Correspondence of nurses' and physiotherapists' records for orthopedic patients with the Nursing Outcomes Classification

Engelman, Bruna; Silva, Marcos Barragan da; Almeida, Miriam de Abreu

doi:10.1590/1983-1447.2020.20190287

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Revista Gaúcha de Enfermagem

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Original Article • Rev. Gaúcha Enferm. 41 • 2020 • https://doi.org/10.1590/1983-1447.2020.20190287 copy

Correspondence of nurses' and physiotherapists' records for orthopedic patients with the Nursing Outcomes Classification

Correspondencia entre registros de enfermeras y fisioterapeutas para pacientes ortopédicos con la Clasificación de Resultados de Enfermería

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To evaluate the correspondence of the terms found in nurses' and physiotherapists' records for orthopedic patients with the Nursing Outcomes Classification (NOC).

Method:

A descriptive study carried out in a university hospital in southern Brazil. The sample consisted of 392 records of 49 patients submitted to Total Hip Arthroplasty (THA). Data collection was retrospective in the electronic health record. Data was analyzed and compared with the NOC outcomes using the cross-mapping method.

Result:

The most prevalent outcomes were the following: Pain Level, Falls Occurrence and Mobility. There was sharing of outcomes between the two categories, except for Falls Occurrence and Respiratory Status. Conclusion: Standardizing nurses' and Physiotherapists' records according to the NOC can improve the quality of the clinical documentation of the outcomes of patients undergoing THA.

Keywords:
Nursing process; Orthopedic Nursing; Outcome assessment, health care; Physical therapy speciality; Orthopedics

Terms recorded by the nurses	NOC Outcomes	Indicators
O: SW looking good, bruises around, no drainage O: SW with dressing externally cleaned O: SW with bleeding dressing O: SW with edema O: SW with excellent healing stage O: SW without phlogistic signs O: SW with mild hyperemia and edema O: Portovac drain with serosanguineous drainage O: Portovac drain with sanguineous drainage O: Portovac drain draining small amounts of sanguineous secretion O: Portovac drain, 380 ml sanguineous O: Portovac drain with 100 ml sanguineous output O: Narrow passage of the portovac drain with small amount of sanguineous drainage	(1102) Wound healing: Primary intention	(11021) Skin approximation (112013) Wound edges approximation (110214) Scar formation (110202) Purulent drainage (110203) Serous drainage (110204) Sanguineous drainage (110205) Serosanguineous drainage (110206) Sanguineous drainage from drain (110207) Serosanguineous drainage from drain (110208) Surrounding skin erythema (110209) Surrounding skin bruising (110209) Periwound edema (110210) Increase skin temperature
	(0703) Infection severity	(070305) Purulent drainage (070303) Pain
S: Reports pain improvement S: Denies pain at the moment of the assessment S: Reports pain to controlled mobilization with analgesia S: Reports 10 on the pain scale, like a "twinge" in the RLL S: Reports pain in the RLL S: Reports 10 on the pain scale in the SW S: Reports a lot of pain during the movements when conducting the physical therapy S: Reports 6 on the pain scale in the SW S: Reports pain after sponge bath S: Reports nausea S: Denies pain at the moment S: Reports 8 on the pain scale in the SW S: Reports 7, throbbing pain, on the pain scale in the SW O: VAS 0/10 O: No pain at the moment	(2102) Pain Level	(210201) Reported pain (210227) Nausea
O: Inappropriate positioning of the hip when trying to turn on the side O: Uses the bed trapeze to sit O: Gait training O: Walks with the aid of a walker O: Difficulty maintaining post-operative positioning O: Postural hypotension when getting out of the bed for gait training O: With risk of falls O: Walks with the aid of crutches	(0208) Mobility	(02080) Balance (020809) Coordination (020810) Gait (020802) Body positioning performance (020805) Transfer performance (020806) Walking (020814) Moves with ease
	(1912) Falls Occurrence	(191202) Falls while walking (191204) Falls from bed
O: Impaired gait O: Keeps bed wheels locked, railings up O: Morse = 45, 50, 60, 70, 75, 85, 110	(0210) Transfer performance	(021009) Transfers from one surface to another while lying (021001) Transfer from bed to chair (021002) Transfer from chair to bed (021003) Transfer from chair to chair
	(0202) Balance	(020202) Maintains balance while sitting without back support (020212) Maintains balance while rising from sitting position (020201) Maintains balance while standing (020203) Maintains balance while walking
	(0200) Ambulation: walking	(020002) Walks with effective gait (020003) Walks at slow pace (020004) Walks at moderate pace (020010) Walks short distance (< 1 block) (020201) Maintains balance while standing (020203) Maintains balance while walking (020211) Posture
	(0222) Gait	(022201) Steadiness of gait (022202) Balance while walking (022203) Walking posture (022204) Walks in straight line (022205) Length of stride (022215) Limping

