ABSTRACT
El Programa de Atención al Paciente Quirúrgico en el Hospital Puerta del Mar (Cádiz) surge con el objetivo de personalizar la atención y garantizar la continuidad de cuidados y la seguridad de nuestros pacientes en cada una de las unidades por las que va desarrollándose la actividad quirúrgica. Este programa se soporta en una herramienta informática que es el circuito quirúrgico, la cual ha sido diseñada siguiendo la metodología de mejora continua y la participación desde el inicio de los profesionales enfermeros como actores de su desarrollo e implantación. En sólo ocho meses se ha conseguido que más del 55 % de los pacientes intervenidos quirúrgicamente disponga de un registro informatizado en el que se valoran, diagnostican, planifican y abordan los aspectos relacionados con la propia intervención quirúrgica como una parte añadida a las respuestas humanas que la misma ocasiona tanto a él como a su familia. Todo ello haciendo uso de las taxonomías enfermeras NANDA, NOC y NIC, con un enfoque holístico, centrado en la persona como agente y receptor de cuidados. Acompaña a este registro un sistema de información desde el que se explotan aspectos tales como la prevalencia diagnóstica enfermera, intervenciones realizadas, alergias, profilaxis antibiótica administrada, etc
The Surgery-needed Care Program, currently under test at the Puerta del Mar Hospital in Cadiz, has been conceived with the aim of both tuning the care level to each individual patient and, at the same time, to secure a continuous assistance through all the units involved in the surgery process. It is based on a computer tool so called Surgery Program. This computer application has been designed on the basis of continually-improving approach while counting with the enrolment, from the very first phases, of nurses in the affected units both in development and set-up steps. After just eight months running this Program, we have been able to create a digital database keeping record about up to 55% of the surgery assistances appointed in this period. In each of these records, the expected emotional responses of both the patient and relatives against the surgery process are diagnosed and carefully evaluated. Likewise those care actions planned to face such responses with the aim of alleviating patient and family-environment anxieties or fears are also recorded. For this, NANDA, NOC and NIC taxonomies has been used with a holistic perspective and considering the person both as the agent and as the final receiver of cares. The information recorded in this database is complemented with other provided by a parallel information system keeping track of additional relevant details as nurse diagnosis, list of all the interventions performed, patient allergies or antibiotic prophylaxis provided to the patient (AU)
Subject(s)
Humans , Medical Records Systems, Computerized , Continuity of Patient Care/standards , Nursing Records , Forms and Records Control/methods , Safety ManagementABSTRACT
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