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Nursing interventions and outcomes classifications in patients with wounds: cross-mapping
Fernanda Pessanha de Oliveira1, Beatriz Guitton Renaud Baptista de Oliveira1, Rosimere Ferreira Santana1
1Escola de Enfermagem Aurora de Afonso Costa, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil.
Revista Gaucha De Enfermagem
|June 3, 2016
Summary
This study cross-mapped nursing interventions and outcomes in wound care patient records. Findings suggest enhancing nursing taxonomies for better outpatient care documentation and classification.
Area of Science:
- Nursing
- Medical Informatics
- Wound Care
Background:
- Accurate documentation of nursing interventions and outcomes is crucial for patient care and research.
- Existing nursing classification systems may not fully capture the nuances of terms used in clinical practice, particularly in outpatient settings.
- Cross-mapping offers a method to bridge the gap between clinical terminology and standardized classifications.
Purpose of the Study:
- To cross-map terms for nursing interventions and outcomes from wound patient medical records against established nursing classifications.
- To identify discrepancies and potential additions for nursing taxonomies based on clinical documentation.
Main Methods:
- An observational retrospective study design was employed.
- Data from 81 outpatients' medical records were analyzed.
- A four-step analysis involved phrase identification, frequency analysis, synonym grouping, and comparison with nursing taxonomies.
Main Results:
- Thirteen nursing interventions were mapped, with "Care with wounds" being the most frequent (47.23%).
- Six nursing outcomes were mapped, with "Wound healing: secondary intention" identified as the priority (45%).
Conclusions:
- Cross-mapping revealed terms used in clinical practice that could enrich existing nursing intervention and outcome classifications.
- The findings support the adaptation of nursing taxonomies to better reflect terminology used in outpatient wound care.
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