Avaliação da Assistência de enfermagem através de indicadores gerados por um software

Abstract

In practice assistance, there is a need to equip nurses to check the quality of nursing care through indicators obtained from the implementation of the nursing process. It´s necessary that nurses have essential nursing data standardized and computerized to assess the effectiveness of care and to demonstrate how much the nursing care contributes to the results achieved by the patient. This study aimed to analyze the effectiveness of the nursing process through indicators generated by software in an intensive care unit. To calculate the indicators incidence, prevalence, rate of risk diagnostic effectiveness and rate of effectiveness in preventing complications, we used the nursing diagnoses risk for acute confusion, risk for constipation, risk for imbalanced body temperature, risk for impaired skin integrity and risk for falls. This is a prospective cohort study with a sample of 17 patients hospitalized in the period 28 June to 26 October 2013. There were formulated 93 nursing diagnoses and 175 nursing actions. Daily, there was formulated a mean of 21 diagnoses and 87 nursing actions per patient. Between the diagnoses, five were formulated to 100% of patients, and 24 to more than 50%. The 93 different title diagnoses are in 12 (of 13) NANDA-I domains. Between 87 nursing actions, five were prescribed to 100% of patients. The diagnoses risk for imbalanced body temperature and risk for impaired skin integrity were the most incidents. The diagnosis risk for impaired skin integrity was prevalent in 100% of patients. The diagnoses risk for constipation and risk for impaired skin integrity had a rate of risk diagnostic effectiveness of 100%. This indicator was 0% to the risk for acute confusion. The rate of effectiveness in preventing complications to the risk for acute confusion and risk for falls was 100%, while to the risk for constipation, risk for imbalanced body temperature and and risk for impaired skin integrity, this indicator was 76,9%; 73,4% e 70,6%, respectively. It is suggested that further studies with larger samples and with other diagnoses based on International NANDA should be conducted to enable a more comprehensive assessment of effectiveness of the nursing process in different patient populations.