NURSI NG PROCESS: FROM LI TERATURE TO PRACTI CE.
W HAT ARE W E ACTUALLY DOI NG?
1Sim on i Pok or sk i2 Mar ia Ant oniet a Mor aes3 Régis Ch iar elli4 An gelit a Pagan in Cost an zi4 En eida Rej an e Rabelo5
Pok or sk i S, Mor aes MA, Chiar elli R, Cost anzi AP, Rabelo ER. Nur sing pr ocess: fr om lit erat ur e t o pr act ice. w hat ar e w e act ually doing?. Rev Lat ino- am Enfer m agem 2009 m aio- j unho; 17( 3) : 302- 7.
Obj ect iv es: To descr ibe t he st eps of t he nur sing pr ocess as pr escr ibed in t he lit er at ur e and t o inv est igat e t he pr ocess as act u ally applied in t h e daily r ou t in e of a gen er al h ospit al. Met h ods: Cr oss- sect ion al r et r ospect iv e st udy ( May/ June 2005) , per for m ed in a hospit al in Por t o Alegr e, RS. Medical r ecor ds of adult pat ient s adm it t ed t o a sur gical, clinical or int ensiv e car e unit w er e r ev iew ed t o ident ify t he nur sing pr ocess st eps accom plished dur ing t he fir st 4 8 h aft er adm ission. The for m for dat a collect ion w as st r uct ur ed accor ding t o ot her r epor t s. Result s: 302 m edical r ecor ds w er e ev aluat ed. Nur sing r ecor ds and phy sical ex am inat ion w er e included in ov er 90% of t hem . Nur sing diagnosis w as not found in any of t he r ecor ds. Am ong t he st eps per for m ed, pr escr ipt ion w as t he least fr equent . Evolut ion of t he case w as descr ibed in over 95% of t he r ecor ds. Conclusions: All nur sing st eps r ecom m ended in t he lit er at ur e, ex cept for diagnosis, ar e per for m ed in t he r esear ch inst it ut ion.
DESCRI PTORS: nur sing pr ocess; nur sing car e; nur sing diagnosis
PROCESO DE EN FERMERÍ A: DE LA LI TERATURA A LA PRÁCTI CA.
¿QUÉ ESTAM OS H ACI EN DO, DE H ECH O?
Obj et iv o: descr ibir los pasos del pr oceso de la enfer m er ía descr it o en la lit er at ur a e inv est igar com o est e es r ealizado en la r u t in a diar ia de u n h ospit al gen er al. Mét odos: Est u dio t r an sv er sal r et r ospect iv o ( m ay o/ j u n io 2 0 0 5 ) r ealizad o en Por t o Aleg r e, RS. Fu er on r ev isad as f ich as d e p acien t es ad u lt os ad m it id os en u n id ad es qu ir ú r gicas, clín icas y u n idades de t er apia in t en siv a con la f in alidad de iden t if icar los pasos del pr oceso de enfer m er ía r ealizados dur ant e las pr im er as 4 8 hor as de la adm isión. El inst r um ent o de r ecolección de dat os fue elabor ado de acuer do con la lit er at ur a. Result ados: 302 fichas fuer on evaluadas. Los r egist r os de enfer m er ía y exam en físico est aban descr it os en m ás de 90% de las fichas r evisadas. El diagnóst ico de enfer m er ía no fue en con t r ado en n in gu n a de los fich as. En t r e los pasos r ealizados en el pr oceso, la pr escr ipción fu e el m en os fr ecuent e. La ev olución de los pacient es fue r egist r ada en m ás de 9 5 % de los fichas. Conclusión: Todos los pasos r ecom en dados en la lit er at u r a, ex cept o el diagn óst ico de en f er m er ía son r ealizados en la in st it u ción in v est ig ad a.
DESCRI PTORES: pr ocesos de en fer m er ía; at en ción de en fer m er ía; diagn óst ico de en fer m er ía
PROCESSO DE ENFERMAGEM: DA LI TERATURA À PRÁTI CA.
O QUÊ DE FATO N ÓS ESTAM OS FAZEN DO?
