Examinando por Materia "Medical Records"

Mostrando 1 - 18 de 18

Acceso abierto
Actividades del proceso de atención nutricional registradas en la historia clínica en pacientes quirúrgicos atendidos en el Hospital María Auxiliadora durante el año 2023
(Universidad Privada Norbert Wiener, 2024-09-06) Ccasa Catalan, Adelma; Taype Cucho, Adeli Francesca; Mauricio Alza, Saby Marisol
El proceso de atención nutricional (PAN) es un conjunto de pasos que garantiza la calidad del servicio realizado por el profesional nutricionista en los diferentes sistemas de salud. El objetivo de nuestra investigación fue Describir las actividades del Proceso de atención nutricional registradas en la Historia Clínica en pacientes quirúrgicos atendidos en el Hospital María Auxiliadora durante el año 2023, a partir de la revisión de 400 historias clínicas en pacientes quirúrgicos atendidos entre agosto y noviembre de 2023, recolectamos información del registro de las actividades que comprende el PAN, encontramos que, el 47.5% tienen entre 30 a 59 años de edad, presentan 1.13+0.63 días de ayuno. El 51.5% presenta estancia hospitalaria prolongada. En cuanto a los indicadores nutricionales, el 100% no registra IMC, el 99% y el 87.75% registra peso y talla respectivamente. El tamizaje nutricional se registró entre 90 a 100%, el 94% registra la dieta, el 96% no registra las calorías, el 90% registra macronutrientes, solo el 2% registra monitoreo nutricional. Conclusiones: Es necesario el registro de las actividades del proceso de atención nutricional considerando que nos permite modificar la estrategia garantizando el éxito de la terapéutica del paciente quirúrgico.
Restringido
Assessment of risk factors of the immediate newborn carried out by nursing, related to Apgar score, in a hospital in Lima-2022
(Universidad Privada Norbert Wiener, 2022-12-11) Malpartida Ariza, Lily Dayana; Cárdenas de Fernández, María Hilda
Objective: Determine how the assessment of the risk factors of the immediate newborn, carried out by nursing, is related to the Apgar score in a hospital in Lima-2022. Methodology: Non-experimental, cross-sectional, hypothetical-deductive design, with a quantitative approach, applied type. Population: 120 medical records of newborns who must meet the inclusion criteria. Instrument: the data collection sheet, where the information obtained from the assessment of the 4 dimensions will be placed through the responses to the 21 items. Conclusions: the relationship that exists between the assessment of risk factors of the immediate newborn carried out by nursing and the score obtained with the Apgar Test applied to the newborn in one minute and five minutes of extrauterine life will be confirmed or denied.
Acceso abierto
Calidad del registro y resistencia al uso de la historia clínica electrónica en enfermeras del hospital Edgardo Rebagliati, 2024
(Universidad Privada Norbert Wiener, 2024-07-19) Muñante Nima, Ninach Christina; Hermoza Moquillaza, Rocío Victoria
La Historia Clínica Electrónica (HCE) es un documento médico legal y recientemente se busca la implementación estandarizada en los profesionales de enfermería; sin embargo, este proceso de atención y cuidado, se ha encontrado con algunas barreras que interceptan la aplicación efectiva. Objetivo: Se determinó la relación entre la calidad de registro y la resistencia en la aplicación de la historia clínica electrónica en el personal de enfermería del Hospital Rebagliati 2024. Material y métodos: Estudio hipotético deductivo, cuantitativo, observacional y de corte transversal. Se investigaron 292 enfermeras del Hospital Rebagliati que tengan acceso al sistema hospitalario de gestión electrónico durante el 2024. Las variables evaluadas fueron la calidad de registro y resistencia al uso y se usó la prueba estadística de Tau-B de Kendall. Resultados: El principal género fue femenino (80.14%), el rango de edad que predominó fue de 51-60 años (42.47%), la calidad de registro de la HCE fue regular (55.48%), el nivel de resistencia a la aplicación de la HCE fue medio (57.53%). Se identificó una correlación inversamente proporcional moderada y estadísticamente significativa entre las dos variables (p=0.040), correlación inversamente proporcional moderada y estadísticamente significativa en las dimensiones de estructura (p=0.037) y contenido (p=0.039) con la variable resistencia en la aplicación de la HCE. Conclusión: Se identificó que existe relación inversamente proporcional en la calidad de registro y la resistencia en la aplicación de la HCE en el personal de enfermería del Hospital Rebagliati. Es necesario realizar más trabajos que mejoren la adherencia de la calidad de registro de la HCE.
