APPLICATION OF THE NURSING THEORY OF CALLISTA ROY TO THE PATIENT WITH CEREBRAL VASCULAR ACCIDENT

Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da. Application of the nursing theory of Callista Roy…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 352

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622

 

 

 

APPLICATION OF THE NURSING THEORY OF CALLISTA ROY TO THE PATIENT WITH CEREBRAL VASCULAR ACCIDENT

APLICAÇÃO DA TEORIA DE ENFERMAGEM DE CALLISTA ROY AO PACIENTE COM ACIDENTE VASCULAR CEREBRAL

APLICACIÓN DE LA TEORÍA DE ENFERMERÍA DE CALLISTA ROY AL PACIENTE CON ACCIDENTE VASCULAR CEREBRAL

Cecília Passos Vaz da Costa1, Maria Helena Barros Araújo Luz2, Alessandra Kelly Freire Bezerra3, Silvana

Santiago da Rocha4

ABSTRACT

Objective: reporting the experience of application of the nursing process implemented in the light of the Theory of Adaptation of Callista Roy to a patient with stroke. Method: a descriptive study of type experience report, resulting from the application of the nursing process to a patient admitted in a neurological clinic of an emergency hospital in the city of Teresina, Piaui, in 2013. Results: showed itself 15 nursing diagnoses listed based on the taxonomy of the North American Nursing Diagnosis Association International and to establish interventions and nursing results there was used respectively the Classification of Nursing Interventions and the Classification and Nursing Outcomes. Conclusion: facing the findings, Roy’s theory contributed to nursing care to patients affected by this pathology by giving importance to the stimuli that trigger responses which require the adaptation of the patient. Descriptors: Stroke; Nursing Theory; Nursing

Care.

RESUMO

Objetivo: relatar a experiência da aplicação do processo de enfermagem implementado à luz da Teoria da Adaptação de Callista Roy a uma paciente com acidente vascular cerebral. Método: estudo descritivo, tipo relato de experiência, resultante da aplicação do processo de enfermagem a uma paciente internada em uma clínica neurológica de um hospital de urgência do município de Teresina, Piauí no ano de 2013. Resultados: evidenciaram-se 15 diagnósticos de enfermagem elencados com base na taxonomia da North American Nursing Diagnoses Association International e para estabelecer as intervenções e resultados de enfermagem utilizou-se respectivamente a Classificação das Intervenções de Enfermagem e a Classificação dos Resultados de Enfermagem. Conclusão: diante dos achados, a teoria de Roy contribuiu com o cuidado de enfermagem a paciente acometida por tal patologia ao dar importância aos estímulos que desencadeiam respostas, as quais exigem a adaptação da paciente. Descritores: Acidente Vascular Cerebral; Teoria de Enfermagem; Cuidados

de Enfermagem.

RESUMEN

Objetivo: presentar la experiencia de la aplicación del proceso de enfermería aplicado a la luz de la Teoría de Adaptación de Callista Roy a un paciente con ictus. Método: un estudio descriptivo del tipo relato de experiencia, resultante de la aplicación del proceso de enfermería a una paciente ingresada en una clínica neurológica de un hospital de emergencia en la ciudad de Teresina, Piauí, en 2013. Resultados: se presentaron 15 diagnósticos de enfermería enumerados basados en la taxonomía de la North American Nursing Diagnoses Association International y para establecer las intervenciones y resultados de enfermería se utilizan, respectivamente, la Clasificación de Intervenciones de Enfermería y la Clasificación de los Resultados de Enfermería. Conclusión: en los resultados, la teoría de Roy contribuyó a los cuidados de enfermería a los pacientes afectados por esta patología, dando importancia a los estímulos que desencadenan respuestas que requieran la adaptación del paciente. Descriptores: Accidente Cerebrovascular; Teoría de Enfermería;

Cuidados de Enfermería. 1Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of Piaui/PPGENF/UFPI. Teresina (PI), Brazil. Email: ceciliapassos14@yahoo.com.br; 2Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of Piaui/PPGENF/UFPI. Teresina (PI), Brazil. Email: mhelenal@yahoo.com.br; 3Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of Piaui. Teresina (PI), Brazil. Email: alessandrakfreire@hotmail.com; 4Nurse, Professor of Nursing, Nursing Postgraduate Program, Federal University of Piaui/PPGENF/UFPI. Teresina (PI), Brazil. Email: silvanasantiago27@gmail.com

