scholarly journals CARACTERIZAÇÃO SOCIODEMOGRÁFICACLÍNICA E DIAGNÓSTICOS DE ENFERMAGEM NA ENFERMARIA PEDIÁTRICA

2020 ◽  
Vol 10 (7) ◽  
Author(s):  
Suelen Reiniack ◽  
Jamile Pascoal Franco Gonçalves ◽  
Alexandre Sousa da Silva ◽  
Teresa Tonini
Keyword(s):  
Medical Records ◽  
Intermediate Care ◽  
Patient Classification ◽  
Quality And Safety ◽  
Nursing Process ◽  
Nursing Diagnosis ◽  
Level Of Significance ◽  
Nursing Diagnoses ◽  
Patient Classification System

Objetivo: caracterizar o perfil de pacientes internados na enfermaria de pediatria e identificar os Diagnósticos de Enfermagem mais prevalentes, de acordo com a taxonomia NANDA-I. Metodologia: estudo descritivo realizado a partir de prontuários de 100 pacientes. Foram consideradas variáveis como: idade, gênero, sistema de classificação de pacientes, diagnóstico clínico e de enfermagem. Utilizou-se o programa Rcommander® para realização da análise exploratória e testes de hipóteses nãoparamétricos, sendo considerado nível de significância de 5%. Resultado: predominância do sexo masculino (71%), idade média de 7,32 anos, o Cuidado Intermediário (49%) foi o mais frequente, Pediatria foi a clínica com maior número de internações (39%), encontrados 44 diagnósticos médicos e 46 diagnósticos de enfermagem, sendo 27 considerados preponderantes. Conclusão: a realização do diagnóstico situacional possibilita um caráter norteador para as demais etapas do Processo de Enfermagem e direciona as ações de cuidado, contribuindo para a melhora contínua da qualidade e segurança dos cuidados.Descritores: Processo de Enfermagem, Diagnósticos de Enfermagem, Enfermagem Pediátrica.CLINICAL SOCIODEMOGRAPHICAL AND DIAGNOSTIC CHARACTERIZATION OF NURSING IN PEDIATRIC NURSINGOjective: to characterize the profile of hospitalized patients in the pediatric ward and to identify the most prevalent Nursing Diagnoses, according to the NANDA-I taxonomy. Methodology: descriptive study based on medical records of 100 patients. Variables such as: age, gender, patient classification system, clinical and nursing diagnosis were considered. The Rcommander® program was used to perform the exploratory analysis and tests of non-parametric hypotheses, being considered level of significance of 5%. Results: predominance of males (71%), mean age of 7.32 years, Intermediate Care (49%) was the most frequent, Pediatrics was the clinic with the greatest number of hospitalizations (39%), 44 medical and 46 nursing diagnoses, of which 27 were considered as preponderant. Conclusion: the accomplishment of the situational diagnosis allows a guiding character for the other stages of the Nursing Process and directs care actions, contributing to the continuous improvement of quality and safety of care.Descriptors: Nursing Process; Nursing Diagnostics; Pediatric Nursing.CARACTERIZACIÓN SOCIODEMOGRÁFICA Y DIAGNÓSTICA CLÍNICA DE ENFERMERÍA EN ENFERMERÍA PEDIÁTRICAObjetivo: caracterizar el perfil de pacientes internados en la enfermería de pediatría e identificar los Diagnósticos de Enfermería más prevalentes, de acuerdo con la taxonomía NANDA-I. Metodología: estudio descriptivo realizado a partir de prontuarios de 100 pacientes. Se consideraron variables como: edad, género, sistema de clasificación de pacientes, diagnóstico clínico y de enfermería. Se utilizó el programa Rcommander® para realizar el análisis exploratorio y pruebas de hipótesis no paramétricas, siendo considerado nivel de significancia del 5%. Resultado: En la mayoría de los casos, el cuidado intermedio (49%) fue el más frecuente, la Pediatría fue la clínica con mayor número de internaciones (39%), encontrados 44 diagnósticos médicos y, 46 diagnósticos de enfermería, siendo 27 considerados preponderantes. Conclusión: la realización del diagnóstico situacional posibilita un carácter orientador para las demás etapas del proceso de enfermería y dirige las acciones de cuidado, contribuyendo a la mejora continua de la calidad y seguridad del cuidado.Descriptores: Proceso de Enfermería; Diagnósticos de Enfermería; Enfermería Pediátrica.

