Registro de enfermagem em unidade de terapia intensiva neonatal: proposta de um software protótipo

• Autor(a) principal: Lima, Luciana de Medeiros
• Data de Publicação: 2012
• Tipo de documento: Dissertação
• Idioma: por
• Título da fonte: Biblioteca Digital de Teses e Dissertações da UFPB
• Texto Completo: https://repositorio.ufpb.br/jspui/handle/tede/5102
• topic: Enfermagem; UTI Neo Natal; Desenvolvimento de software; Neonatologia; Nursing; Software; Neonatology; CIENCIAS DA SAUDE::ENFERMAGEM

Introduction: The present society is characterized by the need and search of communication producing a large amount of information which, in turn, requires strategies for collection, storage and use of knowledge produced. In nursing, some of this information comes from the registers contained in the patient's records and other relevant reports. In the Neonatal Intensive Care Unit of Lauro Wanderley University Hospital, records are made in standardized printed, handwritten. The priority that should be noted at the discretion of each professional, so that some notes are extensive, discouraging to read, with unnecessary information and / or repeated, whereas others are summarized, omitting essential information for care. Objective: In the present study it is proposed develop a software applied to the systematization of nursing care that provides nurses computerized record efficiently and quickly. Methodology: The study was divided in two stages: the first developed a database consisting of the empirical indicators of basic human needs of newborns and their claims of diagnosis and nursing interventions in which was developed an information system to assist the nurse in the development of the nursing process. Results: After the assessment of nurses, the database was composed of 273 statements, which 143 are related to nursing diagnoses and 130 referring to nursing interventions. The software was developed in a way which has specific screens for recording the following information: identification of the newborn, anthropometric data, reason for hospitalization, need for shelter, the need for thermal regulation, the need for oxygenation, hydration needs, nutrition needs,, need for integrity mucocutaneous, physical integrity, care body, needs of exercise, physical activity, mobility, sleep and rest, need for perception, endocrine regulation, need to eliminate, needs of therapy, need for communication and nurses' notes. Finally, it is possible select the nursing diagnoses suggested by the program, as well as the corresponding nursing interventions. All these data will be available for printing if the nurse wants. Final considerations: The software provides the execution of the nursing process, following the criteria of the International Council of Nurses, allowing a full record, uniform and fast. Also provides the construction of an important source of data for searching.