 

 

 

 

 

 

CASE REPORT ARTICLE

 

 

 

 

Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da. Application of the nursing theory of Callista Roy…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 353

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622

 

Through the view of the World Health

Organization the patient affected by a chronic

disease, such as stroke (CVA), needs planned

care able to meet his basic needs and provide

integrated care, in addition, this condition

requires that the same reorganize his daily

life, in order to find new ways of relating to

life.1

As the base of nursing process, Nursing

offers theories or conceptual models

consisting of an organization of central

concepts of the profession in an orderly and

scientific way to direct data collection,

identification of changes in the clinical

condition of the patient, the nursing

interventions and evaluation of the results.

Among these, it emphasizes the conceptual

model of the proposed adaptation by Callista

Roy, which includes the notion of stimuli and

responses. The appearance of stimuli takes

the need for part of the individual responses

for coping mechanisms that are triggered

which are processed through two subsystems

defined as regulator and knowing. That may

be chemical, neural and endocrine, already

recognizing that the subsystem is related to

higher brain functions of perception, emotion

or judgment processing of information.2-3

The resulting behaviors of these subsystems

are observed from four adaptive modes. In

physiological way the person responds like a

physical environmental incentives and involves

five basic needs of physiological integrity

(oxygenation, nutrition, elimination, activity

and rest, and protection) and four complex

processes (sensory, fluid and electrolytes,

neurological function and function endocrine).

The self-mode focuses on the psychological

and spiritual aspects of a person and includes

self-physical (includes sensation and body

image) and self-personnel (includes self-

consistency, self-ideal and self-ethical-moral-

spiritual).2-4

But the function mode/role performance

focuses on the social aspects related to the

roles that one occupies in society and finally

the interdependence so that is related to

emotional fitness as well as to holders of

systems, receptive behavior and contribution

of behavior identified the patterns of human

value, affection, love and affirmation.2-4

The nursing process should not be seized or

held for a mere fulfillment of tasks, as this

methodological tool scientifically underpins

the profession knowledge, allows to develop

effective assistance focused on patient safety

and provides the identification of individual

and collective needs under a holistic and

critical view. 5-6

The nursing process comprises phases

which vary according to nursing theory

adopted. The elements of Roy nursing process

include: research behavior, research stimuli,

nursing diagnosis, goal setting, intervention

and evaluation. The first element consists of

collecting answers or the person’s behavior in

relation to each of the adaptive modes. The

second involves the identification of focal,

contextual and residual stimuli that are

influencing behaviors. The third element of

the process is the identification of nursing

diagnoses, which reflects the nurse’s judgment

on the level of adaptation of the person.4, 7

The fourth element includes goal setting,

time the nurse lists the resulting behaviors of

nursing care. The fifth is for the planning of

interventions that should be selected

according to pre-established goals, aiming to

promote adaptation by stimulating change.

Finally, evaluation, it is believed that the

effectiveness of nursing intervention is related

to human behavior adaptation.4,7

By analysis of Callista Roy adaptation

nursing theory, sees it a theoretical

framework for the development of care for

people with chronic diseases which need to go

through a process of adaptation to the new

conditions of health and disease, among these

the affected by stroke, as this condition

creates stimuli that the patient requires an

adaptive response.

Given the above, the objective of this

study is to reporting the experience of the

application of the nursing process

implemented in the light of the Theory of

Adaptation of Callista Roy to a patient

affected by stroke.

 

This is a descriptive study of type

experience report, resulting from the

application of the nursing process mediated by

the Nursing Theory of Adaptation of Callista

Roy to a hospitalized patient in June, 2013, in

a neurological clinic of an emergency hospital

in the city of Teresina, Piaui.

To implement the first phase of the nursing

process there was drawn up an interview

script with the intention of guiding the

research and behavioral stimuli (Appendix A).