scholarly journals Transplante de Células-Tronco Hematopoéticas: estudo de caso de um paciente com mucosite severa

2018 ◽  
Vol 86 (24) ◽  
Author(s):  
Ana Cristina da Silva Rangel ◽  
Adriana Gomes da Silva de Freitas ◽  
Alice Andrade Antunes ◽  
Cecilia Ferreira da Silva Borges ◽  
Cláudia Valéria Ramos Ribeiro ◽  
...  
Keyword(s):  
Medical Records ◽  
Scientific Evidence ◽  
Signs And Symptoms ◽  
Nursing Process ◽  
Clinical Practices ◽  
Hematopoietic Stem ◽  
Nursing Diagnosis ◽  
Nursing Diagnoses ◽  
Severe Mucositis

Estima-se que 50% a 80% dos pacientes submetidos ao transplante de células-tronco hematopoéticas (TCTH)desenvolveram mucosite oral com significativa gravidade e acentuada morbidade. As complicações e a complexidadedesta afecção exigem da equipe de enfermagem um contínuo treinamento pautado na atualização de práticas clínicasoriundas de evidências científicas. O objetivo é apresentar um estudo de caso, descrevendo os diagnósticos deenfermagem de um paciente submetido ao transplante de células-tronco hematopoiéticas autólogo que evoluiu parauma mucosite severa. Trata-se de um estudo de caso de um paciente com Linfoma de Hodgkin submetido ao TCTH. Osdados foram coletados no período de outubro a dezembro de 2015, a partir do prontuário do paciente. Foram 51 dias dehospitalização, os principais diagnósticos de enfermagem relacionados à mucosite foram: (1) náusea; (2) risco parainfecção; (3) nutrição desequilibrada; (4) deglutição prejudicada; (5) diarreia; (6) mucosa oral prejudicada; (7) dor aguda;(8) hipertermia e (9) risco de sangramento. A mucosite é uma complicação comumente encontrada nos pacientessubmetidos ao transplante. Logo, é importante que o enfermeiro desenvolva um olhar clínico apurado, a fim de detectarna sutileza dos sinais e sintomas o risco para o agravamento desta afecção.Palavras-chave: Mucosite; Transplante de Células-Tronco Hematopoéticas; Diagnóstico de Enfermagem; Processos deEnfermagem. AbstractIt is estimated that 50% to 80% of patients undergoing hematopoietic stem cells (HSCT) transplantation developed oralmucositis with significant severity and marked morbidity. The complications and complexity of this condition require thenursing team to continue training based on the updating of clinical practices stemming from scientific evidence. The aimis to present a case study, describing the nursing diagnoses of a patient submitted to autologous hematopoietic stem celltransplantation that evolved to a severe mucositis. This is a case study of a patient with Hodgkin's lymphoma undergoingHSCT. Data were collected from October to December 2015, from the patient's medical records. There werehospitalization 51 days, the main nursing diagnoses related to mucositis were: (1) nausea; (2) risk for infection; (3)unbalanced nutrition; (4) impaired swallowing; (5) diarrhea; (6) impaired oral mucosa; (7) acute pain; (8) hyperthermiaand (9) risk of bleeding. Mucositis is a complication commonly found in patients undergoing transplantation. Therefore,it is important that the nurse develops an accurate clinical view to detect in the subtlety of the signs and symptoms therisk for the affection worsening.Keywords: Mucositis; Hematopoietic Stem Cell Transplantation; Nursing Diagnosis; Nursing Process.

scholarly journals Profile of the nursing diagnoses in stable heart disease patients

2019 ◽  
Vol 37 (2) ◽  
Author(s):  
Patrícia Cristina Cardoso ◽  
Larissa Gussatschenko Caballero ◽  
Karen Brasil Ruschel ◽  
Maria Antonieta Pereira de Moraes ◽  
Eneida Rejane Rabello da Silva
Keyword(s):  
Heart Disease ◽  
Medical Records ◽  
Sedentary Lifestyle ◽  
World Health ◽  
Nursing Process ◽  
Adherence To Treatment ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Health Organization ◽  
Nursing Diagnoses