Obj et iv o: descr ev er os passos do pr ocesso de en f er m agem descr it o n a lit er at u r a e in v est igar com o est e é r ealizado na r ot ina diár ia de um hospit al ger al. Mét odos: Est udo t r ansv er sal r et r ospect iv o ( m aio/ j unho 2005) r ealizad o em Por t o Aleg r e, RS. For am r ev isad os p r on t u ár ios d e p acien t es ad u lt os ad m it id os em u n id ad es cir ú r g icas, clín icas e u n id ad e d e t er ap ia in t en siv a p ar a id en t if icar os p assos d o p r ocesso d e en f er m ag em r ealizados du r an t e as pr im eir as 4 8 h or as da adm issão. O in st r u m en t o de colet a de dados f oi elabor ado de acor d o com a lit er at u r a. Resu lt ad os: 3 0 2 p r on t u ár ios f or am av aliad os. Reg ist r os d e en f er m ag em e ex am e f ísico est av am descr it os em m ais de 9 0 % dos pr on t u ár ios r ev isados. O diagn óst ico de en f er m agem n ão f oi en con t r ado em n en h u m dos pr on t u ár ios. En t r e os passos r ealizados do pr ocesso, a pr escr ição f oi a m en os f r eqü en t e. A ev olu ção dos pacien t es f oi r egist r ada em m ais de 9 5 % dos pr on t u ár ios. Con clu são: Todos os passos r ecom endados na lit er at ur a, excet o o diagnóst ico de enfer m agem são r ealizados na inst it uição pesquisada.
DESCRI TORES: pr ocessos de en f er m agem ; cu idados de en f er m agem ; diagn óst ico de en f er m agem
1Art icle ext ract ed from specializat ion course conclusion m onograph; 2RN, Hospit al Moinhos de Vent o, Specialist in Cardiology Nursing, I nst it ut o de Cardiologia,
Fundação Univer sit ár ia de Car diologia, Br azil, e- m ail: sim oni.enfa@hot m ail.com ; 3M.Sc. in Healt h Sciences, Facult y, I nst it ut o de Car diologia, Fundação Universit ária de Cardiologia, Brazil, e- m ail: ant oniet a_m oraes@uol.com .br; 4Specialist in Car diology Nur sing, I nst it ut o de Car diologia, Fundação Univer sit ár ia de Car diologia, Brazil, e- m ail: r egis_chiar elli@hot m ail.com , paganin@t er ra.com .br ; 5Ph.D. in Biological Sciences, Adj unct Pr ofessor, Univer sidade Federal do Rio Grande do Sul, Br azil, Facult y, I nst it ut o de Car diologia, Fundação Univer sit ár ia de Car diologia, Brazil, e- m ail: rabelo@port ow eb.com .br.
I NTRODUCTI ON
T
h e n u r si n g p r o ce ss i s a w i d e l y a cce p t e d m e t h o d a n d h a s b e e n s u g g e s t e d a s a s c i e n t i f i cm e t h o d t o g u i d e p r o ce d u r e s a n d q u a l i f y n u r si n g
c a r e . M o r e r e c e n t l y , t h e p r o c e s s h a s b e e n
d e f i n e d a s a s y s t e m a t i c a n d d y n a m i c w a y t o
d e l i v e r n u r s i n g c a r e , o p e r a t i n g t h r o u g h f i v e
i n t e r r e l a t e d s t e p s : a s s e s s m e n t , d i a g n o s i s ,
p l a n n i n g , i m p l e m e n t a t i o n a n d e v a l u a t i o n( 1 - 2 ).
Accor ding t o cur r ent Am er ican and Canadian
p r act i ce st an d ar d s, n u r si n g p r act i ce d em an d s t h e
efficient use of t he nur sing pr ocess and pr ofessional
p a r t i ci p a t i o n i n a ct i v i t i e s t h a t co n t r i b u t e t o t h e
p e r m a n e n t d e v e l o p m e n t o f k n o w l e d g e a b o u t t h i s
m et h odology( 2 ).
Th er e is a dem an d t o est ablish t h e n u r sin g
pr ocess in pr act ical car e in ev er y h ealt h in st it u t ion ,
w it h in h osp it als as w ell as in t h e com m u n it y as a
w hole. The nur sing pr ocess should be est ablished in
care pract ice at all healt h care inst it ut ions, in hospit als
as w ell as in t he com m unit y as a w hole( 3).
I n p r a c t i c e , h o w e v e r, n o t a l l s t e p s a r e
sy st em at ically im p lem en t ed . St u d ies h av e r ev ealed
d i f f i cu l t i e s i n e st a b l i sh i n g a n d u si n g t h e n u r si n g
pr ocess w it h in in st it u t ion s du r in g t h e last y ear s, in
Br azil and in ot her count r ies( 4- 7).
