对巴西一家教学医院所采用护理流程的评估。
Evaluation of the nursing process used at a Brazilian teaching hospital.
作者信息
de Moraes Lopes Maria Helena Baena, Higa Rosângela, Dos Reis Maria José, de Oliveira Neila Regina, Christóforo Fátima Filomena Mafra
机构信息
Nursing Department of the Faculty of Medical Sciences, University of Campinas, Brazil.
出版信息
Int J Nurs Terminol Classif. 2010 Jul-Sep;21(3):116-23. doi: 10.1111/j.1744-618X.2010.01157.x.
PURPOSE
To evaluate how the nursing process has been registered at a Brazilian teaching hospital.
METHODS
Descriptive and retrospective study of 68 medical records.
FINDINGS
The data collection of history was more frequent on the admission day. The documentation of physical exam was prioritized. Sometimes there were records of nursing interventions but not of nursing diagnoses.
CONCLUSIONS
It was found some failures in the record of some steps of the nursing process. Although all steps had been used, they were not carried out consistently.
IMPLICATIONS FOR NURSING PRACTICE
Some aspects deserve to be considered to improve the use and registration of all steps of the nursing process as to develop specific protocols, redesign the formulary of data record with careful and equal consideration of all steps, and empower all members of the nursing staff to implement the nursing process more effectively.
目的
评估巴西一家教学医院对护理程序的记录情况。
方法
对68份病历进行描述性回顾性研究。
结果
入院当天更频繁地收集病史数据。体格检查的记录被列为优先事项。有时有护理干预记录，但没有护理诊断记录。
结论
发现护理程序某些步骤的记录存在一些缺陷。尽管所有步骤都已采用，但执行并不一致。
对护理实践的启示
为改进护理程序所有步骤的使用和记录，应考虑一些方面，如制定具体方案、重新设计数据记录表格并对所有步骤进行仔细且平等的考量，以及赋予所有护理人员更有效地实施护理程序的权力。
Zotero 插件