Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit

Revista Latino-Americana de Enfermagem

Emilia Campos De Carvalho¹  Fernanda Titareli Merizio Martins¹  Maria Célia Barcellos Dalri²  Silvia Rita Marin Da Silva Canini²  Ana Maria Laus²  Maria Marcia Bachion¹  Lidia Aparecida Rossi² 

[1],University of Sao Paulo Ribeirao Preto College of Nursing

关键词: nursing process;    nursing diagnosis;    intensive care unit;    procesos de enfermería;    diagnóstico de enfermería;    unidades de terapia intensiva;    processos de enfermagem;    diagnóstico de enfermagem;    unidades de terapia intensiva;   

DOI  :  10.1590/S0104-11692008000400008

来源: SciELO

【 摘 要 】

This descriptive, retrospective study aimed to analyze the relation between nursing data collection, diagnoses and prescriptions for 26 adult patients who were hospitalized at the intense care unit of a large teaching hospital for at least 24 hours. Through the analysis of medical records, 135 diagnoses and 421 nursing prescriptions were established, and 24 different diagnosis categories and 20 different items for prescriptions were identified. The most frequent diagnosis risk was that for infection, present in the medical records of 22 (84.60%) patients, with 175 prescriptions (42%) related to this diagnosis. The data the nurses collected were sufficient to establish the nursing diagnoses, and the majority of prescriptions (87.9%) were related to the diagnoses.

【 授权许可】

CC BY   
 All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License