Acceso abierto
Characterization of retinopathy of prematurity in a perinatal maternal hospital, Lima 2017-2019
(Universidad Privada Norbert Wiener, 2020-08-30) Espinoza Palomino, Yajahyda Yuliza; Fernández Rengifo, Werther Fernando
Objective: Describe the characteristics of retinopathy of prematurity at a Maternal Perinatal Hospital in Lima during the period 2017-2019. Method: The present investigation has a quantitative approach, in terms of the methodological design it is a descriptive investigation, with the documentary analysis technique and the instrument of the data capture sheet, information was collected from the clinical records. Results: The characteristics were, the predominance of the male sex of the newborn with 60%, due to the type of delivery that the mother had, mostly delivery by cesarean section with 60%, mothers who had chorioamnionitis in 60%, due to the birth weight less than 1000 g in 40%, requirement for oxygen therapy with 60%, those who presented neonatal sepsis in 80%, according to the type of pregnancy single in 92%, gestational age less than 32 weeks with 72%, as for respiratory distress syndrome and intrauterine growth retardation, their percentages are less than 20%. Conclusion: The most important characterizations were: predominantly male gender, cesarean delivery, birth weight less than 1000g, oxygen therapy requirement, neonatal sepsis, type of singleton gestation, gestational age less than 32 weeks, mothers who presented chorioamnionitis, these characteristics being the most relevant and of great significance, they are possible risk factors for developing the disease.
Acceso abierto
Compliance level of nursing records in the adult intensive care unit of a public hospital in Lima - November 2020
(Universidad Privada Norbert Wiener, 2020-10-11) Tumay Melgar, Katherine Juliane; Avila Vargas Machuca, Jeannette Giselle
Objective: Determine the level of compliance with nursing records: graphic sheet of vital signs, water balance sheet, nursing progress notes and nurse card; in the Intensive Care Unit of a Public Hospital in Lima. Material and methods: Quantitative approach, non-experimental, descriptive, cross-sectional design. The population is made up of the medical records of patients hospitalized in the Intensive Care Unit. A non-probabilistic sampling will be carried out, for convenience. The technique that will be used is observation. The instrument to be used will be observation sheets; the four Quality Assessment Formats of Nursing Records, which have been taken from the Technical Standard for Auditing the Quality of Health Care NTS No. 029-MINSA/DIGEPRES-V.02 of 2016.
Acceso abierto
Effectiveness of electronic records compared to manual records for continuity of nursing care in the intensive care unit
(Universidad Privada Norbert Wiener, 2018-11-25) Nestares Jimenez, Jackqueline Melissa; Sayas Baca, Carlos Luis; Glenni Garay, Zarely Zabeli
Systematic Review that synthesizes the results of multiple investigations, identifying what is most relevant to answer specific questions of daily practice. The search was restricted to articles with full text subjected to critical reading, using the GRADE system to assign the strength of recommendation. In the final selection, 10 articles were chosen, finding that 10% (01) correspond to Europe (Italy), 20% (02) correspond to North America (USA), 70% (04) correspond to South America (Brazil). and Argentina). Experimental studies have been studied, with (30%), systematic reviews we find (30%) and with (40%) we have qualitative and quantitative descriptive studies. Results: 70% of the studies affirm that electronic nursing records are more effective in their entirety than manual records for the continuity of nursing care in the intensive care unit (ICU), 20% of the studies show disadvantages in the application of the electronic record, which are directly related to the design of the software which can be modified and 10% show that it is not effective for the continuity of nursing care in the ICU. Conclusions: the electronic nursing record shows greater effectiveness compared to the manual record for the continuity of nursing care in the intensive care unit.
