Preparation of a critical patient data collection instrument: nursing record/Elaboracao de um instrumento para coleta de dados de paciente critico: historico de enfermagem/Elaboracion de un instrumento para recoleccion de datos de paciente critico: historico de enfermeria

• Published in: Revista enfermagem UERJ Vol. 20; no. 2; p. 267
• Main Authors: da Silva, Rudval Souza, Pereira, Alvaro, Ribeiro, Aldacy Goncalves, Marinho, Carina Martins da Silva, Carvalho, Ieda Silva, Ribeiro, Rogerio
• Format: Journal Article
• Language: Spanish
• Published: Universidade do Estado do Rio de Janeiro- Uerj 01-04-2012
• ISSN: 0104-3552

This study described construction of an instrument to collect data to document the first stage of the nursing process in an intensive care unit (ICU). Its development drew on studies based on the literature on care/caring for critical patients. The instrument to document data collection (termed the Nursing History) was evaluated and validated by clinical nurses for layout and a dynamic process. It was guided by the Basic Human Needs Theory. Use of the instrument in the nurses' daily routine has facilitated deployment of the first stage of the nursing process in the ICU, and steered implementation of subsequent steps. Its use made it possible for data recording to be organized and directed, and to make essential data available for planning, implementing and evaluating professional nursing care offered to critically ill patients.