Abstract Objective. To identify the nursing diagnoses through reports in the medical records of patients monitored in a specialized ischemic heart disease outpatient clinic.Methods. Cross-sectional study with retrospective data collection in the medical records. From the data collected, the nursing diagnoses were proposed by the researchers and submitted for validation by specialist cardiology nurses.Results. A total of 13 nursing diagnoses were evaluated from the medical records of 50 outpatients with the following validation agreements among the specialists: Ineffective health management (100%), Noncompliance (100%), Sedentary lifestyle (100%), Activity intolerance (100%), Decreased cardiac output (88%), Risk of decreased cardiac tissue perfusion (65%), Risk of intolerance to activity (65%), Acute pain (76%), Ineffective health maintenance (65%), Risk-prone health behavior (65%), Risk for decreased cardiac output (65%), Risk for intolerance to activity (65%), Ineffective respiratory pattern (53%), Impaired memory (29%).Conclusion. In this study, the nursing diagnoses validated for stable heart disease patients were linked to adherence to treatment and to the cardiovascular responses of the patients, reinforcing the importance of early intervention. These results allow the multidisciplinary team to individualize the goals and interventions proposed for ischemic heart disease patients.Descriptors: ambulatory care; cross-sectional studies; nursing diagnosis; outpatients; nursing process; myocardial ischemia.How to cite this article: Cardoso PC, Caballero LG, Ruschel KB, Moraes MAP, Silva ERR. Profile of the nursing diagnoses in stable heart disease patients. Invest. Educ. Enferm. 2019; 37(2):e08.ReferencesWorld Health Organization. World Health Statistics 2018: monitoring health for the SDGs, sustainable development goals [Internet]. Geneva: WHO; 2018 [cited: 7 May 2019]. Available from: https://www.who.int/gho/publications/world_health_statistics/2018/en/ Ministério da Saúde. Informações de Saúde (TABNET) - Assistência à Saúde. DATASUS. Departamento de Informatica a Serviço do SUS [Internet]. 2016 [cited: 7 May 2019]. Available from: http://datasus.saude.gov.br/informacoes-de-saude/tabnet/assistencia-a-saude Ôunpuu S, Negassa A, Yusuf S. INTER-HEART: A global study of risk factors for acute myocardial infarction. Am. Heart J. 2001; 141(5):711–21. Berwanger O, Guimarães HP, Laranjeira LN, Cavalcanti AB, Kodama AA, Zazula AD, et al. Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: The BRIDGE-ACS randomized trial. 2012; 307(19):2041–9. Saffi MAL, Polanczyk CA, Rabelo-Silva ER. Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial. Eur. J. Cardiovasc. Nurs. 2014; 13(5):436–43. Brasil. Ministerio da Saúde. Diretrizes para o cuidado das pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidado prioritárias [Internet]. Brasília; 2013 [cited: 7 May 2019]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes%20_cuidado_pessoas%20_doencas_cronicas.pdf Gallagher-Lepak S. Fundamentos do diagnóstico de enfermagem. In: Herdman TH, Kamitsuru S O, editor. Diagnósticos de enfermagem da NANDA: Definições e Classificação. 2015. p. 21–30. Santos NA dos, Cavalcante TF, Lopes MV de O, Gomes EB, Oliveira CJ de. Profile of nursing diagnoses in patients with respiratory disorders. Invest. Educ. Enferm. 2015; 33(1):112–8. Sampaio F de C, de Oliveira PP, da Mata LRF, Moraes JT, da Fonseca DF, Vieira VA de S. Profile of nursing diagnoses in people with hypertension and diabetes. Invest. Educ. Enferm. 2017;35(2):139–53. Javier F, Rivas P, Martín-iglesias S, Luis J, Arenas CM, Lagos MB. Effectiveness of Nursing Process Use in Primary Care. Int. J. Nurs. Knowl. 2015; 27(1):43–8. Araújo DD, Carvalho RLR, Chianca TCM. Nursing diagnoses identified in records of hospitalized elderly. Invest. Educ. Enferm. 2014; 31(3):225–35. Menna Barreto LN, Swanson EA, De Abreu Almeida M. Nursing Outcomes for the Diagnosis Impaired Tissue Integrity (00044) in Adults with Pressure Ulcer. Int. J. Nurs. Knowl. 2016; 27(2):104–10. Moreira RP, Guedes NG, Lopes MV de O, Cavalcante TF, Araújo TL de, Moreira RP, et al. Nursing diagnosis of sedentary lifestyle: expert validation. Texto Context - Enferm. 2014; 23(3):547–54. Bowry ADK, Shrank WH, Lee JL, Stedman M, Choudhry NK. A systematic review of adherence to cardiovascular medications in resource-limited settings. J. Gen. Intern. Med. 2011; 26(12):1479–91. Osterberg L, Blaschke T. Adherence to medication. New. Engl. J. Med. 2005; 353(18):1973–4. Vrijens B, De Geest S, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T, et al. A new taxonomy for describing and defining adherence to medications. Br. J. Clin. Pharmacol. 2012; 73(5):691–705. Borges JWP, Moreira TMM, Rodrigues MTP, de Souza ACC, da Silva DB. Content validation of the dimensions constituting non-adherence to treatment of arterial hypertension. Rev. Esc. Enferm. 2013; 47(5):1076–82. Freitas JS de, Silva AEB de C, Minamisava R, Bezerra ALQ, Sousa MRG de. Quality of nursing care and satisfaction of patients attended at a teaching hospital. Rev. Lat. Am. Enfermagem. 2014; 22(3):454–60. World health Organization. Adherence to long-term therapies: evidence for action [Internet]. Geneve: WHO; 2003 [cited: 7 May 2019]. Available from: https://www.who.int/chp/knowledge/publications/adherence_report/en/