Acceso abierto
Factors associated with neonatal jaundice in a full-term newborn in the Maison de Sante clinic from January-September Lima - Peru 2019
(Universidad Privada Norbert Wiener, 2020-10-11) Espinoza Llachua, Dolores; Bonilla Asalde, César Antonio
Introduction: Neonatal jaundice is defined as yellow pigmentation of the skin and mucous membranes, and is considered one of the most common pathologies in newborns. It occurs as a result of increased serum bilirubin concentrations and is associated with a series of predisposing factors present in the mother-child binomial. Aim. Identify the factors associated with neonatal jaundice at term in the Maison de Sante clinic within the period of January - September 2019. Materials and Methods. Quantitative approach. The study is of an applied type, Scope or level of explanatory application, non-experimental or observational, retrospective research design. Data from 120 medical records of full-term neonates with this diagnosis will be used. Subsequently, the data will be processed in the SPSS version 24 program through the use of statistics. The association will be made using the chi-square for qualitative variables.
Acceso abierto
Importance of the perioperative nursing record to improve the safety of the surgical patient
(Universidad Privada Norbert Wiener, 2020-01-19) Checasaca Pariapaza, Nancy Antonelli; Pretell Aguilar, Rosa Maria
Objective: To systematize the evidence on the importance of perioperative nursing documentation to improve the safety of surgical patients. Material and Methods: A systematic review of 10 scientific articles found on the importance of perioperative nursing documentation to improve surgical patient safety was cited in the following databases: Epistemonikos, Scielo; all were analyzed according to the Grade scale to determine their strength and quality of evidence. Results: Of the 10 articles reviewed and analyzed, 90% (n=9/10) are systematic reviews and 10% (n=1/10) is primary study. Of the 10 articles found, 100% indicate the importance of perioperative nursing documentation to improve surgical patient safety. Conclusion: 10 out of 10 articles found highlight the importance of perioperative nursing documentation to improve surgical patient safety.
Acceso abierto
Knowledge about healthy eating and nutritional status of the patient undergoing hemodialysis at the Cayetano Heredia hospital, Lima – 2021
(Universidad Privada Norbert Wiener, 2021-10-17) Solis Roman, Iris Rocio; Cárdenas de Fernández, María Hilda
Chronic kidney disease is one of the most rapidly increasing non-communicable pathologies in the world and is already considered a public health problem due to the complications and impacts it causes and which is closely linked to poor diet and nutrition as a result of a series of factors in which the lack of knowledge is indicated. Objective: Establish the relationship between knowledge about healthy eating and the nutritional status of patients undergoing hemodialysis at the Cayetano Heredia hospital, Lima - 2021. Methods: the research is quantitative, non-experimental, descriptive, correlational and transectional. A non-probabilistic sample will be taken for convenience or intentionally from 80 patients who are receiving hemodialysis treatment, 3 times a week for 3 to 4 hours a day in the Hemodialysis area of the Cayetano Heredia Hospital. Through the survey, a validated and reliable instrument will be applied to determine the level of knowledge and through documentary analysis of the medical records, the different clinical parameters of the patient's nutritional status will be taken. The data collected will be analyzed using parametric and non-parametric correlation tests such as Pearson's coefficient, Kendall's Tau B and Spearman to analyze the relationships in each of the dimensions of nutritional status.
