Desenvolvimento de um instrumento para a sistematização da assistência de enfermagem no período pré-operatório

Abstract

The Nursing Care Systematization organizes the work and the possibility of operationalization of the Nursing Process. Being regulated by Resolution number 358/2009 the COFEN, the nursing process must be based on a theoretical support that guides the development of its stages and a standardization of the language used. In this sense, the present study had the construction of an instrument for the implantation of nursing process in a preoperative semester of patients with the light of Wanda Aguiar Horta Theory. It is the use of research as a means of diagnosis and emergency and preoperative frequency signaling, as potential and subsequent to its implementation, as well as narcotic ones. The findings were found in the early stages of action research, through the collection of non-local study data and medical records, as well as the holding of research sensitization meetings, evidenced the need to sensitize and empower participants for the study research development nursing process steps. To this end, Wanda Horta, Nursing Care Systematization and Nursing Process educational materials on the Basic Human Needs (NHB) were launched and brought to the research seminars, and the training spaces, through continuing education activities, to discuss the data obtained from the collections. The data base and the collective tools base for the development of the nursing process stages were not preoperative. Thus, the products generated in the research were: a) continuing education activities; b) video lessons through a social media channel; c) infographic with an anamnesis rotator and physical examination according to Wanda Horta's NHB and the Nursing Diagnoses implanted in the research; d) Nursing Diagnoses and Nursing Interventions Manual; and e) Insertion in the patient's electronic medical record of the instrument for the development of nursing process, as this is a technology for the implantation of nursing process in no preoperative period. The base date was evaluated by the Delphi method and the application of the Likert scale, obtaining 87.5% of approval. Among the potentialities, it was evidenced that the nursing process organizes care individually and resolutely, adds quality to care through an evidence-based practice, documents the actions taken allowing visibility to the profession, as well as impacting patient and professional safety. Among the obstacles, there was little knowledge and insecurity, lack of time, overwork, lack of resources and inappropriate environment. Thus, the implementation of a technology for the development of the stages of the preoperative period has a positive impact on teaching, care and management, being an important factor related to registration, documentation, autonomy and professional visibility.