scholarly journals Acurácia dos diagnósticos de enfermagem de uma instituição de cardiologia

2018 ◽  
Vol 12 (10) ◽  
pp. 2727
Author(s):  
Nailde Cristina de Freitas ◽  
Ana Paula da Conceição
Keyword(s):  
Diagnostic Accuracy ◽  
Cross Sectional Study ◽  
Nursing Process ◽  
Cross Sectional ◽  
Targeted Interventions ◽  
Clinical Nurses ◽  
Nursing Diagnosis ◽  
Sociodemographic Profile ◽  
Nursing Diagnoses

RESUMOObjetivo: analisar o grau de acurácia diagnóstica dos enfermeiros clínicos de uma instituição de cardiologia. Método: trata-se de estudo quantitativo, observacional, transversal, realizado com 53 enfermeiros que utilizavam os diagnósticos de Enfermagem no trabalho. Utilizaram-se dois instrumentos: um para a caracterização do perfil sociodemográfico e o caso clínico para o levantamento dos diagnósticos de Enfermagem. Mensurou-se o grau de acurácia diagnóstica por meio da Escala de Acurácia de Diagnósticos de Enfermagem (EADE-2). Resultados: revela-se que enfermeiros que participavam da Visita Clínica Setorial e atuavam em unidades não críticas elencaram significativamente menor número de diagnósticos de Enfermagem de acurácia baixa/nula. Não houve diferença em relação ao levantamento de diagnósticos de Enfermagem com acurácia alta/moderada. Conclusão: contribui-se para a melhora da acurácia diagnóstica dos enfermeiros por meio de programas de treinamento para o exercício do raciocínio clínico. Sugere-se que a educação permanente em serviço aconteça de forma efetiva com o objetivo de melhorar a acurácia dos diagnósticos de Enfermagem dos enfermeiros possibilitando-se o levantamento de diagnósticos acurados, de intervenções direcionadas e o estabelecimento de metas possíveis. Descritores: Enfermagem; Diagnóstico de Enfermagem; Processo de Enfermagem; Competência Clínica; Treinamento em Serviço; Educação.  ABSTRACT Objective: to analyze the degree of diagnostic accuracy of the clinical nurses of a cardiology institution. Method: this is a quantitative, observational, cross-sectional study conducted with 53 nurses who used nursing diagnoses at work. Two instruments were used: one for the characterization of the sociodemographic profile and the clinical case for the survey of nursing diagnoses. The degree of diagnostic accuracy was measured using the Nursing Diagnostic Accuracy Scale (NDAS-2). Results: it is revealed that nurses who participated in the Sectorial Clinical Visit and worked in non-critical units listed significantly fewer Nursing diagnoses of low / null accuracy. There was no difference in relation to the survey of Nursing diagnoses with high/moderate accuracy. Conclusion: it contributes to the improvement of the diagnostic accuracy of nurses through training programs for the exercise of clinical reasoning. It is suggested that permanent in-service education take place in an effective way with the objective of improving the accuracy of nursing diagnoses of nurses, making it possible to obtain accurate diagnoses, targeted interventions and the establishment of possible goals. Descriptors: Nursing; Nursing Diagnosis; Nursing Process; Clinical Competence; Inservice Training; Education.RESUMEN Objetivo: analizar el grado de exactitud diagnóstica de los enfermeros clínicos de una institución de cardiología. Método: estudio cuantitativo, observacional, transversal, realizado con 53 enfermeros que utilizaban diagnósticos de enfermería en el trabajo. Se utilizaron dos instrumentos: uno para caracterización del perfil sociodemográfico y el caso clínico para el levantamiento de los diagnósticos de enfermería. El grado de exactitud diagnóstica fue mezclado por medio de la Escala de Precisión de Diagnósticos de Enfermería (EADE-2). Resultados: enfermeros que participaban de la Visita Clínica Sectorial y actuaban en unidades no críticas, consideraron significativamente menor número de diagnósticos de enfermería de precisión baja / nula. No hubo diferencia en relación al levantamiento de diagnósticos de enfermería con precisión alta / moderada. Conclusión: los programas de entrenamiento para el ejercicio de raciocinio clínico contribuyen a mejorar la exactitud diagnóstica de los enfermeros. Se sugiere que la educación permanente en servicio ocurra de forma efectiva con el objetivo de mejorar la exactitud de los diagnósticos de enfermería de los enfermeros posibilitando el levantamiento de diagnósticos precisos, intervenciones dirigidas y establecimiento de metas posibles. Descriptores: Enfermería; Diagnóstico de Enfermería; Proceso de Enfermería Competencia Clínica; Capacitación em Servicio; Educación.

