Identificação e mapeamento dos diagnósticos e ações de enfermagem de pacientes internados em uma uti-adulto

Abstract

Although nursing care is considered essential for the treatment of most patients, thisfact is a little blurry or not recognized. In care practice we see the need to orchestratethe nurses to implement the Nursing Process in a more effective way with systematicactions. This reality has a greater impact, especially when we refer to Intensive CareUnits (ICU). The objective of the study was to analyse the diagnoses records andnursing actions prescribed by nurses in the medical records of patients of an adultICU of Belo Horizonte, Brazil. This is a descriptive study with a sample of 44 medicalrecords of patients hospitalized in the period of September 1st, 2008 to September1st, 2009. It was possible to identify 1087 diagnoses and 2,260 nursing actions. Afterdeleting the repetitions, we found 28 different titles of diagnoses and 124 differentnursing actions. Among the diagnoses, seven were made for more than 50% ofpatients. The 28 different titles of nursing diagnoses are identified in 8 (of the 13)areas of classification of NANDA. Regarding the nursing diagnoses mapping to thetheory of basic human needs (NHB), only two diagnoses were related to thepsychosocial needs and none was related to psychospiritual need. Within the 124nursing actions identified, 19 had frequency higher than 50%. Of these, only 5 wereprescribed for all patients. Most nursing actions identified, 52%, was prescribed forno more than 9% of the patients. All nursing actions identified were mapped topsychobiological basic human needs. Nursing actions identified were also mapped tothe interventions proposed by NIC, all of which could be associated with thisclassification. However, the actions were related to only 42 NIC interventions, amongthe 514 available. One hundred and seventy-two NIC interventions were used in themapping of 124 nursing actions of the sample. The 124 different nursing actionsidentified are included in only 3 of the 7 domains of NIC, in which 25 (55%) wereassociated with Complex Physiological domain. As for NIC classes interventions, theactions identified comprised only 33% of them. It is suggested that similar studies inthe ICU from other places and different contexts/specialties are conducted topossibly identify diagnoses and nursing actions developed and its evolution; followthe evolution of nursing diagnoses and prescriptions regarding identification andattend other human needs beyond the physiological ones.