Entry-instrument used in the patient's evaluation in a post-anaesthetic recovery room: a matter of great concern: care continuity

Instrumento de registro usado en la evaluación de enfermo en sala de recuperación pos-anestésica: importancia de la continuidad de asistencia

Elaine Reda Aparecida de Cássia Giani Peniche About the authors

Abstracts

OBJECTIVE: To know the nurses' evaluation about the continuity of nursing care. METHODS: Fifty-nine nurses from two Hospitals (I and II) were interviewed. The questions addressed the following issues: the difficulties they face to obtain the necessary information to provide patient care in the immediate post-operative period; what is the best strategy to receive information related to this period; and what is their evaluation about the entry-instrument of the post anaesthetic recovery. RESULTS: Difficulties in Hospital I: the instrument was often not included in the patient record and changing shifts over the telephone. Hospital II: incomplete completion of the instrument. Best strategy in Hospital I: entry-instrument associated to the shift change over the telephone. Hospital II: to aggregate the several means of information. Both groups evaluated the entry instrument and reported that it helps in the planning because it is a way to document patient care. They considered the aspects contained in the instrument as important and pertinent. CONCLUSIONS: This instrument consists of an efficient strategy for patient care continuity, in spite of the difficulties described above.

Anesthesia recovery period; Recovery room; Patient care; Nursing records; Perioperative nursing; Communication; Nursing assessment


OBJETIVO: Conocer la evaluación de los enfermeros de las unidades post-operatorias sobre la continuidad de la asistencia de enfermería al paciente quirúrgico. MÉTODOS: Fueron entrevistados 59 enfermeros, de dos Hospitales (1 y 2) y se preguntó respecto cuáles eran las dificultades en la obtención de las informaciones necesarias para la asistencia en el período post-operatorio inmediato; cuál era la mejor estrategia para recibir informaciones pertinentes al período; cuál era la evaluación sobre el instrumento de registro de la recuperación post-anestésica. RESULTADOS: Dificultades en el Hospital 1: ausencia del instrumento en la historia clínica del paciente y de la entrega del turno por teléfono. En el Hospital 2: Llenado incompleto. Mejor estrategia en el Hospital 1: instrumento de registro asociado a la entrega del turno por teléfono. Hospital 2: agregar los diversos medios de informaciones. La evaluación realizada al instrumento de registro utilizado por los dos grupos: el mismo auxilia en la planificación siendo un medio para documentar el cuidado. En cuanto a los aspectos contenidos en el instrumento: importantes y pertinentes. CONCLUSIONES: Constituye una estrategia eficiente en la continuidad de la asistencia a pesar de las dificultades descritas arriba.

Período de recuperación de la anestesia; Sala de recuperación; Asistencia al paciente; Registros de enfermería; Enfermería perioperatoria; Comunicación; Evaluación en enfermería


OBJETIVO: Conhecer a avaliação dos enfermeiros das unidades pós-operatórias sobre a continuidade da assistência de enfermagem ao paciente cirúrgico. MÉTODOS: Foram entrevistados 59 enfermeiros, de dois Hospitais (1 e 2) e se questionou quais as dificuldades na obtenção das informações necessárias para a assistência no período pós-operatório imediato; qual a melhor estratégia para receber informações pertinentes ao período; qual a avaliação sobre o instrumento de registro da recuperação pós-anestésica. RESULTADOS: Dificuldades no Hospital 1: ausência do instrumento no prontuário do paciente e da passagem de plantão pelo telefone. No Hospital 2: preenchimento incompleto. Melhor estratégia no Hospital 1: instrumento de registro associado à passagem de plantão por telefone. Hospital 2: agregar os diversos meios de informações. A avaliação feita do instrumento de registro utilizado pelos dois grupos: o mesmo auxilia no planejamento sendo um meio de documentar o cuidado. Quanto aos aspectos contidos no instrumento: importantes e pertinentes. CONCLUSÕES: Constitui uma estratégia eficiente na continuidade da assistência apesar das dificuldades acima descritas.

