ISBN: Copyright 2018 by ICN International Council of Nurses, 3, place Jean-Marteau, 1201 Geneva, Switzerland

Transkript

1 Dementia Care

2 All rights, including translation into other languages, reserved. No part of this publication may be reproduced in print, by photostatic means or in any other manner, or stored in a retrieval system, or transmitted in any form, or sold without the express written permission of the International Council of Nurses. Short excerpts (under 300 words) may be reproduced without authorization, on condition that the source is indicated. ISBN: , place Jean-Marteau, 1201 Geneva, Switzerland

3 Title: Dementia Care Catalogue : Terminology Subset Publication Date: 2018 Authors: Lene Baagøe Laukvik, RN, PhD-student, Lecture at the University of Agder Department of Health- and Nursing Science, Grimstad, Norway Kathryn Louise Mølstad, RN, Senior Adviser at Nurses Organisation, Oslo, Norway Mariann Fossum, RN, PhD, Professor at the University of Agder Department of Health- and Nursing Science, Grimstad, Norway Unni Stensvold, RN, Clinical Nurse Specialist in Sandefjord municipality, Sandefjord, Norway Kay Jansen, DNP, PMHCNS-BC, RN, Clinical Associate Professor at the University of Wisconsin-Milwaukee College of Nursing, Milwaukee, Wisconsin, USA 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 2

4 Note: This catalogue provides ICNP concepts to support the nursing care of older adults with dementia. Background: The International Classification for Nursing Practice (ICNP ) is a unified nursing language system that supports the standardisation of nursing documentation at the point of care. The resulting data-based information can be used for planning and managing nursing care, financial forecasting, analysis of patient outcomes and policy development. The ICNP Strategic Advisory Group and many other expert nurses involved with ICNP have recognised that manageable subsets of the terminology should be available to nurses working with patients or clients in selected specialties and settings. The purpose of a catalogue is to make ICNP a useful tool for nurses at the point of care. Catalogues are subsets of ICNP that allow nurses to more readily integrate ICNP into their practice as they work in a specialty area or with clients having specific health conditions or needs. Catalogues do not replace the clinical judgement of the nurse. Nurses can use Catalogues as reference tools for documenting care and reflecting on their practice. Nurses clinical judgement and decision-making are essential for individualised care of patients and their families and cannot be replaced by any tool. References: Benner P. The role of experience, narrative, and community in skilled ethical comportment. Adv Nurs Sci. 1991;14(2):1 21. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. Int J Nurs Pract. 2006;12(6): Coenen A, Kim TY, Bartz CC, Jansen K, Hardiker N. ICNP Catalogues for supporting nursing content in electronic health records. Stud Health Technol Inform. 2012; 180: Coenen A, Kim TY. Development of terminology subsets using ICNP. Int J Med Inf. 2010;79(7): Conrick M. The international classification for nursing practice: a tool to support nursing practice? Collegian. 2005;12(3):9 13. Daly JMRNP, Buckwalter KRNPF, Maas MRNPF. Written and computerized care plans. J Gerontol Nurs. 2002;28(9): Dewing J. Personhood and dementia: revisiting Tom Kitwood s ideas. Int J Older People Nurs. 2008;3(1):3 13. Edberg AK, Edfors E. Nursing care for people with frontal-lobe dementia difficulties and possibilities. Int Psychogeriatr. 2008;20(2): Edvardsson D, Winblad B, Sandman P-O. Person-centred care of people with severe Alzheimer's disease: current status and ways forward. Lancet Neurol. 2008;7(4): Ehrenberg A, Ehnfors M. The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses and patients descriptions. Scand J Caring Sci. 2001;15(4): , place Jean-Marteau, 1201 Geneva, Switzerland Page 3

