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Objective: To build an instrument for systematization of nursing care in cardiovascular hospitalization unit at a public institution in the city of Manaus. Methods: applied nature of research, qualitative approach and using descriptive method. Held in the period August 2015 to January 2016 in a unit of cardiovascular hospitalization. Results: It was built on a general approach with interface about the human body systems, signs and symptoms were investigated often found in customers in a cardiovascular clinic and categorized using the Basic Human Needs of Horta, using the format of checklist once which facilitates and optimizes the time during medical practice, and thus can easily be used by nurses, making it as close to the experience of these professionals. The instrument was constructed, according to the Nursing Process (PE): Nursing History, Nursing Diagnosis, Planning, Nursing Requirements and Evaluation. Were drafted 23 (twenty three) nursing diagnoses assessed with the use of the most common clinical evidence on cardiovascular changes, generating a total of ninety-two (92) Nursing prescriptions according to taxonomy, NIC and NOC. Conclusion: It can be inferred from this study that it is important to operationalize the SAE in care practices, based on a care model in order to facilitate the identification of nursing diagnoses, as well as about the development of care. It is expected that this study will contribute to the establishment and implementation of NCS in everyday practice in this institution.

brazilian journal of health review

Sistematização da assistência de enfermagem: uma proposta para unidade de internação cardiovascular / Systematization nursing assistance: a proposal for cardiovascular hospitalization unit