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Research Article | DOI: https://doi.org/10.31579/2690-8808/107
1 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
2 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
3 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
4 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
5 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
*Corresponding Author: Liane Oliveira Souza, Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.
Citation: Liane Oliveira Souza,Diego Henrique Alves Santos, Eliana da Silva Fernandes, Luciana Santos Longo, Rafaela da Cruz Leite, Liane Oliveira Souza Gome (2022) Nursing Care Systematization: Case Study on Wound Care, Journal of Clinical Case Reports and Studies 3(9); DOI: 10.31579/2690-8808/107
Copyright: © 2022 Liane Oliveira Souza, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 06 May 2022 | Accepted: 15 September 2022 | Published: 07 October 2022
Keywords: healing; nursing care; nursing diagnosis; stomatherapy
The wound is defined as a rupture in the continuity of the skin, that is, an interruption of the tissue that, depending on its commitment, can affect the skin, mucosa or organs, being necessary to understand, also as an event of ethical and social responsibility among professionals of nursing.
Wound care is a dynamic, complex process that requires special attention by the nursing professional, especially when referring to a chronic wound. In this context, it should be taken into account that chronic lesions evolve rapidly, are refractory to different types of treatments and result from predisposing conditions that make normal healing impossible. Adding the Systematization of Nursing Care (SAE) in the care of patients with wounds becomes of fundamental importance with the purpose of implementing and organizing care for them, making it possible to organize the nursing process.
The wound is defined as a rupture in the continuity of the skin, that is, an interruption of the tissue that, depending on its commitment, can affect the skin, mucosa or organs, being necessary to understand, also as an event of ethical and social responsibility among professionals. of nursing [1].
Wound care is a dynamic, complex process that requires special attention by the nursing professional, especially when referring to a chronic wound. In this context, it should be taken into account that chronic lesions evolve rapidly, are refractory to different types of treatments and result from predisposing conditions that make normal healing impossible [2]. Adding the Systematization of Nursing Care (SAE) in the care of patients with wounds becomes of fundamental importance with the purpose of implementing and organizing care for them, making it possible to organize the nursing process [3].
Goal
To report on the care of a patient with a chronic wound, at home, in the area covered by the Family Health Unit (USF), in a municipality in Bahia.
This is a descriptive study, of the case study type proposed during the Curricular component Supervised Internship I, offered in the ninth semester of the Undergraduate Nursing Course at the United Colleges of Research, Science and Health (FAPEC). This care was performed at home and at the Family Health Unit (USF) level, in order to investigate the health needs of this patient with a chronic wound, proposing to evaluate and provide care to her in an integral way, in the face of the problems of identified that interfered with the healing of his chronic wound. Several home visits were made to the patient and, when necessary, she was referred to the Family Health Unit (USF) by one of the authors, for reassessment by the health team or by the research authors.
The case study was based on the resolution of the Federal Nursing Council (COFEN) No.: 358/2009, which provides for the Systematization of Nursing Care (SAE) and the implementation of the nursing process (NP) that proposes five steps : 1st stage – carrying out the data collection through the interview; 2nd stage – realization of the nursing diagnosis, which is the process of interpretation and grouping of data collected in the first stage, which culminates with the decision-making on the concepts of nursing diagnoses; 3rd stage – planning of nursing actions through support and education; 4th stage – execution and evaluation of the nursing actions planned for the patient and 5th stage – evaluation of nursing care, which is considered systematic and continuous in the possibility of changes in the patient's responses. The stages of the nursing process are interrelated [4].
After the conclusion of the data collection phase, the work of analyzing the collected information began. In order to arrive at the diagnoses, the defining characteristics and factors determined by the NANDA classification were based on adaptation to our environment according to the authors [3], as well as the authors' knowledge and experience in carrying out the implementation of the Systematization of Child Care Nursing (SAE).
At first, the nursing history was performed: Patient M.J.S. female, 61 years old, brown, single, catholic, housewife, coming from the outskirts of a municipality in Bahia. Type II Diabetes Mellitus and Systemic Arterial Hypertension (SAH). User of Metformin 850 (mg/day), Hydrochlorothiazide (25mg/day) and Lozartan (50mg/day). She reports not taking the medication correctly. The patient has an expression of crying, easy sad, oriented in time and space, in unsatisfactory hygienic conditions, cooperative, eupneic, afebrile, responding to verbal requests clearly, eating habits were also impaired and she was not using a low-sodium diet. She reports malaise, with walking deficits. On examination: she has a symmetrical chest. Globular abdomen. Afebrile (T: 36.8º), Hypertensive (BP: 180 x 80 mmHg).
She has an infected wound on the 1st toe of the Right Lower Limb (MID). Based on ethical issues, the patient signed the free and informed consent form authorizing the performance of the case study and later its publication, after clarification of the purpose of the research.
The results found led us to outline the following nursing diagnoses for this patient, according to NANDA: self-care deficit related to ambulation difficulties, acute pain related to redness and edema, risk of injury related to altered mobility due to mass disorder and vertigo, risk of impaired skin integrity, related to turgor and decreased elasticity, lack of knowledge about the risk factors for your illness, related to the incorrect use of medications, evidencing the persistent elevation of blood pressure and blood glucose, ineffective health maintenance, related to to ineffective individual coping, evidenced by the verbal report that he does not follow the drug treatment and tissues injured by mechanical factors (trauma and accident), risk of low self-esteem related to non-acceptance of the disease.
The identification of the main nursing diagnoses in this patient under study was important for the planning of nursing care, which involved the execution of goals, objectives and nursing prescriptions and, consequently, facilitated the evaluation of care, as it supported the desired actions. to achieve in the patient with the care provided with greater safety by the professional through an organized assistance, through the stages of the nursing process. The nursing prescriptions were mostly based on support and education actions, which shows us the coherence in the decision to guide the nursing process in patients with chronic pathologies, to whom they need guidance, mainly due to the incapacities that the disease produces, such as also by the level of education of this patient.
After the nursing prescriptions and later the implementation of nursing care, the authors noted the complication of the disease Diabetes Mellitus (DM) in the patient and consequently evolution of the worsening of the wound, where they carried out the referral for hospitalization. After several days of hospitalization and stabilization of glycemic and blood pressure levels, she returned to the Family Health Unit (USF), for continuity of treatment by the health team and the authors, once again implementing the Systematization of Nursing Care (SAE) for care.
This study made it possible to understand the importance of the use of the Systematization of Nursing Care (SAE) in the care of a wound patient, as well as the importance of monitoring the individual in their home context, in the face of a patient with incapacity for resolution. of their problems and thus understand the determinants that interfere in their treatment and thus be able to interfere in the process of caring for this wound, in order to successfully heal the wound.
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