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G Ital Nefrol ; 37(5)2020 Oct 05.
Artigo em Italiano | MEDLINE | ID: mdl-33026201


Coronavirus disease 2019 is an infectious respiratory syndrome caused by the virus called SARS-CoV-2, belonging to the family of coronaviruses. The first ever cases were detected during the 2019-2020 pandemic. Coronaviruses can cause a common cold or more serious diseases such as Middle Eastern Respiratory Syndromes (MERS) and Severe Acute Respiratory Syndrome (SARS). They can cause respiratory, lung and gastrointestinal infections with a mild to severe course, sometimes causing the death of the infected person. This new strain has no previous identifiers and its epidemic potential is strongly associated with the absence of immune response/reactivity and immunological memory in the world population, which has never been in contact with this strain before. Most at risk are the elderly, people with pre-existing diseases and/or immunodepressed, dialyzed and transplanted patients, pregnant women, people with debilitating chronic diseases. They are advised to avoid contacts with other people, unless strictly necessary, and to stay away from crowded places, also observing scrupulously the recommendations of the Istituto Superiore di Sanità. In this article we detail the recommendations that must be followed by the nursing care staff when dealing with chronic kidney disease patients in dialysis or with kidney transplant patients. We delve into the procedures that are absolutely essential in this context: social distancing of at least one meter, use of PPI, proper dressing and undressing procedures, frequent hand washing and use of gloves, and finally the increase of dedicated and appropriately trained health personnel on ward.

Betacoronavirus , Infecções por Coronavirus/enfermagem , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Transplante de Rim/enfermagem , Pandemias , Pneumonia Viral/enfermagem , Guias de Prática Clínica como Assunto , Diálise Renal/enfermagem , Insuficiência Renal Crônica/enfermagem , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Desinfecção , Desinfecção das Mãos , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Transmissão de Doença Infecciosa do Profissional para o Paciente/prevenção & controle , Resíduos de Serviços de Saúde , Processo de Enfermagem/normas , Registros de Enfermagem , Pandemias/prevenção & controle , Isolamento de Pacientes , Equipamento de Proteção Individual , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Insuficiência Renal Crônica/cirurgia , Insuficiência Renal Crônica/terapia , Precauções Universais
Stud Health Technol Inform ; 272: 233-236, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604644


A large amount of patient data is produced and documented in patient care. Health care professionals expect that this routinely collected patient data can also be used for secondary purposes such as measuring the quality of care or to gain new knowledge. Routine data needs to be documented in a standardized form, based on clinical terminologies, to allow this secondary use of data. In Austria, hospitals are currently moving from paper-based documentation to computer-based documentation, but parts of the documentation are still done in paper-based form or without using clinical terminologies, especially in nursing. This study aims to analyze the availability of standardized electronic patient data in nursing in Austria. We conducted an online survey of 32 senior nursing managers at 32 Austrian hospitals. The study showed that 79% of hospitals use electronic health records for nursing documentation, but only 29% of the nursing care plans are documented in a standardized way using standardized nursing classification systems such as NANDA-I.

Terminologia Padronizada em Enfermagem , Áustria , Documentação , Registros Eletrônicos de Saúde , Humanos , Registros de Enfermagem , Inquéritos e Questionários
Stud Health Technol Inform ; 270: 38-42, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570342


Nursing Minimum Data Sets (NMDS) intend to systematically describe nursing care. Until now NMDS have been populated with nursing data by manual data ascertainment which is inefficient. The objective of this work was to evaluate an automated mapping pipeline for transforming nursing data into an NMDS. We used LEP Nursing 3 data as source data and the Austrian and German NMDS as target formats. Based on a human expert mapping between LEP and NMDS, an automated data mapping algorithm was developed and implemented in an automatic mapping pipeline. The results show that most LEP nursing interventions can be matched to the NMDS-AT and G-NMDS and that a fully automated mapping process from LEP Nursing 3 data to NMDS-AT performs effectively and very efficiently. The shown approach can also be used to map different nursing classifications and to automatically transform point-of-care nursing data into nursing minimum data sets.

Bases de Dados Factuais , Pesquisa em Enfermagem , Áustria , Humanos , Registros de Enfermagem
Stud Health Technol Inform ; 270: 1233-1234, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570595


OBJECTIVE: To perform a cross-mapping study between nursing documentation from a Electronic Health Record (EHR) of a Brazilian hospital and four nursing terminology systems. METHOD: Descriptive, quantitative and retrospective study. RESULTS: The EHR presents a total of 247 anamnesis / physical examination terms, 75 nursing diagnoses, and 205 nursing interventions terms to nurses make their choice. CONCLUSION: Authors strongly recommend that attempts in building more usable and friendly EHRs for clínical care practice documentation consider classification systems structures in their development, to ensure complete, safe, evidence-based and comparable registries.

