Systematization of nursing care in mediate post-operative of cardiac surgery

Abstract

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.