Diagnósticos de enfermería de la CIPE<sup>®</sup> para la práctica clínica de la rehabilitación en lesiones de la médula espinal

Clares, Jorge Wilker Bezerra; Moreira, Samara Oliveira; Fernandes, Bruna Karen Cavalcante; Freitas, Maria Célia de

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 75 (1) • 2022 • https://doi.org/10.1590/0034-7167-2021-0670 copiar

Diagnósticos de enfermería de la CIPE^® para la práctica clínica de la rehabilitación en lesiones de la médula espinal

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

construir enunciados de diagnósticos de enfermería para la práctica clínica de rehabilitación de personas con lesión medular utilizando la Clasificación Internacional para la Práctica de Enfermería (CIPE^®) y la teoría del autocuidado de Orem.

Métodos:

estudio metodológico desarrollado en cuatro etapas: identificación de términos relevantes para la práctica clínica de enfermería en la rehabilitación de personas con lesión medular; mapeo de términos seleccionados con términos CIPE^®; construcción de enunciados de diagnósticos de enfermería; mapeo de enunciados construidos con conceptos pre-coordinados de la CIPE^®.

Resultados:

fueron construidos 241 enunciados de diagnósticos de enfermería, categorizados de acuerdo con los requisitos de autocuidado de la teoría. Los enunciados más prevalentes fueron los relacionados con los requisitos universales, seguidos de los requisitos de desarrollo y las desviaciones de la salud.

Conclusiones:

los diagnósticos de enfermería construidos reflejan la complejidad de los fenómenos evidenciados en la práctica clínica de rehabilitación, permitiendo una atención sistemática e integral a la persona con lesión medular.

Descriptores:
Diagnóstico de Enfermería; Terminología Normalizada de Enfermería; Clasificación; Enfermería en Rehabilitación; Traumatismos de la Médula Espinal

Universal requisites	Nursing diagnoses
Oxygenation and circulation	Bradycardia (10027274); Heart rate within normal limits (10029229); Effective tissue perfusion (10028593); Impaired peripheral tissue perfusion (10044239); Altered blood pressure (10022954); Blood pressure within normal limits (10027647); Tachycardia (10027288).
Nutrition and hydration	Impaired self feeding (10000973); Low weight (10027316); Impaired swallowing (10001033); Excessive food intake (10000682); Insufficient food intake (10000607); Improved food intake (10047324); Improved fluid intake (10047330); Impaired fluid intake (10029873); Weight within normal limits (10027392); Impaired weight (10013016); Overweight (10027300).
Elimination and excretion	Constipation (10000567); Constipation absent; Improved constipation; Bowel continence (10027741); Urinary continence (10027836); Effective defecation (10028403); Impaired defecation (10022062); Peripheral edema (10027482); No peripheral edema absent (10029020); Increased urinary frequency; Normal urinary frequency; Reduced urinary frequency; Fecal impaction (10021885); Bowel incontinence (10027718); Urinary incontinence (10025686); Stress urinary incontinence (10026797); Urge urinary incontinence (10026811); Functional incontinence of urine (10026778); Overflow incontinence of urine (10026914); Reflex incontinence of urine (10026784); Total urinary incontinence (10026807); Effective urination (10047245); Impaired urination (10021790); Absent urethral resistance; Urethral resistance; Urinary retention (10034654); Risk for constipation (10015053); Risk for urge incontinence of urine (10026848); Risk for urinary retention.
Activity and rest	Effective active range of motion (10052082); Impaired active range of motion (10052095); Impaired ability to transfer (10001005); Able to mobilize (10028461); Able to move in bed (10029240); Able to transfer (10028322); Activity intolerance (10000431); Impaired walking (10001046); Effective wheelchair mobility; Impaired wheelchair mobility (10001363); Effective mobility in bed; Impaired mobility in bed (10001067); Impaired mobility (10001219); Paralysis (10022674); Risk for activity intolerance (10015011); Adequate sleep (10024930); Impaired sleep (10027226); Somnolence (10040141).
Social interaction and loneliness	Effective social support (10045794); Lack of social support (10022753); Social isolation (10001647); Risk for social isolation (10047213).
Prevention of risks to life and wellbeing	Health care associated complication (10042451); No health care associated complication; Aggressive behavior (10002026); No aggressive behavior (10035645); Comfortable (10025574); Confusion (10023633); No confusion (10028847); Pain control (10025831); Inadequate pain control (10039910); Discomfort (10023066); Autonomic dysreflexia (10000496); No autonomic dysreflexia; Acute pain (10000454); Increased pain (10051555); Absent pain (10029008); Chronic pain (10000546); Neurogenic pain (10013125); Reduced pain (10027917); Excoriation (10047060); Spasticity (10018520); increased spasticity; Spasticity absent; Reduced spasticity; Fever (10041539); Suicidal ideation; Infection (10023032); No infection (10028945); Urinary tract infection (10029915); Inflammation (10029927); Effective skin integrity (10028501); Improved skin integrity (10028517); Impaired skin integrity (10001290); Pressure injury (10025798); No pressure injury (10029065); Fall-related injury (10038513); No fall-related injury (10038545); Transfer injury (10030074); No transfer injury (10033659); Friable skin; Dry skin (10047073); Altered perception (10001242); Effective sensory perception (10028173); Fall (10029405); No fall (10034704); Complex medication regime (10022983); Risk for health care associated complications (10041296); Decreased risk for health care associated complications; Reduced risk for plaster cast related complications; Risk for plaster cast related complications; Decreased risk for orthotic device related complications; Risk for orthotic device related complications; Risk for autonomic dysreflexia (10015030); Risk for infection (10015133); Risk for cross infection (10041807); Risk for urinary infection (10051950); Risk for impaired skin integrity (10015237); Risk for pressure injury (10027337); Risk for fall-related injury (10038521); Risk for fall (10015122); Risk for suicide (10015356); Decreased suicide risk (10027938); Risk for impaired thermoregulation (10015244); Risk for deep vein thrombosis (10027509); Risk orf violence (10022487); Body temperature within normal limits (10027652); Effective thermoregulation (10033848); Impaired thermoregulation (10033560); No deep vein thrombosis (10036406); No dizziness (10045681); Dizziness (10045584); No violence (10029168); Improved vision (10047353); Impaired vision (10022748).
Health promotion and maintenance	Impaired ability of caregiver to perform caretaking (10035414); Impaired family ability to manage regime (10000902); Impaired ability to groom (10029632); Ability to perform impaired hygiene (10000987); Impaired ability to perform leisure activity (10040351); Impaired ability to perform oral hygiene (10029645); Impaired ability to perform caretaking (10029621); Ability to manage external continence device (10042548); Impaired ability to participate in care planning (10035134); Improved ability to toilet self (10047266); Impaired ability to dress (10027578); Able to dress and groom (10028207); Effective verbal communication; Impaired verbal communication (10025104); Caregiver able to perform caretaking (10035405); Self-care deficit (10023410).

