Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system.

IF 1.2 4区医学 Q3 NURSING

Revista da Escola de Enfermagem da U S P Pub Date : 2023-01-01 DOI:10.1590/1980-220X-REEUSP-2022-0123en

Aline Fritzen, Danielle Pletes Dos Santos, Bianca Silva da Rocha, Marielli Trevisan Jost, Rita Catalina Aquino Caregnato, Graciele Fernanda da Costa Linch

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引用次数: 0

Abstract

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.

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查看原文本刊更多论文

实施围手术期及术后即时护理诊断的计算机化管理系统。

目的:基于NANDA国际分类，在健康管理软件上实现围手术期护理过程及围手术期和术后即时护理诊断的电子记录。方法:从完成计划-执行-研究-行动周期开始进行经验报告，使改进计划具有更明确的目的，指导每个阶段。本研究在巴西南部的一家综合医院进行，使用Tasy/Philips Healthcare软件。结果:对于护理诊断的纳入，完成了三个周期，建立了预期结果的预测，并分配了任务，定义了“谁，什么，何时，何地”。该结构化模型涵盖了7个方面的可能性，92个需要评估的症状和体征，15个护理诊断用于术中和术后即刻。结论:本研究可在健康管理软件上实现围手术期护理过程的电子记录，包括术中、术后即时护理诊断、护理护理。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Revista da Escola de Enfermagem da U S P 医学-护理

CiteScore

1.70

自引率

11.10%

发文量

254

审稿时长

3-8 weeks

期刊介绍： The University of São Paulo Nursing School Journal (Revista da Escola de Enfermagem da USP, REEUSP) is a bimonthly periodical revised by fellow nurses, which has the objective of publishing empirical or theoretical articles that represent a significant advance for the professional practice or for the fundaments of Nursing Mission: to stimulate knowledge production and dissemination in Nursing and related areas, focusing on international interlocution to advance Nursing science. Areas of Interest: Nursing and Health Its abbreviated title is Rev Esc Enferm USP, which should be used in bibliographies, footnotes and bibliographical references and strips.