The medical records of all patients hospitalized during the study period were

The medical records of all patients hospitalized

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The medical records of all patients hospitalized during the study period were analyzed, i.e., 134 pa - tients (medical records), of which in 129 nursing diag - noses were identified. Daily records were considered in each of the medical records, and the same medical record was evaluated more than once, depending on the length of hospital stay. The study complied with the formal require - ments contained in the national and international regulatory standards for research involving human beings. Results The results indicate an important nursing adhesion to the Nursing Care Systematization, which is performed daily for each of the patients hospitali- zed in the unit studied. It was verified that the nur - sing history, prescription and nursing evolution stages were routinely performed, and that the nursing diag - nosis was no longer recorded in 5 of the 134 charts analyzed. In the analysis of the percentage of occurren- ce of nursing diagnoses in the patients hospitalized at the Clinical Medical Units studied, it was observed that of 129 medical records: 121 (93.2%) had a diag - nosis of infection risk; 78 (60.4%) presented diag - noses of impaired skin integrity risk and anxiety; 65 (59.4%) unstable glycemia risk; 55 (42.6%) impaired skin integrity; 34 (26.4%) chronic pain; 33 (25.5%) ineffective respiratory pattern and 30 (23.3%), impai - red tissue integrity. The diagnoses of unbalanced nutrition: less than the bodily needs; risk of constipation and cons - tipation evaluated in 69 charts, obtained the following percentages of frequency: 31 (44.0%) presented a diagnosis of unbalanced nutrition: less than the bodi- ly needs; 22 (31.8%) had a risk of constipation and 14 (20.2%) had a diagnosis of constipation.
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Rev Rene. 2017 Jan-Feb; 18(1):68-75. NANDA International nursing diagnoses in patients admitted to a medical clinic unit 71 Evaluating the nursing diagnoses together with the related factors, it was obtained that the risk of infection with 287 occurrences was related to inva - sive procedures in 107 (37.2%) situations, increased environmental exposure to pathogens in 80 (27.8% %), Chronic disease 40 (14%), tissue destruction 37 (13.0%) and other risk factors in 23 (8.0%). Risk of impaired skin integrity, present in 237 occurrences, was related to physical immobility 41 (17.4%); extremes of age 38 (16.0%); mechanical factors 31 (13.0%); bone prominences 19 (8.0%) and other risk factors 108 (45.6%). Impaired skin inte - grity with 102 occurrences was related to mechani - cal factors 36 (35.2%); physical immobilization 11 (10.7%); extremities of age 8 (7.8%) and other related factors 47 (46.0%). Of the 39 occurrences of impaired tissue integrity, 16 (41.0%) were related to the alte - red circulation; 9 (23.0%) to mechanical factors and 14 (35.9%) to other related factors. The diagnosis of unstable glycemia risk with 107 occurrences was related to 45 (42.0%); food in - take 9 (8.4%); control of drugs 31 (28.9%); other risk factors 22 (20,5%). Risk of constipation present in 34 situations was related to the change in usual eating patterns 9 (26.4%); irregular evacuation habits 4 (11.7%); men - tal confusion 3 (8.8%); poor dietary habits 3 (8.8%) and other risk factors 15 (44.1%). Constipation with 26 occurrences was related to the change in dietary patterns 4 (15.3%); poor eating habits 3 (11.5%); re - cent changes in environment 3 (11.5%) and other re - lated factors 16 (61.5%).
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  • Fall '16
  • Denise Cauble
  • Nursing, Nursing Care Systematization

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