Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
Objective:To describe the pressure ulcer healing process in critically ill patients treated with conventional dressing therapy plus low-intensity laser therapy evaluated by the Pressure Ulcer Scale for Healing (PUSH) and the result of Wound Healing: Secondary Intention, according to the Nursing Outcomes Classification (NOC). Method: Case report study according to nursing process conducted with an Intensive Care Unit patient. Data were collected with an instrument containing the PUSH and the result of the NOC. In the analysis we used descriptive statistics, considering the scores obtained on the instrument. Results: A reduction in the size of lesions of 7cm to 1.5cm of length and 6cm to 1.1cm width, in addition to the increase of epithelial tissue and granulation, decreased secretion and odor. Conclusion: There was improvement in the healing process of the lesion treated with adjuvant therapy and the use of NOC allowed a more detailed and accurate assessment than the PUSH.
RESUMO:A evolução tecnológica na área da informação tem sido uma constante nos dias atuais, levando a enfermagem a buscar o seu desenvolvimento nesta temática. Para tanto, fezse necessário a criação de classificações para sua prática, com linguagens padronizadas, capazes de comunicar o seu saber e fazer. Na realidade brasileira, ainda são poucas as experiências na aplicação destas classificações, sejam de diagnósticos, intervenções ou resultados, embora existam muitos registros de enfermagem com linguagem não padronizada. Assim é que se propõe, neste artigo, apresentar e descrever o método mapeamento cruzado, o qual possibilita um mapeamento dos registros de enfermagem com linguagem não padronizada em sistemas de classificações padronizados. Aborda-se ainda, de forma suscinta, algumas das classificações existentes e exemplifica-se a aplicação do método de mapeamento cruzado em seu processo e regras, com o intuito de servir de subsídio e auxílio no desenvolvimento de pesquisas na área, contribuindo para o conhecimento da enfermagem. Descritores INTRODUÇÃOO processo de globalização pelo qual passa o mundo atual com crescente aumento e velocidade das informações, evolução tecnológica, necessidade de maximizar recursos, diminuir custos e melhorar a qualidade da assistência prestada, exigem da enfermagem aprimoramento, através do desenvolvimento de pesquisas em sua área de atuação, o que requer registro de informações de sua prática.A prática de enfermagem se caracteriza por uma constante tarefa de coletar, arquivar e fazer uso de informações sobre pacientes, viabilizando o cuidado, pelo qual é responsável. No entanto, o grande volume de dados e a necessidade de controlar a qualidade da assistência realizada, bem como a necessidade de acessar rapidamente as informações têm exigido o uso, cada vez maior, de recursos de informática. Assim, o que se procura, hoje, é a informatização do prontuário do paciente, de modo a ter um registro único de dados, em que todos os profissionais de saúde possam ter acesso e direito ao registro, nas suas respectivas áre-as de atuação (1)(2) . O impacto da tecnologia, com sistemas informatizados, e a necessidade crescente de documentação afetou mais do que a prática clínica da enfermagem, levando ao desenvolvimento de estudos de padronização da linguagem para os problemas e tratamentos prestados, de modo a esclarecer e transmitir o seu verdadeiro papel no atendimento de saúde.
This is a prospective and longitudinal study which aimed to introduce the Braden Scale (BS) as an instrument to predict the risk of pressure ulcer (PU), and to analyze the results of its use in an intensive care unit. The sample was of 74 patients and the data were obtained by an instrument containing BS. Such data were analyzed by a simple descriptive statistic. 58 patients (78.37%) had a score < or = 13 and PU incidence of 25.67%. In 45 patients (60.80%), BS was daily filled in. From these patients, 5 (11.10%) developed PU. In 29 patients (39.10%), BS was not daily filled in. From these patients, 14 (48.20%) showed PU Results showed the efficiency of BS, which allowed identifying patients with PU risk. The difficulties of using BS refer to the periodic filling, which shows the need to educate and prepare nurses to use BS in the care of patients.
