No description available.

People who are homeless rely heavily on acute health care facilities to meet basic health care needs. Medical-surgical nurses play a fundamental role in the health care and health outcomes of patients who are homeless. According to the Institute of Medicine, health care providers’ bias and stereotyping contribute to health disparities among marginalized and vulnerable populations. Because attitudes are linked to clinical decision making and behaviors, revealing how nurses’ attitudes towards patients who are homeless develop and transform is paramount to improving health disparities of the homeless population. The purpose of this study was to explore nurses’ clinical experiences with patients who are homeless in order to discover how attitudes toward care of the homeless develop and transform. Interpretive phenomenology was used to describe and interpret the experiences of 11 medical-surgical nurses who cared for patients who were homeless and reported their attitudes toward this marginalized population had transformed. Nurses’ clinical experiences ranged from 3 to 40 years. Audiotaped semi-structured interviews were conducted. Data analysis was ongoing throughout data collection as delineated by Diekelmann and Allen (1989) and expanded by Minick (1992). Five themes were revealed through interpretation of the rich data. The themes were ‘Discovering homelessness,’ ‘Finding common ground,’ ‘Piecing it together,’ ‘A daily struggle,’ and ‘Relationships based on distrust.’ Nurses’ attitudes were in constant development and transformation. Nurses’ life and clinical experiences created opportunities for attitude transformations. Experiences associated with attitude transformation were identified. Nurses’ experiences revealed how nurses enter practice with an established attitude toward this marginalized population. As nurses came to realize that homelessness was no longer an abstract, intangible concept rather homelessness existed and was present in their day-to-day nursing practices their attitudes began to transform. Nurses sought common experiences with patients who were homeless to create a sense of connectedness in nurse-patient relationships. Nurses described a daily struggle of maintaining positive, non-judgmental attitudes. Nurses shared how early experiences of negative encounters with patients who were homeless created feelings of distrust thus altering nurse-patient relationships with future patients who were homeless. This study contributes to nursing knowledge by revealing how medical-surgical nurses’ attitudes develop and transform and how experiences are associated with attitude change. Recommendations for nursing practice, education, research are identified.

Estudo quantitativo, transversal, prospectivo, realizado com o objetivo de analisar os efeitos da alocação de pessoal e da carga de trabalho de enfermagem nos resultados da assistência em duas unidades de internação (UIs) médico-cirúrgicas, com 20 e 15 leitos cada, denominadas respectivamente UI-A e UI-B, de um hospital do município de São Paulo. Utilizou-se uma metodologia capaz de abranger 87% da variação dos cuidados requeridos pelos pacientes, composta por itens que incluem a dimensão biológica e psicossocial do cuidado: o Patient Focused Solutions/Workload Measurement-Inpatient Methodology (PFS/WM-IM). Foram considerados indicadores de resultado: queda, erro de medicação, retirada não programada de sondas, cateteres ou drenos, úlcera por pressão (UP), infecção urinária (ITU) e pneumonia desenvolvidas durante a internação hospitalar. Os dados foram obtidos dos prontuários e dos registros da Comissão de Controle de Infecção Hospitalar, além da escala diária de pessoal de enfermagem. Após 47 dias consecutivos de coleta de dados, a amostra final foi composta por 387 pacientes - 218 na UI-A e 169 na UI-B. Com distribuição eqüitativa de pacientes do gênero masculino e feminino, predominaram os idosos com 61 anos ou mais (38,5% na UI-A e 36,1% na UI-B), submetidos a tratamento cirúrgico eletivo (62,8% na UI-A e 56,8% na UI-B) e média de internação de 6,0 (+-25,1) dias na UI-A e de 4,6 (+-7,2) dias na UI-B. A maioria dos pacientes da UI-A foi proveniente da residência (52,3%); na UI-B do pronto atendimento (47,3%), seguido pela residência (37,3%). Após a alta, 85,3% dos pacientes da UI-A e 87,6% da UI-B retornaram à residência. Com relação à ocorrência de eventos adversos (EAs), na UI-A, 14 pacientes (6,4%) sofreram 23 EAs (9, 3 e 2 pacientes foram vítimas de 1, 2 e 4 eventos, respectivamente, sendo 