Construção de instrumentos para a documentação do processo de enfermagem em uma clínica de doenças infectocontagiosas

Abstract

Introduction: in Brazil, the infectious and contagious diseases still represent a public health problem, mainly by the meaningful morbidity indexes, when compared to the ones of mortality. Thus, it is observed the importance of qualification of the nurse in service to the patient with infectious and contagious disease, observing his autonomy to evaluate the assistential necessities of the client in an efficient way.It is important that the care of nursing be based in a theoretical model and in the scientific methodology of the process of nursing, as well as registered, being a source of information.In this study, we chose using the concept model Human Basic Needs of Horta, which besides being one to the most spread in allthe country, it is adjustable to the service in the clients chosen, and it is the theoretical model adopted by the hospital where the study was developed. Objective: build up instruments for documentation of the processof nursing in a clinic with infectious and contagious diseases. Methodology: it is a methodological research, performed in the Clinic of Infectious and contagious diseases of the University Hospital LauroWanderley, in the city of João Pessoa PB. It was developed into three phases: identification of the empiric indicators of Basic Human Needs; validation of content of the empiric indicators for construction of the instrumentof data collection; and relationship of empiric indicators of the instrument of data collection with the nomenclature of diagnostic, results and intervention for the construction of the instrument of planning of the assistance. Results: the empiric indicators of the Basic Human Needs were identified from the bank of terms, of the nomenclature of diagnostic, results and interventions of nursing of the clinic of infectious and Contagious Diseases and of the literature updated in the area. The validation of the content in the empiric indicators happened with assistance nurses and professors who work in the Clinic of Infectious and Contagious Diseases.With the validated indicators, a instrument of data collection was build, organized according to the Basic Human Needs of Horta. The empiric indicators validated were also correlated with the nomenclature of the clinic, aiming to identify diagnostics, results and interventions of nursing for the construction of the instrument of planning of the assistance. Conclusion: this research brought big contribution for the Clinic of Infectious and contagious diseases, once there were not instruments that registered the process of nursing. Itis an obligation to point that these instruments will provide a support for the communication and the register of the assistance, making it more effective and promoting a bigger visibility by this part of the team of nursing and of the professionals of other areas.