Name: Dilzilene Cunha Sivirino Farias
Type: MSc dissertation
Publication date: 31/01/2022

Name Rolesort descending
Eliane de Fátima Almeida Lima Advisor *
Cândida Caniçali Primo Co-advisor *

Examining board:

Name Rolesort descending
Eliane de Fátima Almeida Lima Advisor *
Cândida Caniçali Primo Co advisor *
Júlia Valéria de Oliveira Vargas Bitencourt External Alternate *
Marcia Regina Cubas External Examiner *
Mirian Fioresi Internal Alternate *
Karla de Melo Batista Internal Examiner *

Summary: Introduction: Urgent and emergency care is characterized by its fast, dynamic,
stressful and conflicting situations, being necessary to adopt assistance protocols
that guarantee an adequate and timely assistance for those who depend on it. In this
sense, considering the activities of nurses in the risk classification room, the need to
record nursing care with a standardized language in any context of care and the
possibility of naming the elements of nursing practice from the International
Classification for Nursing Practice (ICNP®
), aligned with the line of research,
organization and evaluation of health care systems, this study sought to meet a
demand from the city of Vitoria to constitute nursing care in Emergency Departments.
Objectives: To identify the main ICNP®
diagnoses, nursing outcomes and
interventions applied to urgency and emergency situations; to map and associate
diagnoses with the flowcharts and discriminators of the Manchester Triage
; to relate diagnoses with outcomes and interventions; to develop and
evaluate a nursing record standard for emergency units based on the ICNP®; to
describe the requirements for inserting ICNP® diagnoses, outcomes and
interventions into the municipality`s electronic medical record. Method: Applied
technology development research conducted in seven steps: 1) Literature review; 2)
Cross-mapping between Manchester Triage System terms and ICNP®
terms; 3)
Construction of diagnostic/outcome statements; 4) Evaluation of diagnostic
statements by emergency nurses; 5) Elaboration and association of interventions to
the evaluated diagnoses; 6) Organization of the diagnoses/outcomes according to
Agnes Heller`s health needs described in the Theory of Practical Intervention in
Collective Health Nursing, and 7) Development of the concept map/requirements for
insertion of the registration pattern in the computerized network. Results: Through
the literature review and cross-mapping, it was possible to identify and prepare 185
diagnoses, 124 of which were constant and 61 not constant in the ICNP®
These were submitted to evaluation, as to relevance to practice, by means of the
Delphi Technique. The panel included 32 specialist nurses in urgency and
emergency, who evaluated 143 diagnostic statements as relevant, with IVC> 79%.
The diagnoses/results were associated with the interventions, resulting in 495
interventions and organized in Agnes Heller 18 health needs. Product: A nursing
record pattern was developed with ICNP®
terminology composed of 143 diagnoses,
148 outcomes and 495 nursing interventions. Conclusion: This research has the
potential to generate impact and to be applied at local, regional and national levels,
because it describes in a systematized way the steps for the elaboration of a nursing
record standard for Emergency Care Units. The standard is relevant for scientific and
technological development, and contributes to the standardization of professional
language and serves as a subsidy for the nursing record, giving visibility to the
nursing activities in urgency and emergency. The standard was forwarded to the
technology sector of the health secretariat of Vitória to be incorporated into the
municipality`s electronic medical record.

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