After behavioral and stimulation research

nursing diagnoses were established, using as

basis the taxonomy of the North American

Nursing Diagnosis Association International

(NANDA-I).8 The process of preparing and

inference of nursing diagnoses followed the

steps recommended by the reasoning of

METHOD

INTRODUCTION

 

 

Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da. Application of the nursing theory of Callista Roy…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 354

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622

Risner, namely: categorization of data,

identification of data gaps, clusters of

relevant data, comparison between the groups

with normal patterns, inferences and

propositions of etiological relations.9

Then it set up goals and interventions

needed to promote better adaptive response.

The nursing interventions were defined

according to the Nursing Interventions

Classification (NIC)10 and are shown in Table 1

with its specific code for each intervention

with four digits. For the results we used the

taxonomy Nursing Outcomes Classification

(NOC)11 identifying the result with their

respective specific code, and finally there was

the evaluation of the implemented actions.

 

The application of the Roy Adaptation

Model allowed identify commitment in the

following components of the physiological

mode: oxygenation, protection, nutrition,

activity and rest, senses and neurological

function.

In the oxygen component it showed up the

following nursing diagnoses according to

NANDA-I: ineffective breathing pattern

manifested by tachypnea defining

characteristics and dyspnea, ineffective

airway clearance manifested by ineffective

cough, tachypnea, and dyspnea and risk of

ineffective cardiac tissue perfusion.

For the diagnosis of ineffective breathing

pattern nursing interventions were:

respiratory monitoring, monitoring of vital

signs and respiratory control with the

following activities: monitoring frequency,

pace, depth and effort of breaths, listen

breath sounds, monitor diaphragmatic muscle

fatigue, monitor and record temperature,

pulse, blood pressure and breathing pattern.

Interventions facing the diagnosis of

ineffective airway clearance were: listen

breath sounds, vacuum when necessary, place

the patient in order to maximize breathing,

encourage slow, deep breathing and guide and

encourage the patient to cough after inhaling

and exhaling deeply. For the diagnosis of

cardiac tissue perfusion ineffective risk

interventions were listen heart sounds and

administering antihypertensive medication,

according to prescription.

As adaptive problems of the protection

component, there are the nursing diagnoses,

namely: impaired tissue integrity, impaired

skin integrity, which were listed by the

patient develops pressure ulcers (UPP) Grade

III sacral area and UPP grade II calcaneus

region and the diagnosis of impaired oral

mucosa, and infection risk.

Interventions for the care of UPP were to

describe the ulcer features, monitor the

color, temperature, edema moisture and

appearance of the skin around, monitor

wound infection signs, perform changing

positions of 2 in 2 hours, advise mattress use

appropriate, guide staff and conduct healing

of the wound.

The activities for the intervention of oral

health maintenance guide were doing oral

hygiene after meals and whenever necessary

and guide brush of their teeth, gums and

tongue. For the restoration of intervention of

oral health activities consisted of guiding the

use of brush with soft bristles and monitor

lesions on the lips and mucous membranes.

For the diagnosis of infection risk

interventions were: monitor site of

venipuncture, exchange peripheral access

where necessary and monitor systemic signs

and symptoms and infection sites.

In the nutrition component there was

detected the nursing diagnosis of impaired

dentition related to ineffective oral hygiene

evidenced by loss of teeth and halitosis.

Interventions for these diagnoses were the

same as diagnosis of impaired oral mucosa.

The physical mobility nursing diagnoses

related to impaired neuromuscular

impairment evidenced by hemiplegia and

disturbed sleep pattern related to

environmental changes evidenced by reports

of trouble sleeping and staying asleep were

listed as adaptive problems of the

physiological mode on their activity

component and rest.

Nursing interventions prescribed for the

diagnosis of impaired physical mobility were

neurological positioning and therapy exercises

with the following activities: avoid applying

pressure on the affected side of the body,

supporting the affected body part, hold

stimuli and passive exercises on the affected

side, guide family to monitor the realization

of exercise and physical therapy forward.

For intervention improves sleep has

prescribed the following activities: monitor

sleep patterns and the amount of hours slept,

discouraging daytime sleep and provide

comfort measures while sleeping.

As the adaptive problem senses component

found that the impaired verbal communication

and diagnostics risk of falls.