Terminologia Padronizada em Enfermagem , Brasil , Documentação , Registros Eletrônicos de Saúde , Humanos , Registros de Enfermagem , Estudos Retrospectivos
Stud Health Technol Inform ; 270: 638-642, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570461


Hospitalization expenses account for a high proportion of national medical care expenditure in Japan. In 2015, the total national medical care expenditure in Japan was 42.4 trillion yen, and hospitalization expenses were 15.6 trillion yen (36.8%). Therefore, it is necessary to reduce hospitalization expenses. The labor cost of physicians and nurses accounted for about 1/3rd of all expenditure of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5th of all expenditure, indicating that it has a marked impact on hospital management. Nurses spend a lot of time completing descriptive records; however, the quality of such records is poor. It is necessary to improve nurse's records to make them highly accessible and reduce the amount of time nurses spend producing records. The objective of this study was to improve the processes underlying record-keeping by nurses in order to harmonize structured clinical knowledge among doctors and nurses. We created 778 Patient Condition Adaptive Path System (PCAPS) items, covering all of the clinical departments that were registered for the PCAPS content master. The resultant masters will be standardized by sharing them with hospitals that adopt the "Team Compass" application. We were able to summarize all of the information in clinical progress sheets because we could link the information described in electronic medical records with that described in Team Compass. Therefore, it became easy to collect information by linking information about clinical orders. The system also made it possible for foundational nursing plans to be created in collaboration with doctors instead of being developed by nurses alone because it allowed information regarding patients' problems, the clinical process, and observation selection to be shared smoothly with doctors. We implemented Team Compass in May 2019. On the first day, PCAPS-based care pathways were used to treat 580 of 623 inpatients. Approximately 4,000 patients were treated using this system from May to August 2019. No major problems have arisen since the implementation of Team Compass.

Enfermeiras e Enfermeiros , Registros de Enfermagem , Médicos , Gastos em Saúde , Humanos , Japão , Conhecimento
Gerokomos (Madr., Ed. impr.) ; 31(2): 98-106, jun. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-193891


OBJETIVO: Determinar la prevalencia hospitalaria de lesiones relacionadas con la dependencia (LRD) en la provincia de Burgos. Determinar las características de las LRD. Identificar las valoraciones del riesgo de padecer lesión por presión (LPP) y el uso de dispositivos de prevención de LPP. Cuantificar los registros de enfermería de LRD. METODOLOGÍA: Estudio observacional, descriptivo, transversal y multicéntrico, realizado mediante observación directa y revisión de la historia clínica de adultos ingresados en unidades de hospitalización. Realizado en tres hospitales de Burgos en 2018. RESULTADOS: La población sumó 511 pacientes; presentaron LRD: 188. Se detectaron 328 LRD: 176 (53,65%) LPP, 48 (14,63%) lesiones por humedad, 81 (24,69%) lesiones por fricción, 11 (3,35%) lesiones combinadas y 12 (3,65%) lesiones multicausales. Las LPP de categoría 1 fueron las más numerosas, sumando un 35,36%. El 78,96% de las LRD se consideraron adquiridas en el hospital. La prevalencia de LRD es del 36,79%. Las prevalencias por tipos de LRD son: LPP 20,93%, lesiones por humedad 9%, fricción 12,72%, combinadas 1,76% y multicausales 1,56%. El 35,61% de los pacientes presentaba algún tipo de dispositivo preventivo; el 60,07% presentaba valoración del riesgo de padecer LPP; el 30,31% presentaba registro de la lesión, y el 18,37% contaba con plan de cuidados específico. CONCLUSIONES: La prevalencia e LRD, obtenida por inspección directa, cuadruplica los resultados nacionales, pero parece reflejar con mayor exactitud la realidad que los datos obtenidos mediante los registros de enfermería. Es aconsejable universalizar la valoración del riesgo de padecer LPP a todos los pacientes, la mejora de los registros de enfermería y reforzar los esfuerzos preventivos

AIM: To determine the hospital prevalence of dependence-related lesions (DRL) in the province of Burgos. Determine the characteristics of the DRL. Identify the risk assessments of pressure ulcer (PU) and the use of PU prevention devices. Quantify the DRL nursing records. METHODOLOGY: Observational, descriptive, cross-sectional and multicenter study, performed through direct observation and review of the health record of adults admitted to hospitalization units. RESULTS: The population totaled 511 patients, of wich 188 presented DRL. 328 DRL were detected: 176 (53.65%) PU, 48 (14.63%) moisture lesions, 81 (24,69%) friction lesions, 11 (3.35%) combined lesions, and 12 (3.65%) multifactorial lesions. The most numerous was PU category 1 totaling 35.36%. 78.96% of the DRL were determined to be hospital acquired. The prevalence of DRL is 36.79%. The prevalences for DRL types are: PU 20.93%, moisture lesions 9%, friction 12.72%, combined 1.76% and multifactorial 1.56%. 35.61% of patients had some type of preventive device, 60.07% had a risk assessment for PU, 30.31% had a record of the lesion and 18.37% had a specific care plan. CONCLUSIONS: The prevalence of DRL, obtained by direct inspection, quadruples national results, but it seems to be more accurate than the data obtained through nursing records. It is advisable to universalize the assessment of the risk of suffering PU to all patients, to improve nursing records and to reinforce preventive efforts

Humanos , Masculino , Feminino , Idoso , Lesão por Pressão/complicações , Úlcera Cutânea/classificação , Úlcera Cutânea/prevenção & controle , Segurança do Paciente , Registros de Enfermagem/normas , Enfermagem Geriátrica , Autocuidado/métodos , Autocuidado/normas , Enfermagem Geriátrica/métodos
Notas enferm. (Córdoba) ; 20(35): 21-29, jun. 2020. graf.
Artigo em Espanhol | LILACS, BDENF - Enfermagem, BINACIS, UNISALUD | ID: biblio-1119038


