Simposio Brasileño de Comunicación en Enfermería SIBRACEN
PADUA, Arminda Rezende de. Analysis of nursing annotations: a contribution to the systemization of nursing care. In Anales del 8. Simposio Brasileño de Comunicación en Enfermería, 2002, San Pablo (SP, Brasil) [online]. 2002 [citado 11 Diciembre 2013]. Disponible en: <http://www.proceedings.scielo.br/scielo.php?script=sci_arttext&pid=MSC0000000052002000100023&lng=es&nrm=iso> .
From the perspective of the nursing process, this descriptive study sought to identify the nursing annotations with respect to the immediate postoperative conditions of patients interned in surgery clinic I of the University Hospital in 1999, after Exploratory Laparotomy, by means of content analysis. From a qualitative and quantitative approach, according to the presuppositions of Bardin (1977), the nursing annotations do not display any systematization that attends to the nursing process. We also observe that clinical-surgical therapeutic annotations are emphasized in detriment of the rest and highlight the disproportion between the quantitative nature of the annotations about the physiologic conditions and the nursing interventions. This scenario led to the inference that the nursing care registered in the Immediate Postoperative of the patients submitted to Exploratory Laparotomy do not attend to the needs presented by these patients, turning the records about this care into technical and legally fragile documents, which cannot be useful from the ethical and legal standpoints. Thus, we suggest the immediate structuring of a specific form for systemized nursing annotations and, in the medium term, the implantation of the nursing process as a way of improving the care rendered in the University Hospital.
Palabras llave : nursing annotation; nursing care systemization; nursing.