scholarly journals Mapping nursing goals of an Intensive Care Unit to the Nursing Outcomes Classification

2012 ◽  
Vol 20 (5) ◽  
pp. 854-862 ◽  
Author(s):  
Tânia Couto Machado Chianca ◽  
Patrícia de Oliveira Salgado ◽  
Juliana Peixoto Albuquerque ◽  
Camila Claudia Campos ◽  
Meire Chucre Tannure ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Descriptive Study ◽  
Nursing Process ◽  
Nursing Outcomes ◽  
Nursing Outcomes Classification ◽  
Mapping Process ◽  
Nursing Diagnoses

AIM: to analyze whether nursing goals formulated for nursing diagnoses can be mapped to nursing outcomes classification and to identify the scales most appropriate to the outcomes mapped. METHOD: a descriptive study was developed in an intensive care unit. Data collection involved extraction of goals in 44 medical records, content standardization, cross-mapping to the outcomes, identification of appropriated scales and validation. Descriptive analysis and agreement with the cross-mapping process were performed. RESULTS: nursing goals (59) were mapped to (28) different outcomes, with agreement of 83% in the mapping process. All goals were mapped to outcomes, which allows to affirm that these outcomes contemplates the goals elaborated to patient care. CONCLUSION: these results favor the inclusion of outcomes and scales validated in the planning and evaluation phases of the nursing process of a software in construction.

scholarly journals Description and Validation of Nursing Diagnosis Using Electronic Documentation: Study Cases in Mother and Child Hospital Indonesia

2020 ◽  
Vol 14 (1) ◽  
pp. 300-308
Author(s):  
Rr.Tutik Sri Hariyati ◽  
Hanny Handiyani ◽  
Laode Abdul Rahman ◽  
Tuti Afriani
Keyword(s):  
Clinical Judgment ◽  
Medical Records ◽  
Nursing Assessment ◽  
Normal Delivery ◽  
Mapping Model ◽  
Nursing Diagnosis ◽  
Mothers And Children ◽  
Mother And Child ◽  
Child Hospital ◽  
Nursing Diagnoses

