he person undergoing bone marrow transplantation: an exploratory study on nursing care documentation patterns

Abstract

The documentation on nursing care plays a major role in the quality of assistance in nursing.
However, it is recognized that this documentation has been presenting some gaps that prevent it from reflecting the nurse’s professional work exactly. We understand the need to contribute for the improvement of care quality through the identification of documented information’s categories and items in respect of the nature of nursing care provided to the patients subjected to a Bone Marrow Transplantation (BMT).
In order to achieve that, we have conceived a study in a quantity paradigm of an exploratory-descriptive kind, intending to define the patient’s profile subjected to BMT and to identify the pattern of care documented by nurses and used in the Bone Marrow Transplantation Department (BMTD). In order to meet the proposed goals, we analyzed the content of the information produced by the nurses about the nursing care, from 122 episodes of hospitalization of patient subjected to BMT, who are hospitalized at the BMTD in Instituto Português de Oncologia do Porto Franscisco Gentil, Entidade Pública Empresarial. The obtained data was submitted to both descriptive and inferential statistical analysis.
From the results obtained we stress that: the patient’s profile, subjected to a BMT, is mainly male, middle-aged, married, retired or a skilled worker in industry, in construction, and a craftsman. The pattern of documentation of nursing care lies, essentially, in the domain of a compromise of bodily processes, developing interventions, predominantly, as far as the management of signs and symptoms is concerned. The intensity of therapeutic action documented by nurses is reduced, compared to diagnoses
documented. The documented information suggests not to reflect, as a whole, the care “effectively” provided.
The results of this study may be useful in the improvement of the Systems of Information used in the
Instituto Português de Oncologia do Porto and may bring about the reflection by professionals on the
importance of efficient documentation in nursing care.