Abstract

Objective: construction and validation of a systematization instrument for Nursing Care, characterizing the profile of patients of an intensive care unit in the north of Brazil. Methods: it was a descriptive methodological study that followed a nursing process model in five phases. Results: it was suggested that the instrument be constructed in two formats; one for admission and another for daily assessment. Some items were removed from the instrument according to content validation content by the nurses. Of the 45 patients evaluated, 60.0% were men, 44.0% were married, 40.0% had low education levels, chronic renal failure and cancer. The main nursing diagnoses were risk for infection (100.0%) and impaired physical mobility (97.8%). The main nursing interventions were: handwashing, changing intravenous access, performing aseptic techniques and moving patients every 2 hours. Conclusion: construction and content validation were carried out successfully, promoting instruments capable of providing quality nursing care for patients in intensive care.

Highlights

  • Nursing care for patients in the Intensive Care Unit is specialized and complex, requiring advanced technological equipment, highly qualified human resources and scientific knowledge[1].In this sense, the implementation of the nursing process in this sector constitutes an important instrument for improving the quality and safety of nursing care, both for patients and for professionals, as it aims to organize nursing care through a systematic individualized data collection instrument[1,2,3].The Nursing Process is a method which organizes nursing care, composed of five interdependent and sequenced phases

  • The first phase consists of nursing history, which aims at collecting patient data through anamnesis and physical examinations, which will guide the identification of potential health-related issues; the phase is nursing diagnosis, based on data collected in the previous phase and identifying care needs to be provided

  • With the entire theoretical framework established, the Nursing Care Systematization instrument was elaborated onto a single sheet, being divided into four segments: patient identification, history and physical examination, diagnostic and nursing interventions

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Summary

Introduction

Nursing care for patients in the Intensive Care Unit is specialized and complex, requiring advanced technological equipment, highly qualified human resources and scientific knowledge[1].In this sense, the implementation of the nursing process in this sector constitutes an important instrument for improving the quality and safety of nursing care, both for patients and for professionals, as it aims to organize nursing care through a systematic individualized data collection instrument[1,2,3].The Nursing Process is a method which organizes nursing care, composed of five interdependent and sequenced phases. Nursing care for patients in the Intensive Care Unit is specialized and complex, requiring advanced technological equipment, highly qualified human resources and scientific knowledge[1]. In this sense, the implementation of the nursing process in this sector constitutes an important instrument for improving the quality and safety of nursing care, both for patients and for professionals, as it aims to organize nursing care through a systematic individualized data collection instrument[1,2,3]. In the third phase called nursing planning, the expected outcomes based on nursing diagnoses are tracked along with the nursing interventions to be implemented. It is noteworthy that the entire study should be conducted based on solid scientific knowledge about each abovementioned phase[2]

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Conclusion

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