As a consequence of the quick development of information technologies there has been a natural and gradual transition to the electronic data storage in nursing. The firstversions of the software application for such documentation have been developed in cooperation with professionals dealing with information technologies in the States of the European Union and it is the nurses who decide what the content of the nursing documentation will be. Therefore it is very important that the nurses {--} as the main users of this software {--} are actively involved in the creation process of the electronic nursing documentation. The advantage of introducing the electronic nursing documentation is filing of the important data about a client in the NIS where it is possible to retrieve the history anytime. In contrast to the traditional records, it is easier to read these records and it is not possible to cross any information out or lose it. Further, it saves nurses{\crq} time, it automatically records time and name of the medical worker who logged in the NIS and it meets the recommendations of the accreaditation standards. A qualitative research was used in the research part of this thesis. A semi-standardized interview with the head nurses and a structured interview with the senior staff nurses and ward sisters of the departments of internal medicine and of surginal wards of the selected hospitals were used to collect the data. Further, the method of content analysis was used to compare the electronic nursing documentation in the individua surveyed hospitals. The structured interview with the senior staff nurses and ward nurses was not done in the Hospital České Budějovice, a.s. because the programme of the electronic nursing documentation has not been started there. Case reports are created based on the gained interview results. The case reports comprise the research base on which categorized charts in which the research results are recorded are based. The research was conducted from January till June 2009. The surveyed group consists of head nurses, two senior staff nurses and two ward sisters of the departments of internal medicine and of surginal wards of the selected hospitals of the chosen regions of the Czech Republic. The research was conducted in the South Bohemian Region {--} the Hospital České Budějovice, a.s., the Pilsen Region {--} the Teaching Hospital Plzeň, the South Moravian Region {--} the Teaching Hospital Brno and the Vysočina Region {--} the Hospital Jihlava, p.o. Four research questions were defined at the beginning of our research in order to achieve our goal. The research questions 1: Does the electronic nursing documentation contain all phases of the nursing process (anamnesis, diagnosis, care plan and assessment)? The research questions 2: Is the nursing taxonomy a part of the electronic nursing documentation of each patient? How is the record of the nursing diagnosis created (crossing x filling in)? The research questions 3: Which nursing model has become the basis for the nursing anamnesis of the electronic nursing documentation? The research questions 4: Can the nurses take an active part in the preparation process of the electronic nursing documentation? All our research questions have been answered. We defined the following hypotheses based on the results of our research: H1: The electronic nursing documentation contains nursing anamnesis based on the Marjory Gordon{\crq}s conceptual model. H2: The nurses are offered to cooperate in the creation process of the electronic nursing documentation. H3: There is a taxonomy part in the nursing documentation. H4: The electronic nursing documentation covers all phases of the nursing process. We belive that the results of he

The nursing handover report belongs to everyday activities of nurses. In the work of a nurse it is important to know exactly who, when, where, what and how. This is what the following activity and responsibilities of the duty period are derived from. This diploma thesis, focused on the Nursing Handover Report at a Patient´s Bedside, has a theoretical and practical part. The first, theoretical part, is composed of three chapters, the modern trend of nursing, the nursing report and legislation. The second, practical part, is based on quantitative and qualitative surveys with three defined objectives and four hypotheses. The first objective was to determine what nurses regard as a major contribution of the nursing handover report at a patient´s bedside. The second objective was to define the greatest obstacle in the nursing handover report at a patient´s bedside. The third objective was assessing the patients´ attitude towards the nursing handover report at their bedside. All three objectives were met by the research. The qualitative part of this diploma work was based on a conducted kvasiexperiment and subsequent questions for patients and nurses. The research sample was 5 nurses and 5 patients from the intermediate care unit (IMCU) and 5 nurses and 5 patients from the resuscitation station (RES) of the České Budějovice hospital, PLC. The semi-structured interview consisted of six to eight questions, surveying the feelings, contents, visualization, integration, advantages, disadvantages, departments, nursing handover at the bedside and the quality. The data collection was carried out by means of an anonymous questionnaire designed for nurses to find out how nurses hand the report over or how they would like to hand it over. 303 nurses from the České Budějovice Hospital, PLC, and the Příbram Hospital, PLC, took part in the research. The results were used to confirm or to reject the hypotheses. The first hypothesis: Nurses do not consider an oral handover report as a quality one when done without a visual completion, this has not been confirmed by the investigation. The second hypothesis: In terms of the risk of the patient's damage, the quality of the handover report done by the nurses in the IMCU and the RES is better than that done by the nurses in a standard unit, this has been confirmed. The third hypothesis: Nurses consider the time consuming nature of the handover report at the patient´s bedside as the greatest difficulty, this has not been confirmed. The fourth and last hypothesis: Patients have a positive attitude towards the nursing handover report at the bedside, this has been confirmed by the research. The output of this thesis is to suggest a standard for the nursing handover report at a patient´s bedside. The results can be used for nursing managers, deputy directors of nursing, medical students and nursing professionals.

