Diagnósticos de enfermería para ancianos institucionalizados fundados en la teoría de Henderson

Fernandes, Bruna Karen Cavalcante; Clares, Jorge Wilker Bezerra; Borges, Cíntia Lira; Nóbrega, Maria Miriam Lima da; Freitas, Maria Célia de

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ORIGINAL ARTICLE • Rev. esc. enferm. USP 53 • 2019 • https://doi.org/10.1590/S1980-220X2018004103472 copiar

Diagnósticos de enfermería para ancianos institucionalizados fundados en la teoría de Henderson

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

Plantear enunciados de diagnósticos de enfermería para ancianos institucionalizados.

Método:

Estudio descriptivo, llevado a cabo con ancianos de un Institución de Larga Estancia, mediante aplicación de formularios que subsidiaron la anamnesis y el examen físico, además de la búsqueda en las fichas. Los enunciados de diagnósticos enfermeros fueron elaborados con base en la Clasificación Internacional para la Práctica de Enfermería y categorizados según el modelo teórico de Henderson.

Resultados:

Participaron 203 personas mayores. Fueron elaborados 153 diagnósticos enfermeros, distribuidos de la siguiente manera: 115 (75,1%) en el Componente Biológico/Fisiológico, 14 (9,1%) en el Componente Psicológico, 21 (13,7%) en el Componente Social y tres (1,9%) en el Componente Espiritual/Moral.

Conclusión:

Los enunciados de diagnósticos de enfermería planteados retratan situaciones de vulnerabilidad a la salud de los ancianos institucionalizados, influenciadas por factores biológicos, psicológicos, sociales y culturales, por lo que requieren cuidado sistematizado, individualizado y resolutivo para dicho público.

DESCRIPTORES:
Anciano; Diagnóstico de Enfermería; Hogares para Ancianos; Teoría de Enfermería; Enfermería Geriátrica

Basic human needs	Nursing diagnosis
Biological/Physiological Component
Breathe	Tobacco abuse (11%); Bradycardia (1%); Impaired cardiac function (13%); Impaired respiratory system function (8%); Dyspnea (9%); Anginal pain (0.5%); Activity intolerance (0.5%); Wet cough (14%); Dry cough (8%); Increased respiratory rate (tachypnea) (3%); Respiratory infection (2%); Aspiration risk (0.5%); Risk for impaired cardiac function (2%); Tachycardia (1%)
Eat and drink	Alcohol abuse (4%); Low appetite (13%); Low weight (4%); Dysphagia (2%); Absent dentition (18%); Impaired dentition (13%); Dehydration (3%); Malnutrition (17%); Decompensated Diabetes (4%); Hyperglycemia (1%); Excess food intake (3%); Impaired food intake (6%); Impaired fluid intake (10%); Nausea (3%); Obesity (13%); Heartburn (2%); Risk of malnutrition (4%); Risk of choking (5%); Risk of hypoglycemia (2%); Overweight (2%)
Eliminate	Ascites (0.5%); Constipation (15%); Chronic constipation (3%); Diarrhea (6%); Pain during urination (5%); Abdominal pain (4%); Edema (17%); Overflow incontinence of urine (or Polaciuria) (1%); Impaired kidney function (7%); Hematuria (0.5%); Bowel incontinence (8%); Urinary incontinence (19%); Urge incontinence of urine (5%); Functional incontinence of urine (2%); Urinary tract infection (4%); Nocturia (14%); Urinary retention (0.5%); Risk for constipation (6%); Risk for electrolyte imbalance (2%); Risk for water imbalance (2%)
Sleep and rest	Insomnia (19%); Impaired sleep (25%); Drowsiness (4%)
Move and maintain a desirable posture	Impaired ability to move (8%); Impaired musculoskeletal system function (16%); Discomfort (5%); Joint pain (8%); Arthritis pain (3%); Musculoskeletal pain (10%); Neurogenic pain (1%); Bone pain (3%); Impaired walking (23%); Impaired wheelchair mobility (6%); Impaired mobility in bed (3%); Sensory deficit (6%); Risk for fall (78%); Risk for trauma (2%); Postural dizziness (15%)
Dress and undress	Impaired ability to dress (6%)
Maintain body temperature within normal range	Fever (2%)
Keep the body clean and well groomed and protect the integument	Crust (or Seborrheic dermatitis) (4%); Self-care deficits (21%); Erythema (2%); Excoriation (3%); Hematoma (6%); Impaired ability to perform hygiene (11%); Impaired ability to perform oral hygiene (10%); Hyperbilirubinemia (2%); Infection (9%); Fungal infection (13%); Head lice infestation (7%); Infestation by Sarcoptes scabiei (8%); Impaired skin integrity (3%); Injury (14%); Dry skin (20%); Impaired tissue perfusion (18%); Itching (14%); Risk for infection (8%); Risk for Impaired Skin Integrity (2%); Risk for injury (1%); Risk for bleeding (1%); Risk for pressure ulcer (9%); Bleeding (3%); Ulcer (2%); Pressure ulcer (5%); Chronic venous ulcer (1%)
Avoid dangers	Agitation (4%); Distress (1%); Hallucination (8%); Anxiety (10%); Delirium (1%); Acute pain (9%); Chronic pain (6%); Weakness (1%); Hypertension (9%); Hypotension (2%); Walking (2%); Risk for self-mutilation (0.5%); Risk for seizure (1%); Impaired vision (43%); Risk for suicide (4%)
Psychological Component
Communicate	Impaired hearing (20%); Aggressive behavior (8%); Aphasia (9%); Impaired sexual behavior (2%); Compulsive behavior (2%); Impaired communication (5%); Distorted thinking (14%)
Learn	Non adherence to therapeutic regime (5%); Self-medication (1%); Impaired cognition (30%); Lack of knowledge of medication regime (2%); Disorientation (36%); Impaired memory (26%); Non adherence to medication regime (8%)
Social Component
Work in a way that there is sense of accomplishment	Low self esteem (2%); Depressed mood (17%); Labile mood (10%); Preoccupation (2%); Sadness (13%); Family abandonment (16%); Ineffective family communication (3%); Social isolation (13%); Denial of the institutionalization process (1%); Denial of disease (0.5%); Relationship problem (4%); Impaired institutionalization process (5%); Impaired family process (20%); Conflicting relationship (8%); Risk for loneliness (2%); Impaired socialization (5%); Loneliness (5%); Victim of family violence (2%)
Play	Lack of leisure activity (11%); Lack of play activity (7%); Mental idleness (9%)
Spiritual/Moral Component
Worship according to one’s faith	Fear (3%); Conflicting religious belief (0.5%); Impaired Belief (1%)

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Bruna Karen Cavalcante Fernandes Travessa Michele, 30, Passaré CEP 60861-444 - Fortaleza, CE, Brazil brunacavalcanteff@gmail.com