Systematization of nursing care in mediate post operative of cardiac surgery
Objective: To raise the nursing diagnoses according to NANDA International Taxonomy II; to identify the nursing interventions according to NIC from the diagnosis found; and to present the results expected according to NOC, based on planned interventions. Methods: A qualitative study of case report type, carried out based on the evaluation of a patient who was in mediate postoperative cardiac surgery admitted to the ICU of a university hospital. Results: The nursing diagnoses were: risk of infection, risk of constipation, risk of falls, impaired skin integrity, willingness for increased control of therapeutic regimen, risk of electrolyte imbalance, risk of imbalance in body temperature and impaired mobility in bed. The diagnosis profile of the patient, prepared based on his needs, offered a basis for determination of nursing interventions according to the NIC, resulting in effective actions to solve the problems. Conclusion: Nursing diagnoses were raised inserted in the areas: health promotion, nutrition, elimination and exchange, activity and rest, and safety/protection. Descriptors: Nursing, Thoracic surgery, Nursing Care. 1 Nurse, Federal University of Rio Grande do Norte/UFRN. Natal RN, Brazil. E mail: naianny marlisse@hotmail.com. 2 Nurse, Federal University of Rio Grande do Norte/UFRN. Natal RN, Brazil. E mail: enferdada@hotmail.com. 3 Nurse, Federal University of Rio Grande do Norte/UFRN. Natal RN, Brazil. E mail: ana_nelson88@hotmail.com. 4 Nurse of the Family Health Strategy of Sao Paulo do Potengi RN. Natal RN, Brazil. E mail: fernandohiago@hotmail.com. 5 Nurse. Intern of Neonatal Intensive Therapy. Federal University of Rio Grande do Norte/UFRN. Natal RN, Brazil. E mail: caroline_ k16@hotmail.com. 6 Nurse. PhD in Health Sciences. Adjunct Professor of the Undergraduate Program and the Graduate Program (Academic Masters and PhD) in Nursing at the Federal University of Rio Grande do Norte/UFRN. Natal RN, Brazil. Member of the Research Group Relief and Epidemiologic Practicea in Health and Nursing/PAESE/UFRN. E mail: rirosendo@yahoo.com.br. ISSN 2175 5361. DOI: 10.9789/2175 5361.2016.v8i4.5062 5067 Carvalho IM; Ferreira DKS; Nelson ARC; et al. Systematization of nursing care. J. res. fundam. care. online 2016. out./dez. 8(4) 5062 5067 5063 RESUMO Objetivo: Levantar os diagnosticos de enfermagem segundo a taxonomia II da NANDA Internacional; identificar as intervencoes de enfermagem segundo a NIC, a partir dos diagnosticos encontrados; e apresentar os resultados esperados segundo a NOC, com base nas intervencoes planejadas. Metodos: Estudo de abordagem qualitativa, tipo relato de caso, realizado a partir da avaliacao de um paciente que se encontrava em pos operatorio mediato de cirurgia cardiaca internado na UTI de um hospital universitario. Resultados: Os diagnosticos de enfermagem encontrados foram: risco de infeccao, risco de constipacao, risco de quedas, integridade da pele prejudicada, disposicao para controle aumentado do regime terapeutico, risco de desequilibrio eletrolitico, risco de desequilibrio na temperatura corporal e mobilidade no leito prejudicada. O perfil diagnostico do paciente, elaborado com base em suas necessidades, ofereceu uma fundamentacao para determinacao das intervencoes de enfermagem segundo a NIC, resultando em acoes eficazes para a resolucao dos problemas. Conclusao: Os diagnosticos de enfermagem levantados estavam inseridos nos dominios: promocao da saude, nutricao, eliminacao e troca, atividade e repouso e