Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system*

Authors

DOI:

https://doi.org/10.1590/1980-220X-REEUSP-2022-0123pt

Keywords:

Nursing Process, Operating Room Nursing, Nursing Diagnosis, Nursing Record, Electronic Health Records

Abstract

Objective: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. Method: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. Results: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining “who, what, when, and where”. The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. Conclusion: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.

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Published

2023-04-17

Issue

Section

Original Article

How to Cite

Fritzen , A., Santos, D. P. dos S., Rocha, B. S. da, Jost, M. T., Caregnato, R. C. A., & Costa Linch, G. F. da. (2023). Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system*. Revista Da Escola De Enfermagem Da USP, 57, e20220299. https://doi.org/10.1590/1980-220X-REEUSP-2022-0123pt