Avaliação da realização e do registro da Sistematização da Assistência de enfermagem (SAE) em um hospital universitário

Abstract

This descriptive study was carried out in a teaching hospital at São Paulo city and had as objective to identify the phases performance and registration of nursing care systematization and the most frequent nursing diagnoses. Data were collected retrospectively from 135 patients records of three units: Cardiology, Adult Infectious Diseases and Neurosurgery, from January to July, 2002. The phases: history, nursing diagnoses, prescription, evolution and assessment were performed and registered in the three units, however, it was verified systematization gaps performance related to nursing diagnoses registered without the realization of nursing history and nursing prescriptions without evolution. The most frequent nursing diagnosis in the three units was risk for infection.

Avaliação dos registros de enfermeiros em prontuários de pacientes internados em unidade de clínica médica

“…In this sense, the outcomes of this study support data in the literature in promoting the awareness of nurses to ensure continuous and complete records (8,(9)(10)16) . Regarding the presence of nursing care records (Table 1) findings highlighted the nursing history and physical examination with 99.6% and 94.6%, respectively, as the records fully completed.…”

“…The nurse, according to researchers, should not be restrained with respect to his creativity and the pursuit of clinical reasoning, but results of recent studies have shown that professionals are increasingly restricted to the implementation of nursing diagnoses and prescriptions that do not correspond to these, that is, they make diagnoses, but do not prescribe a related action; the opposite is also true (14,15) . Studies have shown that intelligently designed, nonstandardized forms, that offered space for the nurse to create, and which are directed toward the implementation of activities essential to care, have been facilitating the employment of clinical reasoning on the part of the professional, in order to optimize the relationship between prescription and diagnosis (6,10,14,16) . The literature demonstrates that the creation of intelligent forms is not sufficient for solving the difficulties encountered in relation to achieving the NRs (16,17) .…”

“…Studies have shown that intelligently designed, nonstandardized forms, that offered space for the nurse to create, and which are directed toward the implementation of activities essential to care, have been facilitating the employment of clinical reasoning on the part of the professional, in order to optimize the relationship between prescription and diagnosis (6,10,14,16) . The literature demonstrates that the creation of intelligent forms is not sufficient for solving the difficulties encountered in relation to achieving the NRs (16,17) . The effective scope of deployment and implementation of the NCS is recognized as a measure that develops permanent educational strategies, capable of solving the problems of a mandatory and bureaucratic practice (18) .…”

Utilização Do Processo De Enfermagem E as Dificuldades Encontradas Por Enfermeiros

“…Através de uma intervenção, proporciona os resultados que se esperam dela, pois, como intervenção terapêutica, o cuidado é centralizado nas necessidades do paciente que devem ser atendidas. A ação será de cuidado, se a enfermeira identifica uma necessidade e sabe o que fazer para atendê-la (13) .…”

Continuing Education and the Quality of Health Care: Meaningful Learning in Nursing Practice

“…A educação não é apenas um processo institucional e instrucional, mas também um instrumento formativo do humano, seja na particularidade da relação pedagógica pessoal, seja no âmbito da relação social coletiva sem perder as referências éticas e políticas, tendo como premissa que o processo de formação de um sujeito ético, ou de um cidadão, vai depender da própria construção do sujeito humano (2).…”