Evaluation of nursing process at a university hospital in Campina Grande

Abstract

Objectives: to identify the application of the nursing process and analyze the records of each stage. Methods: This was a retrospective and descriptive study with a quantitative approach, based on the reports and records of the process presented in the records of ward B and that were in the SAME of a University Hospital in Campina Grande. After data collection, the data were analyzed by the descriptive method and the absolute and relative frequencies were calculated. Results: Of the 115 (100%) charts collected, the records presented all stages of the process, except for the expected results. The most frequent diagnoses were ineffective breathing pattern and intolerance to activity and interventions, to check vital signs and oxygen saturation. In 68 (59,1%) the actions implemented were recorded, 114 (99,1%) did not present the patient's answers and 71 (61.7%) made changes to the care plans. Conclusion: It was concluded that it is necessary to improve the registration of the nursing process.