dementia care - icn.ch · törnvall e, wahren lk, wilhelmsson s. advancing nursing documentation -...

Dementia Care

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ISBN: 978-92-95099-52-4

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

Copyright © 2018 by ICN – International Council of Nurses, 3, place Jean-Marteau, 1201 Geneva, Switzerland Page 2

Title: Dementia Care Catalogue Type: 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 Norwegian 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


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):366–74. 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; 180:1075-8. Coenen A, Kim TY. Development of terminology subsets using ICNP®. Int J Med Inf. 2010;79(7):530–8. 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):14–23. 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):361–74. 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):362-7. 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):303–10.


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):108–17. 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) S274-80. International Council of Nurses (ICN): Guidelines for ICNP Catalogue Development. In. Geneva, Switzerland: International Classification for Nursing Practice Programme; 2008. Kärkkäinen O, Bondas T, Eriksson K. Documentation of Individualized Patient Care: a qualitative metasynthesis. Nurs Ethics. 2005;12(2):123–32. Kitwood T, Bredin K: Towards a theory of dementia care: personhood and well-being. Ageing and Soc. 1992;12(3):269-287. Kitwood T. The experience of dementia. Aging Ment Health. 1997;1(1):13–22. Kitwood T. Towards a theory of dementia care: the interpersonal process. Ageing Soc. 1993;13(01):51–67. McCormack B. Person‐centredness in gerontological nursing: an overview of the literature. J Clin Nurs. 2004;13(s1):31–8. 16. Naustdal A-G, Netteland G. Sjukepleiedokumentasjon i eit elektronisk samhandlingsperspektiv [Nursing Documentation in an electronic interaction perspective]. Sykepleien forskning [Norwegian]. 2012;3(7):270–7. Saranto K, Kinnunen U. Evaluating nursing documentation - research designs and methods: systematic review. J Adv Nurs. 2009;65(3):464–76. 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):2196–206. 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):605–17. VAR-Healthcare. https://www.varhealthcare.com/. Accessed on 6 May 2018.

Voutilainen P, Isola A, Muurinen S. Nursing documentation in nursing homes - state-of-the-art and implications for quality improvement. Scand J Caring Sci. 2004;18(1):72–81. 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):1858–75.


Concept Type Code

ICNP Statement (2017 Release)

Translated Statement in Norwegian

Diagnoses 10000449 Acute Confusion Akutt forvirringstilstand

10047087 Aggressive Behaviour Aggressiv adferd 10025705 Agitation Psykomotorisk uro

10002042 Agnosia (focus) Agnosi

10029697 Allergy Allergi

10047209 Ambivalence Ambivalens

10047041 Apraxia Apraxi 10029700 Arterial Ulcer Arterielt sår 10047104 Arthritis Pain Leddgiktsmerte 10027718 Bowel Incontinence Inkontinens for avføring

10000522 Chronic Confusion Kronisk forvirringstilstand

10000546 Chronic Pain Kronisk smerte

10000551 Chronic Sadness Vedvarende tristhet 10047189 Compulsive Behaviour Tvangsatferd 10000567 Constipation Obstipasjon

10047143 Cough Hoste 10047115 Cutaneous Pain Hudsmerte 10000607 Deficient Food Intake Mangelfullt matinntak 10022091 Delirium Delirium 10047002 Delusion Vrangforestilling

10022402 Depressed Mood Depressivt steminingsleie 10047056 Despair Fortvilelse

10000630 Diarrhoea Diarè

10001235 Disorientation Desorientering

10000669 Distorted Thinking Process Forstyrret tankegang 10023097 Disuse Syndrome Problemer med inaktivitet 10045584 Dizziness Svimmelhet