The activities for communication

improvement intervention were listening,

encouraging the patient to repeat words,

offer positive reinforcement and support,

when necessary, to maintain dialogue with the

patient, encourage the patient to talk slowly

and observe nonverbal clues. For diagnosing

EXPERIENCE REPORTS

 

 

Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da. Application of the nursing theory of Callista Roy…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 355

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622

risk of falls, interventions were guiding on the

use of assistive devices and guide the patient

to call help when jogging.

The last mode of the physiological adaptive

problem was identified in neurological

function component with the nursing diagnosis

risk of inefficient brain tissue perfusion.

Although the patient be affected by a

condition in the neurological system, found

only a nursing diagnosis in the component

neurological function, this fact can be

explained because the neurological function is

configured as a component of the hardest

physiological mode analysis due to the

condition of relationship between this

complex process and the other components of

the physiological mode.3

Interventions for diagnosis of neurological

function component were: monitor the size,

shape, symmetry and reactivity of pupils,

monitor level of awareness and guidance,

applying the Glasgow coma scale, observe

headache complaints, monitor speaks

characteristics and monitor the presence of

signs and symptoms of increased intracranial

pressure.

In so self-evident that the adaptive

problem in self-staff component formed by

anxiety as nursing diagnosis. The interventions

were outlined using a calm and safe approach,

explain the procedures to be performed and

encourage the patient to verbalize feelings.

The last way in which it showed an

adaptive problem was the role of performance

mode which nursing diagnosis raised was

ineffective control of the therapeutic

regimen. The activities for the nutrition

counseling intervention were to identify the

behaviors to be changed, provide information

to diet modification and discuss preferences

and food which the patient does not like. For

behavior modification intervention activities

were encouraging the replacement of

undesirable habits by desirable habits,

discussing the process of change with the

patient and caregiver and promote family

involvement in the change process.

The last step of the nursing process, as

Callista Roy, is the evaluation in which the

nurse questions and weaves judgment about

the achievement of objectives in the process

of adaptation by which the individual passes.

After 3 days of use of the nursing process

based on Roy’s theory in patient care it will

found that interventions have allowed changes

in decreased anxiety with positive patient

discourse and planning for execution of daily

life activities after hospital discharge

configurating itself change in strategy

planning indicator is inserted into the nursing

outcome “self-anxiety.” To the result of level

of anxiety became evident change in the

indicator improved in the pattern of sleep and

rest of patients with nocturnal sleep

improvement report allowing adaptation of

the patient to self-concept mode and activity

and rest.

The physiological mode results achieved for

the diagnosis of oral hygiene with an

improvement in halitosis indicator and the

inefficient respiratory pattern diagnosis and

ineffective airway clearance with changes in

respiratory rate indicators and dyspnea at rest

and the result of vital signs there was change

in respiratory rate indicator.

The mode of performance was a result of

knowledge and control of hypertension with

changes in control benefits indicators of the

disease and strategies to improve adherence

to diet and result of family support during

treatment with change in the collaboration

window with family sick in determining the

care and information request indicator.

The other results listed in Figure 1

represent the expected results compared to

the listed diagnoses and nursing interventions.

 

 

Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da. Application of the nursing theory of Callista Roy…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 356

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622

Component Mode of

Adaptation

Nursing diagnosis (NANDA-I) Nursing intervention (NIC)-Code of NIC

Nursing results (NOC)

Physiological

Oxygenation

Ineffective breathing pattern related to hyperventilation manifested by tachypnea and dyspnea

Respiratory monitoring (3350). Monitoring of vital signs (6680). Airway control (3140).

Respiratory status (0415). Vital signs (0802).

Oxygenation

Ineffective airway clearance related to neuromuscular dysfunction and smoking shown by ineffective cough, tachypnea and dyspnea.

Respiratory monitoring (3350). Airway control (3140). Stimulus to cough (3250)

Respiratory status: airway permeability (0410). Respiratory status: ventilation (0403).

Oxygenation

Risk of cardiac tissue perfusion related to decreased hypertension and hyperlipidemia.

Monitoring of vital signs (6680).

Tissue: cardiac perfusion (0405). Vital signs (0802).

Protection

Impaired tissue integrity related to impaired mobility, decreased dermal vascularization secondary to ageing and moisture evidenced by grade III pressure ulcer on sacral region.

