Caracterização dos registros de enfermagem e as condições clínicas/cirúrgicas de pacientes estomizados em uma instituição hospitalar particular da região metropolitana de Porto Alegre/RS

Abstract

Objective: To characterize the nursing records and clinical / surgical conditions of ostomized patients in a private hospital in the metropolitan region of Porto Alegre. Method: Descriptive, retrospective research with a quantitative approach carried out with 56 records of ostomized patients treated at the Hospital Institution. Data were extracted using a structured script from January to December 2019, using the Microsoft Excel ® software version 2016 for typing and the analysis was performed using relative and absolute frequency. Results: The study sample was represented by 56 medical records, and it was found that the majority of patients were men between 61 and 70 years old. The sigmoid neoplasm predominated as the cause for making the stomas (14.3%), followed by the rectum neoplasm (10.7%). Patients had one to four comorbidities, such as Systemic Arterial Hypertension (28.8%) and Diabetes Mellitus (23.7%). In 35.7% of the cases, colostomies were performed. Among the surgical procedures performed, the most prevalent were Hemicolectomy and Retosigmoidectomy, both with 14.3%. The study revealed the absence of registration by the nurse in the medical records regarding the following variables: Presence of complications (71%) and effluents (25%). Conclusion: The study showed the characterization of the clinical and surgical profile of this population, as well as the absence of registration by nurses. In view of the results, it is suggested the implementation of permanent education as a training tool for employees, implementation of nursing systematization, in the quest to qualify the information, which may result in better patient care.