Período de recuperação da anestesia; Sala de recuperação; Assistência ao paciente; Registros de enfermagem; Enfermagem perioperatória; Comunicação; Avaliação em enfermagem


ORIGINAL ARTICLE

Entry-instrument used in the patient's evaluation in a post-anaesthetic recovery room - a matter of great concern: care continuity* Corresponding Author: Elaine Reda R. Tobias Franco, 289 Centro - Itatiba - SP Cep: 13250-310 E-mail: elreda@ig.com.br

Instrumento de registro usado en la evaluación de enfermo en sala de recuperación pos-anestésica: importancia de la continuidad de asistencia

Elaine RedaI; Aparecida de Cássia Giani PenicheII

IGraduate student of the Nursing Graduate Program on Adult Health – Escola de Enfermagem da Universidade de São Paulo - USP- São Paulo (SP), Brazil. RN; Assistant Professor of the São Franciso University - São Paulo (SP), Brazil

IIFree-lecturer Professor of the Preoperative Nursing Department - Escola de Enfermagem da Universidade de São Paulo - USP - São Paulo (SP), Brazil

Corresponding Author Corresponding Author: Elaine Reda R. Tobias Franco, 289 Centro - Itatiba - SP Cep: 13250-310 E-mail: elreda@ig.com.br

ABSTRACT

OBJECTIVE: To know the nurses' evaluation about the continuity of nursing care.

METHODS: Fifty-nine nurses from two Hospitals (I and II) were interviewed. The questions addressed the following issues: the difficulties they face to obtain the necessary information to provide patient care in the immediate post-operative period; what is the best strategy to receive information related to this period; and what is their evaluation about the entry-instrument of the post anaesthetic recovery.

RESULTS: Difficulties in Hospital I: the instrument was often not included in the patient record and changing shifts over the telephone. Hospital II: incomplete completion of the instrument. Best strategy in Hospital I: entry-instrument associated to the shift change over the telephone. Hospital II: to aggregate the several means of information. Both groups evaluated the entry instrument and reported that it helps in the planning because it is a way to document patient care. They considered the aspects contained in the instrument as important and pertinent.

CONCLUSIONS: This instrument consists of an efficient strategy for patient care continuity, in spite of the difficulties described above.

Keywords: Anesthesia recovery period; Recovery room; Patient care; Nursing records; Perioperative nursing; Communication; Nursing assessment

RESUMEN

OBJETIVO: Conocer la evaluación de los enfermeros de las unidades post-operatorias sobre la continuidad de la asistencia de enfermería al paciente quirúrgico.

MÉTODOS: Fueron entrevistados 59 enfermeros, de dos Hospitales (1 y 2) y se preguntó respecto cuáles eran las dificultades en la obtención de las informaciones necesarias para la asistencia en el período post-operatorio inmediato; cuál era la mejor estrategia para recibir informaciones pertinentes al período; cuál era la evaluación sobre el instrumento de registro de la recuperación post-anestésica.

RESULTADOS: Dificultades en el Hospital 1: ausencia del instrumento en la historia clínica del paciente y de la entrega del turno por teléfono. En el Hospital 2: Llenado incompleto. Mejor estrategia en el Hospital 1: instrumento de registro asociado a la entrega del turno por teléfono. Hospital 2: agregar los diversos medios de informaciones. La evaluación realizada al instrumento de registro utilizado por los dos grupos: el mismo auxilia en la planificación siendo un medio para documentar el cuidado. En cuanto a los aspectos contenidos en el instrumento: importantes y pertinentes.

CONCLUSIONES: Constituye una estrategia eficiente en la continuidad de la asistencia a pesar de las dificultades descritas arriba.

Descriptores: Período de recuperación de la anestesia; Sala de recuperación; Asistencia al paciente; Registros de enfermería; Enfermería perioperatoria; Comunicación; Evaluación en enfermería

INTRODUCTION

Since January 2000, the Nursing Care System NCS (Sistema de Atendimento em enfermagem - SAE) became compulsory throughout the State of São Paulo according to the decision of The Regional Nursing Council of the State of São Paulo (COREN) COREN-SP/DIR/0088/99. This becomes evident when it is detected that 65% of the hospital institutions do not know how to implement the system(1).

The NCS is a process that aims the promotion, maintenance, and recovery of patient and community health, and should be developed by the nurse based on the technique and scientific knowledge inherent to the profession. For it implementation, it is necessary to adopt one or more theories of nursing that support the practice of the nursing care(2). This demands from the nurse the will to get to know the patient as an individual, using their knowledge, skills, as well as instructions and team training to accomplish the systematised actions(3).

However, there appears to be a natural difficulty in operating this system in various units of an institution, which is increased in intensive care and surgery centres due to the particularities of these units.