A st u d y co n d u ct e d i n Eu r o p e t o t e st t h e
est ablishm ent of a validat ed m odel of nur sing r ecor ds
aim ed t o pr om ot e individual car e. The r esult s show ed
lim it at ions of t he nursing process conduct ed according
t o t h e m o d e l , p a r t i cu l a r l y i n t h e i d e n t i f i ca t i o n o f
pr oblem s pr esent ed by t he pat ient s and, consequent ly,
diagn osis an d t h e possible in t er v en t ion pr ocedu r es.
A st udy conduct ed in t he Unit ed Kingdom t o assess
w het her dat a obt ained fr om nur sing r ecor ds could be
reliably used t o ident ify int ervent ions for pat ient s w ho
had suffered acut e m yocardial infarct ion or a fract ure
of t he head of t he fem ur, show ed t hat t he analy zed
nur sing r ecor ds did not pr ov ide an adequat e pict ur e
of pat ient s’ needs for nur sing int er vent ions( 8). Sim ilar
r esult s w er e r epor t ed by ot her s aut hor s( 4).
A r ecen t i n v est i g at i o n o f t h e st ep s o f t h e
nur sing pr ocess act ually im plem ent ed in t he r out ine
of a univ er sit y hospit al show ed t hat all phases w er e
per for m ed. How ev er, pr oblem s w er e ident ified in t he
n u r sin g d iag n osis p r ocess, in v olv in g r ecor d in g t h e
h ist or y an d im plem en t in g n u r sin g pr escr ipt ion s. Th e
ev olu t ion of ex pect ed r esu lt s, in par t icu lar, w as n ot
adequ at ely r ecor ded( 9 ).
Specifically seeking t o invest igat e t he phases
of t he nursing process perform ed in t he care pract ice
of a universit y hospit al in Brazil, t he aut hors ident ified
t h e i m p l e m e n t a t i o n o f a l l s t a g e s . H o w e v e r, t h e
ex ist en ce of f ailu r es w as sh ow n am on g t h e n u r sin g
d i a g n o ses i n t h e p a t i en t s’ h i st o r y, a s w el l a s t h e
i m p l e m e n t a t i o n o f n u r si n g p r e scr i p t i o n s w i t h o u t
r ecor d i n g t h e ev ol u t i on of t h e ex p ect ed r esu l t s( 9 ).
Sim ilar r esult s w er e also show n in a st udy published
in 2 0 0 6 d u r in g t h e im p lem en t at ion of t h e n u r sin g
d iag n osis, in w h ich t h e r esear ch su b j ect s in d icat ed
d if f icu lt ies in d ev elop in g t h e n u r sin g p r ocess at all
st ag es, an d t h e n eed f or ch an g es t o sp eed u p t h e
w or k pr ocess an d opt im ize t h e qu alit y of act ion s in
car e and educat ion( 7).
Ef f e c t i v e i m p l e m e n t a t i o n o f t h e n u r s i n g
process leads t o im proved qualit y of care and st im ulat es
t he const ruct ion of t heoret ical and scient ific knowledge
based on t he best clinical pract ice. Aim ing at collect ing
i n f or m at i on t o i m p r ov e t h e n u r si n g car e cu r r en t l y
provided, we perform ed a cross- sect ional ret rospect ive
st udy t o com pare t he st eps of t he nursing process, as
act ually im plem ent ed in t he daily rout ine of a general
hospit al, wit h t hose recom m ended in t he lit erat ure.
