Abstract
folder and computerized nursing 'consists of a care plan, a tool that allows the nurse to design and implement the customization of care to ensure scientific validity and should be directed to a process and a conceptual model used as a reference.
The nursing process is "a guide default, but flexible in the planning, implementation and evaluation of effective assistance." The dynamism and the cyclical nature of the process allows, through its documentation in the care plan, to provide a means of assessment, planning and constant comparison of results favoring the continuity, quality and collaboration within the team in flexible manner, but organized.
Our reference model and 'revision of the conceptual model of Gordon by Carpenito.
E 'in profile professional nurse (DM No. 739 of 1994) which is enshrined in law the responsibility of the nurse: the nurse involved in the identification of health needs of the individual and the community, identifies the needs of nursing care of the person and the community and make its goals, plans, manages and evaluates the nursing care intervention, ensures the correct application of diagnostic and therapeutic.
The process of nursing care and 'divided into four phases:
1) Establishment of Policy Analysis
activation
2) Planning
Definition diagnosis diagnosis related factor
Identification Identification Identification
goal choice interventions NOC
3) Implementation of intervention
4) Evaluation
1) The Establishment
Working Group 10 of the ASL has worked to create standards related to pathology findings: when the doctor inserts a diagnosis for admission automatically generated findings that investigate the nursing diagnosis most often, this in order to concentrate more efforts to those problems common to specific diseases. In literature (Carpenito) is present if the nursing diagnosis-defining features are present, evidence that the nurse has to take into account in formulating his diagnosis, then diagnostic reasoning is a form of circumstantial thinking where the preparation and subjectivity have a large weight. To speed up the investigation and to standardize the behavior, the group has identified a directory parameter in the diagnosis always called criterion of activation. The nurse performing the assessment will analyze the various criteria for activation, which was divided for models when the criterion of activation is altered, the message appears to automatic diagnosis and do choose whether or not display on the ground. When the diagnosis is activated, the nurse should not have to choose related factor, goal and intervention, after that 'intervention will be selected automatically in the daily activity plan.
To better understand the criterion of activation, the cornerstone of our planning, we display a part of the investigation above nursing: the ones highlighted in yellow are the criteria for models and video clips. For example, in nutrition and metabolism have difficulty in swallowing: If we believe that the patient has swallowing difficulties we must not do anything but run the Timed water swallow and if this test is positive diagnosis will be activated automatically. Thus in model elimination: if a patient does not evacuate more than three days will be activated in the diagnosis of constipation, but if there are more than three liquid stools / day activates the diagnosis of diarrhea. All this happens in other models for other nursing diagnoses
2) Clinical Path
The clinical path is the tool that allows us to manage those actions agreed upon in advance between the various professionals. In our portfolio, at the time of medical diagnosis, it automatically will generate the targeted disease and individual actions will be automatic in our daily business plan.
3) Update
nursing interventions that do not generate the nursing diagnoses and clinical path must be written in the update: this data automatically will go into nursing journal and views (list present in the department with information relevant to the management of 'assistance)
4) Plan activities daily
In this space we have the opportunity to work on interventions related to nursing diagnoses and those related to the clinical path. The nurse has three options: to perform the surgery, advise it in the next round, or possibly leave it in stand-by.
5) Diary nursing
All work will be automatically in 24 hours of nursing diary, a document in which we see all actions grouped by day. The documentation of the entire process is assistance, the reality today, the best way for you to plan the work in the business units to follow paths of nursing and acting quality can be measured, evaluated, compared and modified in the pursuit of principles such as effectiveness, efficiency and appropriateness of care.
6) Surveying
This page allows you to enter vital signs, maneuvers and operations performed on the patient, those related to abnormal activation leading to activation criteria for the diagnosis resulting in the generation of steep linked.
The program asks if you confirm the activation of the diagnosis: if "we" must 'choose the related factor, the NOC, the intervention goal.
parameters also have the opportunity to be compared or to be assessed through a chart
7) View of the patients
list of patients on the ward with all the data needed by managers:
this instrument is the change of turn or in the management of daily activities.
data entry can be modified according to the needs of different realities. The folder
nursing has two other very important parts, one is a sheet where we can find the examinations if the examination is being or has been done and then view it, the other is the sheet discharge nursing that grants us continuity with the territory.