Methodological study, whose objective was to bluid validate the content and appearance of a new version of the instrument for Nursing Consultation in Basic Care for individuals with diabetes mellitus type 2 in Basic Care. The study had as a theoretical framework the Theory of Praxis for Intervention in Collective Health (TPICH) by Emiko Egry. The methodological procedure was based on Pascali's theoretical pole of the psychometric model (2010). In this study of the instrument was developed using the International Classification for Nursing Practice - CIPE® Version 2015. This new version was applied in 21 people with diabetes mellitus type 2 who were registered in a Family Health Unit, in the municipality of Aracaju, in Sergipe; this action constituted the pretest phase. At the end of this stage, the instrument with 122 items went down to 99 items, which were submitted to a panel of eleven judges to validate their content and appearance. Using a Likert scale of three points, the judges evaluated each item regarding their permanence in the instrument; they also judged on the psychometric criteria of: objectivity, clarity, precision, typicality, simplicity, relevance, modality and credibility. Subsequently, the Content Validity Index of each of the items (CVI) was calculated. The categorical data were described by means of simple frequencies and percentages and the continuous or discrete data with average and standard deviation. In this study, the content validity of the items was considered when CVI ≥ 0.80, this according to the methodological referential. The results showed that eight items (local of work protected, police service, insomnia, self-perception, psychological condition, eye disturbances, cut nails and foot with blisters) obtained CVI ˂0.80; the first six items were removed from the instrument, while the last two items remained subitems due to the importance of their assessments in individuals with diabetes mellitus type 2. All other items stayed as they were or with the alterations suggested by the specialists. In validating the appearance, 100% of the judges approved the instrument to collect the data in individuals with diabetes mellitus type 2. The suggestions of the judges were accepted in their majority; therefore, a new evaluation was not necessary. To guide the evaluation actions of nurses, in a homogeneous and unequivocal way, it was written an appropriate instruction guide. In this way, it was found that this new version of the instrument has validity of content and appearance. In order to have a technology that can be reproduced in various nursing services of Basic Care with this we will contribute to the organization of the work process of nurses, granting them autonomy and visibility in their practice. / Estudo metodológico, cujo objetivo foi construir e validar o conteúdo e a aparência do instrumento para a consulta de enfermagem ao indivíduo com diabetes mellitus tipo 2 na Atenção Básica. Teve como marco teórico a Teoria da Intervenção Práxica em Saúde Coletiva de Emiko Egry, e no percurso metodológico foi utilizado o polo teórico do modelo psicométrico de Pasquali (2010). Neste estudo foi desenvolvido um instrumento utilizando a Classificação Internacional para a Prática de Enfermagem - CIPE® Versão 2015. O instrumento foi aplicado em 21 pessoas com diabetes mellitus tipo 2 cadastradas em uma Unidade de Saúde da Família do município de Aracaju, Sergipe, o que se constituiu na fase de pré-teste. Ao término dessa etapa, o instrumento que contava com 122 itens, passou a ter 99 itens, que foram submetidos a um painel de onze especialistas para apreciação do seu conteúdo e aparência. Os especialistas avaliaram cada item quanto à sua permanência no instrumento utilizando uma escala de Likert de três pontos. Também fizeram o julgamento quanto aos critérios psicométricos de objetividade, clareza, precisão, tipicidade, simplicidade, relevância, modalidade e credibilidade. Posteriormente foi calculado o Índice de Validade de Conteúdo de cada um dos itens (IVC). Os dados foram descritos por meio de frequências simples e percentagens, quando categórica, e média e desvio padrão quando, contínua ou discreta. A validade de conteúdo dos itens neste estudo foi considerada quando IVC ≥ 0,80, conforme referencial metodológico. Os resultados mostraram que oito itens (local de trabalho protegido, serviço policial, insônia, percepção sobre si próprio, condição psicológica, distúrbios oculares, unhas cortadas e pé com bolhas) obtiveram IVC˂0,80, os seis primeiros itens foram retirados do instrumento, enquanto os dois últimos permaneceram como subitens devido à importância de suas avaliações no indivíduo com diabetes mellitus tipo 2. Os demais itens permaneceram na