It is believed that the lack of information in the patient medical record increases the gap between the perioperative nursing period and the hospitalization units, causing harm to the nursing teams and especially to the patient.

The correct register, in an instrument, of the clinic parameter of the patient in post anaesthetic recovery seems to be a way that assists the filling of the existent gap. Thus, in a study performed to evaluate the data offered by a register instrument used in the post anaesthetic recovery unit, it was noticed that these instruments supported the planning of nursing care in the immediate postoperative period. Furthermore, it was observed there was a lack of communication between the nursing teams of the units involved in delivering care to surgical patients in the postoperative period, i.e., among the nurses in the post anaesthetic recovery unit and surgical clinics. Of the 40 nurses interviewed, 21 reported they did not use any mean of communication to obtain information about the clinical conditions of patients' forwarded from post-anaesthetic recovery(4).

Thus, the legal obligation of implementing the nursing process in the care delivered to surgical patients coincides with the seriousness with which this patient ahould be evaluated. Since these patienta are in a critical condition, the nursing team should have precise information of the perioperative period and, more specifically, regarding the nursing care delivered to the patient in the post-anaesthetic recovery unit.

The facts described above motivated performing this study, with the purpose to identify the appreciation that nurses delivering care to patients forwarded from the post-anaesthetic recovery room have toward the registry instrument used in this sector, regarding the continuity of nursing care to surgical patients and as for the aspects which support the patient evaluation, which is necessary for planning this care.

OBJECTIVES

Objectives General: To get to know the evaluation made by the nurses working in postoperative units regarding the continuity of the nursing care delivered to surgical patients.

Specific objectives

- To identify the nurses' difficulties reported in obtaining information regarding the post-anaesthetic recovery period.

- To identify the best strategy to obtain the necessary information for the continuity of nursing care to surgical patients after being discharged from the post-anaesthetic recovery room.

- To identify the aspects that supported the patients' evaluation regarding the period of post-anaesthetic recovery, which are necessary for planning nursing care in the postoperative period.

METHODS

Type

This is a descriptive, explanatory field study, using a quantitative approach.

Place of Study

This research was developed in two hospitals, referred to as Hospital I and Hospital II. Hospital I was implementing the NCS, and Hospital II had already completed the process of implementation.

- Hospital I: all units receiving patients forwarded from post-anaesthetic recovery were included (private/insured/public; child and adult). The patients were forwarded from a University hospital in the city of Bragança Paulista - SP.

- Hospital Institution II: all the public, child and adult, units receiving patients from post-anaestheticwere included. In this hospital, the patients were forwarded from a state hospital in the city of Sumaré - SP.

Population

The study population consisted of nurses working in hospital 1 and 2, from the morning, afternoon and evening shifts, with experience in delivering care to surgical patients from the post anaesthetic recovery room. A total of 59 nurses were included; 26 from Hospital I and 33 from Hospital II.

Source of Data

The data was collected using a form containing opened and multiple-choice questions, divided in two parts:

Part I addresses:

- The working areas or job position.

- Work time in the area or position.

- Working hours.

- Period since graduation.

- Specialisation or other courses.

Part II consisted of four questions:

- Questions 1 and 2, respectively, addressed the most frequent difficulties that interfere in obtaining the necessary information for the immediate postoperative period.The nurses mark the degrees regarding the frequency of these difficulties and which is the best strategy to receive the information regarding this period.

- Question 3 addresses the nurses' evaluations about the registry instrument concerning the post-anaesthetic recovery, as a legal and accurate mean of communication.

- Question 4 identifies if the aspects, which support patient evaluation, contained in the registry instrument are consulted; if so, the nurse is asked to check the degree of importance referred to these aspects, if not, they are asked why the instrument is not consulted.

Procedures:

Ethical-legal procedure:

- The research project was submitted to the appreciation of the Research Ethics Committee of the studied institutions.

- The study subjects voluntarily agreed to participate and provided written consent.

Data Collection Procedure

After the approval from the Research Ethics Committee of both institutions, the data were collected in the period of July and August 2005. A visit was held in the specified sectors with the aim to present the study objectives and the consent term to the subjects . After their permission, the researcher carried out an interview guided by the previously designed data collection instrument. Those who, for any reason, could not take part in the interview at that moment, another date was scheduled according to their availability during work hours.

Procedures of data analyses

The data were analysed according to the relative and absolute frequency, grouped and discussed in tables.

