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ORIGINAL ARTICLE
Guide for Systematization of Care and Nursing Process: educational technology for professional practice
- Susana Lamara Pedras Almeida
, - Cândida Caniçali Primo ,
- Márcia Valéria de Souza Almeida ,
- Paula de Souza Silva Freitas ,
- Amália de Fátima Lucena , [ ... ],
- Marcos Antônio Gomes Brandão
04-14-2023
Abstract
ORIGINAL ARTICLEGuide for Systematization of Care and Nursing Process: educational technology for professional practice
Revista Brasileira de Enfermagem. 2023;76:e20210975
04-14-2023DOI 10.1590/0034-7167-2021-0975
- Susana Lamara Pedras Almeida ,
- Cândida Caniçali Primo ,
- Márcia Valéria de Souza Almeida ,
- Paula de Souza Silva Freitas ,
- Amália de Fátima Lucena ,
- Eliane de Fátima Almeida Lima ,
- Marcos Antônio Gomes Brandão
Views1ABSTRACT
Objective:
to elaborate and validate the content of a digital guide educational technology on Systematization of Nursing Care and Nursing Process.
Methods:
applied research of technological development, developed between 2020 and 2021, in three steps. First, a scoping review was carried out to elaborate the content. In the second step, the content was validated with 46 nurse judges selected for convenience. The minimum criterion of agreement among judges was 80%. The third step consisted of content organization and layout.
Results:
the guide content was elaborated from the Federal Nursing Council legislation, scientific articles and textbooks. Content was considered appropriate, relevant and organized by judges.
Final considerations:
the digital guide is an alternative that can contribute to the NP execution and implementation, supporting the planning and implementation of actions for quality of care.
Keywords:Educational TechnologyNursing ProcessNursing RecordsProfessional PracticeStandardized Nursing TerminologySee moreViews1
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLEGuide for Systematization of Care and Nursing Process: educational technology for professional practice
Revista Brasileira de Enfermagem. 2023;76:e20210975
04-14-2023DOI 10.1590/0034-7167-2021-0975
- Susana Lamara Pedras Almeida ,
- Cândida Caniçali Primo ,
- Márcia Valéria de Souza Almeida ,
- Paula de Souza Silva Freitas ,
- Amália de Fátima Lucena ,
- Eliane de Fátima Almeida Lima ,
- Marcos Antônio Gomes Brandão
Views1ABSTRACT
Objective:
to elaborate and validate the content of a digital guide educational technology on Systematization of Nursing Care and Nursing Process.
Methods:
applied research of technological development, developed between 2020 and 2021, in three steps. First, a scoping review was carried out to elaborate the content. In the second step, the content was validated with 46 nurse judges selected for convenience. The minimum criterion of agreement among judges was 80%. The third step consisted of content organization and layout.
Results:
the guide content was elaborated from the Federal Nursing Council legislation, scientific articles and textbooks. Content was considered appropriate, relevant and organized by judges.
Final considerations:
the digital guide is an alternative that can contribute to the NP execution and implementation, supporting the planning and implementation of actions for quality of care.
Keywords:Educational TechnologyNursing ProcessNursing RecordsProfessional PracticeStandardized Nursing TerminologySee moreThis is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 
- Susana Lamara Pedras Almeida
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ORIGINAL ARTICLE
Nursing protocol in chronic kidney disease prevention in older adults in primary care
- Fernanda Ferreira Krepker ,
- Cristina Arreguy-Sena ,
- Luciene Muniz Braga ,
- Paula Krempser ,
- Jéssica de Castro Santos , [ ... ],
- Herica Silva Dutra
11-28-2023
Abstract
ORIGINAL ARTICLENursing protocol in chronic kidney disease prevention in older adults in primary care
Revista Brasileira de Enfermagem. 2023;76(1):e20220052
11-28-2023DOI 10.1590/0034-7167-2022-0052
- Fernanda Ferreira Krepker ,
- Cristina Arreguy-Sena ,
- Luciene Muniz Braga ,
- Paula Krempser ,
- Jéssica de Castro Santos ,
- Herica Silva Dutra
Views0See moreASBTRACT
Objectives:
to develop a protocol for Nursing Process operationalization in approaching older adults with vulnerability to chronic kidney disease in Primary Health Care, based on Neuman’s stressors.
Methods:
a methodological study, carried out in two stages: 1) synthesis of evidence using an inductive strategy (mixed method study) and 2) protocol development to support the nursing process operationalization with older adults enrolled in a Basic Health Unit, using a deductive strategy (Neuman’s stressor concepts, NANDA, NIC, and NOC taxonomies, Risner’s line of reasoning, and cross-mapping), described according to A Step-by-Step Guide to Developing Protocols.
