Subconjunto terminológico da CIPE® para pacientes graves com sepse

Abstract

Introduction: Despite all the advances of contemporary science for the artificial support of the organic functions of the severe patient, sepsis is a clinical syndrome in which a dysregulated response of the organism to infection, mediated by a systemic reaction of the host's immune system against an infective given microorganism, causes life-threatening organic dysfunction and, consequently, represents one of the major causes of death in Intensive Care Units (ICUs) around the world. Objective: Develop an ICNP® Terminology Subset for Serious Sepsis patients, with theoretical support from the Horta’s Basic Human Needs. Method: Methodological research developed in four stages. The first stage consisted of the identification of relevant terms for the care of severe sepsis patients from 87 scientific articles on the subject and of nursing records in 47 clinical records of septic patients admitted to the Adult ICU of the University Hospital Lauro Wanderley of the Federal University from Paraiba (HULW-UFPB); in the second stage, there was a cross-mapping of the terms identified with the ICNP® terms; the third step involved the construction and validation of content by consensus of statements of nursing diagnosis/outcomes and interventions for the care of severe sepsis patients; and the fourth step was marked by the structuring of the ICNP® terminological subset for the care of severe sepsis patients according to the Brazilian model for the development of subsets and based on Horta's Theory. The project was approved by the Research Ethics Committee in accordance with Opinion n. 1,933,767. Results: 1,171 terms from the literature and clinical records relevant to clinical practice for severe sepsis patients were identified, of which 1,054 are terms in the 7- Axis Model of the ICNP® Version 2017. A total of 115 statements of nursing diagnoses/ outcomes were constructed with their respective operational definitions and 1,246 statements of nursing interventions were prepared, previously classified according to Horta’s Theory, which allowed the validation of content by consensus of 114 utterances (99.1%) of nursing diagnoses/outcomes, together with 855 statements (68.6%) of nursing interventions to be included in the ICNP® Terminology Subset for Serious Sepsis Patients. Conclusion: The terminological subset as a technological tool at the bedside aims to promote the identification of nursing phenomena on which intensive care nurses develop a process of clinical reasoning with decision-making in face of the affected human needs of severe sepsis patients through the statements validated in this research and grounded in Horta’s Theory, as well as seeking to subsidize an adequate register of intensive nursing care dispensed.