Conjunto Internacional de Dados Mínimos de Enfermagem: estudo comparativo com instrumentos de uma clínica pediátrica

Abstract

Descriptive and comparative study, developed from two historical used to implement the Systematization of Nursing Care in a Pediatric clinic of a teaching hospital. It aimed to compare the International Nursing Minimum Data Set (i-NMDS) with the data contained in nursing clinical assessment tools that are used in the application of the Nursing Process in the area of Children and Teenagers Health in a Pediatric Clinic. From the sixteen items evaluated that belong to the proposal of the i-NMDS, the nursing clinical assessment tool for hospitalized teenagers included 12 (75%), while the instrument for children from 0 to 5 years old presented 7 (43.75%). It was concluded that the nursing clinical assessment tools analyzed did not include the i-NMDS data in its entirety. It is suggested that there should be an improvement on the development of the nursing clinical assessment tools, using standardized nursing language for planning assistance, documenting activities, identify and measure the results of practice.

An educational intervention impact on the quality of nursing records

“…Considering that the patients, whose nursing records were analyzed were hospitalized in a cardiac intensive care unit, information on sexual life, hobbies and leisure are potentially relevant, as patients will need post-discharge instructions for their rehabilitation. From this perspective, the collection of nursing record data will contribute to the processes of decision making and nursing care plans 2 .…”

“…However, the importance of nursing records was expressed by Florence Nightingale in the nineteenth century, when she described, on her notes, a formal collection process to assess people’s health history 2 .…”

Escolares hospitalizados: proposta de um instrumento para coleta de dados à luz da teoria de Horta

“…In addition to the contribution in the identification of empirical indicators, the instruments used in the Pediatric Clinic/HULW served as a model for formatting and presentation. The contents were analyzed from a descriptive and comparative study (17) to support the development of the instrument for hospitalized school age children, where the International Nursing Minimum Data Set-i-NMDS (12) were compared with the data contained in the nursing background.…”

“…Once the instruments were applied in the HULW Pediatric Clinic, it was identified that the elements proposed by the i-NMDS, which should minimally be collected to generate information relevant to the clientele assisted by the nursing staff were not actually considered because they were not designed with this foundation. Of the evaluated elements belonging to the i-NMDS proposal, the instrument for hospitalized adolescents contemplated twelve and the instrument for children between zero and five presented seven (17) .…”

Diagnósticos de enfermagem mais frequentes em uma unidade de terapia intensiva pediátrica

“…Na área de Saúde da Criança e do Adolescente, chama atenção a falta de consenso acerca dos dados que devem ser coletados pelo enfermeiro junto às crianças e aos adolescentes, para gerar informação, a qual possa subsidiar a tomada de decisão clínica e descrever a contribuição da Enfermagem. 7 A implementação efetiva da SAE conduz à melhoria da qualidade dos cuidados de saúde da criança e do adolescente, além de estimular a construção de conhecimentos teóricos e científicos com base na melhor prática clínica, e auxiliar na elaboração de protocolos que sejam efetivos à prática da enfermagem pediátrica. 8 Apesar do número relevante de pesquisas recentes relacionadas à SAE no Brasil, especificamente aos DE, percebe-se que a importância dessa temática na enfermagem pediátrica ainda é pouco elementar 9 , e muitas unidades de saúde encontram barreiras por parte dos profissionais de enfermagem para implementarem a SAE, a exemplo da UTIP referenciada neste estudo.…”