DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622
ISSN: 1981-8963
Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da.
Application of the nursing theory of Callista Roy...
CASE REPORT ARTICLE
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.
1
Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of Piaui/PPGENF/UFPI. Teresina (PI), Brazil. Email:
[email protected]; 2Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of Piaui/PPGENF/UFPI.
Teresina (PI), Brazil. Email: [email protected]; 3Nurse, Master’s Student, Nursing Postgraduate Program, Federal University of
Piaui. Teresina (PI), Brazil. Email: [email protected]; 4Nurse, Professor of Nursing, Nursing Postgraduate Program, Federal
University of Piaui/PPGENF/UFPI. Teresina (PI), Brazil. Email: [email protected]
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INTRODUCTION
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 selfconsistency, self-ideal and self-ethical-moralspiritual).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
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DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622
Application of the nursing theory of Callista Roy...
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.
METHOD
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
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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.
EXPERIENCE REPORTS
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.
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DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622
Application of the nursing theory of Callista Roy...
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
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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
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DOI: 10.5205/reuol.7901-80479-1-SP.1001sup201622
Application of the nursing theory of Callista Roy...
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.
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Costa CPV da, Luz MHBA, Bezerra AKF, Rocha SS da.
Component
Mode of
Adaptation
Application of the nursing theory of Callista Roy...
Nursing diagnosis (NANDA-I)
Nursing intervention
(NIC)-Code of NIC
Nursing results (NOC)
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).
Respiratory monitoring (3350).
Airway control (3140).
Stimulus to cough (3250)
Monitoring of vital signs (6680).
Respiratory status: airway permeability (0410).
Respiratory status: ventilation (0403).
Senses
Ineffective airway clearance related to neuromuscular
dysfunction and smoking shown by ineffective cough,
tachypnea and dyspnea.
Risk of cardiac tissue perfusion related to decreased
hypertension and hyperlipidemia.
Impaired tissue integrity related to impaired mobility,
decreased dermal vascularization secondary to ageing
and moisture evidenced by grade III pressure ulcer on
sacral region.
Impaired skin integrity related to motor deficit, impaired
mobility and decreased Vascularity secondary dermal
aging evidenced by grade II pressure ulcer in calcaneal
region.
The oral mucosa impaired related to ineffective oral
hygiene evidenced by tongue coated, oral lesion and
halitosis.
Risk of infection related to invasive procedures.
Impaired dentition related to ineffective oral hygiene
evidenced by loss of teeth and halitosis.
Impaired physical mobility related to neuromuscular
impairment evidenced by hemiplegia.
Disturbed sleep pattern related to environmental
changes, evidenced by reports of difficulty to sleep and
stay asleep.
Impaired verbal communication related to changes in the
central nervous system, manifested by dysarthria.
Physiological
Senses
Risk of falls related to impaired physical mobility.
Self-concept
Neurological
Function
Self-personal
Risk of cerebral tissue perfusion ineffective related to
cerebral aneurysm and hypertension.
Disease-related anxiety manifested by crying and
insomnia.
Ineffective therapeutic regimen related control the
complexity of the treatment regimen indicated for failure
to take action to reduce risk factors.
Oxygenation
Oxygenation
Oxygenation
Physiological
Protection
Protection
Protection
Physiological
Protection
Nutrition
Activity and
rest
Activity and
rest
Role
performance
Caring for pressure ulcers (3520).
Tissue: cardiac perfusion (0405).
Vital signs (0802).
Wound healing: second intention (1103).
Tissue integrity: skin and mucous membranes (1101).
Caring for pressure ulcers (3520).
Wound healing: second intention (1103). Tissue
integrity: skin and mucous membranes (1101).
Maintenance of oral health (1710).
Restoration of oral health (1730)
Oral hygiene (1100).
Protection against infection (6550)
Maintenance of oral health (1710).
Restoration of oral health (1730).
Neurological positioning (0844).
Exercise therapy: joint mobility (0224).
Sleep improvement (1850).
Risk control: infectious process (1924).
Oral hygiene (1100).
Improvement of communication: speech
deficit (4976).
Listen actively (4920).
Prevention of falls (6490).
Communication (0902).
Communication: expression (0903).
Neurological monitoring (2620).
Monitoring of vital signs (6680).
Anxiety reduction (5820).
Nutritional counseling (5246).
Behavior modification (4360).
Body mechanics performance (1616).
Mobility (0208).
Sleep (0004).
Risk control (1902).
Care with the affected side (0918).
Tissue perfusion: cerebral (0406). Neurological State
(0909).
Level of anxiety (1211).
Anxiety self-control (1402).
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.
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FINAL REMARKS
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.
REFERENCES
1. Organização Mundial de Saúde. Cuidados
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para
condições
crônicas:
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6. Freitas NF, Tannure MC, Chianca TCM.
Implementation of nursing process in a
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ttext&pid=S141481452011000400026&lng=en&nrm=iso
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American
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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.
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11. Moorhead S, Johnson M, Maas M.
Classificação dos resultados de enfermagem
(NOC). 4th ed. Rio de Janeiro: Elsevier; 2010.
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):97104.
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ttext&pid=S010411691999000400013&lng=en&nrm=iso
4. George JB. Teorias de enfermagem: os
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Medeiros SM. Ensino do processo de
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APPENDIX
GUIDE FOR BEHAVIORAL AND STIMULUS RESEARCH
Name: ___________________________________________________
Birthdate: ________________
Age: _____________________
Gender: ( ) Male
( ) Female
Skin color: ( ) White ( ) Black ( ) Yellow
( ) Maroon
Marital status: ( ) Married
( ) Stable union
) Widower/Widow
( ) Single (
( ) Separated
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
Other: ___________________________
( ) Carinate
Respiratory frequency: __________ respiratory movements per minute
Respiratory auscultation: ( ) Adventitious noise absent
( ) Adventitious noises present: ( ) Snoring ( ) Ping ( ) Rattle
Cough: ( ) No
( ) Yes: ( ) Nonproductive
Other: _________
( ) 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
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Aplicabilidade do código de ética nas ações...
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
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016
359
ISSN: 1981-8963
Santos FS, Arruda AJCG de, Vasconcelos JMB.
DOI: 10.5205/reuol.8423-73529-1-RV1001201601
Aplicabilidade do código de ética nas ações...
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
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 1):352-60, Jan., 2016
360