Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system.
| Autor: | Fritzen A; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil., Santos DPD; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil., Rocha BSD; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil., Jost MT; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil., Caregnato RCA; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil., Linch GFDC; Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil. |
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| Jazyk: | English; Portuguese |
| Zdroj: | Revista da Escola de Enfermagem da U S P [Rev Esc Enferm USP] 2023 Apr 14; Vol. 57, pp. e20220123. Date of Electronic Publication: 2023 Apr 14 (Print Publication: 2023). |
| DOI: | 10.1590/1980-220X-REEUSP-2022-0123en |
| Abstrakt: | Objective: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. Method: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. Results: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. Conclusion: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care. |
| Databáze: | MEDLINE |
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