Using the reference terminology model in the formulation of nursing diagnoses

Objective: to report the use of the reference terminology model for formulating nursing diagnoses having NANDA-I and ICNP® 2.0 as a basis. Method: this is an experience report with selection of a fictitious clinical case and use of the conceptual map for identifying relevant data. The priority nursing diagnoses were identified according to NANDA-I and the online version of ICNP® 2.0, observing ISO 18.104. Results: three nursing diagnoses were identified: hyperthermia; impaired physical mobility/compromised body movement; impaired skin integrity/compromised skin integrity. Discussion: having the reference terminology model as a basis for nursing diagnoses, it was possible to view elements identified through this model in the verbal structuring of nursing diagnoses in the two classification systems selected. Conclusion: it is known that the classification systems are in a constant updating process and none of them is able to meet all the needs of clinical practice. It is believed, therefore, that the selection through the terminology in use should be compatible with the needs and resources available in the clinical practice, as well as with the nurse's identification with the classification system which best suits her/his beliefs and values. Descriptors: nursing; nursing diagnosis; terminology.RESUMOObjetivo: relatar a utilização do modelo de terminologia de referência para elaboração de diagnósticos de enfermagem com base na NANDA-I e na CIPE® 2.0. Método: trata-se de um relato de experiência com seleção de um caso clínico fictício e utilização do mapa conceitual para identificação de dados relevantes. Os diagnósticos de enfermagem prioritários foram identificados com base na NANDA-I e na CIPE® 2.0 versão on-line, obedecendo à ISO 18.104. Resultados: identificaram-se três diagnósticos de enfermagem: hipertermia; mobilidade física prejudicada/movimento corporal comprometido; integridade da pele prejudicada/integridade da pele comprometida. Discussão: tendo-se como base o modelo de terminologia de ...