Results:
102 older adults participated, and 17 diagnoses, 34 interventions and 26 nursing outcomes were identified.
Conclusions:
the protocol developed is a technology that makes it possible to operationalize the Nursing Process, based on Neuman’s stressors and on taxonomy, conceptual and care frameworks, guiding care and nursing records.
Views0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLENursing protocol in chronic kidney disease prevention in older adults in primary care
Revista Brasileira de Enfermagem. 2023;76(1):e20220052
11-28-2023DOI 10.1590/0034-7167-2022-0052
- Fernanda Ferreira Krepker ,
- Cristina Arreguy-Sena ,
- Luciene Muniz Braga ,
- Paula Krempser ,
- Jéssica de Castro Santos ,
- Herica Silva Dutra
Views0See moreASBTRACT
Objectives:
to develop a protocol for Nursing Process operationalization in approaching older adults with vulnerability to chronic kidney disease in Primary Health Care, based on Neuman’s stressors.
Methods:
a methodological study, carried out in two stages: 1) synthesis of evidence using an inductive strategy (mixed method study) and 2) protocol development to support the nursing process operationalization with older adults enrolled in a Basic Health Unit, using a deductive strategy (Neuman’s stressor concepts, NANDA, NIC, and NOC taxonomies, Risner’s line of reasoning, and cross-mapping), described according to A Step-by-Step Guide to Developing Protocols.
Results:
102 older adults participated, and 17 diagnoses, 34 interventions and 26 nursing outcomes were identified.
Conclusions:
the protocol developed is a technology that makes it possible to operationalize the Nursing Process, based on Neuman’s stressors and on taxonomy, conceptual and care frameworks, guiding care and nursing records.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 
- Fernanda Ferreira Krepker
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ORIGINAL ARTICLE
Unsatisfactory completeness of nurses’ records in the medical records of users with tuberculosis
- José Nildo de Barros Silva Júnior ,
- Haline Costa dos Santos Guedes ,
- Dilyane Cabral Januário ,
- Ana Cristina de Oliveira e Silva ,
- Pedro Fredemir Palha , [ ... ],
- Anne Jaquelyne Roque Barrêto
11-29-2022
Abstract
ORIGINAL ARTICLEUnsatisfactory completeness of nurses’ records in the medical records of users with tuberculosis
Revista Brasileira de Enfermagem. 2022;75(3):e20210316
11-29-2022DOI 10.1590/0034-7167-2021-0316
- José Nildo de Barros Silva Júnior ,
- Haline Costa dos Santos Guedes ,
- Dilyane Cabral Januário ,
- Ana Cristina de Oliveira e Silva ,
- Pedro Fredemir Palha ,
- Matheus Figueiredo Nogueira ,
- Anne Jaquelyne Roque Barrêto
Views0See moreABSTRACT
Objectives:
to evaluate the completeness of nurses’ records on the execution of the nursing process in assistance of tuberculosis patients at Primary Care.
Methods:
this was a retrospective documental study, with 190 records in Family Health Units of a city in the state of Paraíba. The data were analyzed according to descriptive statistics, Pareto Diagram, and trend analysis.
Results:
the overall mean incompleteness of records was 53.01% (DP=26.13). Therefore, the results presented very poor completeness classification related to nursing diagnosis (88.9%), nursing assessment (66.8%), data collection (60.5%), while nursing interventions were classified as regular (11.1%). The nursing diagnosis was the only variable with a decreasing trend of non-completeness.
Conclusions:
incompleteness of nurses’ records in the medical records of users with tuberculosis. Evaluation strategies, permanent and continuing education are indispensable in the quality of nurses’ documentation, directly implying the Systematization of Quality in Nursing Care.
Views0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLEUnsatisfactory completeness of nurses’ records in the medical records of users with tuberculosis
Revista Brasileira de Enfermagem. 2022;75(3):e20210316
11-29-2022DOI 10.1590/0034-7167-2021-0316
- José Nildo de Barros Silva Júnior ,
- Haline Costa dos Santos Guedes ,
- Dilyane Cabral Januário ,
- Ana Cristina de Oliveira e Silva ,
- Pedro Fredemir Palha ,
- Matheus Figueiredo Nogueira ,
- Anne Jaquelyne Roque Barrêto
Views0See moreABSTRACT
Objectives:
to evaluate the completeness of nurses’ records on the execution of the nursing process in assistance of tuberculosis patients at Primary Care.
Methods:
this was a retrospective documental study, with 190 records in Family Health Units of a city in the state of Paraíba. The data were analyzed according to descriptive statistics, Pareto Diagram, and trend analysis.
