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Resumen La estandarización de los procesos enfermeros es uno de los retos de los diferentes sistemas sanitarios a escala mundial así como el seguimiento de la pre-fragilidad. Actualmente, el modelo de estandarización de los planes de cuidados en Atención Primaria de Andorra no es suficiente y requiere la introducción de las nuevas tecnologías para hacerlo más eficaz. Así mismo, la pre-fragilidad necesita un seguimiento de Atención Primaria. Por ello, esta investigación pretende estandarizar el plan de cuidados de los pacientes potencialmente frágiles usando la taxonomía de la NANDA-I y el estándar semántico SNOMED CT empleando la metodología Delphi en tiempo real.

A narrative review was conducted to propose dental hygiene diagnoses for cancer patients based on dental hygiene process of care in acute care hospitals. Six researchers, including three dental hygienists, all with expertise in oral healthcare for patients with cancer, decided the review outline. All researchers reviewed the literature and developed terminology for dental hygiene diagnoses. The team then modified the terminology and discussed its clarity and acceptability to develop an initial list of dental hygiene diagnosis names according to the dental hygiene human needs conceptual model subscales. In wholesome facial image, one new diagnosis was developed. In protection from health risks, 15 new diagnoses were developed. In biologically sound and functional dentition, 10 new diagnoses were developed. In skin and mucous membrane integrity of the head and neck, 10 new diagnoses were developed. In freedom from head and neck pain, two new diagnoses were developed. In freedom from anxiety and stress, eight new diagnoses were developed. In responsibility for oral health, five new diagnoses were developed. In conceptualization and understanding, three new diagnoses were developed. Based on this study, it is necessary for the academic community to develop a better taxonomy of dental hygiene diagnoses pertaining to dental hygienist clinical practice.

