Abstract

Author(s): Valls Matarín, Josefa; Torrico Rodríguez, Raquel; Quintana Riera, Salvador

Introduction: To evaluate nursery records provides information about the activity performed to detect early nutritional problems.

Objective: To evaluate and quantify the nursing records regarding the patient’s oral intake.

Methodology: Retrospective longitudinal study in a semicrítical unit with 21beds. There were included patients over 18 years old with stays over 24 hours and oral diet. Patients with enteral or parental nutrition were excluded. There were compiled demographics data, medical diagnosis, type of diet, number of data registered linked to weight, size, consciousness, amount of the intake and notes in the graphic.

Results: 495 graphics were evaluated (184 patients), the mean age 64.6 (14.1) years. The type of diet were registered in 92.7% and 62.5% had the registrations of weight and size. 84.4% of the records did not include annotations or quantity or intake. There was a higher registration in post surgical patients (p<0,037) and according to the consistency of the diet. It was superior in the liquid intakes (p<.001).

Discussion: There is a lack of information regarding to the evaluation of the intake; so as in the quantity as in the problems description, due to the fact that most of the records were taken isolated without describing any planification.

Conclusions: The results need to be improved. Nursery needs to review its perform and develop its strategy in order to ensure a correct follow up of the patient’s intake.