Caring for pressure ulcers (3520). Wound healing: second intention (1103). Tissue integrity: skin and mucous membranes (1101).

Physiological

Protection

Impaired skin integrity related to motor deficit, impaired mobility and decreased Vascularity secondary dermal aging evidenced by grade II pressure ulcer in calcaneal region.

Caring for pressure ulcers (3520). Wound healing: second intention (1103). Tissue integrity: skin and mucous membranes (1101).

Protection

The oral mucosa impaired related to ineffective oral hygiene evidenced by tongue coated, oral lesion and halitosis.

Maintenance of oral health (1710). Restoration of oral health (1730)

Oral hygiene (1100).

Protection Risk of infection related to invasive procedures. Protection against infection (6550) Risk control: infectious process (1924). Nutrition Impaired dentition related to ineffective oral hygiene

evidenced by loss of teeth and halitosis. Maintenance of oral health (1710). Restoration of oral health (1730).

Oral hygiene (1100).

Activity and rest

Impaired physical mobility related to neuromuscular impairment evidenced by hemiplegia.

Neurological positioning (0844). Exercise therapy: joint mobility (0224).

Body mechanics performance (1616). Mobility (0208).

Physiological

Activity and rest

Disturbed sleep pattern related to environmental changes, evidenced by reports of difficulty to sleep and stay asleep.

Sleep improvement (1850). Sleep (0004).

Senses

Impaired verbal communication related to changes in the central nervous system, manifested by dysarthria.

Improvement of communication: speech deficit (4976). Listen actively (4920).

Communication (0902). Communication: expression (0903).

Senses Risk of falls related to impaired physical mobility. Prevention of falls (6490). Risk control (1902). Care with the affected side (0918).

Neurological Function

Risk of cerebral tissue perfusion ineffective related to cerebral aneurysm and hypertension.

Neurological monitoring (2620). Monitoring of vital signs (6680).

Tissue perfusion: cerebral (0406). Neurological State (0909).

Self-concept Self-personal Disease-related anxiety manifested by crying and insomnia.

Anxiety reduction (5820). Level of anxiety (1211). Anxiety self-control (1402).

Role performance

Ineffective therapeutic regimen related control the complexity of the treatment regimen indicated for failure to take action to reduce risk factors.

Nutritional counseling (5246). Behavior modification (4360).

Knowledge: control of hypertension (1837). Family support during treatment (2609).

Figure 1. Diagnoses, interventions and outcomes of nursing for a patient with STROKE according to the Adaptive Model of Roy. Teresina-PI, 2014.

 

 

Santos FS, Arruda AJCG de, Vasconcelos JMB. Aplicabilidade do código de ética nas ações…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 357

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.8423-73529-1-RV1001201601

 

The grounded nursing process in Roy’s

theory contributed to effective nursing care to

patients affected by stroke to give importance

to the stimuli that trigger responses which

require the adaptation of the patient.

Before long the patient has demonstrated

adaptive behaviors with regard to diagnosis of

oral hygiene, ineffective breathing pattern,

and ineffective airway pattern of sleep and

rest, anxiety and ineffective control of the

therapeutic regimen.

In view of this is salutary that care

implemented resulting from the nursing

process based on the theoretical model of Roy

and the use of NANDA-I taxonomy, NIC and

NOC allowed direct the activities to adaptive

problems contributing to the adaptation of

the patient, and provide scientific nature to

care practice with consequent empowering

care by nurses. Therefore, the experience

raises the need to use a conceptual

framework in nursing care.

 

1. Organização Mundial de Saúde. Cuidados

inovadores para condições crônicas:

componentes estruturais de ação. Relatório

mundial. Organização Mundial da Saúde.

Brasília, 2003 [Internet]. [cited 2013 July 5].

Available from:

http://www.who.int/chp/knowledge/publicat

ions/icccportuguese.pdf

2. Roy C, Andrews HA. The Roy adaptation

model. Stamford: Appleton e Lange; 1999.