Los registros de enfermería son un fiel reflejo de las actividades que el profesional de enfermería realiza de los cuidados que se brindan y de cuanta dedicación y empeño otorga en favor de lograr el bienestar del paciente. En ellos se debe dejar constancia no solo de los signos vitales, sino también dejar reflejada la visión holística que el enfermero aplica a cada uno de sus pacientes como seres únicos. Se realizó un estudio observacional, descriptivo, evaluativo y retrospectivo, constituido por los registros realizados por el personal de Enfermería en las historias clínicas de los pacientes internados en el internado general del Sanatorio Allende Cerro en Agosto/septiembre de 2019. La selección de la unidad de análisis fue por muestreo aleatorio simple. Se realizó auditoría de los registros de Enfermería de 13 historias clínicas desde el momento de ingreso a la institución hasta el egreso del mismo, constituyendo un total de 208 registros de Enfermería. Esta investigación determinó que 10 de 15 indicadores que se propusieron para valorar la calidad de nuestros registros fueron clasificados como escasamente adecuado, lo que refleja la necesidad de centrar la atención en mejorar la calidad de nuestros registros de enfermería, ya que estos son documentos sobre actos y conductas profesionales que conllevan a responsabilidades de índole profesional y legal[AU]

Controle de Qualidade , Registros de Enfermagem , Auditoria de Enfermagem , Controle de Formulários e Registros
Notas enferm. (Córdoba) ; 20(35): 13-20, jun. 2020. graf.
Artigo em Espanhol | LILACS, BDENF - Enfermagem, BINACIS, UNISALUD | ID: biblio-1119033


La Historia Clínica constituye una de las fuentes de información sobre la asistencia sanitaria que prestan los profesionales de enfermería a través del registro, como una herramienta para el cuidado diario de enfermería, que permite dejar sellado el accionar realizado. Todo ello conlleva una responsabilidad a nivel profesional y legal, que precisa de una práctica basada en el rigor científico, ético y legal. El objetivo fue evaluar la implementación del registro de cuidados relacionados a la seguridad emocional en pacientes internados en el servicio de Unidad Coronaria. Se realizó una investigación evaluativa, utilizando los registros electrónicos de enfermería de las historias clínicas. Las dimensiones estudiadas fueron siete: como la Dimensión Vincular, Ambiental, experticia técnica, Comunicacional, Corporal, Asistencia específica y Afectiva. Resultados: no son registrados en todos los informes los cuidados de seguridad emocional, el turno noche presenta mayor cantidad de registros de cuidados emocionales, en el segundo lugar turno mañana y menor porcentaje turno tarde. La dimensión ambiental fue la mayor registrada y la menos registrada fue la dimensión de experticia. Conclusiones: Se recomienda continuar con las capacitaciones para concientizar sobre la importancia de registrar ya que es la evidencia de los cuidados que se proporcionan. Estos registros demuestran el rol autónomo de enfermería, y la valoración y cuidado de los aspectos emocionales de cada uno de los pacientes asistidos[AU]

Humanos , Registros de Enfermagem , Estudo de Avaliação , Segurança do Paciente , Enfermagem Cardiovascular , Controle de Formulários e Registros
Artigo em Inglês | MEDLINE | ID: mdl-32392838


Nursing documentation is an important proxy of the quality of care, and quality indicators in nursing assessment can be used to assess and improve the quality of care in health care institutions. The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other). The observational ecological pilot study was conducted between September and October 2018 in an Italian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the 'Assessment' phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse-patient ratio showed a significant direct association with the assessment of nutritional status (p = 0.032). The average weight DRG has a negative influence on pain and BMI assessment; the surgical units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing documentation.

Avaliação em Enfermagem , Registros de Enfermagem , Qualidade da Assistência à Saúde , Hospitais , Humanos , Medição da Dor , Projetos Piloto
J Clin Nurs ; 29(13-14): 2482-2494, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32242997


AIMS AND OBJECTIVES: Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases. BACKGROUND: Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals. DESIGN: This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis. METHODS: We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014. RESULTS: The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients. CONCLUSIONS: When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals. RELEVANCE TO CLINICAL PRACTICE: Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.

Atitude do Pessoal de Saúde , Registros de Enfermagem , Recursos Humanos de Enfermagem no Hospital/psicologia , Adulto , Viés , Empatia , Feminino , Humanos , Transtornos Mentais/enfermagem , Enfermagem Psiquiátrica/métodos , Pesquisa Qualitativa , Estudos Retrospectivos
Rev. enferm. Inst. Mex. Seguro Soc ; 28(2): 92-101, Abr-Jun. 2020. graf
Artigo em Espanhol | LILACS, BDENF - Enfermagem | ID: biblio-1121645


Introducción: para garantizar la información y la atención de calidad, la Organización Mundial de la Salud, la Organización Panamericana de la Salud y las normas oficiales del cáncer cervicouterino y los sistemas de salud en México sugieren fortalecer los sistemas de información en salud con el uso de herramientas tecnológicas. Objetivo: el propósito de este estudio es conocer la factibilidad de un proyecto para la innovación de procesos, a través de un sistema electrónico para los registros de las citologías cervicales. Metodología: estudio observacional, transversal, prospectivo, realizado del 4 al 25 de junio de 2018 en la Unidad de Cuidados Integrales e Investigación en Salud de la Universidad Autónoma de San Luis Potosí, México. Se estudió al universo del personal sanitario que implementa el Programa de Detección Oportuna de Cáncer Cervico Uterino, con 7 participantes: personal directivo (2) y operativo (5). Resultados: las políticas y recursos institucionales permiten la implementación del proyecto, pues consideran tendría impacto positivo en la atención. Conclusiones: actualmente, la totalidad del personal cuenta con las competencias básicas para el manejo de sistemas electrónicos.