5 Florin J, Ehrenberg A, Ehnfors M, Björvell C. A comparison between the VIPS model and the ICF for expressing nursing content in the health care record. Int J Med Inf. 2013;82(2): Hardiker NR, Coenen A. Interpretation of an international terminology standard in the development of a logic-based compositional terminology. Int J Med Inf. 2007;76(2) S International Council of Nurses (ICN): Guidelines for ICNP Catalogue Development. In. Geneva, Switzerland: International Classification for Nursing Practice Programme; Kärkkäinen O, Bondas T, Eriksson K. Documentation of Individualized Patient Care: a qualitative metasynthesis. Nurs Ethics. 2005;12(2): Kitwood T, Bredin K: Towards a theory of dementia care: personhood and well-being. Ageing and Soc. 1992;12(3): Kitwood T. The experience of dementia. Aging Ment Health. 1997;1(1): Kitwood T. Towards a theory of dementia care: the interpersonal process. Ageing Soc. 1993;13(01): McCormack B. Person centredness in gerontological nursing: an overview of the literature. J Clin Nurs. 2004;13(s1): Naustdal A-G, Netteland G. Sjukepleiedokumentasjon i eit elektronisk samhandlingsperspektiv [Nursing Documentation in an electronic interaction perspective]. Sykepleien forskning []. 2012;3(7): Saranto K, Kinnunen U. Evaluating nursing documentation - research designs and methods: systematic review. J Adv Nurs. 2009;65(3): Sjögren K, Lindkvist M, Sandman P-O, Zingmark K, Edvardsson D. Personcentredness and its association with resident well-being in dementia care units. J Adv Nurs. 2013;69(10): Törnvall E, Wahren LK, Wilhelmsson S. Advancing nursing documentation - An intervention study using patients with leg ulcer as an example. Int J Med Inf. 2009;78(9): VAR-Healthcare. Accessed on 6 May Voutilainen P, Isola A, Muurinen S. Nursing documentation in nursing homes - state-of-theart and implications for quality improvement. Scand J Caring Sci. 2004;18(1): Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs. 2011;67(9): , place Jean-Marteau, 1201 Geneva, Switzerland Page 4

6 Diagnoses Acute Confusion Akutt forvirringstilstand Aggressive Behaviour Aggressiv adferd Agitation Psykomotorisk uro Agnosia (focus) Agnosi Allergy Allergi Ambivalence Ambivalens Apraxia Apraxi Arterial Ulcer Arterielt sår Arthritis Pain Leddgiktsmerte Bowel Incontinence Inkontinens for avføring Chronic Confusion Kronisk forvirringstilstand Chronic Pain Kronisk smerte Chronic Sadness Vedvarende tristhet Compulsive Behaviour Tvangsatferd Constipation Obstipasjon Cough Hoste Cutaneous Pain Hudsmerte Deficient Food Intake Mangelfullt matinntak Delirium Delirium Delusion Vrangforestilling Depressed Mood Depressivt steminingsleie Despair Fortvilelse Diarrhoea Diarè Disorientation Desorientering Distorted Thinking Process Forstyrret tankegang Disuse Syndrome Problemer med inaktivitet Dizziness Svimmelhet Dry Skin Tørr hud Dyspepsia Dyspepsi Dyspnoea Dyspnè Emaciated Avmagring Excoriation Hudavskrapning Expressive Aphasia Ekspressiv afasi Fatigue Fatigue Fear Frykt Food Allergy Matvareallergi Fracture Pain Bruddsmerte Functional Dyspnoea Funksjonsdyspnè Hallucination Hallusinasjon Hyperthermia Hypertermi Hyperventilation Hyperventilasjon Impaired Ability To Dress Nedsatt evne til å kle av og på seg 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 5

7 Impaired Ability To Groom Nedsatt evne til å stelle seg Manglende evne til å ivareta Impaired Ability To Perform Hygiene personlig hygiene Impaired Ability To Transfer Nedsatt evne til forflytning Impaired Abstract Thinking Problemer med abstarkt tenkning Impaired Balance Problem med balanse Impaired Circulatory System Function Svekket sirkulasjon Impaired Dentition Problem med tannstatus Impaired Fluid Intake Problem med væskeinntak Impaired Hearing Svekket hørsel Impaired Mobility Nedsatt mobilitet Impaired Self Feeding Nedsatt evne til å spise selv Impaired Self Toileting Problem med å utføre toalettbesøk Impaired Swallowing Problemer med svelgevne Impaired Vision Svekket syn Impaired Walking Problemer med gangfunksjon Impressive Aphasia Impressiv afasi Nausea Kvalme Negative Euphoria Negativ Eufori Pain Smerte Phantom Pain Fantomsmerte Positive Euphoria Positiv Eufori Pressure Ulcer Trykksår Risk For Social Isolation Risiko for sosial isolasjon Seizure Anfall Self Care Deficit Svikt i egenomsorg Sleep Deprivation Søvnmangel Somnolence Somnolens Tendency To Wander Tendens til vandring Urinary Incontinence Urininkontinens Urinary Retention Urinretensjon Venous Ulcer Venøst sår Vomiting Oppkast Withdrawn Behaviour Tilbaketrukket atferd 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 6