10047073 Dry Skin Tørr hud 10047094 Dyspepsia Dyspepsi 10029433 Dyspnoea Dyspnè

10047162 Emaciated Avmagring 10047060 Excoriation Hudavskrapning

10047018 Expressive Aphasia Ekspressiv afasi 10000695 Fatigue Fatigue 10000703 Fear Frykt 10047158 Food Allergy Matvareallergi 10047127 Fracture Pain Bruddsmerte 10029414 Functional Dyspnoea Funksjonsdyspnè 10022500 Hallucination Hallusinasjon 10000757 Hyperthermia Hypertermi 10047221 Hyperventilation Hyperventilasjon 10027578 Impaired Ability To Dress Nedsatt evne til å kle av og på seg


Concept Type Code



10029632 Impaired Ability To Groom Nedsatt evne til å stelle seg

10000987 Impaired Ability To Perform Hygiene Manglende evne til å ivareta personlig hygiene

10001005 Impaired Ability To Transfer Nedsatt evne til forflytning 10047191 Impaired Abstract Thinking Problemer med abstarkt tenkning 10047170 Impaired Balance Problem med balanse

10047136 Impaired Circulatory System Function Svekket sirkulasjon

10001131 Impaired Dentition Problem med tannstatus 10029873 Impaired Fluid Intake Problem med væskeinntak 10022544 Impaired Hearing Svekket hørsel

10001219 Impaired Mobility Nedsatt mobilitet 10000973 Impaired Self Feeding Nedsatt evne til å spise selv

10000994 Impaired Self Toileting Problem med å utføre toalettbesøk

10001033 Impaired Swallowing Problemer med svelgevne 10022748 Impaired Vision Svekket syn 10001046 Impaired Walking Problemer med gangfunksjon 10047025 Impressive Aphasia Impressiv afasi 10000859 Nausea Kvalme

10047400 Negative Euphoria Negativ Eufori 10023130 Pain Smerte

10039906 Phantom Pain Fantomsmerte 10047395 Positive Euphoria Positiv Eufori 10025798 Pressure Ulcer Trykksår 10047213 Risk For Social Isolation Risiko for sosial isolasjon 10045668 Seizure Anfall 10023410 Self Care Deficit Svikt i egenomsorg

10041824 Sleep Deprivation Søvnmangel 10040141 Somnolence Somnolens 10001675 Tendency To Wander Tendens til vandring 10025686 Urinary Incontinence Urininkontinens

10034654 Urinary Retention Urinretensjon

10030100 Venous Ulcer Venøst sår 10025981 Vomiting Oppkast

10040765 Withdrawn Behaviour Tilbaketrukket atferd


Concept Type Code



Outcomes 10028224 Able To Bath I stand til å utføre kroppsvask 10025025 Able To Communicate I stand til å kommunisere 10028211 Able To Dress I stand til å kle av/på seg selv 10028253 Able To Feed Self I stand til å spise selv 10028269 Able To Groom Self I stand til å stelle seg selv 10028461 Able To Mobilise I stand til å mobilisere

10028708 Able To Perform Hygiene I stand til å utføre personlig hygiene

10025714 Able To Perform Self Care I stand til å utføre egenomsorg 10028295 Able To Swallow I stand til å svelge 10028314 Able To Toilet Self I stand til å foreta toalettbesøk 10028322 Able To Transfer I stand til å forflytte seg 10028333 Able To Walk I stand til å gå 10024930 Adequate Sleep Tilstrekkelig søvn 10027647 Blood Pressure Within Normal Limits Blodtrykk innenfor normalområdet

10027652 Body Temperature Within Normal Limits

Kroppstemperatur innenfor normalområdet

10027901 Decreased Depressed Mood Depressivt stemningsleie er redusert

10047444 Decreased Despair Redusert fortvilelse 10050070 Decreased Social Isolation Redusert sosial isolasjon 10047459 Decreased Withdrawn Behaviour Redusert tilbaketrekning

10041334 Effective Breathing Tilfredsstillende respirasjonsmønster

10028403 Effective Defaecation Tilfredsstillende defekasjon 10033830 Effective Respiratory Status Tilfredsstillende respiratorisk status

