RESUMO
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 48 h 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.
Assuntos
Processo de Enfermagem , Enfermagem , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
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 percent 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 percent of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.
OBJETIVO: describir los pasos del proceso de la enfermería descrito en la literatura e investigar como este es realizado en la rutina diaria de un hospital general. MÉTODOS: Estudio transversal retrospectivo (mayo/junio 2005) realizado en Porto Alegre, RS. Fueron revisadas fichas de pacientes adultos admitidos en unidades quirúrgicas, clínicas y unidades de terapia intensiva con la finalidad de identificar los pasos del proceso de enfermería realizados durante las primeras 48 horas de la admisión. El instrumento de recolección de datos fue elaborado de acuerdo con la literatura. RESULTADOS: 302 fichas fueron evaluadas. Los registros de enfermería y examen físico estaban descritos en más de 90 por ciento de las fichas revisadas. El diagnóstico de enfermería no fue encontrado en ninguna de los fichas. Entre los pasos realizados en el proceso, la prescripción fue el menos frecuente. La evolución de los pacientes fue registrada en más de 95 por ciento de los fichas. CONCLUSIÓN: Todos los pasos recomendados en la literatura, excepto el diagnóstico de enfermería son realizados en la institución investigada.
OBJETIVO: descrever os passos do processo de enfermagem descrito na literatura e investigar como este é realizado na rotina diária de um hospital geral. MÉTODOS: Estudo transversal retrospectivo (maio/junho 2005) realizado em Porto Alegre, RS. Foram revisados prontuários de pacientes adultos admitidos em unidades cirúrgicas, clínicas e unidade de terapia intensiva para identificar os passos do processo de enfermagem realizados durante as primeiras 48 horas da admissão. O instrumento de coleta de dados foi elaborado de acordo com a literatura. RESULTADOS: 302 prontuários foram avaliados. Registros de enfermagem e exame físico estavam descritos em mais de 90 por cento dos prontuários revisados. O diagnóstico de enfermagem não foi encontrado em nenhum dos prontuários. Entre os passos realizados do processo, a prescrição foi a menos freqüente. A evolução dos pacientes foi registrada em mais de 95 por cento dos prontuários. CONCLUSÃO: Todos os passos recomendados na literatura, exceto o diagnóstico de enfermagem são realizados na instituição pesquisada.
