Abstract
to describe the construction and validation process for a mobile application for development of the nursing history and diagnosis. methodological study conducted in 2018 in three stages: content creation, based on the Basic Human Needs categories and nursing diagnoses; content assessment by nine nursing judges, with calculation of the content validity index; and construction of the application, which included definition of the requirements, a conceptual map, implementation and prototyping options, tests and implementation. the application was organized by sections: Grouped Basic Human Needs, Cranial pair tests, Clinical assessment scales and Additional tests. Two section were adjusted according to the judges' suggestions. it is the first application produced in Brazil based on the Basic Human Need categories, which enables quick access to information, concepts and typical nomenclatures of semiology, recording of clinical data and definition of nursing diagnoses.
Highlights
Technical and scientific improvement of the nursing process (NP) is an ongoing need among students and nurses, since it is the methodological tool that guides care and documentation in professional practice[1,2]
The Basic Human Needs (BHN) can be associated with nursing problems discovered during clinical examinations, which may serve as data for selecting the nursing diagnoses described by taxonomies, such as NANDA International (NANDA-I)(4-5)
The application developed, called CuidarTech Semio – Nursing Clinical Examination, was organized into 17 sections: General instructions: Patient identification; 12 sections in reference to the grouped BHN with content from the interview and physical examination related to the main NANDA-1 diagnosis titles; Cranial pair tests, Clinical assessment scales; and Additional tests
Summary
Technical and scientific improvement of the nursing process (NP) is an ongoing need among students and nurses, since it is the methodological tool that guides care and documentation in professional practice[1,2]. The NP is comprised of the steps of collecting data or history, which includes the interview and physical examination; diagnosis; planning; implementation and nursing assessment[2,3,4]. The NP needs to be based on a theoretical framework that safely and scientifically guides professional practice[2]. Despite the importance of physical examinations, it can be noted that they are not fully carried out in a systematic way by students and nurses in health institutions. Studies indicate that lack of theoretical-practical skills, gaps in the teaching-learning process, forgetting theoretical support and difficulty learning the typical codification of the health area are the main factors that hinder their being performed, impacting the operationalization of the NP, which is essential for scientificity and visibility of the profession[2,87-11]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