8 Outcomes Able To Bath I stand til å utføre kroppsvask Able To Communicate I stand til å kommunisere Able To Dress I stand til å kle av/på seg selv Able To Feed Self I stand til å spise selv Able To Groom Self I stand til å stelle seg selv Able To Mobilise I stand til å mobilisere I stand til å utføre personlig Able To Perform Hygiene hygiene Able To Perform Self Care I stand til å utføre egenomsorg Able To Swallow I stand til å svelge Able To Toilet Self I stand til å foreta toalettbesøk Able To Transfer I stand til å forflytte seg Able To Walk I stand til å gå Adequate Sleep Tilstrekkelig søvn Blood Pressure Within Normal Limits Blodtrykk innenfor normalområdet Body Temperature Within Normal Limits Kroppstemperatur innenfor normalområdet Decreased Depressed Mood Depressivt stemningsleie er redusert Decreased Despair Redusert fortvilelse Decreased Social Isolation Redusert sosial isolasjon Decreased Withdrawn Behaviour Redusert tilbaketrekning Tilfredsstillende Effective Breathing respirasjonsmønster Effective Defaecation Tilfredsstillende defekasjon Effective Respiratory Status Tilfredsstillende respiratorisk status Tilfredsstillende sensorisk Effective Sensory Perception persepsjon Effective Urination Tilfredsstillende vannlatning Faeces Within Normal Limits Avføring innenfor normalområdet Improved Balance Bedret balanse Improved Dentition Bedret tannstatus Improved Fluid Intake Bedret væskeinntak Improved Food Intake Bedret matinntak Improved Hearing Bedret hørsel Improved Mood Bedret stemningsleie Improved Nutritional Status Bedret ernæringsstatus Improved Perception Bedret persepsjon Improved Skin Integrity Tilfredsstillende hudkvalitet Improved Vision Bedret syn No Aggressive Behaviour Ingen aggressiv adferd No Allergy Ingen allergi No Arterial Ulcer Ingen arterielle sår No Cough Ingen hoste 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 7

9 No Dizziness Ingen svimmelhet No Dyspepsia Ingen dyspepsi No Dyspnoea Ingen dyspnè No Euphoria Ingen eufori No Nausea Ingen kvalme No Pain Ingen smerte No Pressure Ulcer Ingen trykksår No Seizure Ingen anfall No Wandering Ingen vandring Nutritional Intake Within Normal Næringsinntak innenfor Limits normalområdet Pain Control Smertekontroll Positive Appetite Positiv appetitt Positive Nutritional Status Positiv ernæringsstatus Reduced Agitation Redusert psykomotorisk uro Reduced Chronic Sadness Vedvarende tristhet er redusert Reduced Fear Tilstand av frykt er redusert Reduced Pain Redusert smerte 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 8

