SYSTEMATIZATION OF NURSING CARE OF A USER WITH PYODERMA GANGRENOSUM BY USING THE CIPESC CLASSIFICATION¹ RESUMO

Transcription

1 SYSTEMATIZATION OF NURSING CARE OF A USER WITH PYODERMA GANGRENOSUM BY USING THE CIPESC CLASSIFICATION¹ ROSA, Bianca Ottes ; SILVA, Mariana Braga da ; SANTOS, Silvana Ramos dos ; GRANDO, Maristel Kasper ; SILVA, Joselaine Rigue da. RESUMO Trata-se de um relato de experiência com o objetivo de apresentar a sistematização da assistência de enfermagem de um usuário com pioderma gangrenoso na atenção básica de saúde. A SAE foi estruturada com informações da última visita domiciliária e guiada por um instrumento padronizado pelo curso de enfermagem do Centro Universitário Franciscano, com base na Teoria de Wanda Horta. A Classificação Internacional das Práticas de Enfermagem em Saúde Coletiva (CIPESC) foi a classificação adotada. Os diagnósticos de enfermagem Autoestima baixa e Imagem corporal alterada embasaram a atuação do enfermeiro nos cuidados prioritários em domicílio, com o objetivo de fortalecer a retomada gradual das atividades da vida diária, com o início da aceitação do novo estilo de vida. Houve significativa alteração dos diagnósticos de enfermagem em relação aos quadros anteriores do usuário, estabelecendo-se novos focos de intervenção, no sentido de promover saúde e prevenir outras complicações. Descritores: Pioderma grangrenoso; Processos de enfermagem; Enfermagem. ABSTRACT This is an experience report with the aim of presenting the systematization of nursing care (SNC) of a user with pioderma gangrenosum in basic health care. SNC was structured with information of the last home visit and guided by a standardized instrument offered by the Nursing Major of the Franciscan University, based on Wanda Horta's Theory. The International Classification of Nursing Practice in Collective Health (ICNPCH) was the classification adopted for this study. The nursing diagnoses of Low Self-esteem and altered body image were the base the performance of nurses in home care priority, with the aim of making the gradual resumption of activities of daily living stronger, with the early acceptance of a new lifestyle. There was observed a significant alteration in the nursing diagnoses in relation to previous health framework of the user, establishing new points of intervention to promote health and prevent further complications. Author and presenter. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Author. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Maria, RS, (UNIFRA), Santa Maria, RS, Author. Clinical nurse of the Municipal Health Secretariat. Santa Maria, RS,

2 Keywords: Pyoderma gangrenosum; Nursing process; Nursing.. INTRODUCTION Pyoderma gangrenosum is an inflammatory skin disease that presents and painful and destructive ulcerations, being commonly found in the lower limbs -. It can be associated with inflammatory bowel disease, rheumatic diseases and other ones or be caused by trauma, including surgical, constituting a phenomenon called pathergy. The disease is chronic and progressive, then it offers risk for death, and the need to provide systematic individualized care in clinical decision making, indicating the completion of the Nursing Care Systematization (NCS). NCS is a methodological instrument that guides the clinical professional nursing care as well as records of their practice. In this context, NCS can identify, understand, describe, organize, and explain how the patient responds to health problems, determining nursing actions which include planning, implementation and evaluation of care. According to COFEN Resolution 8/009, Article, the nursing process must be performed deliberately and systematically in all public or private environments where occurs the nursing professional care. The Nursing Process consists of five interrelated steps: history of nursing, nursing diagnosis, care planning, care implementation and evaluation of results.. OBJECTIVE Describe an experience of systematization of nursing care which was performed for a user with pyoderma gangrenosum in basic health care. Author and presenter. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Author. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Maria, RS, (UNIFRA), Santa Maria, RS, Author. Clinical nurse of the Municipal Health Secretariat. Santa Maria, RS,

