<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>2184-1578</journal-id>
<journal-title><![CDATA[Revista de Investigação & Inovação em Saúde]]></journal-title>
<abbrev-journal-title><![CDATA[RIIS]]></abbrev-journal-title>
<issn>2184-1578</issn>
<publisher>
<publisher-name><![CDATA[Escola Superior de Saúde Norte da Cruz Vermelha Portuguesa, Unidade de Investigação e Desenvolvimento]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S2184-15782023000100073</article-id>
<article-id pub-id-type="doi">10.37914/riis.v6i1.286</article-id>
<title-group>
<article-title xml:lang="en"><![CDATA[Nursing documentation related to respiratory process: content analysis of portuguese health records]]></article-title>
<article-title xml:lang="pt"><![CDATA[Análise de conteúdo à parametrização portuguesa relacionada com o processo respiratório]]></article-title>
<article-title xml:lang="es"><![CDATA[Análisis de contenido de la parametrización portuguesa relacionada con el proceso respiratorio]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Gaspar]]></surname>
<given-names><![CDATA[Luís]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Reis]]></surname>
<given-names><![CDATA[Neuza]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Sousa]]></surname>
<given-names><![CDATA[Paula]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Silva]]></surname>
<given-names><![CDATA[Abel Paiva e]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Pereira]]></surname>
<given-names><![CDATA[Filipe]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Machado]]></surname>
<given-names><![CDATA[Natália]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Centro Hospitalar e Universitário São João Universidade Católica Portuguesa ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Portugal</country>
</aff>
<aff id="Af2">
<institution><![CDATA[,Centro Hospitalar Universitário Lisboa Central Universidade Católica Portuguesa ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Portugal</country>
</aff>
<aff id="Af3">
<institution><![CDATA[,Centre for Information Systems Research and Development of Porto Nursing School Escola Superior de Enfermagem do Porto ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Portugal</country>
</aff>
<aff id="Af4">
<institution><![CDATA[,Escola Superior de Enfermagem do Porto  ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Portugal</country>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>06</month>
<year>2023</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>06</month>
<year>2023</year>
</pub-date>
<volume>6</volume>
<numero>1</numero>
<fpage>73</fpage>
<lpage>83</lpage>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://scielo.pt/scielo.php?script=sci_arttext&amp;pid=S2184-15782023000100073&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.pt/scielo.php?script=sci_abstract&amp;pid=S2184-15782023000100073&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.pt/scielo.php?script=sci_pdf&amp;pid=S2184-15782023000100073&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="en"><p><![CDATA[Abstract  Background:  data sharing from clinical practice is crucial to support nurses' decision-making process, improve nursing outcomes, and increase the quality of care. In Portugal, International Classification for Nursing Practice is used to document care being necessary for the standardization of this process preventing information redundancy.  Objectives:  (1) to identify diagnoses and interventions used by Portuguese nurses related to Respiratory Process, (2) to suggest unified diagnoses and interventions syntaxes.  Methodology:  qualitative study with a content analysis. The sample included data regarding e-documentation of nursing diagnosis and interventions customized in the nursing public information system until 2019.  Results:  of the initial sample of 1502 diagnoses aroused 28 and from 2060 interventions emerged 73 as the most relevant. The main findings were: two areas of nursing attention, one related to respiratory function and the other to patient's learning abilities, diversity of diagnoses and interventions to express the same needs resulting from a variety of taxonomic misunderstandings, and lack of standardized language.  Conclusions:  nursing documentation have two dimensions representing the complexity of nursing care. It also shows that using standardized language does not prevent information redundancy resulting in different diagnoses and interventions to express the same needs.]]></p></abstract>
<abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo  Enquadramento:  a partilha de dados da prática clínica é crucial para apoiar o processo de tomada de decisão, Em Portugal a CIPE é utilizada para documentar os cuidados de enfermagem sendo necessária a uniformização deste processo de forma a evitar redundância de informação.  Objetivos:  (1) identificar diagnósticos e intervenções utilizados por enfermeiros portugueses relacionados com o Processo Respiratório, (2) sugerir sintaxes unificadas de diagnósticos e intervenções.  Metodologia:  estudo qualitativo com análise de conteúdo análise de conteúdo. A amostra incluiu dados referentes à documentação eletrónica customizada no sistema público de informação de enfermagem até 2019.  Resultados:  da amostra inicial de 1502 diagnósticos emergiram 28 e de 2060 intervenções surgiram 73 como os mais relevantes. Os principais achados foram: duas áreas de atenção de enfermagem, uma relacionada com função respiratória e outra com habilidades de aprendizagem do cliente, diversidade de diagnósticos e intervenções para expressarem as mesmas necessidades decorrentes de equívocos taxonómicos e de falta de linguagem padronizada.  Conclusão:  os diagnósticos e intervenções de enfermagem possuem duas dimensões que representam a complexidade do cuidado de enfermagem. O uso de linguagem padronizada não impede a redundância de informações resultando em diagnósticos e intervenções diferentes para expressar as mesmas necessidades.]]></p></abstract>
<abstract abstract-type="short" xml:lang="es"><p><![CDATA[Resumen  Marco contextual:  el cambio de datos resultantes de la práctica clínica es crucial para apoyar el proceso de toma de decisiones. Portugal, utiliza la CIPE para documentar la práctica clínica, siendo necesaria la estandarización de lo proceso evitando redundancia de información.  Objetivos:  (1) identificar diagnósticos e intervenciones utilizados por enfermeros portugueses relacionados con el Proceso Respiratorio, (2) sugerir sintaxis unificadas de diagnósticos e intervenciones.  Metodología:  diseño cualitativo con análisis de contenido. La muestra incluyó datos sobre documentación electrónica en el sistema de información pública de enfermería hasta 2019.  Resultados:  1502 diagnósticos surgieron 28 y de 2060 intervenciones surtieron 73 como los más relevantes. Los principales hallazgos fueron: dos áreas de atención de enfermería, una relacionada con la función respiratoria y otra con las habilidades de aprendizaje del paciente, diversidad de diagnósticos e intervenciones para expresar las mismas necesidades resultantes de una variedad de malentendidos taxonómicos, falta de lenguaje estandarizado.  Conclusión:  los resultados muestran que la documentación de enfermería tiene dos dimensiones representando la complejidad del cuidado de enfermería. También muestra que el uso de un lenguaje estandarizado no evita la redundancia de información resultando en diferentes diagnósticos e intervenciones para expresar las mismas necesidades.]]></p></abstract>
<kwd-group>
<kwd lng="en"><![CDATA[nursing diagnosis]]></kwd>
<kwd lng="en"><![CDATA[nursing process]]></kwd>
<kwd lng="en"><![CDATA[advanced practice nursing]]></kwd>
<kwd lng="en"><![CDATA[respiration]]></kwd>
<kwd lng="pt"><![CDATA[diagnósticos de enfermagem]]></kwd>
<kwd lng="pt"><![CDATA[processo de enfermagem]]></kwd>
<kwd lng="pt"><![CDATA[prática avançada de enfermagem]]></kwd>
<kwd lng="pt"><![CDATA[respiração]]></kwd>
<kwd lng="es"><![CDATA[diagnósticos de enfermería]]></kwd>
<kwd lng="es"><![CDATA[proceso de enfermería]]></kwd>
<kwd lng="es"><![CDATA[enfermería de práctica avanzada]]></kwd>
<kwd lng="es"><![CDATA[respiración]]></kwd>
</kwd-group>
</article-meta>
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