Introduction: To guarantee quality information and care, World Health Organization, Pan American Health Organization and the Official Standards of Cervical Cancer and Health Systems in Mexico suggest strengthening health information systems with the use of technological tools. Objective: The purpose of the study is to know the feasibility of a project for process innovation, through an electronic system for records of cervical cytologies. Methods: An observational, cross-sectional, prospective study conducted from June 4 to 25, 2018 in the Unit of Integral Care and Health Research of the Autonomous University of San Luis Potosí, Mexico. The universe of health personnel that implements the Timely Detection of Cervical Cancer Program was studied, 7 participants: managerial staff (2) and operative staff (5). Results: Institutional policies and resources allow for the implementation of the project, as they consider it would have a positive impact on care. Conclusions: Currently, all the staff has the basic skills for the management of electronic systems.

Humanos , Organização Pan-Americana da Saúde , Organização Mundial da Saúde , Sistemas de Informação , Desenvolvimento Tecnológico , Doenças do Colo do Útero , Estudos de Viabilidade , Registros de Enfermagem , Estudos Transversais , Estudos Prospectivos , Técnicas Citológicas , Teste de Papanicolaou , Estudo Observacional , México
J Clin Nurs ; 29(13-14): 2125-2137, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32243006


INTRODUCTION: Speech recognition technology (SRT) recognises an individual's spoken word signals through a microphone and subsequently processes the user's words into digital text by means of a computer. SRT remains well established and continues to grow in popularity among the various health disciplines. Many studies have been done to examine the effects of SRT on nursing documentation, however, no previous systematic review (SR) on the effects of SRT on accuracy and efficiency of nursing documentation was identified. AIMS AND METHODS: To systematically review the impact of speech recognition technology on the accuracy and efficiency of clinical nursing documentation. A SR was conducted that measures the accuracy and efficiency (time to complete documentation) of SRT on nursing documentation. An extensive search of the literature included Web of Science, CINAHL via EBSCO host, Cochrane Library, Embase, MEDLINE and Google Scholar. The PRISMA checklist screened eligible papers. The quality of each paper was critically appraised, data extracted and analysed/synthesised. RESULTS: A total of 10 studies were included. Various devices and systems have been used to examine the accuracy, efficiency and impact of SRT on nursing documentation. A positive impact of SRT with significant advances in accuracy/productivity of nursing documentation at the point of care was found. However, a substantial degree of initial costing, training requirements and studied interface modification to individual healthcare units are needful in incorporating SRT systems. CONCLUSIONS: Speech recognition technology when applied to nursing documentation could open up a promising new interface for data entry from the point of care, though the full potential of the technology has not been explored. RELEVANCE TO CLINICAL PRACTICE: The compatibility/effectiveness of SRT with existing computer systems remains understudied. SRT training, prompt on-site technical support, maintenance and upgrades cannot be underestimated towards achieving high-level accuracy and efficiency (time to complete documentation) with SRT.

Registros de Enfermagem , Interface para o Reconhecimento da Fala , Interface Usuário-Computador , Humanos , Percepção da Fala
Enferm. clín. (Ed. impr.) ; 30(1): 4-15, ene.-feb. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-186278


OBJETIVO: Validar el contenido de un instrumento para la documentación de las etapas del proceso enfermero, utilizando los sistemas de lenguaje de NANDA-I, NOC y NIC, considerando los pacientes hospitalizados en una unidad de cuidados intensivos. MÉTODO: Investigación metodológica realizada en 3 etapas: diseño del instrumento existente a partir de los sistemas NANDA-I, NOC y NIC; validación de contenido por 13 jueces a partir de una escala tipo Likert de 4 puntos, evaluando los ítems en cuanto a claridad y pertinencia; aplicabilidad: opinión de 40 enfermeros asistenciales sobre el contenido respecto a la claridad, facilidad de lectura y presentación. Se calculó el índice de validez de contenido y el coeficiente de Kappa para medir la proporción de relevancia y claridad, así como para verificar el nivel de concordancia entre especialistas en cada ítem. RESULTADOS: Se consideró el instrumento claro y pertinente, con índice de validez de contenido por encima de 0,8 en la mayoría de los ítems, e índice de concordancia global de 0,90, evidenciando un nivel satisfactorio de concordancia entre los jueces. En cuanto a la aplicabilidad se consideró el instrumento claro, de fácil lectura y con presentación adecuada por la mayoría de los enfermeros asistenciales, siendo validado a través de 11 diagnósticos con sus respectivos resultados e intervenciones de enfermería. CONCLUSIÓN: El instrumento ha demostrado ser válido y aplicable para el grupo estudiado. Se espera que este estudio contribuya a la mejora del proceso enfermero en cuidados intensivos