13 retiradas não programadas de sondas, cateteres ou drenos, 8 erros de medicação, 1 UP e 1 ITU). Na UI-B 12 pacientes (7,1%) sofreram 13 EAs, ou seja, 11 pacientes sofreram 1 EA e 1 foi vítima de 2 EAs, sendo 10 erros de medicação, 2 retiradas não programadas de sondas, cateteres ou drenos e 1UP. Os pacientes foram classificados predominantemente nas categorias 1, 2 e 3 (baixa e intermediária complexidade), alocados em unidades adequadas para o cuidado requerido – as unidades de internação. Havia em média 1 enfermeiro para cada unidade e cada auxiliar de enfermagem cuidou de, no máximo, 5 pacientes. A média de horas de enfermagem disponível foi maior do que o recomendado pelo PFS/WM-IM, respectivamente 7 e 5,8 h na UI-A e 6,2 e 4,9h na UI-B (p<0,001). No período analisado, apesar do excedente de pessoal de enfermagem nas UIs A e B, houve ocorrência de EAs. Os resultados deste estudo se contrapõem, portanto, às solicitações freqüentes de enfermeiros por maior quantidade de pessoal e apontam para a necessidade de novas investigações que complementem as análises realizadas, não só para as UIs médico-cirúrgicas, mas para todas as unidades do hospital / This was a quantitative, transversal, prospective study, performed with the objective of analyzing the effects of nursing personnel allocation and workload on assistance results in two medical-surgical units (MSUs), with 20 and 15 beds each, respectively named MSU-A and MSU-B at a hospital in the city of São Paulo. The methodology used was capable of comprehending 87% of the range of the care required by the patients; it was a compound of items that included a biological and psychosocial dimension of care: Patient Focused Solutions/Workload Measurement-Inpatient Methodology (PFS/WM-IM). Result indicators considered were: falling, medication errors, non-scheduled probe, catheter or drain removals, pressure ulcers (PU), urinary tract infections (UTI) and pneumonia developed during the hospital care. The data were obtained from medical reports and registers of the Commission for Hospital Infection Control, as well as the daily work schedule of the nursing personnel. After 47 consecutive days of data collection, the final sample had 387 patients - 218 in MSU-A and 169 in MSU-B. Having equal quantities of male and female patients, it had a prevalence of elderly patients with 61 years or more (38.5% in MSU-A and 36.1% in MSU-B), patients who were undergoing surgical elective treatment (62.8% in MSU-A and 56.8% in MSU-B) and those with an average number of internment days of 6.0 days (+-25.1) in MSU-A and of 4.6 days (+-7.2) in MSU-B. Most of the patients of MSU-A came from their homes (52.3%); whereas in MSU-B most of them came from emergency room facilities (47.3%), followed by those who came from home (37.3%). After the discharge, 85.3% of the patients of MSU-A and 87.6% of MSU-B returned to their homes. With respect to occurrences of adverse events (AEs), in MSU-A, 14 patients (6.4%) suffered 23 AEs (9, 3 and 2 respectively had 1, 2 and 4 events, among of them there were: 13 non-scheduled probe, catheter or drain removals, 8 medication errors, 1 PU and 1 UTI). In MSU-B, 12 patients (7.1%) suffered 13 AEs, that is, 11 patients had 1 AE and 1 had 2 AEs, in that 10 were medication errors, 2 non-scheduled removals of probes, catheters or drains and 1 PU. The patients predominantly fitted in the categories 1, 2 and 3 (low and medium complexity), allocated in units proper for the required care – the medical surgical units. There was an average of 1 nurse for each unit and each nursing assistant took care of a maximum of 5 patients. The average number of nursing hours available was higher than those recommended by PFS/WM-IM, respectively 7 and 5.8 hours in MSU-A and 6.2 and 4.9 hours in MSU-B (p<0,001). Despite the excess of nursing personnel in MSU-A and MSU-B, AEs occurred. Therefore, the results of this study oppose frequent requirements of nurses for more personnel and point to a necessity of new research to complement the herein made analysis, not only for medical-surgical units, but also for every unit in the hospital

