Os sinais e sintomas identificados na admissão foram psíquicos (40,3%), curativo compressivo em sítio de punção arterial (33,8%), dor torácica (29,9%), taquicardia (22,1%) e instabilidade hemodinâmica (20,8%). CONCLUSÕES E IMPLICAÇÕES PARA A PRÁTICA: De acordo com os dados levantados foram inferidos Dor Aguda, Volume de Líquidos Excessivo, Débito Cardíaco Diminuído, Ventilação Espontânea Prejudicada, Ansiedade e Integridade da Pele Prejudicada como diagnósticos de enfermagem prioritários para a população estudada.
Objective:to evaluate the impact of an educational intervention on the quality of nursing
records. Method:quasi-experimental study with before-and-after design conducted in a hospital. All
the nurses in the cardiac intensive care unit of the hospital received the
intervention, which consisted of weekly meetings during five months. To collect
data, the instrument Quality of Diagnoses, Interventions and Outcomes was applied
to the patients’ charts in two moments: baseline and after intervention. Results:the educational intervention had an impact on the quality of the records, since
most of the items presented a significant increase in their mean values after the
intervention, despite the low values in the two moments. Conclusion:the educational intervention proved to be effective at improving the quality of
nursing records and a lack of quality was identified in the evaluated records,
revealed by the low mean values and by the weakness of some questions presented in
the items, which did not present a significant increase. Therefore, educational
actions focused on real clinical cases may have positive implications for nursing
practice.
The practical consolidation of the steps of the nursing process was verified as well as the possibility of nurses assessing the patients by way of a clinical reasoning and decision making in coherence with the human needs of the patient.
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. Métodos Trata-se de uma revisão integrativa na qual os descritores utilizados foram electronic healthrecords 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. Conclusões 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.
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