Quality of nurses' records concerning neurological assessments in a specialized intensive care unit

Abstract

Recording the actions, observations, and evaluations carried out by the nursing team is a means to manage care, assess the quality of care, and ensure continuity of care. When a nurse performs a neurological examination on patients in the postoperative period of intracranial surgeries and provides proper records, it is possible to identify potential changes that put the patient’s life at risk after the procedure. Therefore, this study aimed to analyze the quality of records of nurses regarding the neurological assessment of patients in the postoperative period of intracranial surgery within a specialized Intensive Care Unit. This was a retrospective, quantitative study, carried out from June to July 2019, with a descriptive analysis. A total of 134 admissions to the neurological intensive care unit were identified, totaling 536 nurse records. There was a predominance of records concerning the assessment of the level of consciousness and pupils (92.5%), in 3.9% they had only the pupillary exam, 2.7% only recorded the level of consciousness, and in 0.7% there were no records. As for comprehensiveness, 90.7% of the assessments of the level of consciousness were complete and 84.3% of the pupillary exam were complete. It was identified that the records of nurses in the Intensive Care Unit where the study was developed were classified as excellent, based on previously defined quality parameters.

Keywords

• nursing records. nursing assessment. neurological examination. quality of health care. intensive care units.