Disreflexia autonômica e intervenções de enfermagem para pacientes com lesão medular

Abstract

RESUMOO presente trabalho trata-se de estudo retrospec vo realizado em 2009 que objevou iden fi car diagnós cos e intervenções de enfermagem para o cuidado de pacientes com lesão medular (LM). Os dados foram coletados de 465 prontuários de pacientes com LM em processo de reabilitação. Idenfi cou-se o diagnós co de enfermagem Risco para disrefl exia autônomica em 271 (58,3%) prontuários, dos quais 80 pacientes desenvolveram disrefl exia autônomica. Predominaram homens jovens, com idade média de 35,7 anos, sendo o trauma a principal causa da LM e o nível neurológico igual ou acima da sexta vértebra torácica. As intervenções de enfermagem foram organizadas em dois grupos, um voltado para a prevenção da disrefl exia autonômica e outro, para seu tratamento. Desenvolveu-se um guia de intervenções para uso na prá ca clínica de enfermeiros reabilitadores e para inserção em sistemas de informação. Ressalta-se a importância da re rada do es mulo causador da disrefl exia autonômica como terapêu ca mais efi caz e como melhor intervenção na prá ca de enfermagem. DESCRITORES Processos de enfermagem Cuidados de enfermagem Enfermagem em reabilitação Disrefl exia autonômica ABSTRACTThis retrospective study, carried out in 2009, aimed to identify nursing diagnoses and interventions for the assistance of patients with spinal cord injury. Data were collected from the nursing records of 465 patients with SCI in the rehabilitation process. The nursing diagnosis Risk for autonomic dysreflexia was identified in 271 clinical records (58.3%), of whom, approximately 80 patients developed Autonomic dysreflexia. The predominance was in young males with a mean age of 35.7 years, with trauma being the primary cause of injury and a neurological level equal to or above the sixth thoracic vertebra. Nursing interventions were arranged in two groups: the first focused on prevention and the other on treatment. An intervention guide was developed; the guide may be used by nurses in their rehabilitation practice and should be inserted in information systems. Removal of the stimulus inducing autonomic dysreflexia was identified as the most effective therapy and the best intervention. DESCRIPTORSNursing process Nursing care Rehabilita on nursing Autonomic dysrefl exia RESUMENEstudio retrospec vas realizado en 2009 obje vando iden fi car diagnós cos e intervenciones de enfermería para el cuidado del paciente con lesión medular (LM). Datos colectados de 465 historias clínicas de pacientes con LM en rehabilitación. Se iden fi có el diagnós co de enfermería Riesgo para disrefl exia autonómica en 271 (58,3%) historias clínicas; 80 de tales pacientes desarrollaron Disrefl exia autonó-mica. Predominaron hombres jóvenes, media etaria de 35,7 años, cons tuyéndose el trauma como causa principal de LM y nivel neurológico igual o por sobre sexta vérte-bra torácica. Las intervenciones de enfermería se organizaron en dos grupos: uno orientado a prevención de la disrefl exia autonómica y otro para su tratamiento. Se desarrolló una guía de intervenciones para uso en p...

Terms of international classification for Nursing Practice in motor and physical rehabilitation

“…Terms such as range of motion of joints, architectural barrier, bladder capacity, contraction, deformity, mobility, physical mobility, hollow foot, varus foot, rehabilitation, quality of life, bowel retraining, and bladder retraining are well used in rehabilitation nursing practices (2,(5)(6) . On the Location axis, the terms like shoulder joint, spine, elbow, iliac crest, knee, lateral malleolus, medial malleolus, leg, arm, shoulder, calf, patella, hip, shoulder region, inguinal region, intergluteal region, sciatic region, and trochanteric region are related to body structures, where joint pain and skin lesions such as pressure ulcers, may occur (14)(15) .…”

“…The use of a nursing classification system for clinical data recording in EPR allows the storage and retrieval of information, generating data for research on the effectiveness and efficiency of a particular procedure, enabling formal and efficient communication, contributing to the access of patient information by professionals involved in the care, and continuity and quality of care (2) . There are currently several nursing classification systems that represent and organize the elements inherent in the nursing process (NP), such as diagnostics, outcomes and nursing interventions.…”

“…Since Version 1.0 released in 2005, ICNP ® has become organized into a seven-axis structure: focus, judgment, action, means, client, location and time. It should be noted that from this version, the ICNP ® started its development with a formal, ontological approach in order to make it consistent with other vocabularies used in health care and with existing standards for terminology development, an aspect which was considered relevant to the representation and retrieval of documentary information about the care provided by nursing their clientele (2) . The data and the information from the nursing records can be used for planning and care management, financial forecasts, analysis of the results and policy development.…”

“…As an international standard, the ICNP ® provides the collection and analysis of Nursing data on health care services between populations of different countries. The data generated by the use of ICNP ® can support decision making, thus improving the safety and quality of care for patients and their families (2,4) . (4) .…”

Diagnósticos E Intervenções De Enfermagem Para O Componente Sentidos Da Teoria De Roy, Aplicados a Adultos Em Neurorreabilitação

“…Ressaltase que a utilização deliberada e sistemática de todas as etapas do PE na assistência às pessoas em neurorreabilitação tem conferido ao enfermeiro maior visibilidade e reconhecimento profissional, e enriquecido seu conhecimento na neurorreabilitação, com a construção de um vocabulário específico para denominar os diagnósticos e intervenções de enfermagem que são próprios da sua prática (4,6,7) .…”