Results:
the overall mean incompleteness of records was 53.01% (DP=26.13). Therefore, the results presented very poor completeness classification related to nursing diagnosis (88.9%), nursing assessment (66.8%), data collection (60.5%), while nursing interventions were classified as regular (11.1%). The nursing diagnosis was the only variable with a decreasing trend of non-completeness.
Conclusions:
incompleteness of nurses’ records in the medical records of users with tuberculosis. Evaluation strategies, permanent and continuing education are indispensable in the quality of nurses’ documentation, directly implying the Systematization of Quality in Nursing Care.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 
- José Nildo de Barros Silva Júnior
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ORIGINAL ARTICLE
Quality indicators of the nursing process documentation in clinical practice
Revista Brasileira de Enfermagem. 2021;74(3):e20201355
07-23-2021
Abstract
ORIGINAL ARTICLEQuality indicators of the nursing process documentation in clinical practice
Revista Brasileira de Enfermagem. 2021;74(3):e20201355
07-23-2021DOI 10.1590/0034-7167-2020-1355
Views0ABSTRACT
Objectives:
to propose quality indicators for clinical nursing documentation
Methods:
methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa.
Results:
the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services.
Conclusions:
seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.
Keywords:DocumentationNursing Methodology ResearchNursing ProcessNursing RecordsQuality Indicators, Health CareSee moreViews0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLEQuality indicators of the nursing process documentation in clinical practice
Revista Brasileira de Enfermagem. 2021;74(3):e20201355
07-23-2021DOI 10.1590/0034-7167-2020-1355
Views0ABSTRACT
Objectives:
to propose quality indicators for clinical nursing documentation
Methods:
methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa.
Results:
the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services.
Conclusions:
seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.
Keywords:DocumentationNursing Methodology ResearchNursing ProcessNursing RecordsQuality Indicators, Health CareSee moreThis is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. -
ORIGINAL ARTICLE
Analysis of records by nursing technicians and nurses in medical records
- Larissa de Lima Ferreira ,
- Flávia Barreto Tavares Chiavone ,
- Manacés dos Santos Bezerril ,
- Kisna Yasmin Andrade Alves ,
- Pétala Tuani Candido de Oliveira Salvador , [ ... ],
- Viviane Euzébia Pereira Santos
02-17-2020
Abstract
ORIGINAL ARTICLEAnalysis of records by nursing technicians and nurses in medical records
Revista Brasileira de Enfermagem. 2020;73(2):e20180542
02-17-2020DOI 10.1590/0034-7167-2018-0542
- Larissa de Lima Ferreira ,
- Flávia Barreto Tavares Chiavone ,
- Manacés dos Santos Bezerril ,
- Kisna Yasmin Andrade Alves ,
- Pétala Tuani Candido de Oliveira Salvador ,
- Viviane Euzébia Pereira Santos
Views0See moreABSTRACT
Objectives:
to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil.
Methods:
this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records.
Results:
the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses’ records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%.
Conclusions:
the study showed that nursing professionals perform their records incompletely and often do not document the care provided.
Views0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLEAnalysis of records by nursing technicians and nurses in medical records
Revista Brasileira de Enfermagem. 2020;73(2):e20180542
02-17-2020DOI 10.1590/0034-7167-2018-0542
- Larissa de Lima Ferreira ,
- Flávia Barreto Tavares Chiavone ,
- Manacés dos Santos Bezerril ,
- Kisna Yasmin Andrade Alves ,
- Pétala Tuani Candido de Oliveira Salvador ,
- Viviane Euzébia Pereira Santos
Views0See moreABSTRACT
Objectives:
to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil.
Methods:
this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records.
Results:
the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses’ records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%.
Conclusions:
the study showed that nursing professionals perform their records incompletely and often do not document the care provided.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 
- Larissa de Lima Ferreira
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ORIGINAL ARTICLE
Male External Catheter in Adults: a glance at nursing care practice
- Vivian Sauer Torres da Silva ,
- Maria Virginia de Almeida Couto Rosa Torres ,
- Melina Araújo de Oliveira Silva ,
- Oneida Silveira Freitas ,
- Priscila Damaceno Santos , [ ... ],
- Gisela Maria Assis
04-18-2019
Abstract
ORIGINAL ARTICLEMale External Catheter in Adults: a glance at nursing care practice
Revista Brasileira de Enfermagem. 2019;72(2):450-454
04-18-2019DOI 10.1590/0034-7167-2018-0327
- Vivian Sauer Torres da Silva ,
- Maria Virginia de Almeida Couto Rosa Torres ,
- Melina Araújo de Oliveira Silva ,
- Oneida Silveira Freitas ,
- Priscila Damaceno Santos ,
- João Júnior Gomes ,
- Gisela Maria Assis
Views0See moreABSTRACT
Objective:
to describe the patients care in the use of the Male External Catheter in Adults in a clinical-surgical hospitalization unit.