Acceso abierto
Lifestyle and nutritional status of the elderly who attend the Manuel Sanchez Villegas Health Center - Chiclayo, 2022
(Universidad Privada Norbert Wiener, 2022-12-11) Ojeda Garcia, Karolain Fiorella; Cárdenas de Fernández, María Hilda
In the present investigation, it is evident that older adults at the Manuel Sánchez Villegas health center in Chiclayo have problems in the way they live, in terms of their physical health and their diet, which can lead to a deterioration in their health. health, and thereby reduce their quality of life. Therefore, the objective of the research is to determine the relationship between lifestyles and the nutritional status of the elderly who attend the Manuel Sánchez Villegas health center - Chiclayo. For which the methodology will be applied, non-experimental, correlational, with a population of 230 older adults in the aforementioned Health Center, to which probabilistic sampling was applied, obtaining a sample of 144 older adults. To whom a questionnaire called Health Promoting Lifestyle Profile II validated by Zhou et al., in 2022, and a documentary analysis guide will be applied, based on finding the BMI with respect to the measurement of weight and height, dividing the weight in kilograms by their height in square meters (kg/m2), locating said data in the medical records of the older adults mentioned, the correlation test being Kendall's Tau b, as it is an ordinal variable (Lifestyle) and another continuous (BMI). In this study, it is expected that there is a statistically significant relationship between the lifestyle and its dimensions and the nutritional status of the elderly who attend the Manuel Sánchez Villegas health center - Chiclayo.
Acceso abierto
Nursing care and complications in the administration of chemotherapy in the oncology unit 2022
(Universidad Privada Norbert Wiener, 2022-12-04) Antón Navarro, Cindy Analí; Cárdenas de Fernández, María Hilda
Objective: Identify the relationship between nursing care and complications in the administration of chemotherapy in the oncology unit of a public hospital in Lima. Methodology: On this occasion the approach that will be used is the quantitative, applied type, with a correlational scope and transversal section. 85 patients and their medical records will be taken, applying a questionnaire for the variable nursing care and for the variable complications in chemotherapy administration a registration guide, which will then be processed statistically using the IBM SPSS version 26.0 program to present the descriptive and inferential. In this way, the conclusions and recommendations of the research can then be presented.
Acceso abierto
Prioritization of care according to triage and waiting time of patients in the emergency room at the Sergio E. Bernales hospital, 2022
(Universidad Privada Norbert Wiener, 2022-12-11) Huamani Lizarbe, Edith Liliana; Gamarra Bustillos, Carlos
Objective: Determine the relationship between the prioritization of care according to Triage and the waiting time of patients in the emergency room at the Sergio E. Bernales Hospital, 2022. Population: Composed of 700 medical records of patients treated in the emergency unit of the Sergio E. Hospital. Bernales in September and October 2022. Sample: It will be made up of 249 medical records, simple random non-probabilistic sampling will be used. Methodological design: Applied, hypothetical-deductive, quantitative, descriptive and cross-sectional study, correlational retrospective. Instruments: For the evaluation of the variable “Prioritization of care according to triage”, a registration form modified by Alarcón in 2022 will be used, reliable with Cronbach's Alpha obtaining values of 0.77 and for the evaluation of the variable “Time "waiting", a registration form also prepared by Alarcón will be used in 2022, reliable with Cronbach's Alpha 0.77. The technique we will use to collect information is observation. Data processing and analysis: We will use descriptive statistics to prepare frequency tables and graphs, on the other hand, we will apply inferential statistics using Spearman's Rho statistical test that will allow us to verify the hypotheses that we have proposed.