íntegra ou com as alterações sugeridas pelos especialistas. Na validação de aparência, 100% dos especialistas aprovaram o instrumento para realização da coleta de dados. Acatou-se a maioria das sugestões dos especialistas sendo desnecessária nova avaliação. Elaborou-se um guia instrucional para nortear as ações de avaliação do usuário de modo homogêneo e inequívoco pelos enfermeiros. Sendo assim, evidenciou-se que a nova versão do instrumento possui validade de conteúdo e aparência, constituindo-se em uma tecnologia passível de ser reproduzida nos diversos serviços de enfermagem da Atenção Básica, com vistas a contribuir para a organização do processo de trabalho dos enfermeiros, conferindo autonomia e visibilidade a sua prática. / Aracaju

Made available in DSpace on 2014-07-29T15:04:44Z (GMT). No. of bitstreams: 1 Dissertacao Cristiane Longo Enfermagem.pdf: 1066583 bytes, checksum: 60b7dfd769cb9d52b2603e69e753f934 (MD5) Previous issue date: 2008-12-22 / The humanization of delivery and childbirth assistance regards actions in which women put in action their right to choose a companion, who will be more active in the birth process, giving physical and emotional support, reminding the roots when women gave birth in their familiar environment. The importance of the companion/father in childbirth is recognized but his acceptance as part of the routine has been being discussed. The objectives of this study were: To identify the profile of the fathers who participated of their children birth; to describe how the father experienced his child birth, and to describe the mother s feelings related to the father s presence. It is a qualitative exploratory research, and semi-structured interviews were used to collect the data. The population of this study corresponds to the mothers and their respective companions/fathers, totalizing 10 couples. The analysis of the collected data enabled the identification of four thematic categories: participants characterization; the companion s experience in the process of birth; the mother s perceptions; the professionals as an indicator of quality in the parturition. When the parents who shared their child birth were identified, we were able to know their social characteristics and their expectations about delivery and birth moments. When we described how the father experienced the moment of their child birth we verified that the traditional father s role is changing. The fathers wanted to be present, they gave verbal support, they provided continuous visual contact, and they felt the emotion. Each mother described their perception of the father s participation in a particular way; however, they recognized the benefits of receiving the father s support, what contributed with elements to materialize the paternity and to strengthen affective ties. The couples evaluated positively the experience, and the companions´ role was effective, satisfying both mothers and fathers´ expectations. The birth humanization involves many possibilities of parturition, and it offers a qualified and flexible assistance centered at the person and at the family, using appropriate technology. Among these technologies, a good interpersonal relationship has been highlighted as an indicator of the assistance quality according to the users´ evaluation. During the delivery, it is extremely important that the health professionals know the mother s and father s profiles in order to promote the assistance humanization, and to enable the experience of being and having a companion to be lived as a right / A humanização da assistência ao parto e nascimento contempla ações nas quais a mulher exerce seu direito de escolha do acompanhante, que será mais atuante em seu parto, com suporte e apoio físico-emocional, remontando às raízes quando a mulher paria em seu ambiente familiar. A importância do acompanhante/pai no parto é reconhecida, mas sua aceitação como parte da rotina ainda vem sendo discutida. Este estudo teve como objetivos: identificar o perfil de pais que participaram do nascimento do filho, descrever como o pai vivenciou o processo de nascimento de seu filho e descrever os sentimentos da puérpera com relação à presença do pai. Trata-se de uma pesquisa qualitativa, exploratória, que utilizou entrevista semiestruturada para a coleta de dados. A população deste estudo compreendeu puérperas e seus respectivos acompanhantes/pai, totalizando 10 casais. A análise dos dados coletados possibilitou a identificação de quatro categorias temáticas: a caracterização dos participantes; a vivência do acompanhante no processo do nascimento; a percepções da puérpera; e os profissionais como indicador de qualidade na parturição. Ao identificar o perfil dos pais que compartilharam juntos o