Objetivo: elaborar e validar instrumento para assistência de enfermagem, baseado em literatura específica para pacientes internados em Unidade de Terapia Intensiva, de um hospital universitário do estado de São Paulo. Método: estudo metodológico, com coleta de dados de agosto a dezembro de 2015, em três fases: caracterização da população e levantamento dos diagnósticos de enfermagem, elaboração, e validação do instrumento para o registro do Processo de Enfermagem. Para a validação de conteúdo, utilizou-se a técnica Delphi, com um grupo de especialistas na área, composto por 11 jurados. Resultados: durante a coleta de dados, 152 pacientes estiveram internados, 61,18% do sexo masculino, com idade média de 54,9 anos. O conteúdo do instrumento foi validado com índice de validação > 0,81. Conclusão: a construção de instrumentos para o processo de Enfermagem é útil para facilitar a implementação da assistência, evidenciar a assistência, incrementar a comunicação e segurança dos cuidados em saúde.

Objective: To generate a Classification Tree for the correct inference of the Nursing Diagnosis Fluid Volume Excess (00026) in chronic renal patients on hemodialysis. Method: Methodological, cross-sectional study with patients undergoing renal treatment. The data were collected through interviews and physical evaluation, using an instrument with socio-demographic variables, related factors, associated conditions and defining characteristics of the studied diagnosis. The classification trees were generated by the Chi-Square Automation Interaction Detection method, which was based on the Chi-square test. Results: A total of 127 patients participated, of which 79.5% (101) presented the diagnosis studied. The trees included the elements “Excessive sodium intake” and “Input exceeds output”, which were significant for the occurrence of the event, as the probability of occurrence of the diagnosis in the presence of these was 0.87 and 0.94, respectively. The prediction accuracy of the trees was 63% and 74%, respectively. Conclusion: The construction of the trees allowed to quantify the probability of the occurrence of Fluid Volume Excess (00026) in the studied population and the elements “Excessive sodium intake” and “Input exceeds output” were considered predictors of this diagnosis in the sample.

Objective: to analyze the content of the defining characteristics of the Disturbed Sleep Pattern Nursing Diagnosis (00198) in patients with Acute Coronary Syndrome. Method: content analysis performed by specialists who achieved a score equal to or greater than five, according to established criteria: clinical experience, teaching and/or research; participation in research groups; doctorate degree; master's degree; specialization and/or residency in cardiology and/or sleep and/or nursing classifications. Eight defining characteristics were evaluated for their relationship to population, relevance, clarity and accuracy. Descriptive statistics were performed to characterize the sample, binomial statistical test to establish if there is agreement between the experts and chi-square and Fisher's exact to establish associations between the evaluated items and the experts' variables. Results: 54 experts participated in the study. The defining characteristics validated by the experts were the following: dissatisfaction with sleep, feeling unrested, sleep deprivation, alteration in sleep pattern, unintentional awakening, difficulty initiating sleep and daytime sleepiness. There was a statistically significant association between evaluated items and the variables time of training, time of operation and punctuation. Conclusion: seven of the eight defining characteristics were considered valid after the application of binomial test. This study will contribute to the refinement of the Disturbed Sleep Pattern Nursing Diagnosis (000198) and may enable the improvement of the quality of care of patients hospitalized with Acute Coronary Syndrome regarding changes in sleep pattern. The content analysis stage will support the next stage of the validation process of the present diagnosis, the clinical validation.

Objective: to construct the conceptual and operational definitions of the defining and conceptual characteristics of the related factors of the nursing diagnosis (ND) hypothermia (00006) of NANDA-I, 2015-2017, in adult patients in the perioperative period. Method: an integrative literature review in the Medical Literature Analysis and Retrieval System Online, Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature and in Latin & American Literature in Health Sciences databases. Results: 2,041 articles were found, 95 selected for reading in full and 24 used to construct such definitions. Gay literature was also explored to ensure robustness to the elucidation of topics not found in articles. Conclusion: such definitions will assist nurses in surgical practice in information collection, in accurate determination of the referred ND, in teaching and in future research related to this theme, as well as in the next validation stages of such ND to the referred population.