Os Sistemas de Informação Hospitalar podem ser definidos como uma rede integrada de informações, projetada para gerenciar aspectos assistenciais, administrativos e jurídicos em organizações de saúde. No contexto da busca pela melhoria da qualidade na assistência à saúde, proporcionada pelos avanços significativos das tecnologias da informação e comunicação, insere-se a necessidade da abordagem da sepse enquanto importante tema de saúde pública mundial. A sepse pode ser definida como síndrome de anormalidades fisiológicas, patológicas e bioquímicas induzidas por um processo infeccioso. A equipe multiprofissional de saúde deve atuar no reconhecimento precoce dos pacientes com quadro sugestivo de infecção e suas potenciais complicações, que podem culminar em síndrome séptica, estabelecendo medidas que garantam seu controle, manuseio precoce, intervenção eficaz e segura, por meio de uma assistência integral e contínua. O objetivo neste estudo foi verificar a contribuição dos Sistemas de Informação Hospitalar para a identificação precoce e o manejo da sepse em pacientes cirúrgicos de um hospital universitário. Trata-se de pesquisa com delineamento quantitativo, retrospectivo, descritivo e correlacional. A coleta de dados foi realizada por meio dos Sistemas de Informação Hospitalar, mediante aprovação do Comitê de Ética em Pesquisa. A população foi composta de 28 pacientes que atenderam os critérios de inclusão da pesquisa. Na caracterização sociodemográfica desses pacientes, constatou-se predominância do sexo masculino (17; 60,7%), brancos (26; 92,9%), com 60 anos ou mais (21; 75,0%). Quanto à análise clínica do paciente, 11 apresentaram predominância do diagnóstico oncológico (39,3%) na admissão hospitalar, assim como 24 (85,7%) tiveram histórico de somente uma internação hospitalar no período. No final do período de internação (desfecho), predominantemente 20 pacientes (71,4%) evoluíram para óbito. Quanto ao tempo de internação, 13 pacientes (46,4%) permaneceram internados por tempo superior a 30 dias, com média de 30,5 (DP=25,0), a maioria dos pacientes (18; 64,8%) passou pelo procedimento cirúrgico até o quinto dia de internação, com média de 8,25 dias (DP=15,2). Da mesma forma, apresentaram predominância de desenvolvimento dos primeiros sinais de SIRS e de disfunção orgânica também até o quinto dia de internação 19 pacientes (67,8%), com média de 5,2 dias (DP=4,8), e 15 (53,6%), com média de 9,14 dias (DP=12,23), respectivamente. A confirmação ou hipótese do diagnóstico de sepse ocorreu até o décimo dia de internação com 15 pacientes (53,5%), com média de 11,6 (DP=13,4). Na análise da evolução dos pacientes para óbito, identificou-se significância estatística em relação à idade, à especialidade do diagnóstico na admissão e ao tempo de internação. O conteúdo dos registros realizados diariamente pela equipe multidisciplinar evidenciou que os primeiros sinais de SIRS foram identificados, predominantemente, no sistema de monitorização dos pacientes (26; 92,9%), enquanto os primeiros sinais de disfunção orgânica foram descritos nas evoluções da equipe de enfermagem (24; 85,7%). Os resultados evidenciam a importância da qualidade dos registros de enfermagem nos Sistemas de Informações Hospitalares, para identificação dos riscos, reconhecimento precoce e manejo adequado da sepse em pacientes submetidos a procedimentos cirúrgicos, enquanto integrantes da equipe multidisciplinar, visando o alcance de maior efetividade das ações de gerenciamento dos processos de assistência à saúde / Hospital information systems can be defined as an integrated network of information, designed to manage assistance, administrative and legal aspects in healthcare organizations. In the context of the quest for quality improvement in health care, provided by the significant advances of information and communication technologies, the need of sepsis as an important theme of global public health. Sepsis can be defined as abnormalities syndrome, pathological and physiological biochemical induced by an infectious process. The multidisciplinary team of health should act in the early recognition of patients with suggestive of infection and its potential complications, which can lead to septic syndrome, establishing measures to ensure the control, early intervention handling effective and safe, through a full and continuous assistance. The objective of this study was to verify the contribution of hospital information systems for early identification and management of sepsis in surgical patients in a university hospital. This is a quantitative, descriptive, retrospective and correlational research. The data collection was performed through hospital information systems, subject to the approval of the Research Ethics Committee. The population was composed of 28 patients who attended the inclusion criteria of the survey. In demographic characterization of these patients, there was a predominance of males (17; 60.7%), white (26; 92.9%), 60 years or older (21; 75.0%). For the clinical analysis of patient, 11 showed predominance of oncological diagnostics (39.3%) in hospital admission, as well as 24 (85.7%) had a history of only one hospitalization. At the end of the period of hospitalization (outcome), predominantly 20 patients (71.4%) evolved to death. Regarding length of stay 13 patients (46.4%) remained hospitalized for more than 30 days, with an average of 30.5 (SD = 25.0), most patients (18; 64.8%) passed the surgical procedure until the fifth day of hospitalization, averaging 8.25 days (SD = 15.2). Similarly, showed a predominance of development of the first signs of SIRS and organic dysfunction, too, until the fifth day of hospitalization 19 patients (67.8%), with an average of 5.2 days (DP = 4.8), and 15 (53.6%), with an average of 9.14 days (SD = 12.23), respectively. Confirmation or chance of diagnosis of sepsis occur until the tenth day of hospitalization with 15 patients (53.5%), with an average of 11.6 (SD = 13.4). In the analysis of the evolution of the patients to death, statistical significance was identified in relation to age, the speciality of the diagnosis on admission and length of stay. The contents of the records held daily by the multidisciplinary team showed that the first signs of SIRS were identified, predominantly, in the system of monitoring of the patients (92.9%), while 26; the first signs of organic dysfunction were described in the evolutions of the nursing staff (24; 85.7%). The results highlight the importance of the quality of nursing records in hospital information systems, to identify the risks, early recognition and appropriate management of sepsis in patients undergoing surgical procedures, while members of the multidisciplinary team, aiming at the achievement of greater effectiveness of the actions of management of care processes health

People with severe mental illness experience medical comorbidities to a greater extent than the general population. When hospitalized in general hospital settings, they experience poorer outcomes and are experienced as difficult by nurses. An understanding of the experience of hospitalization from the patient's perspective is important to improving care and outcomes for this population. The purpose of this study was to explore the lived experience of nonpsychiatric hospitalization for persons with severe mental illness. Heideggarian phenomenology provided the philosophical underpinning and informed the methodology employed. Participants were recruited through mental health providers. Ten individuals with severe mental illness participated in minimally structured interviews and described their experience of hospitalization on a medical-surgical unit. Data, including transcribed interviews and field notes, were analyzed within the hermeneutic tradition as described by Cohen et al. (2000). The lived experience of nonpsychiatric hospitalization was expressed in four themes: taking care of me (subthemes: being cared for, not being cared for), it's my life, on my toes (subthemes: needing an advocate, managing my mental health), and being a good patient. Care providers' comportment, perception of the patient's illness, attentiveness, responsiveness, and personalized caring behaviors characterized the participant experience of being cared for or not being cared for. It's my life reflected participants' desire to be informed and involved so they could contribute to their recovery. Participants felt the need to be on my toes in order to look out for and advocate for themselves. The need to be on my toes extended to the management of a chronic illness while hospitalized for an unrelated acute condition. The final theme reflected the perceived patient role obligation to be a "good patient". Findings were consistent with the literature regarding experiences of hospitalization from the perspective of persons without mental illness. Identified themes emphasize the critical importance of the nurse-patient relationship to the patient experience. There are significant implications for how nurses come to know their patients in medical-surgical settings so that they can effectively personalize care. Reflective practices may empower nurses to solicit assistance and support to improve caring practices / text

No description available.

The problem of this study was to ascertain (a) the teaching practices of medical-surgical nursing teachers in the clinical laboratory of baccalaureate nursing schools in the State of Texas, and (b) some variables possibly associated with these practices.

