Nursing process and septic shock: intensive nursing care

Objective: to employ the Nursing Process by using the International Classification for Nursing Practices (ICNP®) and the Campaign Guidelines Surviving to Sepsis. Method: descriptive research, of case study, which was evaluated by the Committee of Ethics in Research of the Lauro Wanderley University Hospital/UFPB according to CAAE number 0085.0.126.000-08, and carried out with a woman who was hospitalized in the General Intensive Care Unit of a school-hospital having been diagnosed with Septic Shock. The data analysis was accomplished from a clinical judgment about the patient’s basic needs, which led to diagnoses, results and nursing interventions defined with the ICNP®. Results: the identified nursing diagnoses and results were: septic shock, decreased cardiac output, inefficient tissue perfusion, impaired spontaneous ventilation, hyperthermia, self-care deficit syndrome, risk for unstable glucose and impaired skin integrity risk. The planned and established interventions were focused on hemodynamic support, antibiotic therapy and interruption trial of the physiopathological sequence which would culminate, potentially, with the dysfunction of multiple organs and death. Conclusion: it is considered that the use of the Nursing Process guided the effective interventions which influenced, positively, the patient’s prognosis as well as her intensive care unit discharge. Descriptors: septic shock; critical care; nursing; nursing process; intensive care units.RESUMOObjetivo: aplicar o Processo de Enfermagem utilizando a Classificação Internacional das Práticas de Enfermagem (CIPE®) e as diretrizes da Campanha Sobrevivendo à Sepse. Método: pesquisa descritiva do tipo estudo de caso, apreciada pelo Comitê de Ética em Pesquisa do Hospital Universitário Lauro Wanderley/UFPB mediante CAAE nº 0085.0.126.000-08, e desenvolvida com uma mulher internada na Unidade de Terapia Intensiva Geral de um hospital escola com diagnóstico de Choque Séptico. A análise dos dados foi realizada a partir do julgamento clínico sobre ...