急诊护理单位护理记录标准的细化。

IF 1.2 4区 医学 Q3 NURSING Revista da Escola de Enfermagem da U S P Pub Date : 2023-01-01 DOI:10.1590/1980-220X-REEUSP-2022-0253en
Dilzilene Cunha Sivirino Farias, Eliane de Fátima Almeida Lima, Karla de Melo Batista, Marcia Regina Cubas, Júlia Valéria de Oliveira Vargas Bitencourt, Cândida Caniçali Primo
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引用次数: 0

摘要

目的:为急诊科制定诊断、预后和护理干预的登记标准。方法:分三步进行技术发展的应用研究:根据国际护理实践分类详细阐述诊断/结果和干预措施;诊断/结果相关性评估;根据TIPESC中描述的健康需求组织诊断/结果和干预声明。结果:共编制185例诊断,其中124例(67%)分类不变,61例无对应。在185项诊断中,有143项(77%)被32名经验丰富的急诊室护士评为相关,495项护理干预与诊断/结果相关。结论:有可能根据标准化的术语建立急诊护理单元的记录标准,包括由急诊执业护士评估的诊断陈述/结果和护理实践的相关干预措施。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

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Elaboration of a nursing record standard for an Emergency Care Unit.

Objective: To develop a registration standard with diagnoses, outcomes and nursing interventions for an Emergency Care Unit.

Method: This is applied research of technological development developed in three steps: elaboration of diagnoses/outcomes and interventions statements following the International Classification for Nursing Practice; assessment of diagnosis/outcome relevance; organization of diagnosis/outcome and interventions statements according to health needs described in TIPESC.

Results: A total of 185 diagnoses were prepared, of which 124 (67%) were constant in the classification, and 61 had no correspondence. Of the 185 diagnoses, 143 (77%) were rated as relevant by 32 experienced emergency room nurses, and 495 nursing interventions were correlated to diagnoses/outcomes.

Conclusion: It was possible to build a record standard for the Emergency Care Unit following standardized terminology, containing diagnostic statements/outcomes and relevant interventions for nursing practice assessed by nurses with practice in emergency.

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来源期刊
CiteScore
1.70
自引率
11.10%
发文量
254
审稿时长
3-8 weeks
期刊介绍: The University of São Paulo Nursing School Journal (Revista da Escola de Enfermagem da USP, REEUSP) is a bimonthly periodical revised by fellow nurses, which has the objective of publishing empirical or theoretical articles that represent a significant advance for the professional practice or for the fundaments of Nursing Mission: to stimulate knowledge production and dissemination in Nursing and related areas, focusing on international interlocution to advance Nursing science. Areas of Interest: Nursing and Health Its abbreviated title is Rev Esc Enferm USP, which should be used in bibliographies, footnotes and bibliographical references and strips.
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