METHODS
This cr oss- sect ional r et r ospect iv e st u dy w as
b a se d o n d a t a o b t a i n e d f r o m m e d i ca l r e co r d s o f
pat ient s w it hin t he fir st 48 hour s aft er adm ission t o
su r g ical, clin ical or in t en siv e car e u n it s. Th e st u d y
w a s co n d u ct e d d u r i n g Ma y a n d Ju n e 2 0 0 5 , i n a
m ed iu m - sized g en er al h osp it al in Por t o Aleg r e, Rio
Gr an d e d o Su l , Br azi l an d i n cl u d ed d at a r eco r d ed
d u r i n g t h e se co n d se m e st e r o f 2 0 0 4 . Re co r d s o f
p at ien t s ov er 1 8 y ear s old , ad m it t ed f or clin ical or
s u r g i c a l t r e a t m e n t , w i t h a t l e a s t 4 8 h o u r s o f
h ospit alizat ion in su r gical, clin ical, or in t en siv e car e
unit s, w er e included in t he st udy. Dat a obt ained for
pat ient s in t he t hr ee differ ent unit s w er e com par ed t o
ev alu at e t h e im plem en t at ion of t h e n u r sin g pr ocess
b y n u r se s a l l o ca t e d t o t h o se w a r d s a t t h e sa m e
hospit al. The for m used for dat a collect ion w as based
on report s in t he lit erat ure( 2) and includes dat a on t he
healt h hist or y and com plet e phy sical ex am inat ion. I n
t his st udy, w e defined t hat a syst em at ic “ head- t o- t oe”
p h y si ca l a ssessm en t( 2 ) sh o u l d b e p e r f o r m e d u p o n
adm it t ance and daily dur ing t he hospit alizat ion per iod.
w ho is t he nurse in charge of t he cont inued educat ion
pr ogr am at t he inst it ut ion.
Th i s st u d y w as ap p r ov ed b y t h e Resear ch
Et h ics Com m it t ee of t h e in st it u t ion , an d du e t o t h e
im possibilit y of obt ain in g in f or m ed con sen t f r om all
t he pat ient s, a consent t er m for use of t he dat a w as
obt ain ed f r om m edical r ecor ds.
St at ist ical an aly sis
D a t a w e r e a n a l y ze d u si n g t h e St a t i st i ca l
Pack age for Social Sciences ( SPSS) 12.0. Cat egor ical
v ar iables w er e descr ibed as r elat iv e fr equ en cy ( % ) ,
an d com p ar ed w it h t h e ch i- sq u ar e or Fish er ex act
t i n u l a c i g r u
S Clinicalunit Intensivecareunit P-value
) n ( s t n e it a
P 105 99 98
) s r a e y ( e g
A 57±18a 66±19b 72±16c <0.001
) s y a d ( n o it a z il a t i p s o h f o d o i r e
P 6,33±4.30a 10.61±8.50b 26.06±33.50c <0.001
) % ( n r e d n e g e l a
M 39(37.0) 41(41.4) 53(54.1) 0.043
t est s, f ollow ed b y st an d ar d ized ad j u st ed r esid u als.
Qu an t it at iv e v ar iables w er e pr esen t ed as m ean an d
st andar d dev iat ion and, w hen cr ossed w it h poly t om ic
ca t e g o r i ca l v a r i a b l e s, w e r e a n a l y ze d b y AN OVA,
follow ed by Tu key ’s t est .
RESULTS
A t ot al of 302 r ecor ds of pat ient s adm it t ed t o
su r g ical, clin ical or in t en siv e car e u n it s ( I CU) w er e
a n a l y z e d . I CU p a t i e n t s w e r e o l d e r a n d w e r e
hospit alized for longer per iods t han pat ient s fr om ot her
unit s. These r esult s ar e pr esent ed in Table 1.
Table 1 – Charact er ist ics of t he sam ple. Por t o Alegr e ( RS) , 2005
a, b, c differ ence bet w een m ean ( Tukey’s t est ) . Quant it at ive var iables expr essed as m ean ± st andar d deviat ion and cat egor ical var iables expr essed as n ( % )
St eps of t he nur sing pr ocess
Nu r sin g r ecor ds, alt h ou gh in com plet e, w er e
g en er ally av ailab le. Th e r esu lt s ob ser v ed f or each
u n i t a r e d e scr i b e d i n Ta b l e 2 . I n v e st i g a t i o n w a s
perform ed in m ore t han 90% of t he cases in all unit s.
Ph y sical ex am in at ion , alt h ou g h n ot as com p let e as
r e co m m e n d e d i n t h e l i t e r a t u r e , w a s d e scr i b e d i n
98.7% of t he r ecor ds. Using t he t ax onom y language
o f t h e No r t h Am e r i ca n Nu r si n g D i a g n o si s( 1 0 ) , w e
defin ed t h e descr ipt ion of act u al or pot en t ial h ealt h
pr oblem s in t he pat ient ’s m edical r ecor ds as DE.
