Banco de termos em enfermagem para uma unidade de internação em infectologia.

Abstract

The documentation is the only way to record the care provided by nursing staff to patient , therefore the use of specialized terminology to articulate the professional practice is of paramount importance to have an organized record . The use of a standardized terminology , based on the classification of nursing systems , has established himself worldwide as a trend towards unification of the language of the profession , ensuring communication and exchange of information between nurses and other health professionals . This study aimed to build a database of terms of special nursing language in an inpatient facility in infectious diseases , based on the Model Seven Axis of ICNP ® Version 2.0 . Descriptive research with quantitative approach , which was developed in the inpatient unit of the University Hospital for Infectious Diseases Alcides Carneiro . A given population for research constitutes the records of patients hospitalized in the inpatient unit in Infectious Diseases of the aforementioned hospital. Establishing the following inclusion criteria : records of patients hospitalized at the hospital in the period of data collection . Were excluded from the study : records with illegible letters , which did not show data representative of nursing care . Data were collected through a structured questionnaire . We used 20 records of which were extracted terms of nursing records , which were mapped to the seven axes of ICNP ® Version 2.0 and distributed in graphs and figures , discussed by the literature of the area . After achieving the operational steps , 224 terms were identified , of which 114 were constant terms in ICNP ® Version 2.0 and 110 terms were not constant. The terms found and classified as constants were distributed among seven axles and presented the data: Focus : 59 terms ; Judgment: 7 terms ; Client: 4 terms ; Medium: 10 terms ; Location : 17 terms ; Time : 6 terms ; and Action : 11 terms . The terms classified as non constant undergone an analysis for identification and exclusion of terms considered examinations ; medical terms ; Synonyms of constant terms ; etermos considered as specific features of terms in the ICNP ® Version 2.0 . After step the remaining terms were distributed , with the following results : Focus : 31 terms ; Judgment: 12 terms ; Media: 03 terms ; Location : 13 terms ; Time : 01 term ; and Action : 05 terms . The development of definitions of the terms contained classified as occurred through the use of the definitions presented in this classification system ; and non- constant terms definitions were developed using the literature review from the consulting textbooks and dictionaries for Nursing and Health Thus was built a Bank Terms of nursing through terms found in the records of nursing records of patients hospitalized in the inpatient unit in Infectious Diseases of the HUAC / UFCG.