نبذة مختصرة : Objectives: to describe the main nursing diagnoses in the light of the theory of basic human needs, proposed by Wanda de Aguiar Horta, according to the NANDA-I taxonomy, and propose interventions and outcomes according to the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) for the 5 nursing diagnoses more frequently documented in a post-anesthetic recovery service at a reference hospital in traumatology. Method: quantitative, cross-sectional, retrospective, descriptive study of the main nursing diagnoses identified in medical records, consisting of 3 steps: preparation of the data collection instrument; data collection; and data processing and analysis. Results: the 5 most frequent diagnoses were: Risk of infection (100%); Impaired skin integrity (96.9%); Impaired tissue integrity (93.8%); Acute pain (87.9%); and Self-care deficit for bath/hygiene (69.2%). Conclusion: the diagnoses contributed to a better applicability of the nursing process in an individual and holistic way, so that interventions with more specific outcomes can be implemented and aimed at the priority needs of these patients. Descriptors: nursing diagnoses; perioperative nursing; orthopedic nursing; nursing care. RESUMO Objetivos: descrever os principais diagnósticos de enfermagem à luz da teoria das necessidades humanas básicas, proposta por Wanda de Aguiar Horta, segundo a taxonomia da NANDA-I, e propor intervenções e resultados de acordo com a Nursing Interventions Classification (NIC) e a Nursing Outcomes Classification (NOC) para os 5 diagnósticos de enfermagem mais frequentes documentados em um serviço de recuperação pós-anestésica de um hospital de referência em traumatologia. Método: estudo quantitativo, transversal, retrospectivo, descritivo de registro dos principais diagnósticos de enfermagem identificados em prontuários, sendo constituído por 3 etapas: construção do instrumento de coleta de dados; coleta de dados; e processamento e análise dos dados. Resultados: os 5 diagnósticos ...
No Comments.