10028173 Effective Sensory Perception Tilfredsstillende sensorisk persepsjon

10047245 Effective Urination Tilfredsstillende vannlatning 10047250 Faeces Within Normal Limits Avføring innenfor normalområdet 10047348 Improved Balance Bedret balanse 10047232 Improved Dentition Bedret tannstatus 10047330 Improved Fluid Intake Bedret væskeinntak 10047324 Improved Food Intake Bedret matinntak 10047369 Improved Hearing Bedret hørsel 10050027 Improved Mood Bedret stemningsleie 10035569 Improved Nutritional Status Bedret ernæringsstatus 10047437 Improved Perception Bedret persepsjon 10028517 Improved Skin Integrity Tilfredsstillende hudkvalitet 10047353 Improved Vision Bedret syn 10035645 No Aggressive Behaviour Ingen aggressiv adferd 10047492 No Allergy Ingen allergi 10050043 No Arterial Ulcer Ingen arterielle sår 10047297 No Cough Ingen hoste


Concept Type Code



10045681 No Dizziness Ingen svimmelhet 10050062 No Dyspepsia Ingen dyspepsi 10029264 No Dyspnoea Ingen dyspnè 10047428 No Euphoria Ingen eufori 10028984 No Nausea Ingen kvalme 10029008 No Pain Ingen smerte 10029065 No Pressure Ulcer Ingen trykksår 10047311 No Seizure Ingen anfall 10029201 No Wandering Ingen vandring

10037572 Nutritional Intake Within Normal Limits

Næringsinntak innenfor normalområdet

10025831 Pain Control Smertekontroll 10040333 Positive Appetite Positiv appetitt 10025002 Positive Nutritional Status Positiv ernæringsstatus 10027843 Reduced Agitation Redusert psykomotorisk uro 10027862 Reduced Chronic Sadness Vedvarende tristhet er redusert 10027889 Reduced Fear Tilstand av frykt er redusert 10027917 Reduced Pain Redusert smerte


Concept Type Code



Interventions

10025444 Administering Medication Administrere legemiddel

10001804 Administering Medication And Solution Administrere legemiddel- og væskeoppløsning

10050350 Applying Ointment Anvende salve 10050101 Assessing Ability To Feed Self Vurdere evne til å spise selv 10046790 Assessing Behaviour Vurdere atferd 10050223 Assessing Body Movement Vurdere kroppsbevegelse 10030558 Assessing Bowel Continence Vurdere kontinens for avføring 10036475 Assessing Bowel Status Vurdere tarmstatus 10050193 Assessing Circulatory System Vurdere sirkulasjon 10025883 Assessing Cognition Vurdere kognisjon 10050186 Assessing Consciousness Vurdere bevissthet 10002710 Assessing Control Of Pain Vurdere smertekontroll 10050129 Assessing Delirium Vurdere delir 10037875 Assessing Dietary Need Vurdere kostholdsbehov 10050089 Assessing Discomfort Vurdere ubehag 10002747 Assessing Eating Or Drinking Behaviour Vurdere spise- eller drikkeatferd 10050172 Assessing Faeces Vurdere avføring 10050210 Assessing Fine Motor Function Vurdere finmotorikk 10037881 Assessing Fluid Balance Vurdere væskebalanse 10044176 Assessing Fluid Intake Vurdere væskeinntak 10050140 Assessing Hearing Vurdere hørsel

10050117 Assessing Information Processing Vurdere informasjonsbearbeiding

10039087 Assessing Medication Side Effect Vurdere legemiddelbivirkning 10030527 Assessing Mobility Vurdere mobilitetsevne 10050234 Assessing Necrosis Vurdere nekrose 10030660 Assessing Nutritional Status Vurdere ernæringsstatus 10044202 Assessing Oral Status Vurdere status av munnhule 10026119 Assessing Pain Vurdere smerte 10030694 Assessing Physiological Status Vurdere fysisk status 10040586 Assessing Preferences Vurdere preferanser 10030734 Assessing Psychological Status Vurdere psykisk tilstand 10036786 Assessing Respiratory Status Vurdere respirasjonsstatus

