PADRÃO DE REGISTRO DE ENFERMAGEM PARA UNIDADE DE PRONTO ATENDIMENTO

• Autor(a) principal: Sivirino, Dilzilene Cunha
• Data de Publicação: 2022
• Tipo de documento: Dissertação
• Idioma: por
• Título da fonte: Repositório Institucional da Universidade Federal do Espírito Santo (riUfes)
• Texto Completo: http://repositorio.ufes.br/handle/10/16449
• topic: Emergências; Diagnóstico de Enfermagem; Registros Eletrônicos de Saúde; Tecnologia da Informação; Terminologia Padronizada em Enfermagem; Tipologia de Estudo; subject.br-rjbn; Enfermagem

Introduction: Urgent and emergency care is characterized by its fast, dynamic, stressful and conflicting situations, being necessary to adopt assistance protocols that guarantee an adequate and timely assistance for those who depend on it. In this sense, considering the activities of nurses in the risk classification room, the need to record nursing care with a standardized language in any context of care and the possibility of naming the elements of nursing practice from the International Classification for Nursing Practice (ICNP® ), aligned with the line of research, organization and evaluation of health care systems, this study sought to meet a demand from the city of Vitoria to constitute nursing care in Emergency Departments. Objectives: To identify the main ICNP® diagnoses, nursing outcomes and interventions applied to urgency and emergency situations; to map and associate ICNP® diagnoses with the flowcharts and discriminators of the Manchester Triage System® ; to relate diagnoses with outcomes and interventions; to develop and evaluate a nursing record standard for emergency units based on the ICNP®; to describe the requirements for inserting ICNP® diagnoses, outcomes and interventions into the municipality's electronic medical record. Method: Applied technology development research conducted in seven steps: 1) Literature review; 2) Cross-mapping between Manchester Triage System terms and ICNP® terms; 3) Construction of diagnostic/outcome statements; 4) Evaluation of diagnostic statements by emergency nurses; 5) Elaboration and association of interventions to the evaluated diagnoses; 6) Organization of the diagnoses/outcomes according to Agnes Heller's health needs described in the Theory of Practical Intervention in Collective Health Nursing, and 7) Development of the concept map/requirements for insertion of the registration pattern in the computerized network. Results: Through the literature review and cross-mapping, it was possible to identify and prepare 185 diagnoses, 124 of which were constant and 61 not constant in the ICNP® 2019. These were submitted to evaluation, as to relevance to practice, by means of the Delphi Technique. The panel included 32 specialist nurses in urgency and emergency, who evaluated 143 diagnostic statements as relevant, with IVC> 79%. The diagnoses/results were associated with the interventions, resulting in 495 interventions and organized in Agnes Heller 18 health needs. Product: A nursing record pattern was developed with ICNP® terminology composed of 143 diagnoses, 148 outcomes and 495 nursing interventions. Conclusion: This research has the potential to generate impact and to be applied at local, regional and national levels, because it describes in a systematized way the steps for the elaboration of a nursing record standard for Emergency Care Units. The standard is relevant for scientific and technological development, and contributes to the standardization of professional language and serves as a subsidy for the nursing record, giving visibility to the nursing activities in urgency and emergency. The standard was forwarded to the technology sector of the health secretariat of Vitória to be incorporated into the municipality's electronic medical record.