Method:
a cross-sectional study. Evaluation of 30 patients hospitalized in clinical-surgical units to collect items related to the specific care provided.
Results:
100% had no reference to the use of external catheter in the evolution of the nurse; 43.3% of the assistants or technicians recorded; 36.6% presented skin lesions; 100% had a latex device attached with adhesive tape; 90% were not submitted to hair removal; 96.7% had daily genital hygiene; 70% received no guidance at all.
Conclusion:
no individualized evaluation was observed for the use of the device, nursing records did not include prescription and description of installation and care, latex device and micropore paper adhesive tape were predominant; skin lesions were prevalent, hygiene and exchange were adequate, few patients were advised regarding the use of the device.
Views0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
ORIGINAL ARTICLEMale External Catheter in Adults: a glance at nursing care practice
Revista Brasileira de Enfermagem. 2019;72(2):450-454
04-18-2019DOI 10.1590/0034-7167-2018-0327
- Vivian Sauer Torres da Silva ,
- Maria Virginia de Almeida Couto Rosa Torres ,
- Melina Araújo de Oliveira Silva ,
- Oneida Silveira Freitas ,
- Priscila Damaceno Santos ,
- João Júnior Gomes ,
- Gisela Maria Assis
Views0See moreABSTRACT
Objective:
to describe the patients care in the use of the Male External Catheter in Adults in a clinical-surgical hospitalization unit.
Method:
a cross-sectional study. Evaluation of 30 patients hospitalized in clinical-surgical units to collect items related to the specific care provided.
Results:
100% had no reference to the use of external catheter in the evolution of the nurse; 43.3% of the assistants or technicians recorded; 36.6% presented skin lesions; 100% had a latex device attached with adhesive tape; 90% were not submitted to hair removal; 96.7% had daily genital hygiene; 70% received no guidance at all.
Conclusion:
no individualized evaluation was observed for the use of the device, nursing records did not include prescription and description of installation and care, latex device and micropore paper adhesive tape were predominant; skin lesions were prevalent, hygiene and exchange were adequate, few patients were advised regarding the use of the device.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. - Vivian Sauer Torres da Silva
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RESEARCH
Nursing Appointment in Mental Health: experience of nurses of the network
Revista Brasileira de Enfermagem. 2018;71:2154-2160
01-01-2018
Abstract
RESEARCHNursing Appointment in Mental Health: experience of nurses of the network
Revista Brasileira de Enfermagem. 2018;71:2154-2160
01-01-2018DOI 10.1590/0034-7167-2017-0678
Views0See moreABSTRACT
Objective:
To know the experience of nurses of the Psychosocial Care Networks on the development of Nursing Appointment in Mental Health.
Method:
Qualitative study, with interview of 20 nurses, through the analysis of the statements in the search of the meaning core.
Results:
was unveiled as meaning core: lack of preparation for Mental Health Care, Non-identification of the work of the nurse in Mental Health; and Performance of Nursing Appointment as bureaucratic fulfillment.
Final considerations:
Nurses understand Nursing Appointment as an individualized and bureaucratic activity, to consider professional regulations, and not as a work process in the multiprofessional work, thus, the Projeto Terapêutico Singular (freely translated as Unique Therapeutic Project) is not cited as a possibility of work process. It was identified necessary space for discussion of actuation and updates of the nurse in Mental Health Care in the health services studied, with emphasis on their performance in a multiprofessional team in consonance with the Mental Health Policy.
Views0This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
RESEARCHNursing Appointment in Mental Health: experience of nurses of the network
Revista Brasileira de Enfermagem. 2018;71:2154-2160
01-01-2018DOI 10.1590/0034-7167-2017-0678
Views0See moreABSTRACT
Objective:
To know the experience of nurses of the Psychosocial Care Networks on the development of Nursing Appointment in Mental Health.
Method:
Qualitative study, with interview of 20 nurses, through the analysis of the statements in the search of the meaning core.
Results:
was unveiled as meaning core: lack of preparation for Mental Health Care, Non-identification of the work of the nurse in Mental Health; and Performance of Nursing Appointment as bureaucratic fulfillment.
Final considerations:
Nurses understand Nursing Appointment as an individualized and bureaucratic activity, to consider professional regulations, and not as a work process in the multiprofessional work, thus, the Projeto Terapêutico Singular (freely translated as Unique Therapeutic Project) is not cited as a possibility of work process. It was identified necessary space for discussion of actuation and updates of the nurse in Mental Health Care in the health services studied, with emphasis on their performance in a multiprofessional team in consonance with the Mental Health Policy.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Nursing Records Archives - Revista Brasileira de Enfermagem