Cross-sectional study that aimed to compare the data reported in a system for the indication of pressure ulcer (PU) care quality, with the nursing evolution data available in the patients' medical records, and to describe the clinical profile and nursing diagnosis of those who developed PU grade 2 or higher Sample consisted of 188 patients at risk for PU in clinical and surgical units. Data were collected retrospectively from medical records and a computerized system of care indicators and statistically analyzed. Of the 188 patients, 6 (3%) were reported for pressure ulcers grade 2 or higher; however, only 19 (10%) were recorded in the nursing evolution records, thus revealing the underreporting of data. Most patients were women, older adults and patients with cerebrovascular diseases. The most frequent nursing diagnosis was risk of infection. The use of two or more research methodologies such as incident reporting data and retrospective review of patients' records makes the results trustworthy.
RESUMO Introdução:As lesões medulares constituem evento grave que acomete principalmente jovens, requerendo um planejamento cuidadoso da assistência de enfermagem Este estudo tem a finalidade de contribuir nesse planejamento, oferecendo subsídios para melhorar a qualidade do cuidado desses pacientes. Objetivos: Identificar os diagnósticos de enfermagem, segundo a NANDA, em portadores de lesão medular internados numa Unidade de Ortopedia e Traumatologia; e propor as intervenções de enfermagem, conforme a NIC. Métodos: Estudo descritivo prospectivo, com 10 casos analisados no período de janeiro/2000 a julho/2002. Os dados foram coletados por meio de um instrumento criado para uso na unidade de estudo, identificando-se os diagnósticos de enfermagem. As intervenções foram propostas pelas autoras e submetidas à avaliação de duas especialistas. Resultados: Foram identificados 15 diagnósticos de enfermagem prevalentes, para os quais foram propostas 26 intervenções de enfermagem. Conclusão: Os resultados poderão subsidiar as enfermeiras ao cuidado do paciente com lesão medular, auxiliando-o e contribuindo à sua autonomia, através das intervenções propostas.Descritores: Diagnóstico de enfermagem; Traumatismos da coluna vertebral; Cuidados de enfermagem ABSTRACT Introduction: Spinal cord lesions constitute very serious events that occur mostly among young people. Providing care to these patients is a complex task because they are greatly dependent on nursing staff and require a very carefully designed plan of care. The purpose of this study was to contribute ways to design a quality plan of care to attend these patients. Objectives: To identify nursing diagnoses according to the NANDA for patients with spinal cord lesions from an Orthopedic and Trauma Unit, and to propose appropriate nursing interventions according to the NIC. Methods: This study used a descriptive and prospective research design. The sample consisted of 10 patients with spinal cord lesions. Data were colleted from January, 2000 to July, 2002 using a specific assessment tool. Data analysis led the researchers to propose nursing diagnoses which were validated by two clinical nursing specialists. Results: Fifteen prevalent nursing diagnoses were identified and 26 nursing interventions were proposed. Conclusion: The results can be used to assist nurse to provide quality care for patients with spinal cord lesions, so as to improve the patients independence.Keywords: Nursing diagnosis; Spinal injuries; Nursing care RESUMEN Introducción: Las lesiones medulares constituyen un evento grave que afecta, en su mayoría, a los jóvenes, las cuales requirien una planificación cuidadosa para la atencion de enfermeria. Este estudio tiene la finalidad de contribuir con subsidios para mejorar la calidad de los cuidados prestados a esos pacientes. Objetivos: Identificar los diagnósticos de enfermería, según la taxonomía de la NANDA, en pacientes con lesión medular, internados en una Unidad de Ortopedia y Traumatología; y proponer las intervenciones de enfermería, conforme el...
Objectives to identify the prevalence of the Nursing Diagnosis (ND) Risk for falls in the hospitalizations of adult patients in clinical and surgical units, to characterize the clinical profile and to identify the risk factors of the patients with this ND. Method a cross-sectional study with 174 patients. The data was collected from the computerized nursing care prescriptions system and on-line hospital records, and analyzed statistically. Results the prevalence of the ND Risk for falls was 4%. The patients' profile indicated older adults, males (57%), those hospitalized in the clinical units (63.2%), with a median length of hospitalization of 20 (10-24) days, with neurological illnesses (26%), cardio-vascular illnesses (74.1%) and various co-morbidities (3±1.8). The prevalent risk factors were neurological alterations (43.1%), impaired mobility (35.6%) and extremes of age (10.3%). Conclusion the findings contributed to evidencing the profile of the patients with a risk of falling hospitalized in clinical and surgical wards, which favors the planning of interventions for preventing this adverse event.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
334 Leonard St
Brooklyn, NY 11211
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.