Processo de enfermagem em unidade de terapia intensiva cardiológica: construção de conteúdo para prontuário eletrônico

Abstract

The nursing process comprises the dynamics of systematized and interrelated actions aimed at assisting human beings. Through the development and application of its steps, it is possible to develop nursing care with the aim of providing patient safety. The objective is to build content relating to the stages of the nursing process: nursing diagnosis, planning and implementation for the electronic medical record of a cardiological intensive care unit. This is methodological development research, with a quantitative approach, structured in three stages relevant to the theoretical pole. In the first stage, a scoping review was carried out with the aim of mapping the nursing diagnoses, results and interventions most commonly used in patients with cardiac responses in the scientific literature. The second stage referred to the construction of content for the electronic medical record of the cardiac ICU, in which the findings from the scoping review were considered, linked to the international NANDA-I, NIC and NOC taxonomy. Finally, the constructed content was inserted into the electronic medical record of the cardiac ICU. The data were analyzed using descriptive statistics and presented in table format. The research followed all ethical and legal aspects of research on human beings, obtaining the opinion of the Research Ethics Committee under nº 69691723.7.0000.5537. The selected studies demonstrated that the most common nursing diagnoses in patients with cardiac responses are decreased cardiac output and impaired physical mobility; there was a predominance of interventions related to skin care/supervision; with the most frequent results being pain control. The constructed content consisted of 15 nursing diagnoses, with their definitions, related factors and defining characteristics; the planning stage was composed of 10 expected results, 31 interventions and 246 activities. Finally, the implementation stage was constructed, the purpose of which will be to detail the way in which each activity will be carried out, as well as checking the intervention carried out as a way of recording the implementation of the care plan. After construction, the content was inserted into the electronic medical record tabs. It is expected that the technological product constructed will contribute to the optimization of nursing care, as well as favoring effective coordination between the multidisciplinary team and adequate support for patients suffering from cardiac responses admitted to the intensive care unit studied.