Nursing process in the care of patients with surgical wounds healing by secondary intention

Abstract

Objective: To analyze nursing records regarding the inclusion of nursing process steps in the medical records of patients with wounds. Method: Cross-sectional study that uses documentary analysis carried out in a teaching hospital, in the state of Goiás, from March to June 2016. The sample consisted of 180 patient care record cards from individuals with wounds. The records were classified according to the stages of the nursing process. A checklist was used in the characterization of the wounds, and the characteristics observed were compared to the information included in the records. Frequency and percentage statistics were used in descriptive analysis. Results: It was found that 91.6% of the patient care record cards contained information about the stage of data collection. The stages of nursing diagnosis, planning, implementation and care assessment were poorly reported. Conclusion: Weaknesses were detected in the documentation of the nursing process of patients with wounds, which may compromise their safety, the assessment of care and future research.