Nursing diagnoses in post-anesthetic recovery: outcomes and interventions according to standardized languages

Abstract

Introduction: the classification systems with standardized languages are established in a set of structured knowledge, concepts founded in a logical and coherent way, based on their similarities. In this sense, identifying a profile with the populations can cooperate for a better definition and situational understanding for that unit and/or patients. Objectives: to perform cross-mapping between the nursing diagnoses of NANDA-I with the manual nursing records in the post-anesthetic recovery room; and, to propose interventions and outcomes, according to standardized language. Method: exploratory, descriptive and retrospective analysis of the nursing records of 187 patients hospitalized from June to July 2018, in the post-anesthetic recovery room of an oncology hospital. Cross-mapping was carried out in three stages: identification of diagnostic indicators; proposition of interventions and activities; and outcomes indicators. The data were analyzed and described in absolute and relative frequencies. Results: of the 13 NANDA-I domains, five were highlighted; were identified five risk diagnoses and 11 focused on the problem; 100% frequency was observed for the diagnoses of: Aspiration, infection and falling risk; Impaired transfer capacity; Impaired bed mobility; Impaired skin/tissue integrity and impaired comfort. Conclusions: from the 16 nursing diagnoses mapped, were selected 22 interventions and 58 activities; 23 results and 48 outcomes indicators.

Keywords

• postanesthesia nursing
• nursing records
• nanda-i
• nic terminology
• noc terminology