3 . METHODOLOGY SNC was structured with information of the last home visit, and the user received monitoring of the health unit nurse for months and home care for six months. For data collection, it was used an instrument offered by the Nursing Major of the Franciscan University (UNIFRA), taking into account the physiological, psychological, social and psychospiritual needs, based on Wanda Horta's Theory. From these data collection, it was identified nursing diagnoses by using the International Classification of Nursing Practice in Collective Health (ICNPCH).. RESULTS AND DISCUSSION. Background of the user SB, male, 8 years old, married, vigilant, insured by disability benefit in consequence of work incapacity for months. The family sought the basic health unit to make a dressing in relation to an MMII lesion and to verify the capillary blood glucose at home. He had a history of diabetes mellitus and hypertension. In the first contact made during the home visit, he was oriented in time and space, communication and bedridden for months. He affirmed to be making use of NPH insulin, aspirin, enalapril, Bactrim, Clopedogrel, Benapril, Espinolatrona, simvastatin, bromopride, Warfarin, Fluoxetine, Selozok, and nutritional supplements: Designate albumin, Nurse activ. Vital signs were: BP: 0/80 mmhg, HR: 86 bpm, RR: 6 mpm, Tax: 6 C. Physical examination: User stained, nourished, hydrated. Head and neck: with good scalp hygiene, normal visual acuity. Thorax: vesicular murmurs were present, absence of breath sounds. Abdomen: distended, deletions vesico-intestinal Author and presenter. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Author. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Maria, RS, (UNIFRA), Santa Maria, RS, Author. Clinical nurse of the Municipal Health Secretariat. Santa Maria, RS,

4 present, made in the diaper and urinal, respectively. MMSS: sp. Musculoskeletal System: pressure damage in the right trochanteric region, with good healing. LL: healed stump of the left lower limb, right lower limb injury with excellent epithelialization process, presenting only small crusts over the lesion. Pedal pulse, anterior and posterior tibial pulse, present.. Planning and Implementation Table - List of nursing diagnoses and interventions Nursing Diagnoses Low Self-esteem Altered Body Image Nursing Interventions Assist the reflection on the interference of the disease in his life; Encourage the identification of strengths and capabilities; Encourage social interaction; Clarify uncertainties about the current health situation; Encourage the verbalization of feelings, perceptions and fears. Encourage the verbalization of feelings, perceptions and fears; Encourage body self-care ; Encourage the control of food intake; Conduct home visits; Guide the control of medication.. Evolution The nursing diagnoses of Low self-esteem and altered body image, which were identified in the recovery phase of the user, based the performance of the nurses in home care priority, with the aim of making the gradual resumption of activities of daily living stronger, with the acceptance of the new lifestyle. The results for the diagnosis of Low self-esteem showed an increase in the interest of the user to return to the activities that he had as a radio announcer Author and presenter. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Author. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Maria, RS, (UNIFRA), Santa Maria, RS, Author. Clinical nurse of the Municipal Health Secretariat. Santa Maria, RS,

5 at the local community and the help in the family chores. Regarding the results for altered body image, it was observed significant improvement in general, the regulation of capillary blood glucose and blood pressure, with no pain in the right MMII, with excellent epithelialization process. In contrast, in the left MMII, an amputation was carried out four months ago presenting stump fully healed. A significant alteration in the nursing diagnoses in relation to previous health framework of the user, establishing new points of intervention to promote health and prevent complications.. CONSIDERATIONS The development of SNC proved to be a decisive factor for the clinical decision of the nurse and it also contributed to the stabilization of the disease and restore health of the user, showing a competent and qualified professional performance. REFERENCES Fraga JCS,Valvede RV,Souza VL,et al.pioderma gangrenoso.apresentação atípica.ann Bras Dermatol 006; 8(): S0-8. Costa IMC,Nogueira LSC.Pioderma gangrenoso e artrite reumatóide Relato de caso. An Bras Dermatol 00;80():8-. Fuly PSC, Leite JL, Lima SBS. Correntes de pensamentos nacionais sobre a sistematização da assistência de enfermagem. Rev Bras Enferm 008; 6(6):88-7. Conselho Federal de Enfermagem (Cofen) Resolução Cofen n. 8, de de outubro de 009. Brasília: Cofen; 009. Secretaria de Município da Saúde. CIPESCANDO EM CURITIBA: Construção e Implementação da Nomenclatura de Diagnósticos e Intervenções de Enfermagem na Rede Básica de Saúde. Curitiba (PR); 00. Author and presenter. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Author. Nursing student of the rd period at the Franciscan University (UNIFRA), Santa Maria, RS, (UNIFRA), Santa Maria, RS, Author. Clinical nurse of the Municipal Health Secretariat. Santa Maria, RS,