NURSING CARE SYSTEMATIZATION BY NANDA _ NIC _ NOC STRATEGY IN PRACTICE SISTEMATIZACAO DA ASSISTENCIA DE ENFERMAGEM PELA ESTRATEGIA NANDA
Objective: to characterize the implementation of the nursing care systematization through NANDA_NIC_NOC strategy to a person with surgical dehiscence. Method: clinical and prospective study, applying the NANDANIC NOC strategy on an outpatient evaluated in four stages, held at the Health Institute of a private university with rooms for nursing practices and a wound center. Results: the diagnoses were identified: Impaired skin integrity and pattern of disturbed sleep. We used the NOC to assess what level of indicators was committed, then the NIC for interventions and the reassessments for the NOC. Conclusion: NANDA_NIC_NOC strategy allows nurses to measure the quality and the effect of their interventions in care and develop a care plan based on results. Descriptors: Nursing Care; Nursing Process; Patient Centered Care. RESUMO Objetivo: caracterizar a implementacao da sistematizacao da assistencia de enfermagem por meio da estrategia NANDA_NIC_NOC a uma pessoa com deiscencia cirurgica. Metodo: estudo clinico, prospectivo, aplicando a estrategia NANDA NIC NOC em nivel ambulatorial avaliado em quatro momentos, realizado no Instituto de Saude de uma faculdade particular que possui salas de consultorios de enfermagem e um centro de feridas. Resultados: os diagnosticos identificados foram: integridade da pele prejudicada e padrao de sono prejudicado. Utilizou se a NOC para avaliar qual nivel dos indicadores estava comprometido, posteriormente a NIC para as intervencoes e nas reavaliacoes para a NOC. Conclusao: a estrategia NANDA_NIC_NOC possibilita ao enfermeiro mensurar a qualidade e o efeito de suas intervencoes na assistencia e elaborar um plano de cuidados baseado em resultados. Descritores: Cuidados de Enfermagem; Processos de Enfermagem; Assistencia Centrada no Paciente. RESUMEN Objetivo: caracterizar la implementacion de la sistematizacion de la asistencia de enfermeria por medio de la estrategia NANDA_NIC_NOC a una persona con dehiscencia quirurgica. Metodo: estudio clinico, prospectivo, aplicando la estrategia NANDA NIC NOC en nivel ambulatoria evaluado en cuatro momentos, realizado en el Instituto de Salud de una facultad particular que posee salas de consultorios de enfermeria y un centro de heridas. Resultados: los diagnosticos identificados fueron: integridad de la piel perjudicada ye padron de sueno perjudicado. Se utilizo la NOC para evaluar cual nivel de los indicadores estaba comprometido, posteriormente a NIC para las intervenciones y en las revaluaciones para NOC. Conclusion: la estrategia NANDA_NIC_NOC posibilita al enfermero medir la calidad y el efecto de sus intervenciones en la asistencia y elaborar un plano de cuidados basado en resultados. Descriptors: Cuidados de Enfermeria; Procesos de Enfermeria; Asistencia Centrada en el Paciente. Nurse, Master, Specialist in Clinical surgery, University Center Jorge Amado UNIJORGE. Bahia (BA) Brazil. E mail: renata.s.schulz@gmail.com; Orthopedist, Specialist in surgery of the foot and ankle, Complex University Hospital Professor Edgard Santos HUPES. Bahia (BA) Brazil. E mail: thiagofaleiro@yahoo.com.br; Nursing Undergraduate, University Center Jorge Amado UNIJORGE. Bahia (BA) Brazil. E mail: jamile.guerra@hotmail.com; Nursing Undergraduate, University Center Jorge Amado UNIJORGE. Bahia (BA) Brazil. E mail: maryanabatista@yahoo.com.br; Nurse. Master, Specialist in Collective health, University Center Jorge Amado UNIJORGE. Bahia (BA) Brazil. E mail: moniquefaith@gmail.com; Nurse, Specialist in Emergency, University Center Jorge Amado UNIJORGE. Bahia (BA) Brazil. E mail: paulaelis_@hotmail.com CLINICAL CASE REPORT ARTICLE Schulz RS, Faleiro TB, Ribeiro JJG et al. Nursing care systematization by. English/Portuguese J Nurs UFPE on line. Recife, 10(6):2159 66, June. 2016 2160 ISSN: 1981 8963 DOI: 10.5205/reuol.9199 80250 1 SM1006201631 The Systematization of Nursing Assistance (SAE) consists of a methodology to organize and systematize care based on scientific knowledge and promote greater safety and quality for the assistance. In Brazil, it began with the studies of Dr. Wanda Horta and implementation involves five phases: Data collection