Abstract
To adapt data collection of the Information System software with the nursing process in Intensive Therapy for use in medical and surgical clinic units. A descriptive study developed in three stages. The first consisted of team training; in the second, the software was applied in clinical practice with 100 patients; and in the third, we analyzed the modifications to be done. There was inter-observer agreement of 91%, followed by application of the software in 100 patients. In the "patient registration" module, it was suggested the exclusion of one item, inclusion of six and modification of four of them. In the anamnesis screens, no items were flagged to be deleted; 26 inclusions and 7 changes were proposed. In the physical examination screens, it was suggested the exclusion of 31 items, inclusion of 26 and modification of 27. Modifying information systems and going through stages methodologically constructed and implemented was important.
Highlights
The Conselho Federal de Enfermagem (COFEN - Federal Nursing Council) aims to develop a holistic, individualized approach that can contemplate the specificities of human beings through Resolution 358/09
This study aims to adapt the data collection stage of the SIPETi software to use in medical and surgical clinic units
As the agreement index obtained in the third training was 91%, greater than 90%, researchers were considered fit to use the software
Summary
The Conselho Federal de Enfermagem (COFEN - Federal Nursing Council) aims to develop a holistic, individualized approach that can contemplate the specificities of human beings through Resolution 358/09. This Resolution is recommended to be systematized and based on a theoretical support and that the nursing process (NP) stages be implemented in all environments that require this professional category(1). NP is a private activity of nurses and includes five stages: research, nursing diagnosis (ND), planning, implementation and evaluation of care With its application, it is recognized the critical thinking used by nurses in identifying the needs of patients, and determining the care prescribed to minimize them/solve them in a way that the expected results can be reached(2). It should be emphasized that NP must be based on a nursing theory in order to avoid it being reduced to a methodological way of grouping information unrelated to the subject’s subjectivity(4)
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