Uvod: Informatika v zdravstveni negi je pomembno specializirano področje zdravstvene nege, katerega naloga je aktivno sodelovanje pri snovanju in implementaciji aplikacij za elektronsko dokumentiranje v zdravstvu. Proces zdravstvene nege je temeljno izhodišče za načrtovanje in izvajanje zdravstvene nege in mora biti ustrezno reprezentiran v sodobnih načinih dokumentiranja zdravstvene nege. Namen: Namen magistrskega dela je primerjati uporabniško izkušnjo in kakovost dokumentiranih načrtov zdravstvene nege pri uporabi dveh različnih aplikacij za dokumentiranje v zdravstveni negi. Metode dela: V raziskavi smo primerjali aplikacijo E-dokumentacija v patronažni zdravstveni negi in aplikacijo Think!Med Clinical™. Podatke za ocenjevanje kakovosti uporabniške izkušnje smo zbirali z anketo. Dokumentirane načrte zdravstvene nege smo kvantitativno in kvalitativno analizirali. Kvalitativna analiza je temeljila na oceni z dvema preizkušenima orodjema za ocenjevanje kakovosti negovalnih načrtov. V raziskavi je sodelovalo 69 študentov zdravstvene nege. Rezultati: Študenti so aplikacijo Think!Med Clinical™ ocenili statistično značilno boljše v vseh vsebinskih sklopih vprašalnika. S kvantitativno analizo smo zaznali statistično značilne razlike pri doslednosti dokumentiranja posameznih segmentov načrta zdravstvene nege v prid aplikacije E-dokumentacija v patronažni zdravstveni negi. Pri ocenjevanju dokumentiranih načrtov zdravstvene nege z avstralskim orodjem za ocenjevanje kakovosti dokumentacije v zdravstveni negi starostnika nismo zaznali statistično značilnih razlik (p = 0,098). Pri ocenjevanju dokumentiranih načrtov zdravstvene nege z orodjem za ocenjevanje kakovosti negovalnih diagnoz in intervencij ter ciljev zdravstvene nege smo zaznali statistično značilno razliko srednjih vrednosti končnih ocen v prid aplikacije E dokumentacija v patronažni zdravstveni negi (p = 0,035). Razprava in zaključek: Aplikacija Think!Med Clinical™ je zagotovila boljšo uporabniško izkušnjo, ker je vizualno privlačna, hitra in omogoča preprosto dokumentiranje negovalnih diagnoz. Študenti so z aplikacijo E-dokumentacija v patronažni zdravstveni negi doslednejše dokumentirali ključne segmente načrta zdravstvene nege in posledično bolj kakovostno dokumentirali proces zdravstvene nege. Strukturne pomanjkljivosti načrtov zdravstvene nege v aplikaciji Think!Med Clinical™ so posledica nepopolne vključitve standardiziranih negovalnih diagnoz v zasnovo aplikacije, saj aplikacija uporabniku ne nudi dovolj etioloških dejavnikov in v svoji zasnovi ne predvideva dokumentiranja diagnostičnih kazalcev. Introduction: Nursing informatics is an important nursing specialty that should actively engage in development and implementation of electronic applications for healthcare documentation. The nursing process is a foundation of systematic planning and implementation of nursing care and as such, it should be adequately represented in modern applications for electronic documentation in nursing. Purpose: The purpose of this Master’s thesis is to compare two applications for electronic documentation in nursing. The comparison is focused on the user experience and on the quality of documented nursing care plans. Methods: The study compared the applications E-documentation in community nursing (E-dokumentacija v patronažni zdravstveni negi) and Think!Med Clinical™. The user experience data was collected with a survey and the documented nursing care plans were qualitatively and quantitatively analyzed. Qualitative analysis was implemented with two previously validated instruments for quality evaluation of nursing documentation. The study sample included 69 undergraduate nursing students. Results: The Think!Med Clinical™ application was significantly better evaluated by the students in all the survey segments. However, the quantitative analysis of documented nursing care plans revealed a significant difference in consistent use of crucial nursing care plan segments in the documentation, where the E-documentation in community nursing application showed better results. The assessment of nursing care plans with the Quality of Australian Nursing Documentation in Aged Care instrument revealed no significant differences (p = 0,098), while the assessment with the Quality of Nursing Diagnoses, Interventions, and Outcomes instrument revealed a significant difference in the final score means (p = 0,035) in favor of the E-documentation in community nursing application. Discussion and conclusion: The Think!Med Clinical™ application delivered a better user experience thanks to its visual design, speed and simplicity of use for nursing diagnosis documentation. However, the students using the E-documentation in community nursing application more consistently documented crucial nursing care plan segments, which resulted in better quality of the nursing process documentation. The structural faults of nursing care plans made with the Think!Med Clinical™ application are a consequence of incomplete implementation of standardized nursing diagnoses in the application design, since the application includes an inadequate number of possible related factors and does not include defining characteristics as a structural part of the nursing diagnosis.

Resumen: En la 11ª edición NANDA-I 2018-2020 no ha habido apenas cambios significativos en diagnosticos relacionados con la piel, a no ser la inclusión de un nuevo diagnostico relacionado con la herida quirúrgica, concretamente: (00266) Riesgo de Infección del sitio quirúrgico (Risk for surgical site infection). También, mencionar ciertas modificaciones en la etiqueta diagnóstica de otros NANDA-I asociados a traumatismos y dermatisis, realizados para mejorar su conceptualización, estandarización y codificación clínica. NEW FEATURES OF THE NEW VERSION NANDA 2018-2020, RELATED TO LESIONS OF THE SKIN AND MUCOUS MEMBRANES Abstract: In the 11th edition NANDA-I 2018-2020 there have been hardly any significant changes in skin-related diagnoses, other than the inclusion of a new diagnosis related to the surgical wound, specifically: (00266) Risk for surgical site infection. Also, mention certain modifications in the diagnostic label of other NANDA-I associated with trauma and dermatitis, made to improve its conceptualization, standardization and clinical coding.

