Authors

Imma Besora Torradeflot, Carme Del Olmo Macià, Elvira Gibert Llorach, Àngels Ondiviela Cariteu, Claustre Solé Brichs

Position

Enfermeras de Atención Primaria de l’Institut Catalá de la Salut (ICS).

Contact address

C/ Regent Mendieta, 14-20, esc. B-Ático 3ª. 08028 Barcelona.

Contact email: ibesora.bcn.ics@gencat.net

Abstract

In 1994 a group of healthcare nurses serving at Primary Care Health units in Barcelona started a project aimed at developing the specificity of nursing care by adopting the Virginia Henderson’s model and by utilising care process methodology. Our objective was to contribute with a useful working tool that helped in all the stages of the process to shorten the distance between theory and the nursing models used in clinical practice so that these could be subsequently used to validate the contents of the elaborated nursing diagnoses.
Methodology: the nursing diagnoses most frequently used in healthcare practice were selected using the nominal group technique. Each of the elaborated diagnoses was revised for the first time in 2000 to include the contribution of the scientific literature regarding objectives and the interventions using the “Nursing Intervention Classifications (NIC)”. The second revision was performed in 2005 to incorporate the codification of already existing objectives according to the “Nursing Outcome Classification (NOC)”.
Results: identification of 36 nursing diagnosis and elaboration of a clinical practice guideline for each of these diagnoses.
Conclusions: standardised clinical care guidelines serve as a work guideline and are essential to personalise the assessment in order to individualise the care given, which also permits to identify the autonomous role of the nurse. Automation of standardised guides has facilitated the nursing process. It would be interesting to compile possible variations from the proposed guidelines for their analysis and amendment if necessary.

Keywords:

clinical practice guidelines; standardisation; nursing care plan; nursing diagnoses; nursing methodologyprotocol

Versión en Español

Título:

Diagnósticos enfermeros estandarizados: guía para la práctica clínica en Atención Primaria