OBJECTIVE: to validate the content of an instrument for documenting the steps of the Nursing Process, using the standardized languages NANDA-I, NOC, and NIC (NNN), aiming at hospitalized patients in an Intensive Care Unit (ICU). METHOD: A methodological research performed in three steps: design of the existing instrument from the systems NANDA-I, NOC and NIC; content validation by 13 judges, from a four-point Likert-type scale - items were evaluated as to their clarity and pertinence; applicability: judgement of the content regarding clarity, reading ease, and presentation for 40 critical-care nurses. The Content Validity Index (CVI) and the Kappa coefficient (k) was calculated to measure the proportion of relevance and clarity, was well as to verify the level of agreement between the experts in each item. RESULTS: The instrument was considered clear and pertinent, with CVI above 0.8 in most items and overall Concordance Index (CI) of 0.90, showing a satisfactory level of agreement between judges. Regarding applicability, the instrument was deliberated clear, of easy reading, and with proper presentation by most critical-care nurses, being validated through 11 diagnoses with their respective results and nursing interventions. Conclusion; The instrument showed to be valid and applicable for the group studied. It is expected that this study is able to contribute to the improvement of the Nursing Process in intensive care

Humanos , Avaliação de Programas e Instrumentos de Pesquisa , Registros de Enfermagem , Processo de Enfermagem/organização & administração , Documentação/normas , Cuidados Críticos/métodos , Terminologia Padronizada em Enfermagem , Unidades de Terapia Intensiva , 24960
Pflege ; 33(1): 3-12, 2020 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-31595828


The congruence of nursing diagnoses, interventions, and outcomes between care observations, patient perceptions, and nursing records: a qualitative multiple case study Abstract. Background: Nurses with good decision-making competencies state more relevant and accurate nursing diagnoses, perform more effective nursing interventions, and achieve better nursing-sensitive patient outcomes. It was reported that the content of nursing records sometimes doesn't match with statements of patients and nurses. RESEARCH QUESTION: In what extent do the recorded nursing diagnoses, interventions, and outcomes match with observed care situations and patients' statements? METHODS: A multiple case study with structured observations, guided interviews, and document analyses was performed. The congruence of nursing diagnoses, interventions, and outcomes between the three data sources was investigated by within- and cross-case-analysis in a sample of 24 patients. RESULTS: In total, 114 nursing diagnoses were identified of which 66 were recorded, 37 were found by observations, and 11 by patient interviews. A high congruence between the three perspectives was determined in 59 % of the recorded nursing diagnoses, in 41 % of nursing interventions, and in 33 % of nursing-sensitive patient outcomes. Almost all documented nursing diagnoses (89 %) were supported by most codes from all three sources. CONCLUSIONS: To increase the congruence of the three perspectives, nurses' clinical decision-making competencies should be fostered, so that nurses choose more effective nursing interventions that lead to better nursing-sensitive patient outcomes. Patient participation should be fostered.

Competência Clínica , Diagnóstico de Enfermagem , Registros de Enfermagem , Participação do Paciente , Humanos , Pesquisa Qualitativa
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 12: 12-19, jan.-dez. 2020. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1047786


Objetivo: o estudo objetivou identificar quais estratégias estão sendo utilizadas na implementação de registros eletrônicos relacionados ao processo de enfermagem, nas bases de dados: PubMed, Scopus e Web of Science. Método: trata-se de uma revisão integrativa na qual os descritores utilizados foram electronic health records e nursing process. Resultados: Os dados encontrados indicam que os estudos em sua maioria foram pesquisas quantitativas, publicadas no periódico Nursing informatics (Studies in Health Technology and Informatics) desenvolvidas em universidades e no continente americano. Conclusão: os dados apontam que a maior parte das pesquisas são referentes a usabilidade do registro eletrônico em saúde. Outros aspectos abordados foram as fragilidades e perspectivas associados ao uso do registro eletrônico, bem como o processo de enfermagem em sistemas informatizados

Objective: the objective of this study was to identify which strategies are being used in the implementation of electronic records related to the nursing process, in PubMed, Scopus and Web of Science databases. Method: this is an integrative review in which the descriptors used were electronic health records and nursing process. Results: the data found indicate that the studies were mostly quantitative research, published in the journal Nursing informatics (Studies in Health Technology and Informatics) developed in universities and in the American continent. Conclusion: the data indicate that most of the researches are referring to the usability of electronic health records. Other aspects addressed were the weaknesses and perspectives associated with the use of electronic registration, as well as the nursing process in computerized systems

Objetivo: el estudio tuvo como objetivo identificar qué estrategias están siendo utilizadas en la implementación de registros electrónicos relacionados al proceso de enfermería, en las bases de datos: PubMed, Scopus y Web of Science. Métodos: se trata de una revisión integrativa en la cual los descriptores utilizados fueron electronic health records y kind process. Resultados: los datos encontrados indican que los estudios en su mayoría fueron investigaciones cuantitativas, publicadas en el periódico Nursing informatics (Studies in Health Technology and Informática) desarrolladas en universidades y en el continente americano. Conclusiones: los datos apuntan que la mayor parte de las encuestas son referentes a la usabilidad del registro electrónico en salud. Otros aspectos abordados fueron las fragilidades y perspectivas asociadas al uso del registro electrónico, así como el proceso de enfermería en sistemas informatizados

Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Registros de Enfermagem , Registros Eletrônicos de Saúde/instrumentação , Processo de Enfermagem , Alfabetização Digital , Educação Continuada em Enfermagem
Rev. baiana enferm ; 34: e35099, 2020. tab
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1115322


Objetivo avaliar a qualidade dos registros na caderneta da gestante averiguando a legibilidade e completude dos registros da assistência pré-natal de risco habitual. Método estudo avaliativo, descritivo e quantitativo, realizado em nove unidades de saúde da atenção básica em São Luís, Maranhão, Brasil, no período de maio de 2017 a setembro de 2018. Os registros foram avaliados quanto à legibilidade e completude. Resultados 92,4% das cadernetas foram consideradas com registros legíveis. A avaliação da completude evidenciou que 72,4% apresentaram completude ruim. Nenhuma caderneta foi classificada com registro bom ou excelente. A avaliação por seções demonstrou que a seção de Exames Complementares de Rotina apresentou os melhores resultados, enquanto a seção de Atividades Complementares apresentou os menores níveis de completude. Conclusão os registros nas cadernetas da gestante foram predominantemente ruins, denotando uma desvalorização desse instrumento e um provável descumprimento das recomendações do Ministério da Saúde para uma assistência de qualidade.

Objetivo evaluar la calidad de los registros en la cartilla de las mujeres embarazadas, evaluando la legibilidad y la integridad de los registros de control prenatal de riesgo habitual. Método estudio evaluativo, descriptivo y cuantitativo, realizado en nueve unidades de atención básica en salud en São Luís, Maranhão, Brasil, en el período de mayo de 2017 a septiembre de 2018. Los registros fueron evaluados en cuanto a la legibilidad y la integridad. Resultados el 92,4% de las cartillas fueron consideradas con registros legibles. La evaluación de la integridad mostró que el 72,4% tenía mala integridad. Ningún registro de la cartilla fue clasificado como bueno o excelente. La evaluación por secciones mostró que la sección de Exámenes Complementarios de Rutina obtuvo los mejores resultados, mientras que la sección de Actividades Complementarias obtuvo los niveles más bajos de la integridad. Conclusión los registros de la cartilla de mujeres embarazadas eran, en su mayoría, pobres, denotando una devaluación de este instrumento y un probable incumplimiento de las recomendaciones del Ministerio de Salud para una asistencia de calidad.

Objective to evaluate the quality of the records in the pregnant women's booklet, assessing the legibility and completeness of usual-risk pre-natal records. Method evaluative, descriptive and quantitative study, conducted in nine basic health care units in São Luís, Maranhão, Brazil, in the period from May 2017 to September 2018. The records were evaluated according to legibility and completeness. Results 92.4% of the booklets were considered with legible records. The assessment of the completeness showed that 72.4% had bad completeness. No record booklet was classified as good or excellent. The assessment by sections showed that the Routine Complementary Test section showed the best results, whereas the Complementary Activities section showed the lowest levels of completeness. Conclusion the records in the pregnant women's booklet were predominantly bad, denoting a devaluation of this instrument and a probable noncompliance with the recommendations of the Ministry of Health for a quality assistance.

Humanos , Feminino , Gravidez , Cuidado Pré-Natal , Qualidade da Assistência à Saúde , Avaliação em Saúde , Registros de Saúde Pessoal , Avaliação de Programas e Projetos de Saúde , Registros de Enfermagem
Enferm. foco (Brasília) ; 10(7): 135-140, dez. 2019. ilus
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1051469


Objetivo: identificar e analisar artigos científicos que descrevam a sistematização da assistência de enfermagem (SAE) na sala de recuperação pós-anestésica (SRPA). Metodologia: revisão integrativa da literatura realizada no mês de maio de 2019, mediante consulta às bases de dados e/ou portais US National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Scopus, Web of Science e nos portais da Biblioteca Virtual da Saúde (BVS). Resultado: dois artigos compuseram a amostra desta revisão, a qual propôs identificar modelos de registro de SAE na SRPA. Conclusão: torna-se evidente a necessidade de estudos que proponham instrumentos para SAE na SRPA. As evidências identificadas possuem elementos que contribuem para a natureza das categorias dos diagnósticos de enfermagem, que podem representar as necessidades de cuidados dos pacientes na SRPA. (AU)

Objective: To identify and analyze scientific articles describing the systematization of nursing care (SAE) in the Postanesthetic Care Units (PACU). Methodology: integrative review of the literature conducted in May 2019, through consultation of the databases and/or portals US National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Scopus, Web of Science and in the portals of the Virtual Health Library (VHL). Results: two articles composed the sample of this review, which proposed to identify SAE registration models in the PACU. Conclusion: There is a need for studies that propose instruments for SAE in the PACU. The evidence identified has elements that contribute to the nature of the categories of nursing diagnoses, which may represent the care needs of patients in PACU. (AU)

