Nursing process: from literature to practice. What are we actually doing?

Authors

  • Simoni Pokorski Fundação Universitária de Cardiologia; Instituto de Cardiologia
  • Maria Antonieta Moraes Fundação Universitária de Cardiologia; Instituto de Cardiologia
  • Régis Chiarelli Fundação Universitária de Cardiologia; Instituto de Cardiologia
  • Angelita Paganin Costanzi Fundação Universitária de Cardiologia; Instituto de Cardiologia
  • Eneida Rejane Rabelo Universidade Federal do Rio Grande do Sul

DOI:

https://doi.org/10.1590/S0104-11692009000300004

Keywords:

nursing process, nursing care, nursing diagnosis

Abstract

OBJECTIVES: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. RESULTS: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

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Published

2009-06-01

Issue

Vol. 17 No. 3 (2009)

Section

Original Articles

License

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How to Cite

Nursing process: from literature to practice. What are we actually doing?. (2009). Revista Latino-Americana De Enfermagem, 17(3), 302-307. https://doi.org/10.1590/S0104-11692009000300004