ABSTRACT
Objective
To map the terms recorded in medical records of patients with decompensated heart failure for nursing diagnoses and interventions from the NANDA International and Nursing Interventions Classification.
Method
This is an exploratory and descriptive research, carried out by a cross-mapping study. Data were collected from 107 medical records of a Hospital Institute in the city of Rio de Janeiro/Brazil, in a period between October 2017 to February 2019. The diagnoses and interventions mapped were assessed by four clinical experts. Data analysis was performed using the content validation index and the Fleiss Kappa.
Results
The most frequent nursing diagnoses were: risk for infection (74.8%), decreased cardiac output (55.1%) and excessive fluid volume (49.5%). The interventions were: vital signs monitoring (79.4%), fluid monitoring (72.9%) and positioning (52.3%).
Conclusion
The research mapped 32 titles of nursing diagnoses from NANDA-I and 21 nursing interventions from NIC. The diagnoses and interventions mapped will contribute to the quality of the nurses’ records and patient safety.
Keywords
Nursing process; Nursing records; Heart failure