Terms recorded by the physiotherapists	NOC Outcomes	NOC Indicators
S: Denies pain S: Reports a lot of pain when being mobilized S: Reports mild hip pain S: Reports mild discomfort in the SW S: Reports gastric discomfort S: Reports nausea S: Reports 4 on the pain level (VAS) in the SW	(2102) Pain Level	(210201) Reported pain (210227) Nausea
S: Reports using a walker during the day S: Reports having done the exercises proposed O: Walks with ease O: Walks with the aid of a walker O: Walks around the room O: Walks across the entire length of the room O: Walks in the hallway O: Walks with the aid of a walker to the bathroom O: Walks with good performance O: Walks with the aid of crutches O: Walks with slow steps O: Returns to bed O: Moves from bed to chair O: Gait training O: Chair sitting O: Orthostasis O: Walks with the assistance of the orthopedics team O: Postural hypotension	(0208) Mobility	(02080) Balance (020809) Coordination (020810) Gait (020802) Body positioning performance (020805) Transfer performance (020806) Walking (020806) Moves with ease
	(0210) Transfer performance	(021009) Transfers from one surface to another while lying (021001) Transfer from bed to chair (021002) Transfer from chair to bed (021003) Transfer from chair to chair
	(0202) Balance	(020202) Maintains balance while sitting without back support (020212) Maintains balance while rising from sitting position (020201) Maintains balance while standing (020203) Maintains balance while walking (020211) Posture
	(0200) Ambulation: walking	(020002) Walks with effective gait (020003) Walks at slow pace (020004) Walks at moderate pace (020010) Walks short distance (< 1 block) (020014) Walks around room
	(0222) Gait	(022201) Steadiness of gait (022202) Balance while walking (022203) Walking posture (022204) Walks in straight line (022205) Length of stride (022207) Speed appropriate for activity
S: Reports redness around the SW O: Portovac drain around the SW area O: Bleeding from the SW O: Portovac drain with high sanguineous drainage	(0703) Infection severity	(070305) Purulent drainage
	(1102) Wound healing: Primary intention	(110204) Sanguineous drainage (110208) Surrounding skin erythema (110206) Sanguineous drainage from drain (110207) Serosanguineous drainage from drain
S: Denies dyspnea	(0415) Respiratory Status	(041514) Dyspnea at rest (041515) Dyspnea with mild exertion

Domains	Classes	NOC Outcomes	N(Nurs)	(%)	N(Physio)	(%)
Health knowledge and behavior	Risk control and safety	(1912) Falls Occurrence	196	100	-	-
Perceived health	Symptom status	(2102) Pain Level	164	83.6	107	54.6
Physiological health	Tissue integrity	(1102) Wound healing: Primary intention	113	57.6	7	3.5
	Immune response	(0703) Infection Severity
Functional health	Mobility	(0208) Mobility	22	11.2	196	100
		(0210) Transfer performance
		(0202) Balance
		(0200) Ambulation: walking
		(0222) Gait

Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
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[1] Corresponding author:
Bruna Engelman brunaengelman@gmail.com