Mental health assistance: identification of nursing diagnoses in a community mental health service

Rev Bras Enferm. 2021 Oct 1;75(2):e20201175. doi: 10.1590/0034-7167-2020-1175. eCollection 2021.
[Article in English, Portuguese]

Abstract

Objective: to map and identify nursing diagnoses targeted at night care users in a Psychosocial Care Center according to NANDA-I Taxonomy.

Method: this is a descriptive-exploratory study, of documentary research type of 319 records in medical records. It was held in a Psychosocial Care Center III in Goiás, from 2014-2018. Nursing diagnoses and records were extracted with non-standardized language.

Results: 813 records of nursing diagnoses identified in 53 different titles, in 10 domains, were identified. The most frequent diagnosis was risk for self-extermination. The domain with the highest number of diagnostic records was activity/rest. There was a predominance of diagnoses focused on the problem.

Final considerations: mapping contributes to the planning of evidence-based nursing interventions and to the strengthening of professional identity in mental health. It is evident the need for practices that go beyond the symptoms in a preventive perspective, with a view to comprehensiveness.

MeSH terms

  • Community Mental Health Services*
  • Humans
  • Mental Health
  • Nursing Diagnosis