Background: A nursing diagnosis is a clinical judgment concerning a human response to a health condition, vulnerability for that response, by an individual, family, group, or community. For the determination of the right nursing diagnosis, a system that guides nurses in implementing care professionally is needed. Objective: To describe the nursing diagnosis in mother and child cases validated by using a management nursing information system. Methods: This case study used secondary data from 5.294 medical records. Medical records were retrieved from the server, analyzed, and validated by using the mapping model in accordance with the most frequent cases in mothers and children in the hospital. Approximately ten million (10.021) nursing diagnoses were performed by nurses and validated by using a mapping model of medical cases and nursing assessment. The selected medical cases were the five most frequent cases, namely normal delivery, cesarean delivery, healthy newborn, fever, and dengue in children. Results: This study yielded the five most frequent nursing diagnoses, namely risk for infection (20.1%), pain (13.37%), anxiety (9.37%), the risk for imbalanced fluid volume (9.36%), and risk for bleeding (9.27%). Conclusion: The electronic nursing documentation could help to determine a nursing diagnosis and had been validated for its appropriateness with assessment and the most common cases in mothers and children. Information and system training development are required to carry out the nursing process comprehensively.

scholarly journals The Most Commonly Determined Nursing Diagnoses According to NANDA-I Taxonomy and Difficulties Using the Nursing Process in COVID-19 Outbreak

2021 ◽  
pp. 105477382110515
Author(s):  
Hale Tosun ◽  
Ayşe Tosun ◽  
Birgül Ödül Özkaya ◽  
Asiye Gül
Keyword(s):  
High School ◽  
Nursing Care ◽  
High School Graduates ◽  
Cross Sectional Study ◽  
Nursing Process ◽  
Sectional Study ◽  
Cross Sectional ◽  
Nursing Diagnosis ◽  
Acute Confusion ◽  
Nursing Diagnoses

The study was planned to determine the most common nursing diagnoses according to NANDA International (NANDA-I) taxonomy and difficulties experienced in using of nursing process in COVID-19 outbreak. The sample of the descriptive cross-sectional study consisted of nurses cared for patients with COVID-19 ( n = 114). Average age of nurses is 26.86 ± 6.68. Commonly determined nursing diagnoses according to NANDA-I taxonomy in patients with COVID-19 were imbalanced nutrition (66.7%), impaired gas exchange (40.4%), insomnia (21.1%), acute confusion (31.6%), hopelessness (96.5%), difficulty playing caregiver (84.2%), anxiety (38.6%) willingness to strengthen religious bond (71.9%), risk for infection (64.9%), nausea (49.1%). Twenty-four-years old and younger, high school graduates, caring for intubated patients, and those who stated that they did not use nursing diagnosis had more difficulty in using nursing process (<0.05). The use of nursing diagnoses and process for patients with COVID-19 is extremely important in ensuring individual and qualified nursing care.

scholarly journals Síndrome de Guillain Barré: perfil clínico epidemiológico e assistência de enfermagem

2019 ◽  
Vol 19 (1) ◽  
pp. 346-389
Author(s):  
Denise de Fátima Hoffmann Rigo ◽  
Claudia Ross ◽  
Lili Marlene Hofstatter ◽  
Maria Fernanda Azevedo Pompílio Leonel Ferreira
Keyword(s):  
Clinical Epidemiology ◽  
Health Planning ◽  
Electronic Records ◽  
Patient Classification ◽  
Specific Group ◽  
Venous Puncture ◽  
Symmetrical Form ◽  
Guillain Barré ◽  
Patient Classification System

