Introduction:

Nursing Care Report allows nurses recording their care activity.

Aims:

enumerating Nursing Diagnosis labels, analyzing the typology, determining the prevalence.

Methods:

observational, descriptive, retrospective study. Findings: n=1985 (59.24%) Nursing Diagnosis at hospital admission; n=210 (6.27%) ones solved in the stay; and n=1156 (34.25%) ones at patient's discharge. Domains stood out: Safety-Protection, Activity-Rest, Comfort and Elimination-Exchange. Prevalent Nursing Diagnosis: Risk for infection, Risk for bleeding, Disturbed sleep pattern, Risk of constipation and Acute pain. Prevalent collaborative problems: Hyperthermia, Hypoxia, Pain and Fever.

Conclusions:

Nurses have predilection for biological sphere Nursing Diagnosis, mainly related to pathophysiological signs and symptoms. Since a pragmatic point of view, if we accept a care bifocal perspective practice, they agree with collaboration problems; from transdisciplinary perspective, with a joint and coordinated practice, professionals must develop their own disciplinary skills, without discriminating medical problems and nurses problems.

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