Registros de enfermagem nos prontuários de pacientes atendidos no Navio Hope em Alagoas - 1973

Abstract

Introduction: The object of this study is the content of the records of nursing found in the medical records of patients treated at the HOPE Ship, in Maceió-Alagoas, from February to November of 1973. These registers reveal a facet of american influence on Nursing in Alagoas. Objectives: To analyze the nursing records found in the medical records of patients treated at the HOPE Ship from February to November 1973; subdividing into introduce the forms in which were found nursing records that made up medical records of patients treated at the HOPE Ship, in 1973; Raise the content present in the nursing records of the medical records, referred to; Verify if the content of the nursing records of these medical records points to to the application of the nursing process in the care of these patients. Methods: Quantitative, descriptive, historical-documentary study carried out with support for the Research Support Center of the university hospital Professor Alberto Antunes of the Federal University of Alagoas with a sample of 446 in the universe of 951 medical records. Social data and nursing records were collected through a form developed in Google Spreadsheets and treated with functions of this same application saved in the cloud for descriptive, statistical analysis. Results: The instruments of nursing records were widely used for americans and brazilians but the americans participation were wider than brazilians participation. The nurses used evolution sheets as well as recording vital signs, checking medications, monitoring of treatments prescribed by the medical and nursing team and the nursing process was registered in Kardex. However, in the later, few consultations received this kind of document correctly filled out, indicating that the nursing process, even though it was present in the intellectual exercise of their work, was not registered properly in the patient’s medical record. Conclusion: The nursing records used indicated a large appropriation of technical and scientific knowledge of the american nurses. However, a low proportion of the application of the nursing process registration was still found, indicating a low appropriation of this practice.