the performance of personal hygiene of the child; Assess the site of peripheral venous access daily; Teach protective measures to minimize the risk for infection; Install the medication to infuse in 2h; Advise on necessary care, such as the location of the puncture, to avoid infection; Monitor vital signs; Orient the team regarding care with aseptic techniques; Guide the mother about the importance of handwashing and maintaining bodily hygiene; Perform procedures using aseptic technique; Make puncture using aseptic technique and check AP* before, during and after infusion of methylprednisolone.
Lack of knowledge of mother / caregiver about disease and treatment	Assess the mother's learning ability; Clarify the mother's questionsabout the illness and treatment of the child; Clarify questions that arise after the technique performed; Explain the procedures to be performed; Orient the mother on care for handling and positioning of the NB** for breastfeeding; Orient the mother regarding nipple care; Orient the mother on signs indicative of convulsion; Guide the mother about the illness and treatment of the child; Employ feedback technique for guidance on diagnosis and treatment.
Dehydration	Control the volume of fluid infused; Control venous infusion; Evaluate the control of diuresis (weighing diapers); Evaluate signs and symptoms of dehydration (depressed fontanelle, decreased diuresis, dry skin); Stimulate the intake of 20 ml of liquids in the interval between each bottle; Stimulate the intake of liquids of 30 to 50 ml in the intervals between diet; Maintain peripheral venous access; Guide the mother about the importance of fluid intake; Guide the mother about maintaining breastfeeding on demand.
Diarrhea	Administer ointment (vitamins A and D) in the affected region; Assess the affected region for appearance and coloration daily; Evaluate the frequency and characteristics of feces; Evaluate the skin and mucous membranes of the genital area; Maintain the intimate hygiene of the infant/newborn; Keep skin clean and dry; Monitor the perianal skin to detect irritations and ulcers daily; Guide the mother to perform hygiene with soap and water, not with moist tissues; Provide guidance on pre and post evacuation care; Guide regarding diaper changes; Guide the hygiene of the bottles daily; Guidance on hand hygiene; Supervise skin care; Check the weight once a week.
Impaired Skin Integrity	Administer EFAs (essential fatty acids) on the sites of lesions with crusts and cicatrization; Administer prescribed ointment at the site of open lesions; Assess the affected region daily; Evaluate lesion characteristics daily; Stimulate hydration by offering 100 ml cups of water; Keep skin clean and dry; Orient the mother regarding the corporal hygiene of the child; Orient the mother on hand washing and maintenance of the child's corporal and oral hygiene; Orient the mother on the care of lesions; Guidance on care with application and removal of ointment in the perianal region; Guide the prevention of rashes and supervise skin care.
Impaired oral hygiene	Evaluate oral hygiene daily; Evaluate after each oral hygiene; Evaluate the characteristics of mouth odor; Contact the dentist for the treatment of cavities; Praise the child or the mother regarding the continuity of care with oral hygiene; Teach the child and mother the principles of good oral hygiene; Provide guidance on the need to brush teeth and oral hygiene with bicarbonate water.
Impaired Sleep	Encourage recreational activities during the day; Provide a calm and safe environment; Guide the nursing team and mother to perform nasal lavage whenever the nostrils are clogged and before bed; Orient the mother on measures to improve sleep, for example: raising the headboard; Assess the clinical picture to check for daily airway discomfort and obstruction;
Impaired breathing	Administer nebulization with saline solution at the drug nebulization intervals; Assess respiratory auscultation daily; Contact the physiotherapist to discuss child care; Raise the head of the bed; Stimulate the intake of liquids, offering glasses of 50 to 100ml; Guide the mother to keep the child clothed; Orient the mother on the child's nasal hygiene; Perform nasal lavage with 0.9% saline prior to nebulization; Check for vital signs every 6 h

Necessidades humanas básicas	Diagnóstico de enfermagem	F	%
Necessidades psicobiológicas
Oxigenação	Respiração prejudicada	2	33,3
Hidratação	Desidratação	3	50,0
Hidratação	Edema	1	16,8
Nutrição	Apetite prejudicado	1	16,8
Nutrição	Intolerância alimentar	1	16,8
Eliminação	Diarreia	2	33,3
Sono e repouso	Sono prejudicado	2	33,3
Sono e repouso	Sono preservado	1	16,8
Exercício e atividade física/mecânica corporal/ motilidade	Mobilidade Física prejudicada	1	16,8
Cuidado corporal	Higiene oral prejudicada	2	33,3
Cuidado corporal	Higiene corporal preservada	1	16,8
Integridade física e cutaneomucosa	Integridade da pele prejudicada	2	33,3
Regulação térmica	Hipertermia	1	16,8
Regulação imunológica	Risco de infecção	4	66,8
Percepção	Dor	1	16,8
Necessidade psicossocial
Educação para a saúde/aprendizagem	Falta de conhecimento da mãe/responsável sobre a doença e tratamento	4	66,8
Recreação e lazer, criatividade	Atividades de recreação interrompida	1	16,8

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Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[TFN1] Notes:

[TFN2] ^*
Arterial Pressure

[TFN3] ^**
Newborn