title: Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit.
abstract: This descriptive, retrospective study aimed to analyze the relation between nursing data collection, diagnoses and prescriptions for 26 adult patients who were hospitalized at the intense care unit of a large teaching hospital for at least 24 hours. Through the analysis of medical records, 135 diagnoses and 421 nursing prescriptions were established, and 24 different diagnosis categories and 20 different items for prescriptions were identified. The most frequent diagnosis risk was that for infection, present in the medical records of 22 (84.60%) patients, with 175 prescriptions (42%) related to this diagnosis. The data the nurses collected were sufficient to establish the nursing diagnoses, and the majority of prescriptions (87.9%) were related to the diagnoses.
authors.affiliation: University of Sao Paulo at Ribeirao Preto College of Nursing, WHO Collaborating Center for Nursing Research Development, Brazil. ecdcava@eerp.usp.br
authors.forename: Emilia Campos
authors.initials: EC
authors.lastname: de Carvalho
authors.forename: Fernanda Titareli Merizio
authors.initials: FT
authors.lastname: Martins
authors.forename: Maria Célia Barcellos
authors.initials: MC
authors.lastname: Dalri
authors.forename: Silvia Rita Marin da Silva
authors.initials: SR
authors.lastname: Canini
authors.forename: Ana Maria
authors.initials: AM
authors.lastname: Laus
authors.forename: Maria Marcia
authors.initials: MM
authors.lastname: Bachion
authors.forename: Lidia Aparecida
authors.initials: LA
authors.lastname: Rossi
mesh_terms: D000328:Adult; D003625:Data Collection; D011307:Drug Prescriptions; D006801:Humans; D007362:Intensive Care Units; D009729:Nursing / Q000706:statistics & numerical data*; D009733:Nursing Diagnosis; D012189:Retrospective Studies