Construção e validação de um padrão de registro para implementação do processo de enfermagem em um setor de urgência e emergência

Abstract

The Nursing Process (NP) is essential to ensure safe and effective care. However, itsimplementation faces challenges, particularly in high-demand and dynamic settings such asemergency and urgency departments. This study proposed a mapping between the ManchesterTriage System (MTS) and the languages of NANDA-International, Nursing OutcomesClassification (NOC), and Nursing Interventions Classification (NIC). The goal was to developand validate a standardized record that simplifies and accelerates the application of the NP inhigh-priority patients (red and orange classifications), benefiting both healthcare professionalsand patients. This methodological study used a descriptive and qualitative approach,characterized by a participatory and intensive interface. The Consolidated Criteria forReporting Qualitative Research (COREQ) guided the study's framework. The research wasconducted in the Emergency Department of the Regional Hospital of the West in Chapecó,Santa Catarina, between May and September 2024, with seven nurses selected throughconvenience sampling. Data collection occurred in six phases: first, sociodemographic datacollection and analysis of the prevalence of red and orange MTS flowcharts; second, dataorganization and cross-mapping with NANDA-I, NOC, and NIC taxonomies; third, validationof the developed record by participating nurses; fourth, refinement of the record based on thenurses' suggestions; fifth, final validation by the president of the Nursing Process Commission(COMPENF); and sixth, final refinement and presentation of the record to the COMPENF andthe service coordinator. Data analysis followed Bardin's content analysis methods, groupingdata based on clinical relevance and frequency. The study adhered to strict ethical principles,with participants providing informed consent and respecting Resolution No. 466/12. The resultsyielded a standardized record organized into four categories: 1) situations affecting spontaneousbreathing and/or tissue oxygenation; 2) situations affecting consciousness level and behavior;3) health situations affecting comfort; and 4) situations affecting volemia. These categoriesaimed to focus on the affected health condition in light of the selected discriminators andflowcharts, as well as the priority nursing diagnoses, outcomes, and interventions for thesesituations. The study demonstrated that the employed methodology enabled the creation andvalidation of a practical and sector-aligned standardized record with active nurse participation.Nonetheless, challenges such as professional overload and a lack of understanding regardingthe study's relevance were noted, highlighting the need to raise awareness of the benefits of theNP. Given the literature gaps on the application of NANDA, NIC, and NOC taxonomies inhigh-complexity contexts, the study recommends implementing strategies to facilitate thegradual application of the NP, such as digitizing and standardizing records, to enhance carequality, patient safety, and work organization while ensuring legal support for professionals andcontinuity of care.