title: [Documented nursing diagnoses for medical clinic patients].
abstract: This paper reports a descriptive study, based on nursing records, of nursing diagnoses documented three months after the implementation of the NANDA-I classification at the University of São Paulo's Hospital Universitário (HU-USP) and proposes outcomes and interventions for the 3 most frequent diagnoses. The convenience sample (34% of the month's admissions) consisted of 30 charts of patients admitted in the Medical Clinic in August of 2004 (60% female, average age 60.9 +/- 23.1 years, mean length of stay = 5.8 +/- 2.7 days). The diagnoses documented on the admission day were manually transcribed from the charts and analyzed according to their frequency. There were 144 diagnoses (31 categories), with an average of 4.8 +/- 4.0 diagnoses per patient (range = 1-10). The most frequent were: acute pain (66.7%), impaired tissue integrity (63.3%), ineffective airway clearance (43.3%), risk of impaired skin integrity (36.7%), and impaired skin integrity (33.3%). The proposed outcomes and interventions are presented.
authors.affiliation: Programa de Pós-Graduação em Enfermagem na Saúde do Adulto da EEUSP, Brasil.
authors.forename: Cassiana Mendes Bertoncello
authors.initials: CM
authors.lastname: Fontes
authors.forename: Diná Almeida Lopes Monteiro
authors.initials: DA
authors.lastname: da Cruz
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009733:Nursing Diagnosis / Q000592:standards*; D012189:Retrospective Studies