[Implementation of the nursing process in a radiotherapy unit: development of a medical record].
The goal of our service is to systematize the nursing care provided to the clients with gynecological and mammary cancer who underwent radiation therapy, using the nursing process, the North American Nursing Diagnosis Association (NANDA) taxonomy and collaborative problems in the diagnoses phase. Therefore, we created a record card in which we briefly reported the relevant data to nursing care, containing: anamnesis, general explanations about treatment, main collaborative problems, nursing diagnoses, interventions, outcomes and evolution. This card was tested in service and evaluated by the group that had created it regarding content and design, enabling the elaboration of its last version that is presented in the article.
Vaz
Ana Francisca
AF
Departamento de Enfermagem da Faculdade de Ciências Médicas e Enfermeira do Programa de Educação Continuada da Divisão de Enfermagem do CAISM, Endereço: Rua: Conceição, 552-Ap. 25-Centro-CEP: 13010-050, Universidade Estadual de Campinas, Brasil.
Macedo
Denise Diniz
DD
Montagnoli
Edina Tavares de Lima
ET
Lopes
Maria Helena
MH
Grion
Regina Célia
RC
D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000451:nursing / Q000532:radiotherapy*; D005260:Female; D005833:Genital Neoplasms, Female / Q000451:nursing / Q000532:radiotherapy*; D006801:Humans; D009733:Nursing Diagnosis; D009736:Nursing Process / Q000458:organization & administration*; D009737:Nursing Records; D009859:Oncology Nursing; D011878:Radiotherapy / Q000009:adverse effects