心不全患者における看護診断とその進化：クロス・マッピング研究

Heart failure is a complex disease requiring urgent hospitalization for decompensation. Nurses play important role in accurately identifying signs of clinical deterioration. Although standardized terminologies are used worldwide to standardize practice concepts and language, there is a gap in the literature on cross-mapping in heart failure patients.

To identify and map nursing terms from medical records of hospitalized heart failure patients to nursing diagnoses with clinical indicators according to NANDA-I.

Documentary study cross-mapping data from medical records of adult heart failure patients hospitalized for ≥24 hours. Inclusion criteria included records containing medical diagnosis and nursing documentation for three consecutive days. Nursing terms were manually identified and extracted following specific rules for subsequent NANDA-I mapping. Records lacking sufficient information to infer nursing diagnoses were excluded. The study received research ethics committee approval.

Sixty-eight medical records of heart failure patients were included. Nursing records contained limited information, hindering nursing diagnosis identification through cross-mapping. Insufficient details on clinical deterioration or improvement compromised analysis of diagnostic progression over the three consecutive days for mapped diagnoses, most frequent were: "Risk for infection", "Risk for falls in adults", "Risk for decreased activity tolerance", "Imbalanced nutrition: less than body requirements", and "Acute pain". Key indicators identified included vulnerability in elderly populations and frailty with high risk for falls.

Cross-mapping identified nursing diagnoses and clinical indicators; however, inconsistent documentation limited understanding of clinical progression. Standardizing and ensuring completeness of nursing records can facilitate more effective clinical monitoring and improve communication and health outcomes.