3. Lopes MVO, Araújo TL, Rodrigues DP. A

relação entre os modos adaptativos de ROY e

a taxonomia de diagnósticos de enfermagem

da NANDA. Rev Latino-Am Enfermagem

[Internet]. 1999; [cited 2013 July 12];7(4):97-

104. Available from:

http://www.scielo.br/scielo.php?script=sci_ar

ttext&pid=S0104-

11691999000400013&lng=en&nrm=iso

4. George JB. Teorias de enfermagem: os

fundamentos à prática profissional. Porto

Alegre: Artes Médicas; 2000.

5. Pereira CFD, Tourinho FSV, Miranda FAN,

Medeiros SM. Ensino do processo de

enfermagem: análise contextual. J Nurs UFPE

on line [Internet]. 2014 [cited 2014 Mar

15];8(3):757-64. Available from:

http://www.revista.ufpe.br/revistaenfermage

m/index.php/revista/article/view/5473

6. Freitas NF, Tannure MC, Chianca TCM.

Implementation of nursing process in a

neonatal intensive care unit of Belo

Horizonte. J Nurs UFPE on line [Internet].

2010 [cited 2014 Jan 10];4(esp):1287-293.

Available from:

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m/index.php/revista/article/view/1053/pdf_

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7. Coelho SMS, Mendes IMDM. Da pesquisa à

prática de enfermagem aplicando o modelo de

adaptação de Roy. Esc Anna Nery [Internet].

2011 Dec [cited 2013 July 11];15(4):845-50.

Available from:

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ttext&pid=S1414-

81452011000400026&lng=en&nrm=iso

8. North American Nursing Diagnosis

Association International (NANDA-I).

Diagnóstico de enfermagem da NANDA:

definições e classificação – 2012-2014. Porto

Alegre: Artmed; 2013.

9. Risner PB. Diagnosis: analysis and

synthesis of data. In: Griffith-Kenney JW,

Christensen PJ. Nursing Process application of

theories, frameworks, and models. 2nd ed. St.

Louis Mosby; 1986

10. Buthcher H, Bulechek GM. Classificação

das Intervenções de Enfermagem (NIC). 3 ed.

Porto Alegre: Artmed; 2004.

11. Moorhead S, Johnson M, Maas M.

Classificação dos resultados de enfermagem

(NOC). 4th ed. Rio de Janeiro: Elsevier; 2010.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

FINAL REMARKS

 

 

Santos FS, Arruda AJCG de, Vasconcelos JMB. Aplicabilidade do código de ética nas ações…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 358

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.8423-73529-1-RV1001201601

 

GUIDE FOR BEHAVIORAL AND STIMULUS RESEARCH

 

Name: ___________________________________________________

Birthdate: ________________ Age: _____________________

Gender: ( ) Male ( ) Female

 

Skin color: ( ) White ( ) Black ( ) Yellow ( ) Maroon

 

Marital status: ( ) Married ( ) Single ( ) Widower/Widow ( ) Separated

( ) Stable union

 

Schooling: ( ) Illiterate ( ) Incomplete elementary school ( ) Complete elementary school ( )

Incomplete high school ( ) Complete high school ( ) Incomplete higher education ( ) Complete

higher education

 

Occupation: ______________________________________________________

Address: _______________________________________________________

City: ________________________ State: _________________________

Date of admission: ___________________

Origin: Home Hospital Other: ________________

Nursing: ________________ Bed: _________________

 

 

2 PHYSIOLOGICAL MODES

2.1 OXIGENATION

2.1.1 Breath

Breath: ( ) Spontaneous ( ) Nasal catheter ( ) Mask

 

Chest: ( ) Flat ( ) Cask or Barrel ( ) Funnel-shaped ( ) Carinate

Other: ___________________________

 

Respiratory frequency: __________ respiratory movements per minute

 

Respiratory auscultation: ( ) Adventitious noise absent

( ) Adventitious noises present: ( ) Snoring ( ) Ping ( ) Rattle Other: _________

 

Cough: ( ) No ( ) Yes: ( ) Nonproductive ( ) Productive

 