A m o n g t h e n u r s i n g p r o c e s s s t e p s
i m p l e m e n t e d , n u r si n g p r e scr i p t i o n w a s t h e l e a st
f r e q u e n t l y p e r f o r m e d d u r i n g t h e f i r s t 4 8 h o f
h ospit alizat ion in all gr ou ps ( 7 4 . 8 % ) , par t icu lar ly in
sur gical and clinical unit s; ev olut ion w as descr ibed in
m or e t han 97% of t he r ecor ds.
t i n u l a c i g r u S
5 0 1 = n
t i n u l a c i n i l C
9 9 =
n ICUn=98 *P
y r o t s i
H 97(92.4) 94(94.9) 97(99.0) 0.049
l a c i s y h P
n o it a n i m a x
e 103(98.1) 98(99.0) 97(99.0) 0.000
n o it p i r c s e r
P 71(67.6) 61(61.6) 94(95.9) <0.001
n o it u l o v
E 104(99.0) 97(98.0) 95(96.9) 0.545
Table 2 - St eps of t he nur sing pr ocess r egist er ed in
t he r ecor ds. Por t o Alegr e ( RS) , 2005
Cat egor ical var iables expr essed as n ( % ) .* Chi- Squar e Test .
I n v est ig at ion
Tab l e 3 d et ai l s t h e i t em s m o r e f r eq u en t l y
obser v ed in t h e h ist or y of pat ien t s. Dat a r elat ed t o
sk i n co l o u r, o ccu p a t i o n , r el i g i o n , m a i n co m p l a i n t ,
fam ily and social hist ory, habit s of life- sleep and rest ,
physical act ivit y and eat ing habit s - w er e not differ ent
bet w een t he t hr ee unit s evaluat ed, and ar e not show n.
Dat a for ident ificat ion of t he pat ient w ere not included
in 21% of t he r ecor ds fr om pat ient s in clinical unit s,
differ ent ly fr om I CU r ecor ds ( 2% ) ( P< 0.001) . Am ong
t he r ecor ds cont aining t his infor m at ion, t he nam e of
t he pat ient w as m issing in 50.5% of t he r ecor ds fr om
t h e s u r g i c a l u n i t . Th e m a i n c o m p l a i n t w a s l e s s
r egist er ed in r ecor ds of su r gical pat ien t s. On ly on e
r eco r d o f f am i l y h i st o r y w as o b ser v ed am o n g t h e
r ecor ds analyzed. Only 19.4% of I CU pat ient s’ r ecords
i n c l u d e d i n f o r m a t i o n a b o u t t h e d r u g s b e i n g
a d m i n i st er ed t o t h e p a t i en t , a n d l i f e h a b i t s w er e
descr ibed in only 20.4% of t hem .
Ph y sical ex am in at ion
We c o m p a r e d t h e p h y s i c a l e x a m i n a t i o n
per f or m ed u pon adm it t an ce, as par t of t h is st ep of
invest igat ion, w it h t he daily physical exam inat ion t hat
t h e p r o ce ss w a s si m i l a r l y co n d u ct e d d u r i n g b o t h
p h a s e s . I n t h e s e p r o c e d u r e s , r e l a t i v e l y l e s s
im por t an ce w as giv en t o t h e car diov ascu lar sy st em
an d m u cosas.
Table 3 - I nv est igat ion ( hist or y ) and phy sical ex am inat ion. Por t o Alegr e ( RS) , 2005
Cat egor ical var iables expr essed as n ( % ) ; * Chi- Squar e Test
Fi g u r e 1 - Co m p a r i s o n o f p h y s i c a l e x a m i n a t i o n
per for m ed dur ing nur sing r ecor d upon adm ission and
daily ev olu t ion
0 10 20 30 40 50 60 70 80 90 100 Le v e l of c ons c iou s n es s Che s t/ Lung s C h e s t/H e a rt A b dom en U pper ex tr em it ie s Lo wer ex tr em it ie s Mu c o s a s Admission Daily evolution
Pr escr ip t ion
Only 25% of t he pat ient s in surgical unit s had
a car e plan adj ust ed t o t heir needs, a fr equency t hat
w a s h i g h er i n p a t i en t s i n cl i n i ca l u n i t s a n d m o r e
com plet e in I CU pat ient s. These and ot her significant
r esult s ar e pr esent ed in Figur e 2.
Figu r e 2 - Pr ior it ies est ablish ed daily in t h e n u r sin g
p r escr ip t ion
0 10 20 30 40 50 60 70 80 90
Surgical Clinical ICU
DI SCUSSI ON
The r esult s of t he pr esent st udy agr ee w it h
p r ev iou s f in d in g s ab ou t d ef icien cies in t h e p r act ice
involved in t he im plem ent at ion of t he nursing process.
