NURSING CARE DOCUMENTATION DURING THE DYING PROCESS - HOW DO THE REHABILITATION NURSES DIFFER?

Abstract

Objective: To analyze the nursing foci / diagnoses documented by nurse specialists in rehabilitation nursing during the process of dying in a hospital context. Method: descriptive, retrospective and quantitative study conducted at a hospital in northern Portugal in February 2017. Data on documentation of nursing outbreaks / diagnoses identified in clients who died in 2016 were collected using two information systems: SClinic and BICUcare. Results: From the 4115 records made by 148 nurses who specialize in rehabilitation nursing, we found that despite the evolution that has taken place over the last decade in the documentation of nursing care, there are some concerns about the practice of care that evidences. Due to the emphasis placed on documenting changes in the field of function, specialist nurses in rehabilitation nursing tend to underestimate the record of changes and needs that emerge from the transitions experienced by people, specifically during death and dying processes. Conclusion: Given that the information recorded contributes to the visibility of the care provided, there is a need to adopt strategies that solve the problem of underdocumentation, particularly in the face of death and dying processes.

Keywords

• death
• nursing
• rehabilitation nursing
• electronic health records
• nursing diagnosis