Avaliação de enfermagem para admissão de pacientes em unidade cirúrgica de um hospital universitário: desenvolvimento de um instrumento

Abstract

Introduction: The admission of surgical patients is a crucial step for the safety and quality of care, requiring the systematization of physical, emotional, social, and spiritual aspects during the Nursing Assessment phase. The admission process should be optimized and standardized, minimizing the impact on the nursing team's workload. Objective: To develop a nursing assessment instrument for the admission of patients to the surgical unit of a university hospital. Method: Methodological research. The study involved developing the instrument through a document review from a university hospital in the Zona da Mata region of Minas Gerais, in accordance with COFEN Resolution 736/2024, and the International Patient Safety Goals, considering the pre-surgical patient from the perspective of Afaf Meleis' transition theory. The situational diagnosis was conducted through document analysis from March to June 2024, and the instrument was developed between June 2024 and July 2025. All ethical precepts were respected. Results: The documentary research revealed the absence of a standardized instrument for pre-surgical patient admission. The content developed was organized into the following axes: identification, communication, surgical preparation (adverse risks), vital signs, and the Fugulin Scale. Conclusion: The documentary research that supported the development of the instrument identified that the admission process is not performed systematically by all nurses, in addition to the lack of an institutional protocol to standardize this procedure. This absence may contribute to the weakening of the patient’s admission process.