At t h e in st it u t ion w h er e t h is st u d y w as con d u ct ed ,
except for t he diagnost ic st ep, all ot her phases of t he
5 0 1 = n t i n u l a c i g r u
S Clinicalunitn=99 ICUn=98
P *
n % n % n %
n o it a c if it n e d
I 90 85.7 78 78.8 96 98.0 <0.001
e m a
N 53 50.5 62 62.6 96 98.0 <0.001
e g
A 21 20.0 59 59.6 93 94.9 <0.001
r e d n e
G 9 8.6 31 31.3 2 2.0 <0.001
a t a d c i r t e m o p o r h t n
A 65 61.9 19 19.2 11 11.2 <0.001
e s a e s i d t n e r r u c f o y r o t s i h e t e l p m o
C 19 18.1 24 24.2 56 57.1 <0.001
e s a e s i d t n e r r u c f o y r o t s i h e t e l p m o c n
I 20 19.0 42 42.4 40 40.8 <0.001
t n i a l p m o c n i a
M 75 71.4 87 87.9 75 76.5 0.014
y r o t s i h l a c i n il c s u o i v e r
P 68 64.8 85 85.9 86 87.8 <0.001
y r o t s i h l a c i g r u s s u o i v e r
P 72 68.6 62 62.6 53 54.1 <0.103
y r o t s i h y li m a
F 0 0 0 0 1 1.0 0.352
s g u r
D 89 84.8 77 77.8 19 19.4 <0.001
s e i g r e ll
A 96 91.4 89 89.9 25 25.5 <0.001
n o i s u f s n a r t d o o l
B 75 71.4 57 57.6 16 16.3 <0.001
s t i b a h e f i
L 94 89.5 91 91.9 20 20.4 <0.001
s t i b a h l o o t
S 94 89.5 85 85.9 20 20.4 <0.001
o c c a b o
T 90 85.7 79 79.8 15 15.3 <0.001
l o h o c l
A 74 70.5 64 64.6 11 11.2 <0.001
s g u r
D 64 61.9 58 58.6 10 10.2 <0.001
n o it a n i m a x e l a c i s y h p e t e l p m o
nur sing pr ocess r ecom m ended in t he lit er at ur e w er e
per for m ed, alt hough not as com plet ely as ex pect ed.
A r ecent r ev iew inv est igat ed t he r elat ionship
bet w een pu blish ed r esear ch r esu lt s an d t h e n u r sin g
process, ident ifying am ong published report s a concern
w i t h l an g u ag e st an d ar d s an d sp eci f i c t er m i n o l o g y
relat ed t o m et hods of t his process( 11- 12). I n England, a
s t u d y a b o u t t h e a p p a r e n t c o n f l i c t b e t w e e n t h e
e x p r e ssi o n s “ n u r si n g d i a g n o si s” v e r su s “ n u r si n g
problem ” in t he lit erat ure showed t hat t his st ep of t he
nur sing pr ocess, w hich car e plans ar e based on, is a
crit ical phase t hat corresponds t o t he final product of
dat a collect ion and organizat ion( 11). A recent Am erican
review showed t hat nursing diagnosis reflect s t he clinical
a s s e s s m e n t o f t h e n u r s e , b a s e d o n c o n s t a n t
s u r v e i l l a n c e o f a c t i o n s , r e c o g n i z i n g r i s k s a n d
m onit oring result s( 13). I n a Canadian ret rospect ive st udy
aim ed at in v est ig at in g f act or s associat ed w it h t h e
i m p l em en t a t i o n o f n u r si n g d i a g n o ses, t h e r esu l t s
sh ow ed t h at n u r ses t en d t o r egist er a d iag n osis at
inst it ut ions t hat have a form al program of cont inuous
educat ion and com put er - gener at ed car e plans( 14). I n
Brazil, a study conducted to investigate the establishm ent
and recording of st eps in t he nursing process ident ified
the m ost frequent diagnoses in hospital wards, and showed
t hat a sm aller num ber of recordings were done in t he
st eps relat ive t o nursing diagnosis and evolut ion. The
im portance of previous organization of the data collected
t o allow accurat e diagnoses and t o qualify nursing care
was stressed in this report(9).