Acceso abierto
Quality of nursing notes of the emergency department of the regional hospital - La Merced, 2021
(Universidad Privada Norbert Wiener, 2021-09-12) Montero Pomalaya, Lourdes; Pretell Aguilar, Rosa Maria
Objective: “Determine the quality of emergency service nursing notes.” Methodology: It will be with a quantitative, descriptive, cross-sectional approach. The population will consist of 62 stories of patients from the emergency service of Merced Hospital, selected according to inclusion and exclusion criteria set out in the research. Techniques: The documentary analysis technique will be used, the instrument is the check list. The authorship instrument was developed by Lic. Elizabeth Catalina Quispe (2017) that will be used on the quality variable. It was validated by expert judges in 2020 and had reliability through the pilot test, the Kuder Richardson test was used with results of 0.81, which indicates a high degree of reliability. Therefore, it is not valid for this research because we were working with a similar population. Procedure: Data collection will be carried out in the last 3 consecutive months, in the emergency service. Once the information has been collected through the application of the instrument, the data will be entered into a database in the SPSS Version 27 program. Statistical Analysis: For the descriptive analysis, frequency tables, measures of central tendency and dispersion, as well as representations will be made. graphics.
Acceso abierto
Relación entre concentraciones de antígeno prostático específico e índices aterogénicos en pacientes de 45 a 65 años en el centro de salud público, noviembre 2022 - mayo 2023
(Universidad Privada Norbert Wiener, 2024-10-04) De La Cruz Mendoza, Ivan Alexander; Borja Velezmoro, Gustavo Adolfo
En este estudio, el objetivo es identificar la relación entre la concentración de antígeno prostático especifico (PSA) e índice aterogénico, para ello, se emplearán fórmulas que consideran las concentraciones del colesterol total (CT), triglicéridos (TG) y lipoproteína de alta densidad (HDL), esto permitirá estimar los cocientes del índice aterogénico y relacionarlos con el riesgo asociado a los niveles de PSA. El presente estudio, de carácter descriptivo comparativo, con un diseño transversal y retrospectivo, se basa en el análisis de 130 registros médicos de pacientes entre 45 y 65 años; estos pacientes se sometieron a pruebas de colesterol total (CT), lipoproteína de alta densidad (HDLc), triglicéridos (TG) y PSA en el laboratorio clínico del centro de salud público de Surquillo, durante el período de noviembre de 2022 a mayo de 2023. Al estudiar la correlación entre las concentraciones de PSA e índice aterogénico, se obtuvo un coeficiente de correlación de estadísticas no paramétricas (Rho) de 0,610 para el cociente CT/HDLc y 0,604 para el cociente TG/HDLc, ambos análisis indican que los valores de significancia sugieren la inexistencia de una relación entre estos parámetros y el PSA. Se concluye que no existe una relación significativa entre las concentraciones del antígeno prostático especifico (PSA) e índice aterogénico en pacientes de 45 a 65 años.
Acceso abierto
Results of cardiotocography in relation to funicular dystocia, condition of the newborn and type of delivery at the “Las Mercedes” regional teaching hospital in Chiclayo in the year 2016-2017
(Universidad Privada Norbert Wiener, 2018-03-23) Moreno Llanos, María Evelyn; Vidaurre Cortez, Giovanna; Huaman Elera, Jose Manuel
Material and methods: A quantitative, non-experimental, prospective, longitudinal, analytical study was carried out. The sample was obtained by non-probabilistic or convenience sampling. Information was collected from the review of medical records. The statistical test used was the chi square. Results: The sociodemographic maternal characteristics with the highest percentage were adulthood, level of secondary education, nulliparous, and full-term gestation. The presence of funicular dystocia recorded a normal baseline, silent variability (7.2%), absence of accelerations (46.4%), variable decelerations (43.5%), present fetal movements; The result of the non-reactive stress test was 62.8% and the positive non-reactive stress test was 30.8%. The most frequent was clear amniotic fluid, simple circular cord, rejectable and located in the neck of the newborn. The highest percentage of births was by cesarean section. Newborns with Apgar scores of 7 to 10 at one minute and funicular dystocia had a non-reactive stress test or a reactive negative stress test. Cardiotocography showed low sensitivity, high specificity, a positive predictive value of 75%, a negative predictive value of 52.4% and a statistically significant relationship between cardiotocographic results and funicular dystocia. Conclusion: There is a statistically significant relationship (p<0.05) between cardiotocographic results and the presence of funicular dystocia. The non-stressful test had a statistically significant relationship with the type of delivery.