10040921 Assessing Risk For Impaired Nutritional Status

Vurdere risiko for svekket ernæring

10002813 Assessing Risk For Ineffective Tissue Perfusion

Vurdere risiko for utilfredsstillende vevsgjennomblødning

10033922 Assessing Skin Integrity Vurdere hudkvalitet 10050206 Assessing Sputum Vurdere ekspektorat 10040529 Assessing Stoma Vurdere stomi 10002821 Assessing Susceptibility To Infection Vurdere infeksjonsmottagelighet 10050155 Assessing Swallowing Vurdere svelgevne


Concept Type Code



10030781 Assessing Urinary Continence Vurdere kontinens for urin

10030656 Assessing Urinary Retention Using Ultrasound

Vurdere urinretensjon med ultralyd

10036499 Assessing Urinary Status Vurdere status av urinveiene 10050164 Assessing Urine Vurdere urin 10050138 Assessing Vision Vurdere syn 10050268 Assisting With Dressing Assistere med av / på kledning

10037269 Assisting With Eating Or Drinking Assistere ved spising eller drikke

10050275 Assisting With Grooming Assistere ved stell 10030821 Assisting With Hygiene Hjelp til hygiene 10023531 Assisting With Toileting Assistere ved toalettbesøk 10039158 Assistive Device Therapy Sørge for hjelpemiddel 10050332 Changing Diaper Bytte bleie

10040435 Collaborating With Nutritionist Samarbeide med ernæringsfysiolog

10050378 Collaborating With Physiotherapist Samarbeid med fysioterapeut 10050384 Decreasing Noise Reduksjon av støy 10045098 Denture Care Stell av tannprotese 10039348 Diversional Therapy Implementere avledningsterapi 10039330 Fluid Therapy Administrere væskebehandling 10023861 Managing Dietary Regime Håndtere kostholdsregime 10050345 Managing Excoriation Håndtere hudavskrapning 10023890 Managing Exercise Regime Håndtere treningsregime 10031954 Managing Stoma Care Regime Håndtere stomistell 10031977 Managing Urinary Catheter Håndtere urinkateter 10031996 Measuring Blood Pressure Måle blodtrykk 10044740 Measuring Radial Pulse Måle radialispuls 10046338 Measuring Respirations Telle respirasjonsfrekvens 10050252 Milieu Therapy Miljøterapi 10032052 Monitoring Blood Pressure Overvåke blodtrykk 10012165 Monitoring Body Temperature Overvåke kroppstermperatur 10032121 Monitoring Weight Overvåke vekt 10050313 Offering Drink Tilby drikke 10032184 Oral Care Munnstell 10014761 Positioning Patient Leire pasient 10037691 Promoting Bladder Routine Fremme blæretømmingsrutiner 10037689 Promoting Bowel Routine Fremme tarmtømmingsrutiner

10036717 Promoting Effective Bowel Elimination Fremme tilfredsstillende eliminasjon av tarmtømming

10036729 Promoting Effective Urinary Elimination Fremme tilfredsstillende eliminasjon av urin

10032477 Promoting Hygiene Fremme hygiene

10050366 Promoting Self Bathing Fremme selvhjulpenhet I bading/dusjing

10026347 Promoting Self Care Fremme egenomsorg


Concept Type Code



10050321 Promoting Self Toileting Fremme selvhjulpenhet i toalettbesøk

10041161 Providing Food Sørge for mat 10050247 Providing Palliation Gi palliativ omsorg

10050281 Providing Pressure Relieving Mattress Sørge for trykkavlastende madrass

10050309 Reinforcing Communication Forsterke kommunikasjon 10026443 Reinforcing Personal Identity Forsterke personlig identitet

10039376 Reminiscence Therapy Implementere hukommelsesterapi

10040125 Teaching About Exercise Undervise om trening 10050299 Use Calming Technique Bruke beroligende teknikk 10033323 Weighing Patient Veie pasient 10033347 Wound Care Sårstell

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