Lima Ana Paula Souza, Chianca Tânia Couto Machado, Tannure Meire Chucre
Hospital da Polícia Militar, Belo Horizonte, MG, Brazil.
Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
Rev Lat Am Enfermagem. 2015 Feb-Apr;23(2):234-41. doi: 10.1590/0104-1169.0177.2547.
to analyze the efficacy of the Nursing Process in an Intensive Care Unit using indicators generated by software.
cross-sectional study using data collected for four months. RNs and students daily registered patients, took history (at admission), performed physical assessments, and established nursing diagnoses, nursing plans/prescriptions, and assessed care delivered to 17 patients using software. Indicators concerning the incidence and prevalence of nursing diagnoses, rate of effectiveness, risk diagnoses, and rate of effective prevention of complications were computed.
the Risk for imbalanced body temperature was the most frequent diagnosis (23.53%), while the least frequent was Risk for constipation (0%). The Risk for Impaired skin integrity was prevalent in 100% of the patients, while Risk for acute confusion was the least prevalent (11.76%). Risk for constipation and Risk for impaired skin integrity obtained a rate of risk diagnostic effectiveness of 100%. The rate of effective prevention of acute confusion and falls was 100%.
the efficacy of the Nursing Process using indicators was analyzed because these indicators reveal how nurses have identified patients' risks and conditions, and planned care in a systematized manner.
使用软件生成的指标分析重症监护病房护理程序的效果。
采用横断面研究，收集四个月的数据。注册护士和学生每天使用软件记录17例患者的信息，进行病史采集（入院时）、体格检查，并确定护理诊断、护理计划/医嘱，以及评估所提供的护理。计算有关护理诊断的发生率和患病率、有效率、风险诊断以及并发症有效预防率的指标。
体温失衡风险是最常见的诊断（23.53%），而便秘风险是最不常见的（0%）。皮肤完整性受损风险在100%的患者中普遍存在，而急性意识模糊风险是最不普遍的（11.76%）。便秘风险和皮肤完整性受损风险的风险诊断有效率为100%。急性意识模糊和跌倒的有效预防率为100%。
分析了使用指标的护理程序的效果，因为这些指标揭示了护士如何识别患者的风险和状况，并以系统化的方式规划护理。
