Nursing diagnoses and their evolution in heart failure patients: A cross-mapping study

Area of Science:

• Nursing Informatics
• Clinical Documentation
• Heart Failure Management

Background:

• Heart failure decompensation necessitates hospitalization and accurate nursing assessment of clinical deterioration.
• Standardized terminologies exist, yet cross-mapping specific to heart failure nursing documentation is under-researched.

Purpose of the Study:

• To map nursing terms from heart failure patient records to NANDA-International (NANDA-I) nursing diagnoses and clinical indicators.
• To assess the feasibility and limitations of cross-mapping in this patient population.

Main Methods:

• A documentary study involving cross-mapping of nursing terms from adult heart failure patient medical records.
• Manual extraction of nursing terms and mapping to NANDA-I criteria over three consecutive days of documentation.
• Exclusion of records lacking sufficient detail for diagnosis inference.

Main Results:

• Sixty-eight records were analyzed, revealing limited nursing documentation hindering diagnosis identification.
• Frequent diagnoses included 'Risk for infection,' 'Risk for falls,' and 'Acute pain.'
• Vulnerability and frailty in elderly patients emerged as key indicators for falls risk.

Conclusions:

• Cross-mapping successfully identified potential nursing diagnoses and indicators in heart failure patients.
• Inconsistent and incomplete nursing documentation significantly limited the understanding of clinical progression.
• Standardizing nursing records is crucial for effective clinical monitoring and improved patient outcomes.