Objetivo: Identificar y analizar artículos científicos que describen la sistematización de la asistencia de enfermería (SAE) en la sala de recuperación postanestésica (SRPA). La metodología de la investigación de la literatura en el mes de mayo de 2019, mediante la consulta a las bases de datos y/o portales US National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Scopus, Web de Science y en los portales de la Biblioteca Virtual de la Salud (BVS). Resultado: dos artículos compusieron la muestra de esta revisión, la cual propuso identificar modelos de registro de SAE en la SRPA. Conclusión: Se hace evidente la necesidad de estudios que proponen instrumentos para SAE en la SRPA. Las evidencias identificadas poseen elementos que contribuyen a la naturaleza de las categorías de los diagnósticos de enfermería, que pueden representar las necesidades de atención de los pacientes en la SRPA. (AU)

Enfermagem em Pós-Anestésico , Período Pós-Operatório , Registros de Enfermagem , Cuidados de Enfermagem , Processo de Enfermagem
Rev. Esc. Enferm. USP ; 53: e03471, Jan.-Dez. 2019. tab
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1020378


RESUMO Objetivo Identificar a prevalência de documentação do Processo de Enfermagem nos hospitais e ambulatórios administrados pela Secretaria de Estado da Saúde de São Paulo. Método Estudo descritivo, realizado por meio de entrevistas com enfermeiros responsáveis por 416 setores de 40 instituições sobre a documentação de quatro fases do Processo de Enfermagem (levantamento de dados, diagnóstico, prescrição e evolução) e de anotações de enfermagem. Resultados Dos 416 setores estudados, 89,9% documentavam pelo menos uma fase; 56,0% documentavam as quatro fases; 4,3% documentavam apenas anotações de enfermagem; 5,8% não documentavam nenhuma fase, nem as anotações de enfermagem. Os tipos de setores que menos documentavam foram: ambulatório, apoio diagnóstico, centro cirúrgico e centro obstétrico; os que mais documentavam: unidades de terapia intensiva, prontos-socorros e unidades de internação. O levantamento de dados e o diagnóstico foram as fases menos documentadas, ambas em 78,8% dos setores. Conclusão A maior parte dos setores estudados documenta o Processo de Enfermagem e faz anotações de enfermagem, mas há setores em que a documentação não corresponde às exigências formais. A viabilidade da documentação de todas as fases do Processo de Enfermagem em determinados tipos de setores precisa ser mais bem estudada.

RESUMEN Objetivo Identificar la prevalencia de documentación del Proceso de Enfermería en los hospitales y ambulatorios administrados por la Secretaría de Estado de la Salud de São Paulo. Método Estudio descriptivo, llevado a cabo mediante entrevistas con enfermeros responsables de 416 sectores de 40 centros acerca de la documentación de cuatro fases del Proceso de Enfermería (inventario de datos, diagnóstico, prescripción y evolución) y de apuntes de enfermería. Resultados De los 416 sectores estudiados, el 89,9% documentaban por lo menos una fase; el 56,0% documentaban las cuatro fases; el 4,3% documentaban solo apuntes de enfermería; el 5,8% no documentaban ninguna fase, ni los apuntes de enfermería. Los tipos de sectores que menos documentaban fueron: ambulatorio, apoyo diagnóstico, quirófano y centro obstétrico; los que más documentaban: unidades de cuidados intensivos, urgencias y unidades de estancia hospitalaria. El inventario de datos y el diagnóstico fueron las bases menos documentadas, ambas en el 78,8% de los sectores. Conclusión La mayor parte de los sectores estudiados documenta el Proceso de Enfermería y hace apuntes de enfermería, pero hay sectores en los que la documentación no corresponde a los requerimientos formales. La factibilidad de la documentación de todas las fases del Proceso de Enfermería en determinados tipos de sectores necesita ser más bien estudiada.

ABSTRACT Objective To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health. Method A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations. Results Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors. Conclusion Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.

Registros de Enfermagem , Padrões de Prática em Enfermagem , Processo de Enfermagem , Serviços de Enfermagem
Rev. SOBECC ; 24(4): 200-210, 30-12-2019.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1096047


Objetivos: Construir e validar conteúdos de um instrumento para registro da sistematização da assistência de enfermagem perioperatória. Método: Estudo metodológico realizado em um hospital-escola do sul do Brasil que incluiu revisão de literatura, mapeamento cruzado entre observação não estruturada e taxonomias da North American Nursing Diagnosis Association para construção do instrumento e aplicação da técnica Delphi para validação, realizada entre novembro e dezembro de 2018. Disponibilizou-se formulário eletrônico a dez expertos para avaliação da objetividade, clareza/compreensão, aparência e exequibilidade dos conteúdos do instrumento, registrada em escala Likert. As respostas obtidas foram submetidas ao índice de validade de conteúdo (IVC), e escores ≥0,8 confirmaram a validação do conteúdo. Resultados: Os nove grupos de informações do instrumento foram avaliados por enfermeiros expertos. A média do IVC obtido entre todos os conteúdos foi de 0,92 na primeira rodada de validação. Os resultados demonstraram que a estratégia metodológica permitiu a construção de conteúdos que representam a necessidade clínica para os registros de enfermagem no período perioperatório. Conclusão: A implementação de instrumento validado contribui para uma prática de enfermagem mais segura e qualificada.