Acceso abierto
Risk factors associated with iron deficiency anemia in children aged 6 to 35 months attending the Carlos Lanfranco la Hoz hospital, Lima 2021
(Universidad Privada Norbert Wiener, 2021-10-10) Salinas Calderón, Johana Magaly; Gamarra Bustillos, Carlos
Iron deficiency anemia affects about half of children between 6 and 35 months of age in Peru, bringing with it alterations in their physical, psychological and socio-emotional growth; In addition, it causes delays in psychomotor development and learning and intelligence problems; In this sense, immediate intervention is required by health decision-makers, in order to reduce and prevent it. In this scenario, the objective of the present study is to “determine the risk factors associated with iron deficiency anemia in children from 6 to 35 months of age who attend the Carlos Lanfranco La Hoz Hospital, Lima 2021.” Research with a quantitative approach, correlational and prospective design, which will be carried out with 173 children who have a hemoglobin level <11 gr/dl, and who attend the growth and development control clinic of the Carlos Lanfranco La Hoz Hospital. Documentary analysis of medical records will be used as a technique and a data collection sheet as an instrument to determine the risk factors associated with iron deficiency anemia.
Acceso abierto
Risk factors in the development of chronic kidney disease in patients treated at the Ayacucho hospital, January 2021 – December 2021
(Universidad Privada Norbert Wiener, 2021-10-03) Fernandez Flores, Fidel; Cárdenas de Fernández, María Hilda
Objective: Determine the risk factors in the development of Chronic Kidney Disease in patients treated at the Ayacucho hospital, January 2021 - December 2021. Methodology: Deductive method, quantitative approach, basic, descriptive type and cross-sectional design. The population: There will be 80 medical records of patients diagnosed with Chronic Kidney Disease at the Ayacucho hospital from January to December 2021. Data collection technique and instrument: The documentary analysis technique will be applied and a data collection sheet as an instrument. Procedures: Data collection will be carried out over a period of 3 months, in the admission service, where all the medical records of the users treated at the Ayacucho hospital are located. Once the information has been collected in the instrument, it will be entered into a data carrier of a statistical program SPSS version 25. Statistical analysis: The statistical comparison and verification of the results will be carried out in a descriptive frequency table, with their respective graphs.
Acceso abierto
Tiempo de respuesta y calidad del registro de historias clínicas en un servicio privado de ambulancias, Lima 2022-2023
(Universidad Privada Norbert Wiener, 2024-10-15) Echaiz Veliz, Maria De Los Milagros; Diaz del Olmo Morey, Fernando Luis
Objetivo: El presente estudio determina la relación entre el tiempo de respuesta y la calidad del registro de historias clínicas en un servicio privado de ambulancias en Lima durante el período 2022-2023. Metodología: la investigación fue de tipo aplicada con un enfoque cuantitativo y un método hipotético-deductivo. El nivel fue correlacional descriptiva y el diseño no experimental, de corte transversal. La población fueron 344 historias clínicas que forman parte del Servicio Privado de Ambulancias en Lima, las cuales representan el total de registros disponibles desde principios de 2022 hasta el último mes de 2023, siendo la muestra de 182 historias clínicas bajo un muestreo probabilístico aleatorio simple. La técnica que se utilizó la técnica de análisis documental y la ficha de recolección fue el instrumento considerado para ambas variables. Resultados: Se observó una relación estadísticamente significativa entre ambas variables (p = .000), donde los resultados indican que el 94.5% de los casos con tiempos de respuesta deficientes también presentaron una baja calidad en el registro de historias clínicas. Conclusión: A medida que se presentan tiempo de respuesta deficientes, el registro de las historias clínicas presenta una baja calidad.