nascimento de seu filho, conhecemos suas características sociais e suas expectativas acerca do momento do parto. Ao descrever como o pai vivenciou o processo do nascimento de seu filho, constatou-se que o papel tradicional do pai está em transformação. Os pais desejaram estar presente, apoiaram verbalmente, proporcionaram contato físico e contínuo, emocionaram-se. Cada puérpera descreveu seus sentimentos com relação à participação do pai com sua particularidade, mas apontaram em direção ao reconhecimento do benefício do suporte e apoio do pai, contribuindo com elementos para concretizar a paternidade e fortalecer vínculos afetivos. Os casais avaliaram a experiência positivamente e o papel de acompanhante foi efetivo, atendendo à expectativa tanto das puérperas como dos pais. A humanização do parto encerra várias possibilidades de parir e propõe uma assistência centrada na pessoa e na família, qualificada e flexível, utilizando a tecnologia apropriada. Dentre elas uma boa relação interpessoal profissional-usuário foi destacada como indicador de qualidade da assistência na avaliação dos usuários. Durante o parto, a equipe de saúde inteirar-se do perfil e das percepções do pai e da puérpera é fundamental para a humanização da assistência e para que a experiência de ser e ter um acompanhante durante a parturição no contexto institucional seja exercida como um direito

Made available in DSpace on 2016-08-03T16:34:49Z (GMT). No. of bitstreams: 1 GENY DA SILVA NASCIMENTO LISBOA.pdf: 511930 bytes, checksum: bbda0f3ffb215b0317e4ec8f9cd62b2d (MD5) Previous issue date: 2005-02-28 / The present study had as an objective to investigate the opinion of the nurse on the Systematization of the Nursing Assistance, verify the effect of the Systematization of the Nursing Assistance on the organization of the work of the nurse and identify if the Implementation of the Systematization of the Nursing Assistance causes psychical suffering in these professionals. It is about a qualitative research, carried through with 22 nurses who act in a public institution of health of the great ABCD, in the State of São Paulo. Semi structuralized interviews has been used, by means of recording of the depositions. The analysis of the data was carried through trying to apprehend the representational content of the effect of the Implementation of the Systematization of the Nursing Assistance on the Nurses. The categories of analysis under the influence of the SNA on the citizens had been: a)knowledge of the SNA: it has knowledge and it has little knowledge; b)opinion about the SNA: favorable and partially favorable; c)development of the SNA in the context of the work: it occurs partially and it does not occur; d)influence of the Implementation of the SNA on the performance of the tasks: it affects and it does not affect; e)occurrence of psychical suffering in the Implementation of the SNA: it has and it does not have direct expressions of psychical suffering. The data has disclosed that the effect of the Implementation of the Systematization of the Nursing Assistance on the Nurses causes psychical suffering, as a result of the inadequate conditions of the work to promote the Systematization of the Nursing Assistance. / O presente estudo teve como objetivos investigar a opinião do enfermeiro sobre a Sistematização da Assistência de Enfermagem, verificar os efeitos da Sistematização da Assistência de Enfermagem na organização do trabalho do enfermeiro e identificar se a Implementação da Sistematização da Assistência de Enfermagem causa sofrimento psíquico nesses profissionais. Trata-se de uma pesquisa qualitativa, realizada com 22 enfermeiros que atuam em uma instituição pública de saúde do grande ABCD, no Estado de São Paulo. Foram utilizadas entrevistas semi-estruturadas, por meio de gravação dos depoimentos. A análise dos dados foi realizada buscando apreender os conteúdos representacionais sobre os efeitos da Implementação da Sistematização da Assistência de Enfermagem nos Enfermeiros. As categorias de análise sobre a influência da SAE nos sujeitos foram: a)conhecimento sobre a SAE: tem conhecimento e tem pouco conhecimento; b)opinião sobre a SAE: favorável e parcialmente favorável; c)desenvolvimento da SAE no contexto do trabalho: ocorre parcialmente e não ocorre; d)influência da Implementação da SAE no desempenho das tarefas: afeta e não afeta; e)ocorrência de sofrimento psíquico na Implementação da SAE : há e não há expressões diretas de sofrimento psíquico. Os dados revelaram que os efeitos da Implementação da Sistematização da Assistência de Enfermagem nos Enfermeiros causam sofrimento psíquico, resultantes das condições de trabalho inadequadas para promover a Sistematização da Assistência de Enfermagem.