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- Expression Of Nursing Records - Retrospective StudyPublication . Cardoso, Filomena; Lessa Silva, Maria Do Carmo Cardoso Morais; Cecilia, Alves; Martins, Maria ManuelaTo analyze which focus/nursing diagnosis are documented by nurses in the process of caring of patients in the dying process in Medicine, Surgery and Intensive Care hospital áreas A descriptive, retrospective and quantitative study, conducted in 2016, in a central university hospital in the north of Portugal. Data on documentation of focus / diagnosis identified in patients who came to die in that year were collected through two information systems: SClinico and BICU care, structured on the basis of ICNP version B2
- The dying process: its manifestation in nursing recordsPublication . Cardoso, Filomena; Lessa Silva, Maria do Carmo Cardoso Morais; Alves, Cecília; Pereira da Silva Martins, MariaBackground: Despite the changes over the last decade in nursing care, some concerns about the care practice in the process of dying remain. Objective: To analyze the focus documented by nurses during the dying process within the hospital context and to identify the differences in records relating to the focus valued in the different clinical areas. Methodology: As part of a larger research project called Living Death: the challenge of the nursing profession, this quantitative, descriptive, and retrospective documentary study was performed based on the analysis of 36,281 nursing actions documented by 1,270 nurses. Results: Of the 36,281 actions recorded, most of the documentation is related to Function (56.5%), followed by Person (43.5%), which shows an apparent disregard for the transitions experienced by patients within the context of death and the processes of dying. Conclusion: It is increasingly important to decentralize the attention of a practice that is predominantly focused on the biomedical component, in favor of care focusing on the experiences facing the imminence and inevitability of death.