or research (made by history and physical examination) nursing diagnosis; care planning; implementation of assistance; and evaluation of results. Studies developed by nurses in recent years show different difficulties in its implementation. Among them, there are: lack of knowledge by the nurse about the care methodology and theoretical models; deficiency in the thematic approach during the undergraduate course; great demand for bureaucratic and administrative services, and the lack of personnel and material resources for care. The difficulty of classification handling can be understood as a result of lack of knowledge of this tool, which has a direct impact on the implementation of theoretical and scientific knowledge to the care practice. The conscious use of SAE in the care process can contribute to the uniformity of terms and concepts helping to Nurses professionals in the clinical planning. The taxonomies NANDA I classification (North American Nursing Diagnosis Association) NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) is an enabling strategy implementation of SAE as a complement if used together. The result of their employment, in practice, should take place as follows: NANDA I NOC (initial result, conducted before interventions) NIC NOC (results after the interventions) The nursing diagnosis is defined by NANDA I as a clinical trial of individual responses, family or community health problems/real or potential vital processes. The diagnosis of Nursing is the basis for selection of nursing interventions to achieve the results for which the nurse is responsible. For NIC, a nursing intervention is any treatment based on the judgment and clinical knowledge, which is performed by a nurse to improve the results of patient/client. It is an autonomous action taken as a scientific base and customer benefit, related to a nursing diagnosis to achieve the best possible results. The NOCis considered complementary to taxonomies NANDA I and NIC and may also be used in other classifications. Its main role is describing the results achieved by patients through nursing interventions being considered first standardized and comprehensive classification. It is a multidisciplinary tool despite oriented approach to nursing actions to assist in evaluating the effectiveness of interventions. In 2002, the Federal Council of Nursing (COFEN) established the mandatory implementation of the Systematization of Nursing Assistance (SAE) in all health institutions in Brazil, through Resolution 272/2002. In 2009, COFEN recast and extends the mandatory SAE and implementation of the nursing process for all environments, public or private having professional nursing care. The nursing theories include that process and serve to support the SAE for nurses be based on priority care for assistance. In general, they follow a model that is based according to the concepts, assumptions, and propositions of each theory. In this study, we chose to Wanda de Aguiar Horta s theory, which was based on the theory of human motivation, Maslow, and Joao Mohana. Maslow classified the basic human needs into five levels: physiological needs, safety, love, esteem, and selfactualization; Joao Mohana classified them in three major dimensions: psychobiological, psychosocial and psychospiritual. In practical training, it was perceived difficulties of academics to unite theory with practice in the SAE. Thus, to help nursing students and nurses in clinical practice and familiarize them with the information about the patient record, it was traced to characterize the implementation of systematization of nursing care through NANDA_NIC_NOC strategy to a person dehiscence points in a suprapubic region monitored on an outpatient basis. The prospective clinical study, using the NANDA NIC NOC strategy on an outpatient basis. The structuring of the nursing process was based on Wanda de Aguiar Horta. For this study, the NANDA_NIC_NOC bibliographies were used and equally necessary (the three books form separately) The collection of nursing records was obtained along with physical examination for nursing consultation to continue to structure planning with diagnoses, interventions and expected results. In the end, they compared the expected results with the results. INTRODUCTION