2.2.2 Circulation

Blood pressure: ___________mmHg Heart frequency: ______bpm

Pulse: ( ) Regular ( ) Irregular ( ) Thready ( ) Full ( ) Impalpable

Capillary filling time: ________seconds

The presence of edema: ( ) No ( ) Yes: ( ) MMSS ( ) MMII Other: ____________

2.2 NUTRITION AND ELIMINATION

Diet: ( ) Oral ( ) SNG ( ) SNE ( ) Parenteral

Dentition: ( ) Absence of teeth ( ) Loss of teeth ( ) Presence of teeth

Oral mucosa: ( ) Full ( ) With lesions

Oral hygiene: ( ) Unsatisfactory ( ) Satisfactory

Abdomen: ( ) Flat ( ) Globulous ( ) Distended ( ) Flaccid ( ) Painful on palpation

Fluid intake per day: ( ) less than 5 glasses ( ) 5-10 glasses

( ) more than 10 glasses

Number of meals a day: ( ) less than 3 meals ( ) between 3-5 meals

( ) more than 5 meals

Weight: ______kg Height: _____m BMI: _________

Bowel sounds: ( ) Absent ( ) Present ( ) Increased ( ) Diminished

Nausea: ( ) No ( ) Yes Vomiting: ( ) No ( ) Yes

Dyspepsia: ( ) No ( ) Yes Diarrhea: ( ) No ( ) Yes

Frequency of defecation: __________times per week

APPENDIX

 

 

Santos FS, Arruda AJCG de, Vasconcelos JMB. Aplicabilidade do código de ética nas ações…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 359

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.8423-73529-1-RV1001201601

Date of the last defecation: _______________

Urinary elimination: ( ) Spontaneous ( ) SVD ( ) Urinary device

( ) Urinary retention ( ) Urinary incontinence ( ) Dysuria ( ) Hematuria ( ) Anuria ( ) Oliguria

Urinary volume: __________

2.3 Activity/rest and protection, and four complex processes (sensitive, liquid and electrolytes,

neurological function and endocrine function).

Sleep: ( ) Increased ( ) Diminished ( ) Without complaints

Sleep on the day shift: ( ) No ( ) Yes: _________hours

Mobility: ( ) Not changed ( ) Changed: __________________________

Mucous membranes: ( ) Normochromic ( ) Hypochromic _____/4+ ( ) Icteric

Eyes: ( ) Jaundice ( ) Eyelid edema Other: ______________

Skin: ( ) Normal ( ) Cyanosis ( ) Jaundice ( ) Pallor

Wound: ( ) No ( ) Yes Local: ________________________________

Dimensions: ______________________________________________________

CLASSIFICATION:

The wound: ( ) Closed ( ) Open ( ) Chronic ( ) Acute

The tissue: ( ) Necrosis ( ) Mortification of tissues ( ) Granulation ( )

Epithelialization

The exudate: ( ) Serous ( ) Sanguineous ( ) Purulent ( ) Fibrinous exudation

Quantity of the exudate: ( ) Small ( ) Moderate ( ) Intense ( ) Abundant

Odor: ( ) Odorless ( ) Fetid

Recommended therapy for wound treatment:

_______________________________________________________________

 

2.4 NEUROLOGICAL FUNCTION

Glasgow Coma Scale: Eye Opening: ______

Verbal answer: __________ Motor answer: ________

Pupils: ( ) Equal ( ) Anisocoric ( ) Miosis on the right ( ) Miosis on the left ( ) Mydriasis

on the right ( ) Mydriasis on the left

Conscious: ( ) Yes ( ) No

Guided: ( ) Yes ( ) No

 

 

3. What do you know about your present illness?

_______________________________________________________________

 

4. Important complaints:

______________________________________________________________________________________

______________________________________________________________________________________

_________________

 

VITAL SIGNS:

T: _______ P: _________ R: _________ PA: _______

IMPORTANT LABORATORY DATA:

______________________________________________________________________________________

______________________________________________________________________________________

________________

 

________________________________________________

SIGNATURE

 

 

 

 

Santos FS, Arruda AJCG de, Vasconcelos JMB. Aplicabilidade do código de ética nas ações…

English/Portuguese

J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016 360

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.8423-73529-1-RV1001201601

Submission: 04/07/2015 Accepted: 25/07/2015 Published: 01/01/2016

Correspondence Address

Cecília Passos Vaz da Costa

Avenida Centenário, 3052

Bairro Aeroporto

CEP 64003-700  Teresina (PI), Brazil

 

 

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