Nursing process: from literature to practice. What are we actually doing?

Revista Latino-Americana de Enfermagem

Simoni Pokorski²  Maria Antonieta Moraes¹  Régis Chiarelli¹  Angelita Paganin Costanzi¹  Eneida Rejane Rabelo² 

[1] ,Fundação Universitária de Cardiologia Instituto de Cardiologia ,Brazil

关键词: nursing process;    nursing care;    nursing diagnosis;    procesos de enfermería;    atención de enfermería;    diagnóstico de enfermería;    processos de enfermagem;    cuidados de enfermagem;    diagnóstico de enfermagem;   

DOI  :  10.1590/S0104-11692009000300004

来源: SciELO

【 摘 要 】

OBJECTIVES: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. RESULTS: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

【 授权许可】

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