APLICAÇÃO DO MODELO OUTCOME PRESENT STATE-TEST NO CUIDADO EM PACIENTE COM FRATURA EXPOSTA DE TORNOZELO E INFECÇÃO EM LESÃO NO CALCÂNEO
APLICAÇÃO DO MODELO OUTCOME PRESENT STATE-TEST NO CUIDADO EM PACIENTE COM FRATURA EXPOSTA DE TORNOZELO E INFECÇÃO EM LESÃO NO CALCÂNEO
-
DOI: 10.22533/at.ed.04423031116
-
Palavras-chave: Fraturas ósseas; Processo de enfermagem; Sistematização da Assistência de Enfermagem.
-
Keywords: Bone fractures; Nursing process; Nursing Care Systematization.
-
Abstract: The objective of this article is to identify, through the Outcome Present State-Test (OPT) clinical reasoning model, the central nursing diagnoses, outcomes, and interventions for a patient with a left ankle open fracture and an infection in the calcaneal lesion. This is a case study conducted in a perioperative care unit. Data collection consisted of patient identification and characterization, clinical history, and physical examination. The diagnoses, outcomes, and interventions were performed using standardized language systems NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC), respectively. The central diagnoses were impaired physical mobility and impaired tissue integrity. Four outcomes and three interventions related to wound care and healing, as well as promoting comfort, were derived. Therefore, it was possible to identify, through the use of the OPT model, the patient's main needs, identified in eight diagnoses, two of which are central, benefiting care planning based on care priorities.
- Eduarda Nicolly dos Santos Sousa
- Isadora Christina da Cruz Lima
- Paloma Santos Alencar Sousa
- Camila de Sousa Costa
- Amanda Mendes de Freitas
- Luis Eduardo Soares dos Santos
- Antonia Fabiana Rodrigues da Silva
- Francisco Gilberto Fernandes Pereira