RESULTS

Regarding the difficulties presented by the nurses for obtaining patient information regarding the post-anaesthetic recovery period (Table 1), it is noticed that, in Hospital I, considering all 26 nurses, some difficulties were reported with the same frequency. Twenty-two nurses (84.62%) claimed the patient record did not include the instrument used in the post anaesthetic recovery, and absence of information in the shift change over the telephone. Nineteen nurses (73.08%) reported a lack of important information in the instrument, 45.16% reported the instrument has incomplete data, and 7.69% said the shift changed over the phone lacked information.

Regarding the level of the intensity at which these difficulties occurred, therefore considering the values the nurses assigned to the main difficulties, described in the subtotal, the difficulty with the highest level of intensity (always) was the lack of information in the shift change over the telephone. This difficulty was reported by 10 nurses (73.08%), followed by the lack of important information in the patient record (53.85%), and the patient record missing the instrument (42.31%).

In Hospital II, where the health care system had already been implemented, considering all 33 nurses, all the difficulties presented frequencies up to 50%. Those reported the most were: completing the instrument incorrectly, mentioned by 25 nurses (75.76%), followed by the lack of important information in the instrument (57.58%). Each of the following had 18 reports (54.55%): patient records without the instrument used in the post anaesthetic recovery, lack of shift change over the telephone, and incomplete information in the shift change over the telephone. As in Hospital I, the lack of information in the shift change over the telephone was the most often reported difficulty, mentioned by 12 nurses (36.36%). It was verified that the lack of important information in the instrument as well as incomplete completion also presented an important level of intensity (many times) (39.39%) and (33.33%), respectively. It is worth stating that this latter data, regarding the how often these difficulties occurred, were analysed according to the values described in the subtotal of the referred table.

As for the strategies to obtain information about the patient who is discharged from the post anaesthetic recovery room (Table 2), in Hospital I, 17 (65.38%) out of 26 nurses answered that they used the post-anaesthetic recovery registry instrument combined with the shift change over the telephone; 5 (19.23%) reported various means for obtaining information; 2 (7.69%) used the registry instrument regarding post-anaesthetic recovery, and 2 (7.69%) obtain information with the worker who transports the patient from the post-anaesthetic recovery room to the origin unit. In Hospital II, 20 (60.61%) out of 33 nurses reported various means for obtaining information; 10 (30.30%) used the telephone.

Tables 3 and 4 identify the aspects, regarding the post-anaesthetic period, considered necessary for planning the nursing carec in the post-operative period, bringing complementary information. Table 3 represents the nurses who checked the registry instrument and Table 4 refers to those who did not.

As observed, of all 26 nurses from Hospital I, 8 (30.77%) consulted the post-anaesthetic recovery registry instrument. Of these nurses, most of them classified the aspects that supported patient evaluation as extremely important. The only difference in opinion regarding the level of importance was about the parameters referring to temperature and pulse – Table 3.

The 18 (69.23%) nurses that did not consult the post-anaesthetic recovery registry instrument claimed that they did not know about this instrument. Therefore, they evaluated the patient in the moment of admission. The most common aspects used were the following: 16 (10.81%) reported dressing characteristics; 15 (10.14%) reported drainage characteristics; 14 (9.46%) stated consciousness level; 12 (8.11%) catheter control; 9 (6.08%) vital signs, and 8 (5.41%) reported venous access – Table 4.

It is worth emphasizing that the analysis of this scenario was based on the total answers provided. In Hospital II, of 21 (63.64%) out of 33 nurses consulted the instrument, and the majority classified the aspects presented in Table 3 as extremely important. However, 12 (36.36%) did not consult the post-anaesthetic recovery registry instrument. Considering these 12 professionals (100%), it was observed that 6 (50.0%) said there were various reasons for their not consulting the instrument, which were not addressed in this study. Regarding the other 50%, 4 (33.33%) did not consult the instrument because they evaluated the patient in the moment of admission; 8.33% reported the cause was lack of time, and one nurse (8.33%) said there was no need to obtain information about the post-anaesthetic recovery period.

Among the aspects used by those who did not refer to the instrument, that is, those who evaluated the patient in the moment of admission, the most common were: drainage characteristics and vital signs, with three reports each (14.29%), followed by the dressing characteristics, physical evaluation, and oxygen saturation with two reports each (9.52%) – Table 4.

