Terms of specialized nursing language for people with pressure injury

ABSTRACT Objective: to validate the terms of the specialized nursing language used in care for hospitalized patients with Pressure Injury, identified in nurses’ records, mapping them with the terms of the International Classification for Nursing Practice (ICNP® 2017). Methods: methodological study, carried out at a School Hospital in 2018. It was performed: extraction of terms of medical records; normalization; cross-mapping between extracted terms and those in ICNP®; distribution in the seven axes; theoretical definition and validation of terms. Results: 27,756 terms were extracted. The normalization resulted in 370 relevant terms, being: 225 listed and 145 not listed in the ICNP®, being 60 similar, 13 more comprehensive, 38 more restricted and 34 without agreement, all of which are validated. Conclusion: this study identified and validated terms used by nurses to assist people with Pressure Injury. These may contribute to the unification of professional nursing language in care for these clients.摘要 研究目的：本研究旨在验证从护士护理记录中提取的压疮（Pressure Injury）住院患者护理专用术语，并将其与2017版国际护理实践分类（International Classification for Nursing Practice, ICNP® 2017）的术语进行映射匹配。 研究方法：本研究为方法学研究，于2018年在某院校附属教学医院开展。具体研究流程包括：病历术语提取、术语规范化处理、提取术语与ICNP®术语的交叉映射、按七大轴线进行分类、术语的理论定义与验证。 研究结果：共提取27756条术语，经规范化处理后得到370条有效术语，其中225条可在ICNP®中检索到对应条目，145条未检索到匹配条目；在未检索到匹配条目的145条术语中，60条与ICNP®现有术语相似，13条涵盖范围更广，38条涵盖范围更窄，34条无对应匹配术语，上述所有术语均已完成验证。 研究结论：本研究明确并验证了护士用于压疮患者护理的专用术语，这些术语有助于统一该领域的护理专业用语，为压疮患者临床照护的标准化建设提供支撑。