As m e n t i o n e d b e f o r e , t h e p r e s e n t s t u d y
sh o w ed d ef i ci en ci es i n d at a co l l ect i o n f o r n u r si n g
r e co r d s a n d a b se n ce o f t h e d i a g n o si s st e p . Th i s
deficiency m ay be due t o lack of clinical assessm ent
of t he dat a concer ning t he hist or y of t he pat ient and
p h y si ca l e x a m i n a t i o n r e g i st e r e d b y t h e n u r se o r,
p r ob ab ly, t o lack of k n ow led g e on h ow t o u se t h is
st ep dur ing pr act ice at t he r esear ch inst it ut ion.
O t h e r d e f i c i e n c i e s i n v o l v i n g a d d i t i o n a l
in f or m at ion on n u r sin g r ecor ds in clu ded in com plet e
recording of dat a, such as ident ificat ion of t he pat ient ,
cu r r en t , pr ev iou s an d f am ily diseases, an d ph y sical
ex am in at ion , w h ich w as in com p let e p ar t icu lar ly f or
t he evaluat ion of m ucosa and car diovascular funct ion.
Recording of physical exam inat ions w as also deficient ,
an d h ear t an d lu n g au scu lt at ion w as n ot r ecor d ed .
Ph y si ca l e x a m i n a t i o n , co m b i n e d w i t h a r e co r d o f
h e a l t h h i s t o r y, p r o v i d e s t h e b a s i s f o r t h e
im p lem en t at ion of sy st em at izat ion in n u r sin g car e.
Th o se el em en t s a r e cr i t i ca l f o r t h e q u a l i t y o f t h e
nursing process( 15). A r ecent st udy conduct ed in Br azil
t o suppor t t he syst em at izat ion of car e at a univer sit y
hospit al show ed t hat t he level of under gr aduat e st udies
has m aj or consequences for t he pr ofessional qualit y
of n u r ses, r esu lt in g in a m or e scien t if ic, or g an ized
a n d s y s t e m a t i c a p p r o a c h t o h e a l t h c a r e . Th e s e
o b s e r v a t i o n s s t r e s s t h e i m p o r t a n c e l e c t u r e r s
r e s p o n s i b l e f o r t h e e d u c a t i o n o f n u r s e s s h o u l d
at t r ib u t e t o t h e im p r ov em en t of asp ect s r elat ed t o
sem iology( 16). Result s obt ained in t he pr esent st udy,
sh o w i n g t h a t i n co m p l e t e p h y si ca l e x a m i n a t i o n i s
usual, suggest poor pr epar at ion of t he nur sing t eam
in b asic sem iolog y t ech n iq u es, su ch as in sp ect ion ,
palpat ion, per cussion and auscult at ion. Fur t her m or e,
w e o b se r v e d t h a t t h e st a n d a r d f o r m u se d a t t h e
in st it u t ion f or d at a collect ion is d ef icien t r eg ar d in g
n u r s i n g r e c o r d s , p a r t i c u l a r l y f o r m o r e s p e c i f i c
i n f o r m a t i o n o n f a m i l y h i s t o r y a n d p h y s i c a l
e x a m i n a t i o n . Th i s i n f o r m a t i o n i s a n i m p o r t a n t
co n t r i b u t i o n t o t h e f u t u r e i m p l e m e n t a t i o n o f a n
ef f ect iv e n u r sin g pr ocess.
Th e d e f i ci e n ci e s o b se r v e d co n ce r n i n g t h e
r ecor ding of fam ily hist or y w ould be expect ed t o affect
t h e e v a l u a t i o n o f c a r d i o v a s c u l a r a n d o n c o l o g i c
diseases am ong ot her s, but t hat w as not appar ent in
t he pr esent st udy. Som e st udies have suggest ed t hat
d i f f i cu l t i es i n t h e co m p l et e r eg i st r at i o n o f n u r si n g
r ecor ds ar e r elat ed t o t he t im e spent on t he t ask( 9).
We ob ser v ed t h at st u d ies in w h ich n u r sin g r ecor d s
ar e ev aluat ed for assessm ent of t he st eps per for m ed
do not invest igat e dat a cont ent s( 6,9), so t hat t he above
r esult s m ay be at t r ibut ed t o inadequat e st andar dized
dat a collect ion inst rum ent s , w hich do not cont em plat e
all cont ent s of t hese st eps. I n t his cont ext , an Am erican
st u d y con d u ct ed f or t h e ev al u at ion of h ealt h car e
efficiency and it s im pact on cost s and qualit y of t he
ser vice show ed t hat a com m on st r uct ur e is em er ging,
represent ing t he essent ial inform at ion concerning care
- r ef er en ce t er m in olog ies, in f or m at ion m od els an d
com pu t er ized st an dar ds( 1 2 ).