DISCUSSION

Previous studies show the importance of notes and their difficulties of translating all the actions practised by the nursing professionals, which agrees with the results presented in Table 1. A particular study showed that, in a surgery unit of a university hospital in Campo Grande, that the nursing notes were not systemized consistent with the nursing process, with most notes referring to to clinical-surgerical therapy above any other, with a tendency to the biomedical care model. Furtermore, it was verified that some reports were factual, random, redundant, subjective, technically incorrect, and unprovided of any systematic that could support the nursing care planning. The conclusion was that the notes do not answer to patient needs, and, thus, nursing records become technical and legal documents, considered fragile in the ethic and juridical domain. Hence, these aspects are worrisome in terms of content quality, if it is use in court is necessary(5).

Another study confirmed the hypothesis that the notes regarding the systematisation were not adequate for the continuity of the care delivered to the surgical patient, since it confirmed that the data were incomplete and did not guarantee a comprehensive observation of each and every patient by the nursing professional involved in delivering perioperative care. After the analysis, it was certified that important data for the patient, in the period, could have been evaluated or not and the notes brought doubts about these evaluations, considering that the nursing notes did not reflect or vlue the work and care delivered by nurses in the perioperative period(6).

Therefore, it is observed that, in both hospitals, the alleged difficulties are related to the written and verbal communication. Hence, there is a failure in implementing the NCS process, since the registry instrument in Hospital I is not found in the patient records, while in Hospital II the registry instrument is included in the record more frequently. Nevertheless, it is useless to have an instrument included in the record if it is left incomplete or if it does not included the necessary information.Finally, the results show difficulties that hamper the process of obtaining patient information regarding the post-anaesthetic recovery period, compromising care continuity.

The strategies that nurses allegedly use to obtain information about the patient discharged from the post-anaesthetic recovery room also coincide with the previously presented difficulties, i.e., there is incoherence in these results. This proves that the referred difficulties are factual, since the tools to obtain this information, though correct, do not work out properly.

Therefore, it is evidenced that the registers in the patient record and the working shifts changes are fundamental resources for effective communication. Only through qualitative information, that is, exact and updated information, is it possible to develop a process in decision-making that reverts into benefits for clients, company, and employees.

Nursing communication is defined as:

The process in which the nursing team offers and receives information of the person, client/patient, to plan, perform, evaluate, and participate together with other members of the health team, of the care delivered in the health/disease process(7).

A previous study has confirmed that seven (61.11%) out of 11 nurses from a hospitalization unitreported there is an information interchange among the nurses of the hospitalization unit and nurses from the surgical centre.

This interchange was characterized by written and verbal communication. Regarding the information interchange established among the nurses from the surgical centre and the hospitalization unit, it was demonstrated that eight (66.67%) nurses from the surgical centre kept the verbal interchange, by the telephone, with the nurses from the hospitalization unit, however, this communication only happened in some situations(8).

A study verified the opinion of second-year nursing undergraduates about how appropriate a proposed instrument was for registering nurse actions in the post-anaesthetic recovery room. The studied instrument was desgined based on the SAEP, and the study counted with the participation of 77 students. The majority of subjects stressed the importance of the instrument for transmitting information to the nurse who receives the patient in the hospitalization units, so that they can continue the planning and interventions. In their opinion, this register makes it possible to avoid complications in the postoperative, immediate and mediate, providing a safer and more comfortable recovery to the patient. Furthermore, it minimizes the risks, the stay and cost of hospitalization. The study also confirmed that most students pointed out that making shift changes based on the instrument was a positive experience, which allows for evaluating the patient's conditions besides documenting the nursing actions(9).

Another study sought to identify the factors that interfere in the nurses' communication during the shift change, as well as the consequences due to the lack of communication in public and private hospitals of Aracajú-SE State. The reported difficulties regarding the shift change included the absence of direct communication, unclear registers, little time invested in the exchange, insufficient documentation, and a devaluing of this activity.

