da Cunha Sandra Maria Botelho, Barros Alba Lúcia Botura Leite
Enfermeria do Hospital São Camilo, Pompéia.
Rev Bras Enferm. 2005 Sep-Oct;58(5):568-72. doi: 10.1590/s0034-71672005000500013.
This study has as purpose to analyse the implementation of the Nursing Care Systematization in a private hospital in medical surgical units. Results evidenced that the Horta's Conceptual Model was present only in part of nursing hystory instrument, that the remaining phases of nursing process were not inter-related and that there was a lack of coherence of the prescribed actions in relation to the patient's health condition. From the results of the study it can be concluded that the model used for Nursing Care Systematization is eclectic, not obeying therefore, only to Horta's conceptual model; the totality of the data had not been collected in some phases of the nursing process; there is no correlation of the phases in the majority of analyzed patient records; diagnostic and planning phases do not comprise the phases of the nursing process as proposed by Horta.
本研究旨在分析一家私立医院外科病房护理系统化的实施情况。结果表明，奥尔塔概念模型仅部分体现在护理病史记录工具中，护理程序的其余阶段未相互关联，且规定的护理措施与患者健康状况缺乏连贯性。从研究结果可以得出结论，用于护理系统化的模型是折衷的，因此并不只遵循奥尔塔的概念模型；护理程序的某些阶段未收集到全部数据；大多数分析的患者病历中各阶段之间没有相关性；诊断和计划阶段并不包含奥尔塔所提出的护理程序阶段。
