Diagnósticos de enfermagem em pacientes com doenças cardiovasculares: aplicação do modelo Outcome-Present State-Test

Abstract

Contemporary nursing is focused on results and complex analysis of the patient´s multiple conditions. The Outcome-Present State-Test (OPT), a diagnostic reasoning model, is pointed out as a tool to aid clinical reasoning and, consequently, to stimulate new cognitive abilities. Therefore, the contribution of this research is based on the use of an innovative and transforming method to perform the nursing diagnosis in Brazil, since the traditional form has been presenting some failures and generating concerns. Objective: To identify the agreement and disagreement between the statements of the nursing diagnoses of patients with cardiovascular diseases elaborated by researchers and those recorded in electronic medical records by nurses on their clinical practice and to verify the presence of association between the medical diagnoses and the nursing diagnosis of the patients with cardiovascular diseases. Method: A descriptive study performed in a nonprobabilistic sample of 50 adult patients hospitalized for some sort of cardiovascular disease in a public hospital. Data were collected through a form, applied simultaneously by two researchers. This was comprised by identification data, sociodemographic characterization and clinical data. After the patient's evaluation, the researchers formulated NANDA-I Nursing Diagnoses by means of the OPT model. The patient´s collected information was transcribed as a clinical case, and the nursing diagnoses related to that case were listed, to facilitate the content validation process, carried out by six experts. Afterwards, the electronic medical record was accessed to collect the diagnoses documented that day by the nurses from the cardiology unit. Diagnoses with high scores by the experts were compared to the diagnoses elaborated by the clinical nurses, to observe the agreement, through the cross-mapping. Results: Congestive heart failure was the medical diagnosis of 44% of the patients, followed by coronary diseases (36%), arrhythmias (12%) and endocarditis (8%). According to the researchers and experts, 14 different nursing diagnoses were present (± 3.3), but only three obtained a frequency greater than 50%: Risk for bleeding, Decreased cardiac output and Deficient knowledge. The nurses from the clinical practice registered 15 different nursing diagnoses (± 3.3), being Risk for infection and Risk for falls; the two statements with frequency greater than 50% :Of the 307 diagnostic titles distributed among the 50 participants, only two nursing diagnoses (0.7%) were in agreement and 305 (99.3%), in disagreement. Conclusions: Nursing diagnosis agreement was low among researchers and clinical nurses. The diagnoses listed by the researchers were focused on cardiovascular answers, and the clinical nurses were more concerned with the patient´s safety issues. The clinical reasoning performed by OPT is an important tool for caring patients in complex situations, such as those with cardiovascular diseases, as well as a valuable resource for the teachinglearning process, which can stimulate the students' clinical reasoning process.