Banco de termos da linguagem especial de Enfermagem para Unidade de Terapia Intensiva de adultos

Abstract

The new scenario brought about by globalization has created the need for a reorganization of patient care and the use of a language understood by all members of the nursing staff. This aim can be achieved with the use of classification systems, but no such system has been found for nursing care in the Intensive Care Unit (ICU), despite International Counsil of Nursing interest. Collecting and codifying terms used by nursing staff in specific areas is a necessary step for the production of ICNP® catalogues in these specific areas. The main aim of this study is the building of a terminology bank of nursing language for the adult intensive care unit, and the secondary objectives include identifying terms employed by nurses in patients clinical records in the ICU- adult; the matching of these terms with the ones already included in ICNP® version 1.0; and the classification of the terms which are not included in ICNP® version 1.0, considering the seven axes of the classification. This is a descriptive study that collected 164.016 terms from the 102 records filled out by nurses in an ICU in Belo Horizonte, Brazil. For the analysis of the corpus, the terms extracted were submitted to a process that excluded repetitions, rectified misspellings, searched for synonymous expressions, standardized verbal tenses and word gender, and excluded pseudo-terminological expressions and other terms that were subfeatures of terms present in the seven axes in ICNP®-Version 1.0. After these procedures, terms amounted to 1.312 terms. The matching of these with the terms in ICNP® revealed a total of 1.016 terms absent from the classification. This list contained medical terms that were excluded; terms related to drugs, which were reorganized into the pharmacological classes; and terms which used to represent specific characteristics of constant terms in the classification, which were also excluded. These actions led to a total of 548 terms not included in the classification, which were then classified according to the ICNP®-Version 1.0 seven axes model. As a result, 156 terms (28,5%) were categorized in the focus axis; 77 (14,0%) in the location axis; 4 (0,7%) in the client axis; 29 (5,3%) in the time axis; 87 (15.9%) in the judgment axis; 70 (12.8%) in the action axis; and 125 (22.8%) in the medios axis. These results show that in this particular ICU nurses frequently employ terms not included in the classification, revealing the specific language used in this kind of unit. The distribution of terms in the axes is directly related to the particularities of patients in the ICU, who require constant watch and specialized equipment, and also have the recording of the nursing process steps by the nursing staff. These printouts were used in this study. We observed certain problems in the categorization of some terms in the classification, and suggest other analysis of the terminological branches in ICNP®, as well as of some concepts revision. This study made possible a greater knowledge of the vocabulary employed in the nursing care of patients in adult ICU and can contribute to the creation of a specific terminology for this specialized nursing care.