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Type: Artigo de periódico
Title: Evaluation of the Nursing Process Used at a Brazilian Teaching Hospital
Author: Lopes, MHBD
Higa, R
dos Reis, MJ
de Oliveira, NR
Christoforo, FFM
Abstract: 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.
Subject: Nursing assessment
nursing diagnosis
nursing process
Country: EUA
Editor: Wiley-blackwell
Citation: International Journal Of Nursing Terminologies And Classifications. Wiley-blackwell, v. 21, n. 3, n. 116, n. 123, 2010.
Rights: fechado
Identifier DOI: 10.1111/j.1744-618X.2010.01157.x
Date Issue: 2010
Appears in Collections:Unicamp - Artigos e Outros Documentos

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