10 Interventions Administering Medication Administrere legemiddel Administrere legemiddel- og Administering Medication And Solution væskeoppløsning Applying Ointment Anvende salve Assessing Ability To Feed Self Vurdere evne til å spise selv Assessing Behaviour Vurdere atferd Assessing Body Movement Vurdere kroppsbevegelse Assessing Bowel Continence Vurdere kontinens for avføring Assessing Bowel Status Vurdere tarmstatus Assessing Circulatory System Vurdere sirkulasjon Assessing Cognition Vurdere kognisjon Assessing Consciousness Vurdere bevissthet Assessing Control Of Pain Vurdere smertekontroll Assessing Delirium Vurdere delir Assessing Dietary Need Vurdere kostholdsbehov Assessing Discomfort Vurdere ubehag Assessing Eating Or Drinking Behaviour Vurdere spise- eller drikkeatferd Assessing Faeces Vurdere avføring Assessing Fine Motor Function Vurdere finmotorikk Assessing Fluid Balance Vurdere væskebalanse Assessing Fluid Intake Vurdere væskeinntak Assessing Hearing Vurdere hørsel Vurdere Assessing Information Processing informasjonsbearbeiding Assessing Medication Side Effect Vurdere legemiddelbivirkning Assessing Mobility Vurdere mobilitetsevne Assessing Necrosis Vurdere nekrose Assessing Nutritional Status Vurdere ernæringsstatus Assessing Oral Status Vurdere status av munnhule Assessing Pain Vurdere smerte Assessing Physiological Status Vurdere fysisk status Assessing Preferences Vurdere preferanser Assessing Psychological Status Vurdere psykisk tilstand Assessing Respiratory Status Vurdere respirasjonsstatus Assessing Risk For Impaired Nutritional Status Vurdere risiko for svekket ernæring Assessing Risk For Ineffective Tissue Perfusion Vurdere risiko for utilfredsstillende vevsgjennomblødning Assessing Skin Integrity Vurdere hudkvalitet Assessing Sputum Vurdere ekspektorat Assessing Stoma Vurdere stomi Assessing Susceptibility To Infection Vurdere infeksjonsmottagelighet Assessing Swallowing Vurdere svelgevne 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 9

11 Assessing Urinary Continence Vurdere kontinens for urin Assessing Urinary Retention Using Vurdere urinretensjon med Ultrasound ultralyd Assessing Urinary Status Vurdere status av urinveiene Assessing Urine Vurdere urin Assessing Vision Vurdere syn Assisting With Dressing Assistere med av / på kledning Assistere ved spising eller Assisting With Eating Or Drinking drikke Assisting With Grooming Assistere ved stell Assisting With Hygiene Hjelp til hygiene Assisting With Toileting Assistere ved toalettbesøk Assistive Device Therapy Sørge for hjelpemiddel Changing Diaper Bytte bleie Collaborating With Nutritionist Samarbeide med ernæringsfysiolog Collaborating With Physiotherapist Samarbeid med fysioterapeut Decreasing Noise Reduksjon av støy Denture Care Stell av tannprotese Diversional Therapy Implementere avledningsterapi Fluid Therapy Administrere væskebehandling Managing Dietary Regime Håndtere kostholdsregime Managing Excoriation Håndtere hudavskrapning Managing Exercise Regime Håndtere treningsregime Managing Stoma Care Regime Håndtere stomistell Managing Urinary Catheter Håndtere urinkateter Measuring Blood Pressure Måle blodtrykk Measuring Radial Pulse Måle radialispuls Measuring Respirations Telle respirasjonsfrekvens Milieu Therapy Miljøterapi Monitoring Blood Pressure Overvåke blodtrykk Monitoring Body Temperature Overvåke kroppstermperatur Monitoring Weight Overvåke vekt Offering Drink Tilby drikke Oral Care Munnstell Positioning Patient Leire pasient Promoting Bladder Routine Fremme blæretømmingsrutiner Promoting Bowel Routine Fremme tarmtømmingsrutiner Promoting Effective Bowel Elimination Fremme tilfredsstillende eliminasjon av tarmtømming Promoting Effective Urinary Elimination Fremme tilfredsstillende eliminasjon av urin Promoting Hygiene Fremme hygiene Fremme selvhjulpenhet I Promoting Self Bathing bading/dusjing Promoting Self Care Fremme egenomsorg 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 10

12 Promoting Self Toileting Providing Food Sørge for mat Fremme selvhjulpenhet i toalettbesøk Providing Palliation Gi palliativ omsorg Sørge for trykkavlastende Providing Pressure Relieving Mattress madrass Reinforcing Communication Forsterke kommunikasjon Reinforcing Personal Identity Forsterke personlig identitet Implementere Reminiscence Therapy hukommelsesterapi Teaching About Exercise Undervise om trening Use Calming Technique Bruke beroligende teknikk Weighing Patient Veie pasient Wound Care Sårstell 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 11

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