Nursing process, one of the most important tools in transferring nursing knowledge into practice, is a systematic and scientific problem solving method, which is primarily used in individual health care services. Determining problems by observing patient behavior is an important part of diagnosis stage of nursing process. In 1982, North American Nursing Diagnosis Association was founded. NANDA's purpose is to identify, simplify and improve diagnostic terminology to be used by professional nurses. Between 2012 and 2014, diagnoses list was reorganized, 11 diagnoses were revised and 16 new diagnoses were added. NANDA diagnoses are classified in accordance with Gordon's Functional Health Patterns. In recent years, one of the most used and largely accepted models in the field of nursing education and nursing practice is the Nursing Model Based on Activities of Living. The purpose of this model is to systematically collect data from the individual and build a foundation for nursing practices. This model is often adopted by nurses because it help building an appropriate basis for nursing process, it can be used not only for patients but for health individuals as well and it facilitates nursing process practices, especially diagnosis stage. The aim of this article is to reclassify NANDA's nursing diagnoses (which are classified by using Gordon's Functional Health Patterns) in accordance with Nursing Model Based on Activities of Living, which is more commonly used in practice. This will hopefully provide ease of use to nurses and students. ÖzetHemşirelik bilgisini uygulamaya aktarmada en önemli araçlardan biri olan hemşirelik süreci; bireye özgü bakım verilmesinde kullanılan sistematik, bilimsel bir sorun çözme yöntemidir. Hastanın gözlenen davranışları ile ilgili sorunların belirlenmesi, hemşirelik sürecinin tanı aşaması için önemlidir. 1982 yılında Kuzey Amerika Hemşirelik Tanıları Birliği kurulmuştur. NANDA’nın amacı profesyonel hemşirelerin kullanımı için tanı terminolojisini belirlemek, sadeleştirmek ve geliştirmektir. 2012-2014 yılında tanı listesi yeniden düzenlenmiş 11 tanı revize edilmiş, 16 yeni tanı eklenmiştir. NANDA tanıları Gordon’nun Fonksiyonel Sağlık Örüntülerine göre sınıflandırılmıştır. Son yıllarda hemşirelik eğitimi ve uygulama alanında büyük ölçüde kabul gören, çok kullanılan modellerden biri Yaşam Aktivitelerine Dayalı Hemşirelik Modelidir. Bu modelin amacı bireyden sistematik doğrultuda veri toplayarak hemşirelik girişimleri için bir yapı oluşturmaktır. Modelin hemşireler tarafından benimsenme nedeni; hemşirelik süreci için uygun bir temel oluşturması, sadece hasta bireylerin bakımında değil, sağlıklı bireylerin bakımında da uygulanabilen bir model olması, hemşirelik süreci uygulamasının özellikle tanılama aşamasında kolaylık sağlamasıdır. Bu makalenin amacı, Gordon’nun Fonksiyonel Sağlık Örüntülerine göre sınıflandırılmış olan NANDA hemşirelik tanılarını, uygulama alanında sık kullanılan Yaşam Aktivitelerine Dayalı Hemşirelik Modeli’ne uygun şekilde sınıflandırarak hemşirelere ve öğrencilere kullanım kolaylığı sağlamaktır.

Uno de los problemas actuales en el dominio de la salud es reutilizar y compartir la información clínica entre profesionales, ya que ésta se encuentra escrita usando terminologías específicas. Una posible solución es usar un recurso de conocimiento común sobre el que mapear la información existente. Nuestro objetivo es comprobar si la adición de conocimiento semántico superficial puede mejorar los mapeados establecidos. Para ello experimentamos con un conjunto de etiquetas de NANDA-I y con un conjunto de descripciones de SNOMED-CT en castellano. Los resultados obtenidos en los experimentos muestran que la inclusión de conocimiento semántico superficial mejora significativamente el mapeado léxico entre los dos recursos estudiados. In health domain, one of the current problems is the reusing and the sharing the clinical information between professionals, due to this information is written using specific terminologies. One possible solution is to use a common knowledge resource for mapping the existing information. In this paper, our aim is to analyze if the use of lexical similarity algorithms enriched with shallow semantic knowledge can improve these mappings. In order to achieve this, we experiment with a set of NANDA-I labels and a set of SNOMED-CT descriptions in Spanish. The results obtained show that the addition of shallow semantic knowledge significantly improves the lexical mapping between both studied resources. Este artículo ha sido cofinanciado por el Ministerio de Ciencia e Innovación (proyecto TIN2009-13391-C04-01), y la Conselleria d'Educació de la Generalitat Valenciana (proyectos PROMETEO/2009/119, ACOMP/2010/286 y ACOMP/2011/001).