According to the respondants' perception, these difficulaties caused problems at the management and direct care levels, like misunderstandings, rescheduling exams, unfamiliarity of information regarding the previous shift, omission about the seriousness of the clients' condition, and compromising the transference of patients to other hospitals. Although the respondants were aware of the problems and were able to identify the factors that compromised this communication, they were unable to apply the strategies for an improvement. Therefore, this communication was considered insufficient and in need of serious adjustments in its operationalization. This study allowed for elaborating suggestions for an effective shift change, among them: the adjustment of this activity in institutions that still do not include it in their process; the systematization of written communication ; the communication of objectives among the nurses in order to guarantee care quality and establish of a value scale in terms of assigning priority to the information. The authors also stressed that the shift change, when properly performed, can benefit the institution, the patient, and to all the professionals involved, thus guaranteeing the continuity of care delivery. In conclusion, it is noticed that a systemized communication improves the interpersonal relations in the work environment, increases the mutual respect among nurses, and is a helpful instrument in delivering nursing care(10). Regarding the aspects that should be present in the registry instrument concerning post-anaesthetic recovery, which are considered necessary for planning the nursing care delivered in the postoperative period, it is verified that information is an essential requirement for performing effective health care and management. The clinical register in the patient record is the main mean to communicate patient information among the members of the multi professional health team and an important tool for evaluating health service quality. Hence, the patient report should include the observations about the patient's condition, the performed interventions, and the obtained results(11).Several authors(12-15), due to the pateints' vulnerability and to the common, frequent problems in the immediate postoperative period, suggest, in addition to the Aldrete and Kroulik index, restructuring the registry instruments used, so that it helps to control and, above all, provide a safe and continuous evaluation of the general condition of patients in the post- anaesthetic recovery period.

The present study results reveal that although various studies have demonstrated the vulnerability of surgical patients in the immediate postoperative period and the importance of the registry instrument in this period, it is observed that many nurses still do not refer to this instrument, and evaluate the patient in the moment of admission, using non-standardized aspects. These confirmations can contribute to failures in answering the patient's needs, which implies causing possible complications associated wit the patient's illness or the surgical procedure used.

CONCLUSIONS

The present study results allow the following conclusions:

In Hospital I, the difficulties for obtaining patient information regarding the post-anaesthetic recovery period most reported by the nurses were: the patient record not including the instrument used in the post-anaesthetic recovery period; absence of the shift change over the telephone, followed by instruments missing important information; instruments with incomplete information and incomplete shift change over the telephone. In Hospital II, the most often reports were: instruments with incomplete information, followed by instruments missing important information; patient record not inclusing the instrument used in the post anaesthetic-recovery period; absence of shift change over the telephone and incomplete shift change over the telephone.

In Hospital I, nurses reported that the best strategy for obtaining information about the patient discharged from post-anaesthetic recovery was using a registry instrument concerning the post-anaesthetic recovery associated with the shift change over the telephone of the nurse in this sector. As for the nurses in Hospital II, various means were associated to obtain information.

Among the aspects that support patient evaluation, which are considered necessary by the nurses who did not refer to the registry instrument concerning the post anaesthetic recovery to plan the care delivered to the surgical patient, in Hospital I, were shown: dressing and drainage characteristics; consciousness level; catheter control; vital signs, and venous access. In Hospital II: drainage characteristic and vital signs, followed by the dressing characteristics, physical exam, and oxygen saturation. As for the nurses who consulted this record, in both Hospital I and II, it was verified that most classified the aspects, which should be present in this instrument, as extremely important.

There was difference in opinion only in Hospital I, concerning the level of importance, in the parameters regarding temperature and pulse. Therefore, although the results have demonstrated that the registry instrument is an inefficient mean of communication, since it is not included in the patient record and presents incomplete information, thus, not showing the real conditions of the patient, and contributing offering little contribution as an indicator of quality, nurses evaluated the resgistry instrument as one of the most efficient strategies to give continuity to the care and a correct space to document health care, nonetheless.

  • Corresponding Author:
    Elaine Reda
    R. Tobias Franco, 289
    Centro - Itatiba - SP
    Cep: 13250-310
    E-mail:
  • Received Article 08/03/2007 and accepted 22/05/2007

    * Extracted from a Master's Thesis presented to the Nursing Graduate Program on Adult Health – Escola de Enfermagem da Universidade de São Paulo - USP - São Paulo (SP), Brazil.

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    Corresponding Author: Elaine Reda R. Tobias Franco, 289 Centro - Itatiba - SP Cep: 13250-310 E-mail: elreda@ig.com.br

    Publication Dates

    • Publication in this collection
      02 Apr 2009
    • Date of issue
      Mar 2008

    History

    • Accepted
      22 May 2007
    • Received
      08 Mar 2007
    Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
    E-mail: actapaulista@unifesp.br