Estudo quantitativo, transversal, prospectivo, realizado com o objetivo de analisar os efeitos da alocação de pessoal e da carga de trabalho de enfermagem nos resultados da assistência em duas unidades de internação (UIs) médico-cirúrgicas, com 20 e 15 leitos cada, denominadas respectivamente UI-A e UI-B, de um hospital do município de São Paulo. Utilizou-se uma metodologia capaz de abranger 87% da variação dos cuidados requeridos pelos pacientes, composta por itens que incluem a dimensão biológica e psicossocial do cuidado: o Patient Focused Solutions/Workload Measurement-Inpatient Methodology (PFS/WM-IM). Foram considerados indicadores de resultado: queda, erro de medicação, retirada não programada de sondas, cateteres ou drenos, úlcera por pressão (UP), infecção urinária (ITU) e pneumonia desenvolvidas durante a internação hospitalar. Os dados foram obtidos dos prontuários e dos registros da Comissão de Controle de Infecção Hospitalar, além da escala diária de pessoal de enfermagem. Após 47 dias consecutivos de coleta de dados, a amostra final foi composta por 387 pacientes - 218 na UI-A e 169 na UI-B. Com distribuição eqüitativa de pacientes do gênero masculino e feminino, predominaram os idosos com 61 anos ou mais (38,5% na UI-A e 36,1% na UI-B), submetidos a tratamento cirúrgico eletivo (62,8% na UI-A e 56,8% na UI-B) e média de internação de 6,0 (+-25,1) dias na UI-A e de 4,6 (+-7,2) dias na UI-B. A maioria dos pacientes da UI-A foi proveniente da residência (52,3%); na UI-B do pronto atendimento (47,3%), seguido pela residência (37,3%). Após a alta, 85,3% dos pacientes da UI-A e 87,6% da UI-B retornaram à residência. Com relação à ocorrência de eventos adversos (EAs), na UI-A, 14 pacientes (6,4%) sofreram 23 EAs (9, 3 e 2 pacientes foram vítimas de 1, 2 e 4 eventos, respectivamente, sendo 13 retiradas não programadas de sondas, cateteres ou drenos, 8 erros de medicação, 1 UP e 1 ITU). Na UI-B 12 pacientes (7,1%) sofreram 13 EAs, ou seja, 11 pacientes sofreram 1 EA e 1 foi vítima de 2 EAs, sendo 10 erros de medicação, 2 retiradas não programadas de sondas, cateteres ou drenos e 1UP. Os pacientes foram classificados predominantemente nas categorias 1, 2 e 3 (baixa e intermediária complexidade), alocados em unidades adequadas para o cuidado requerido – as unidades de internação. Havia em média 1 enfermeiro para cada unidade e cada auxiliar de enfermagem cuidou de, no máximo, 5 pacientes. A média de horas de enfermagem disponível foi maior do que o recomendado pelo PFS/WM-IM, respectivamente 7 e 5,8 h na UI-A e 6,2 e 4,9h na UI-B (p<0,001). No período analisado, apesar do excedente de pessoal de enfermagem nas UIs A e B, houve ocorrência de EAs. Os resultados deste estudo se contrapõem, portanto, às solicitações freqüentes de enfermeiros por maior quantidade de pessoal e apontam para a necessidade de novas investigações que complementem as análises realizadas, não só para as UIs médico-cirúrgicas, mas para todas as unidades do hospital / This was a quantitative, transversal, prospective study, performed with the objective of analyzing the effects of nursing personnel allocation and workload on assistance results in two medical-surgical units (MSUs), with 20 and 15 beds each, respectively named MSU-A and MSU-B at a hospital in the city of São Paulo. The methodology used was capable of comprehending 87% of the range of the care required by the patients; it was a compound of items that included a biological and psychosocial dimension of care: Patient Focused Solutions/Workload Measurement-Inpatient Methodology (PFS/WM-IM). Result indicators considered were: falling, medication errors, non-scheduled probe, catheter or drain removals, pressure ulcers (PU), urinary tract infections (UTI) and pneumonia developed during the hospital care. The data were obtained from medical reports and registers of the Commission for Hospital Infection Control, as well as the daily work schedule of the nursing personnel. After 47 consecutive days of data collection, the final sample had 387 patients - 218 in MSU-A and 169 in MSU-B. Having equal quantities of male and female patients, it had a prevalence of elderly patients with 61 years or more (38.5% in MSU-A and 36.1% in MSU-B), patients who were undergoing surgical elective treatment (62.8% in MSU-A and 56.8% in MSU-B) and those with an average number of internment days of 6.0 days (+-25.1) in MSU-A and of 4.6 days (+-7.2) in MSU-B. Most of the patients of MSU-A came from their homes (52.3%); whereas in MSU-B most of them came from emergency room facilities (47.3%), followed by those who came from home (37.3%). After the discharge, 85.3% of the patients of MSU-A and 87.6% of