Introducción: El Síndrome de Guillain-Barré (SGB) se considera una polineuropatía inflamatoria aguda.Objetivo: Conocer las características sociodemográficas, clínicas epidemiológicas y asistenciales de pacientes internados con SGB en un hospital escolar del Oeste de Paraná.Metodología: Se trata de una investigación cuantitativa, retrospectiva acerca de la caracterización sociodemográfica, clínica epidemiológica y asistencial de pacientes internados con SGB en un hospital escolar en el período de 2013 a 2017. Totalizando 23 pacientes cuyos prontuarios electrónicos fueron analizados.Todos los análisis estadísticos se realizaron en el programa XLStat (2010).Resultados: La mayoría de los pacientes presentó edades entre 51 y 60 años (31,12%), seguidas de las edades de 41 a 50 años (13,04%) y menores de 15 años (13,04%), sexo masculino (60, 87), con gran parte presentando síntomas infecciosos previos como mialgia, cefalea, fiebre, diarrea. Los síntomas referentes a SGB presentados en el período de 4 a 9 días antes de la internación englobó la forma ascendente, simétrica, con disminución de la fuerza muscular. Durante la internación fueron sometidos a procedimientos como cateterismo vesical y punción venosa periférica. Entre los exámenes de laboratorio se destacó el hemograma y diagnóstico a la electroneuromiografía. El tratamiento principal fue la inmunoglobulina. La mayoría de los pacientes presentó alta dependencia de asistencia de enfermería conforme sistema de clasificación de pacientes de Fugulin.Conclusión: El desarrollo de estudios que propician el conocimiento de la caracterización de un grupo específico de pacientes atacados por una enfermedad considerada rara, se constituyen en instrumentos para la planificación en salud. Introduction: Guillain-Barré syndrome (GBS) is considered an acute inflammatory polyneuropathy. Objective: To know the socio-demographic, clinical epidemiological and care characteristics of patients hospitalized with GBS in a school hospital in the West of Paraná. Methodology: This is a quantitative, retrospective study about the socio-demographic characterization, clinical epidemiology and care of hospitalized patients with GBS in a school hospital from 2013 to 2017. Totaling 23 patients whose electronic records were analyzed. All statistical analyzes were performed in the XLStat program (2010). Results: The majority of the patients presented ages ranging from 51 to 60 years (31.12%), followed by ages 41 to 50 (13.04%) and under 15 (13.04%), male (60.87) , with most presenting previous infectious symptoms such as myalgia, headache, fever, diarrhea. The symptoms related to GBS presented in the period from four to nine days before admission included the ascending, symmetrical form with a decrease in muscle strength. During the hospitalization they underwent procedures such as bladder catheterization and peripheral venous puncture. Among the laboratory exams, the blood test and diagnosis of electro-urography were highlighted. The main treatment was immunoglobulin. Most of the patients presented high dependence for nursing care according to Fugulin's patient classification system. Conclusion: The development of studies that allow the knowledge of the characterization of a specific group of patients affected by a disease considered rare, constitute instruments for health planning. Introdução: A Síndrome de Guillain-Barré (SGB) é considerada uma polineuropatia inflamatória aguda. Objetivo: Conhecer as características sócio demográficas, clínica epidemiológicas e assistenciais de pacientes internados com SGB em um hospital escola do Oeste do Paraná. Metodologia: Trata-se de uma pesquisa quantitativa, retrospectiva acerca da caracterização sócio demográfica, clínica epidemiológica e assistencial de pacientes internados com SGB em um hospital escola no período de 2013 a 2017. Totalizando 23 pacientes cujos prontuários eletrônicos foram analisados. Todas as análises estatísticas foram realizadas no programa XLStat (2010). Resultados: A maioria dos pacientes apresentou idades entre 51 e 60 anos (31,12%), seguidas das idades 41 a 50 anos (13,04%) e menores de 15 anos (13,04%), sexo masculino (60,87), com grande parte apresentando sintomas infecciosos prévios como mialgia, cefaleia, febre, diarreia. Os sintomas referentes a SGB apresentados no período de 4 a 9 dias antes da internação englobou a forma ascendente, simétrica, com diminuição da força muscular. Durante a internação foram submetidos a procedimentos como cateterismo vesical e punção venosa periférica. Entre os exames laboratoriais destacou-se o hemograma e diagnóstico a eletroneuromiografia. O tratamento principal foi a imunoglobulina. A maioria dos pacientes apresentou alta dependência para assistência de enfermagem conforme sistema de classificação de pacientes de Fugulin. Conclusão: O desenvolvimento de estudos que propiciam o conhecimento da caracterização de um grupo específico de pacientes acometidos por uma doença considerada rara, constituem-se em instrumentos para o planejamento em saúde.

scholarly journals Unsatisfactory completeness of nurses’ records in the medical records of users with tuberculosis

2022 ◽  
Vol 75 (3) ◽  
Author(s):  
José Nildo de Barros Silva Júnior ◽  
Haline Costa dos Santos Guedes ◽  
Dilyane Cabral Januário ◽  
Ana Cristina de Oliveira e Silva ◽  
Pedro Fredemir Palha ◽  
...  
Keyword(s):  
Medical Records ◽  
Family Health ◽  
Descriptive Statistics ◽  
Nursing Interventions ◽  
Nursing Process ◽  
Nursing Assessment ◽  
Tuberculosis Patients ◽  
Nursing Diagnosis ◽  
Evaluation Strategies