At pr esent , it is consensual t hat t he nur sing
p r ocess in Br azil, USA an d Can ad a h as d ev elop ed
t o o l s , c o m p u t e r i z e d o r n o t , t o i m p l e m e n t t h i s
m e t h o d o l o g y i n p r a c t i c e . D a t a r e p o r t e d a t t h e
begin n in g of t h e 1 9 9 0 ’s in Eu r ope sh ow ed con cer n s
w it h t h e v alidat ion of t ools t o est ablish cu st om ized
n u r si n g ca r e( 5 ). El ect r o n i c r eco r d s m a y p r o v i d e a
s i g n i f i c a n t c o n t r i b u t i o n t o t h e s u c c e s s f u l
im plem ent at ion of t he nur sing pr ocess, par t icular ly if
Sev er al f act or s can in t er f er e in t h e ef f icien t
im p lem en t at ion of t h e n u r sin g p r ocess. Op er at ion al
d i f f i c u l t i e s i n v o l v e d i n t h e s y s t e m a t i z a t i o n o f
n u r sin g car e in p r act ice, su ch as lack of k n ow led g e
o f t h e s t e p s i n v o l v e d i n t h e p r o c e s s , e x c e s s i v e
n u m b er of t ask s assig n ed t o t h e n u r sin g t eam , p oor
q u a l i t y o f p r o f e ssi o n a l e d u ca t i o n a n d i n su f f i ci e n t
r e p o r t s o n p h y s i c a l e x a m i n a t i o n r e l a t e d t o t h e
d isease ar e am on g t h ese f act or s. Nu r sin g p r act ice
i s a l s o f r e q u e n t l y l i n k e d t o t h e p e r f o r m a n c e o f
b u r e a u c r a t i c a n d t e c h n i c a l a c t i v i t i e s , t o t h e
d e t r i m e n t o f t h e n u r s i n g p r o c e s s( 9 ). W h e n t h i s
m et h o d o l o g y i s n o t u sed , p r o b l em s su ch a s p o o r
q u alit y of car e, ab sen ce of a sy st em at ic act iv it y in
ser v ice, lit t le r ecog n it ion of n u r sin g act iv it ies w it h in
t h e h osp it al en v ir on m en t an d t im e loss m ay r esu lt ,
accor d in g t o a r ecen t Br azilian st u d y( 1 , 6 , 2 0 ). A r ecen t
r e v i e w o f t h e n u r s i n g p r o c e s s s y s t e m a t i z a t i o n
i n d i c a t e s t h a t k n o w l e d g e o f t h e i n s t i t u t i o n a l
s t r u c t u r e , i t s d e m a n d s a n d f a c i l i t i e s a r e b a s i c
r eq u ir em en t s t o b eg in t h is ch allen g e( 2 1 ).
FI NAL CONSI DERATI ONS
The present st udy showed t hat nursing records
and physical exam inat ion were conduct ed in over 90%
of t he cases. Diagnosis was t he only nursing st ep not
r egist er ed in any of t h e r ecor ds. We obser v ed t h at
phy sical ex am inat ion is poor ly descr ibed, par t icular ly
as t o t he cardiovascular and respirat ory syst em s. These
r esult s show t hat sy st em at izat ion of nur sing car e at
t his inst it ut ion is present in t he daily act ivit ies of t he
nursing t eam . Com parison of t he unit s allowed for t he
ident ificat ion of differences in t heoret ical and pract ical
infor m at ion, w hose lack im pair ed t he im plem ent at ion
of t he nursing process. The lit erat ure support s t he idea
t hat t he developm ent of act ions based on a t heoret ical
r ef er en ce f r am ew or k m ak es it easier t o in st all an d
im p lem en t t h e n u r sin g p r ocess in car e p r act ice at
hospit al unit s. Program s t o t rain, im prove and updat e
t h e n u r ses can t h u s b e im p lem en t ed im m ed iat ely.
Th ese d at a ar e v er y im p or t an t f or p lan n in g f u t u r e
act ion s in or d er t o im p lem en t t h e n u r sin g p r ocess
effect ively at our and ot her inst it ut ions.
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