MSU-B returned to their homes. With respect to occurrences of adverse events (AEs), in MSU-A, 14 patients (6.4%) suffered 23 AEs (9, 3 and 2 respectively had 1, 2 and 4 events, among of them there were: 13 non-scheduled probe, catheter or drain removals, 8 medication errors, 1 PU and 1 UTI). In MSU-B, 12 patients (7.1%) suffered 13 AEs, that is, 11 patients had 1 AE and 1 had 2 AEs, in that 10 were medication errors, 2 non-scheduled removals of probes, catheters or drains and 1 PU. The patients predominantly fitted in the categories 1, 2 and 3 (low and medium complexity), allocated in units proper for the required care – the medical surgical units. There was an average of 1 nurse for each unit and each nursing assistant took care of a maximum of 5 patients. The average number of nursing hours available was higher than those recommended by PFS/WM-IM, respectively 7 and 5.8 hours in MSU-A and 6.2 and 4.9 hours in MSU-B (p<0,001). Despite the excess of nursing personnel in MSU-A and MSU-B, AEs occurred. Therefore, the results of this study oppose frequent requirements of nurses for more personnel and point to a necessity of new research to complement the herein made analysis, not only for medical-surgical units, but also for every unit in the hospital

Millions of people in the United States are living with a serious mental illness or substance abuse disorder. These individuals suffer from a high rate of medical co-morbidities. Because of this, patients hospitalized on medical-surgical units for medical reasons often are living with psychiatric/substance abuse co-morbidities, which are not addressed during their medical hospital admission. These patients can be perceived as difficult and even dangerous by nurses who have not received training or education in mental health care. The purpose of this project is to measure medical-surgical nurse’s perceptions of their abilities to recognize psychiatric/substance abuse symptoms and their perception of self-competency to provide appropriate interventions. This project utilized the Behavioral Health Care Competency (BHCC) instrument to measure hospital nurse perceptions of behavioral healthcare competency to determine if additional education and training are needed. The BHCC tool was administered to 19 nurses working on two medical-surgical units in Southern Arizona. Findings support the need for educational intervention, especially in the areas of psychotropic medication recommendation and intervention for patients experiencing hallucinations.

Os Sistemas de Informação Hospitalar podem ser definidos como uma rede integrada de informações, projetada para gerenciar aspectos assistenciais, administrativos e jurídicos em organizações de saúde. No contexto da busca pela melhoria da qualidade na assistência à saúde, proporcionada pelos avanços significativos das tecnologias da informação e comunicação, insere-se a necessidade da abordagem da sepse enquanto importante tema de saúde pública mundial. A sepse pode ser definida como síndrome de anormalidades fisiológicas, patológicas e bioquímicas induzidas por um processo infeccioso. A equipe multiprofissional de saúde deve atuar no reconhecimento precoce dos pacientes com quadro sugestivo de infecção e suas potenciais complicações, que podem culminar em síndrome séptica, estabelecendo medidas que garantam seu controle, manuseio precoce, intervenção eficaz e segura, por meio de uma assistência integral e contínua. O objetivo neste estudo foi verificar a contribuição dos Sistemas de Informação Hospitalar para a identificação precoce e o manejo da sepse em pacientes cirúrgicos de um hospital universitário. Trata-se de pesquisa com delineamento quantitativo, retrospectivo, descritivo e correlacional. A coleta de dados foi realizada por meio dos Sistemas de Informação Hospitalar, mediante aprovação do Comitê de Ética em Pesquisa. A população foi composta de 28 pacientes que atenderam os critérios de inclusão da pesquisa. Na caracterização sociodemográfica desses pacientes, constatou-se predominância do sexo masculino (17; 60,7%), brancos (26; 92,9%), com 60 anos ou mais (21; 75,0%). Quanto à análise clínica do paciente, 11 apresentaram predominância do diagnóstico oncológico (39,3%) na admissão hospitalar, assim como 24 (85,7%) tiveram histórico de somente uma internação hospitalar no período. No final do período de internação (desfecho), predominantemente 20 pacientes (71,4%) evoluíram para óbito. Quanto ao tempo de internação, 13 pacientes (46,4%) permaneceram internados por tempo superior a 30 dias, com média de 30,5 (DP=25,0), a maioria dos pacientes (18; 64,8%) passou pelo procedimento cirúrgico até o quinto dia de internação, com