ABSTRACT Objectives: to evaluate the completeness of nurses’ records on the execution of the nursing process in assistance of tuberculosis patients at Primary Care. Methods: this was a retrospective documental study, with 190 records in Family Health Units of a city in the state of Paraíba. The data were analyzed according to descriptive statistics, Pareto Diagram, and trend analysis. Results: the overall mean incompleteness of records was 53.01% (DP=26.13). Therefore, the results presented very poor completeness classification related to nursing diagnosis (88.9%), nursing assessment (66.8%), data collection (60.5%), while nursing interventions were classified as regular (11.1%). The nursing diagnosis was the only variable with a decreasing trend of non-completeness. Conclusions: incompleteness of nurses’ records in the medical records of users with tuberculosis. Evaluation strategies, permanent and continuing education are indispensable in the quality of nurses’ documentation, directly implying the Systematization of Quality in Nursing Care.

scholarly journals Nursing process: from literature to practice. What are we actually doing?

2009 ◽  
Vol 17 (3) ◽  
pp. 302-307 ◽  
Author(s):  
Simoni Pokorski ◽  
Maria Antonieta Moraes ◽  
Régis Chiarelli ◽  
Angelita Paganin Costanzi ◽  
Eneida Rejane Rabelo
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Retrospective Study ◽  
Medical Records ◽  
Daily Routine ◽  
Nursing Process ◽  
Porto Alegre ◽  
Cross Sectional ◽  
Research Institution ◽  
Nursing Diagnosis

OBJECTIVES: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. RESULTS: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

scholarly journals A relação entre a dependência de cuidados, risco e úlcera por pressão*

2012 ◽  
Vol 3 (4) ◽  
pp. 198-201
Author(s):  
Janete De Souza Urbanetto ◽  
Maria Angélica Casa Nova Dos Santos ◽  
Angeline Francines Poltozi ◽  
Ana Lúcia Comparsi Pechansky ◽  
Graziela Hax ◽  
...  
Keyword(s):  
Pressure Ulcer ◽  
Classification System ◽  
Intermediate Care ◽  
Patient Classification ◽  
Moderate Risk ◽  
Cross Sectional ◽  
Braden Scale ◽  
El Alto ◽  
Cross Sectional Design ◽  
Patient Classification System

Estudo com objetivo de analisar a associação entre os escores de cuidados do Sistema de Classificação de Pacientes (SCP) com as classificações de risco da Escala de Braden e a ocorrência de úlcera por pressão (UP). Delineamento transversal, com 2.562 pacientes adultos hospitalizados. Foram encontradas associações significativas dos cuidados intermediários e semi-intensivos do SCP e do risco elevado/moderado da Braden com a ocorrência de UP. Conclui-se que a utilização de instrumentos de avaliação dos pacientes são ferramentas valiosas para a prevenção de UP.Descritores: Úlcera por Pressão, Classificação, Escalas, Segurança do Paciente.The relationship between care dependency and risk of pressure ulcersThis study aims to analyze the association between scores for the care of Patient Classification System (PCS) with the risk ratings of the Braden Scale and the occurrence of pressure ulcers (PU). Cross-sectional design, with 2562 patients hospitalized adults. Significant associations were found for intermediate care and semi-intensive SCP and the high/moderate risk Braden with the occurrence of PU. It is concluded that the use of tools for evaluating patients are valuable tools for the prevention of pressure ulcers.Descriptors: Pressure Ulcer, Classification, Scales, Patient Safety.La relación entre la dependencia de cuidados y el riesgo de úlceras por presión Se trata de un estudio cuyo objetivo es examinar la asociación entre las puntuaciones para el cuidado del Sistema de Clasificación de Pacientes (SCP) con las calificaciones de riesgo de la Escala de Braden y la aparición de úlceras por presión (UPP). Diseño transversal, con 2562 pacientes adultos hospitalizados. Se encontraron asociaciones significativas para los cuidados intermedios y semi-intensivo de SCP y el alto/moderado riesgo Braden, con la ocurrencia de UP. Se concluye que el uso de herramientas para la evaluación de los pacientes son herramientas valiosas para la prevención de úlceras por presiónDescriptores: Úlcera por Presión, Clasificación, Escalas, Seguridad del Paciente.

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