Objectives: To construct and validate the contents of an instrument to register the systematization of perioperative nursing care. Method: Methodological study conducted in a teaching hospital in Southern Brazil, which included literature review, cross-mapping between unstructured observation and North American Nursing Diagnosis Association taxonomies for instrument construction and application of the Delphi technique for validation, performed between November and December 2018. An electronic form was made available to ten experts to evaluate the objectivity, clarity/understanding, appearance and feasibility of the instrument contents, registered on a Likert scale. The answers obtained were submitted to the content validity index (CVI), and scores ≥0.8 confirmed the content validation. Results: The nine information groups of the instrument were evaluated by expert nurses. The average CVI obtained among all contents was 0.92 in the first round of validation. The results showed that the methodological strategy allowed the construction of contents that represent the clinical need for perioperative nursing records. Conclusion: The implementation of a validated instrument contributes to a safer and more qualified nursing practice.

Objetivos: Construir y validar los contenidos de un instrumento para registrar la sistematización de la atención de enfermería perioperatoria. Método: Estudio metodológico, realizado en un hospital universitario en el sur de Brasil, que incluyó revisión de literatura, mapeo cruzado entre observación no estructurada y taxonomías de la Asociación Norteamericana de Diagnóstico de Enfermería para la construcción de instrumentos y la aplicación de la técnica Delphi para validación, realizada entre noviembre y diciembre de 2018, con la disponibilidad de un formulario electrónico para diez expertos para evaluar la objetividad, claridad/comprensión, apariencia y viabilidad del contenido del instrumento, registrado en la escala Likert. Las respuestas obtenidas se enviaron al índice de validez de contenido (IVC), y las puntuaciones ≥0,8 confirmaron la validación de contenido. Resultados: Los nueve grupos de información del instrumento fueron evaluados por enfermeras expertas. El IVC promedio obtenido entre todos los contenidos fue de 0.92 en la primera ronda de validación. Los resultados mostraron que la estrategia metodológica permitió la construcción de contenidos que representan la necesidad clínica de registros de enfermería perioperatoria. Conclusión: la implementación de un instrumento validado contribuye a una práctica de enfermería más segura y más calificada.

Humanos , Registros de Enfermagem , Enfermagem , Lista de Checagem , Período Pós-Operatório , Cirurgia Geral , Período Pré-Operatório
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 11(5): 1226-1235, out.-dez. 2019. ilus
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1022343


Objetivo: Analisar a percepção dos enfermeiros sobre a implantação e o uso do Prontuário Eletrônico do Cidadão (PEC) no cuidado de enfermagem. Método: Pesquisa de abordagem qualitativa realizada com 11 enfermeiros da Atenção Básica. Resultados: Emergiram três categoriais: O Prontuário Eletrônico do Cidadão sob a ótica dos enfermeiros da Atenção Básica (AB); A Implantação do Prontuário Eletrônico do Cidadão nas Unidades de Atenção Básica (UBS); Contribuições e desafios na utilização do PEC para o cuidado de enfermagem. Identificou-se que PEC é uma ferramenta que pode contribuir para a melhoria do funcionamento das UBS e para a qualificação do cuidado de enfermagem.Conclusão: O PEC colabora nos processos de trabalho do enfermeiro no assistir, administrar e pesquisar. Para funcionamento do PEC nas UBS é preciso implementar suporte e manutenção da rede lógica e internet; capacitação dos profissionais no uso da informática e organização de educação permanente

Objective: The study's purpose has been to analyze the nurses' viewpoint regarding both implementation and use of the Electronic Citizen Record (ECR) in nursing care. Methods: It is a descriptive research with a qualitative approach that was carried out with 11 nurses from the primary health care service. Results: The following three categories appeared: The ECR from the primary care nurses' viewpoint; Implementation of the ECR in the basic health units; Contributions and challenges by using the ECR for nursing care. It was identified that the ECR is a tool that can contribute to the improvement of basic health units functioning, as well as, to the nursing care qualification. Conclusion: The ECR collaborates in the nurses' work processes by assisting, administering and researching. In order to make sure the ECR functioning in basic health units, it is necessary to implement support and maintenance of the logical network and internet; to promote training for health professionals using data processing, and also organizing the permanent education activity

Objetivo: Analizar la percepción de los enfermeros sobre la implantación y el uso del registro electrónico del ciudadano (REC) en la atención de enfermería.Método: Investigación de enfoque cualitativo realizada com 11 enfermeras . Resultados: Surgieron tres categorias: REC bajo la percepción de losenfermeros de Atención Primária de Salud; implantación del REC em las Unidades de Atención Primária (UNAPS); contribuciones y desafios em la utilización del REC en la atención de enfermería. Se identifico que REC es uma herramienta que podrá contribuir para lamejoría del funcionamento de las UNAPS y para la cualificación de La atención de enfermería.Conclusión: El REC colabora en los procesos de trabajo del enfermero en el asistir, administrar e investigar.Para el funcionamento del REC es necessariosoporte y manutención de lared lógica y del internet; capacitación de losprofissionalesen informática y organización de educación permanente

Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Atenção Primária à Saúde , Registros de Enfermagem , Registros Eletrônicos de Saúde/instrumentação , Alfabetização Digital , Educação Continuada , Processo de Enfermagem