The importance from relationship with the patient surgical for implementation of nursing psychosocial diagnoses: report study

Resumo

Objectives: to apply the nursing process using the language of classification and to show the effectiveness of care systematization. Methodology: report of clinical case conducted with a female patient of 26 years old, admitted in a General Hospital at the city of Niteroi, Rio de Janeiro, during the period from March to April 2008. We used the technique of semi-structured interview based on Carpenito and the documentary survey of medical records analysis. The analysis proceeded second clinical reasoning of Risner. Results: nursing diagnosis were identified according to North American Nursing Diagnosis Association-NANDA, the main are: denial ineffective; hypothermia, acute pain, impared skin integrity, risk for infection, risk for fluid volume deficit, risk for situational low self-steem. Then was built a plan of care with the interventions proposed by Nursing Intervention Classification-NIC and the results were evaluated by Nursing Outcomes Classification-NOC. And to allow evaluation of nursing actions the results of the NOC were described in two phases, before and after intervention. Conclusion: we concluded that the nursing care based on NANDA, NIC and NOC is effective and transparent to the team of professionals. Descriptors: Nursing process; Nursing assessment; Perioperative care.