Development and implementation of a nursing patient history in Pediatric Intensive Care

摘要

Objective To develop and implement a nursing patient history planning care in pediatric intensive care. Methods A qualitative and descriptive study, with support of a bibliographical research and convergent care, conducted in the pediatric intensive care unit of a university hospital, involving the participation of 13 nurses. Group meetings, workshops and participant observation were the methodological resources for conducting the research. Results Fourteen Basic Human Needs and scientific evidence underpin the development of the nursing patient history, composed of seven blocks arranged in a checklist format with open spaces for recording complications and nurse impressions. An instruction guide was provided to facilitate its use. Implementation was preceded by a test phase and historical validation. Conclusion The instrument was developed based on scientific evidence, and included contributions from the nurses. The participatory involvement of nurses favored the implementation and use of the nursing patient history in care practices.