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      Validación de intervenciones enfermeras en el postoperatorio de cirugías laparoscópicas no complicadas en el Hospital Universitario de Canarias

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          Abstract

          Resumen Introducción y Justificación: Las Intervenciones enfermeras fueron normalizadas de forma teórica a través del Proyecto de Normalización de las Intervenciones para la Práctica en Enfermería (NIPE), identificando las intervenciones aplicables a los grupos de diagnósticos relacionados (GDR). Los niveles de evidencia carecen de soporte clínico suficiente y se recomiendan estudios de validación clínica. Objetivo: clasificar los pacientes atendidos en el Hospital Universitario de Canarias (HUC) de cirugías laparoscópicas no complicadas realizadas por el Servicio de Cirugía General y Digestiva (CGD) identificando intervenciones normalizadas de enfermería al GDR 494 (Colecistectomía Laparoscópica sin Exploración del Conducto Biliar. Sin complicaciones) y validarlas clínicamente, identificando las actividades enfermeras de una intervención seleccionada. Metodología: Estudio observacional descriptivo retrospectivo para determinar y validar las Intervenciones Enfermeras normalizadas más frecuentes para el GDR 494. Estudio observacional descriptivo prospectivo con técnica de auto-cuestionario para determinar las actividades normalizadas para la Intervención Enfermera “1400 Manejo del Dolor”, en el contexto del GDR 494. Se elaboró una Base de Datos Relacional con una población de 444 casos, codificados por GDR según la CIE-9-MC y con la taxonomía enfermera NANDA-NIC-NOC. Resultados: se identificó el GDR 494 como el más frecuente de las cirugías laparoscópicas de CGD del HUC (27,25%). Se validaron clínicamente 12 intervenciones enfermeras propuestas en el proyecto NIPE para el GDR 494, de las cuales 5 fueron seleccionadas con frecuencia muy alta (>50%). Se proponen 9 intervenciones enfermeras, seleccionadas en alta y muy alta frecuencia, para ser incluidas en los modelos teóricos. Se validaron las actividades propuestas para la intervención enfermera “1400 Manejo del Dolor”. Conclusión: Se observa que más del 60% de las intervenciones propuestas en el proyecto NIPE para el GDR 494 no fueron seleccionadas. Se propone revisar y actualizar las intervenciones enfermeras teorizadas en base a los avances científicos y los cambios taxonómicos cada 5 años.

          Translated abstract

          Abstract Introduction and Justification: Nursing interventions were theoretically standardized through the Project for Standardization of Interventions for Nursing Practice (NIPE), identifying the interventions applicable to the related diagnostic groups (RDG). The levels of evidence lack sufficient clinical support and clinical validation studies are recommended. Aim: to classify the patients attended in the University Hospital of the Canary Islands (HUC) of uncomplicated laparoscopic surgeries performed by the General and Digestive Surgery Service (CGD) identifying standardized nursing interventions to GDR 494 (Laparoscopic Cholecystectomy without Exploration of the Bile Duct. complications) and validate them clinically, identifying the nursing activities of a selected intervention. Methodology: Retrospective descriptive observational study to determine and validate the most frequent standardized Nursing Interventions for RDG 494. Prospective descriptive observational study with self-questionnaire technique to determine the normalized activities for the Nursing Intervention "1400 Pain Management", in the context of the RDG 494. A Relational Database was developed with a population of 444 cases, coded by GDR according to the ICD-9-CM and with the nurse taxonomy NANDA-NIC-NOC. Results: GDR 494 was identified as the most frequent of the laparoscopic CGD surgeries of the HUC (27.25%). Clinically, 12 nursery interventions proposed in the NIPE project for GDR 494 were validated, of which 5 were selected with very high frequency (> 50%). Nine nursing interventions are proposed, selected in high and very high frequency, to be included in the theoretical models. The proposed activities for the nurse intervention "1400 Pain Management" were validated. Conclusion: It is observed that more than 60% of the interventions proposed in the NIPE project for GDR 494 were not selected. It is proposed to review and update theorized nursing interventions based on scientific advances and taxonomic changes every 5 years

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          Perspectivas de incorporação da Classificação Internacional para a Prática de Enfermagem (CIPE®) no Brasil

          Neste artigo são discutidos alguns aspectos acerca dos sistemas de classificação em enfermagem, com ênfase na Classificação Internacional para a Prática de Enfermagem (CIPE®) e as suas perspectivas de incorporação na prática de enfermagem no Brasil. As autoras relatam três experiências brasileiras de incorporação desse sistema de classificação: o projeto de implantação da linguagem CIPE/CIPESC no prontuário eletrônico da Secretaria Municipal de Saúde de Curitiba-PR; o projeto de sistematização da assistência de Enfermagem em UTI, que vem sendo desenvolvido em Florianópolis-SC; e o desenvolvimento de um instrumental tecnológico, tendo por base os termos da linguagem dos componentes da equipe de enfermagem, para inserção em sistemas de informação de um hospital escola, em João Pessoa - PB.
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            Costing nursing care: using the clinical care classification system to value nursing intervention in an acute-care setting.

            The purpose of this study was to combine an established methodology for coding nursing interventions and action types using the Clinical Care Classification System with a reliable formula (relative value units) to cost nursing services. Using a flat per-diem rate to cost nursing care greatly understates the actual costs and fails to address the high levels of variability within and across units. We observed nurses performing commonly executed nursing interventions and recorded these into an electronic database with corresponding Clinical Care Classification System codes. The duration of these observations was used to calculate intervention costs using relative value unit calculation formulas. The costs of the five most commonly executed interventions were nursing care coordination/manage-refer ($2.43), nursing status report/assess-monitor ($4.22), medication treatment/perform-direct ($6.33), physical examination/assess-monitor ($3.20), and universal precautions/perform-direct ($1.96). Future studies across a variety of nursing specialties and units are needed to validate the relative value unit for Clinical Care Classification System action types developed for use with the Clinical Care Classification System nursing interventions as a method to cost nursing care.
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              Calidad de los informes de alta hospitalaria respecto a la legislación vigente y las recomendaciones consensuadas por expertos

              Objetivos: Conocer la calidad de los informes de alta hospitalaria respecto a la legislación vigente y el consenso para la elaboración de informes de alta hospitalaria en especialidades médicas en 11 hospitales de Andalucía. Material y métodos: Estudio transversal de 1708 informes de alta hospitalaria. Analizamos la presencia o no de los diferentes ítems requeridos tanto por la legislación actual como por las recomendaciones del consenso. Resultados: El 97,4% (intervalo de confianza del 95% [IC95%]: 96,5-98,2) de los informes de alta hospitalaria fueron catalogados como adecuados si nos ajustamos a los requisitos que contempla la legislación vigente. Si la evaluación era respecto al consenso, el porcentaje de adecuación descendía al 72,1% (IC95%:70,0-74,3). Destaca la ausencia de la duración del tratamiento tras el alta en el 39,4% de los informes. Conclusiones: Los informes de alta hospitalaria ofrecen un excelente grado de cumplimentación de los datos exigidos por la normativa vigente, pero deben mejorar en su calidad intrínseca.
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                Author and article information

                Journal
                ene
                Ene
                Ene.
                Martín Rodríguez Álvaro (Santa Cruz de La Palma, La Palma, Spain )
                1988-348X
                2019
                : 13
                : 3
                Affiliations
                orgnameHospital Universitario de Canarias España
                orgnameUniversidad de La Laguna España
                Article
                S1988-348X2019000300007 S1988-348X(19)01300300007

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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