média de 8,25 dias (DP=15,2). Da mesma forma, apresentaram predominância de desenvolvimento dos primeiros sinais de SIRS e de disfunção orgânica também até o quinto dia de internação 19 pacientes (67,8%), com média de 5,2 dias (DP=4,8), e 15 (53,6%), com média de 9,14 dias (DP=12,23), respectivamente. A confirmação ou hipótese do diagnóstico de sepse ocorreu até o décimo dia de internação com 15 pacientes (53,5%), com média de 11,6 (DP=13,4). Na análise da evolução dos pacientes para óbito, identificou-se significância estatística em relação à idade, à especialidade do diagnóstico na admissão e ao tempo de internação. O conteúdo dos registros realizados diariamente pela equipe multidisciplinar evidenciou que os primeiros sinais de SIRS foram identificados, predominantemente, no sistema de monitorização dos pacientes (26; 92,9%), enquanto os primeiros sinais de disfunção orgânica foram descritos nas evoluções da equipe de enfermagem (24; 85,7%). Os resultados evidenciam a importância da qualidade dos registros de enfermagem nos Sistemas de Informações Hospitalares, para identificação dos riscos, reconhecimento precoce e manejo adequado da sepse em pacientes submetidos a procedimentos cirúrgicos, enquanto integrantes da equipe multidisciplinar, visando o alcance de maior efetividade das ações de gerenciamento dos processos de assistência à saúde / Hospital information systems can be defined as an integrated network of information, designed to manage assistance, administrative and legal aspects in healthcare organizations. In the context of the quest for quality improvement in health care, provided by the significant advances of information and communication technologies, the need of sepsis as an important theme of global public health. Sepsis can be defined as abnormalities syndrome, pathological and physiological biochemical induced by an infectious process. The multidisciplinary team of health should act in the early recognition of patients with suggestive of infection and its potential complications, which can lead to septic syndrome, establishing measures to ensure the control, early intervention handling effective and safe, through a full and continuous assistance. The objective of this study was to verify the contribution of hospital information systems for early identification and management of sepsis in surgical patients in a university hospital. This is a quantitative, descriptive, retrospective and correlational research. The data collection was performed through hospital information systems, subject to the approval of the Research Ethics Committee. The population was composed of 28 patients who attended the inclusion criteria of the survey. In demographic characterization of these patients, there was a predominance of males (17; 60.7%), white (26; 92.9%), 60 years or older (21; 75.0%). For the clinical analysis of patient, 11 showed predominance of oncological diagnostics (39.3%) in hospital admission, as well as 24 (85.7%) had a history of only one hospitalization. At the end of the period of hospitalization (outcome), predominantly 20 patients (71.4%) evolved to death. Regarding length of stay 13 patients (46.4%) remained hospitalized for more than 30 days, with an average of 30.5 (SD = 25.0), most patients (18; 64.8%) passed the surgical procedure until the fifth day of hospitalization, averaging 8.25 days (SD = 15.2). Similarly, showed a predominance of development of the first signs of SIRS and organic dysfunction, too, until the fifth day of hospitalization 19 patients (67.8%), with an average of 5.2 days (DP = 4.8), and 15 (53.6%), with an average of 9.14 days (SD = 12.23), respectively. Confirmation or chance of diagnosis of sepsis occur until the tenth day of hospitalization with 15 patients (53.5%), with an average of 11.6 (SD = 13.4). In the analysis of the evolution of the patients to death, statistical significance was identified in relation to age, the speciality of the diagnosis on admission and length of stay. The contents of the records held daily by the multidisciplinary team showed that the first signs of SIRS were identified, predominantly, in the system of monitoring of the patients (92.9%), while 26; the first signs of organic dysfunction were described in the evolutions of the nursing staff (24; 85.7%). The results highlight the importance of the quality of nursing records in hospital information systems, to identify the risks, early recognition and appropriate management of sepsis in patients undergoing surgical procedures, while members of the multidisciplinary team, aiming at the achievement of greater effectiveness of the actions of management of care processes health