Self-care requisites

Nursing diagnoses

Developmental requisites

Spiritual distress (10001652); Decreased spiritual distress (10027149); Anxiety (10000477); Reduced anxiety (10027858); Positive self-esteem (10025751); Negative self-image (10022724); Positive self-image (10027108); Low self-esteem (10029507); Chronic low self-esteem (10000533); Situational low self-esteem (10000844); Adequate knowledge (10027112); Knowledge of skin care; Knowledge of care with plaster casts; Knowledge of orthotic device care; Knowledge of wound care (10033784); Knowledge of disease (10023826); Knowledge of spinal cord injury; Knowledge of pain management (control) (10033750); Knowledge of medication (10025968); Knowledge of safety measures (10028643); Knowledge of rehabilitation regime; Knowledge of medication regime (10023819); Knowledge of fall prevention (10040276); Knowledge of treatment regime (10025733); Helplessness (10039952); Impaired sexual functioning (10001288); Difficulty coping (10001120); Readiness for effective coping (10001469); Effective caregiver coping (10034838); Impaired coping of the caregiver; Effective coping (10022378); Effective family coping (10034770); Impaired family coping (10034789); Lack of knowledge (10000837); Lack of knowledge about skin care; Lack of knowledge of plaster cast care; Lack of knowledge of orthotic device care; Lack of knowledge of wound care; Lack of knowledge of disease (10021994); Lack of knowledge of pain management (10040016); Lack of knowledge of medication (10025975); Lack of knowledge of safety measure (10022015); Lack of knowledge of medication regime (10021941); Lack of knowledge of rehabilitation regime; Lack of knowledge of fall prevention (10040230); Lack of knowledge of treatment regime (10021925); Lack of knowledge of spinal cord injury; Depressed mood (10022402); Improved Mood (10050027); Fear about death (10037834); Reduced fear (10027889); Risk for situational low self-esteem (10015180).

Health deviation requisites

Effective adaptation; Impaired adaptation (10022027); Adherence to rehabilitation regime (10033671); Adherence to dietary regime (10030159); Adherence to medication regime (10030192); Adherence to therapeutic regime (10030205); Health-seeking behavior (10000735); Impaired health-seeking behavior (10022920); Effective Continuity of Care (10035507); Effective role performance (10027940); Impaired role performance (10000941); Impaired health maintenance (10000918); Non-adherence to rehabilitation regime; Non-adherence to dietary regime (10022117); Non-adherence to medication regime (10021682); Non-adherence to therapeutic regime (10022155); Denial (10000624); No denial (10044260); Inadequate income (10022563).

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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[1] Corresponding author: Jorge Wilker Bezerra Clares E-mail: jorgewilker_clares@yahoo.com.br

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Diagnósticos de enfermería de la CIPE® para la práctica clínica de la rehabilitación en lesiones de la médula espinal

RESUMEN

Objetivos:

Métodos:

Resultados:

Conclusiones:

Diagnósticos de enfermería de la CIPE^® para la práctica clínica de la rehabilitación en lesiones de la médula espinal