Vitória Costa Oliveira¹

Isabelle e Silva Sousa²

Raphaella Castro Jansen³

Maria Rayssa do Nascimento Nogueira^=
4

Iorana Candido da Silva⁵=

Leidiane Minervina Moraes de Sabino⁶

¹Acadêmica de Enfermagem na Universidade da Integração Internacional = da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0001-7341-8596

²Acadêmica de Enfermagem na Universidade da Integração Internacional = da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0003-3387-6722

³Acadêmica de Enfermagem na Universidade da Integração Internacional = da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0002-4032-5825

⁴Acadêmica de Enfermagem na Universidade da Integração Internacional = da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0003-0355-5901

⁵Acadêmica de Enfermagem na Universidade da Integração Internacional = da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0003-0815-1703

⁶Doutora em Enfermagem pela Universidade Federal do Ceará e docente do curso de Enfermagem na Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Redenção, Brasil. ORCID: https://orc= id.org/0000-0003-2938-870X

Autor correspondente

Vitór= ia Costa Oliveira. Av. da Abolição, nº 3, Centro, Redenção - CE, 62790-000. E-mail: vitoriaoliverebj@gmai= l.com.

<= /p>

ABSTRACT

Objective: To report = the experience of elaborating the Systematization of Nursing Care (SNC) to a patient diagnosed with Premature Labor (PL). Method: This is an experience report, carried out in January 2020 in a tertiary hospital locat= ed in the State of Ceará. For data collection, the steps of the nursing process were followed. In the first stage (nursing history), medical records, anamn= esis and physical examination were consulted. For the other stages of the process (diagnoses, planning, implementation and evaluation), the NANDA-I, NIC and = NOC taxonomies were used, respecting ethical aspects. Results: Pregnant woman with a gestational age of 34 weeks, hospitalized for PL, with bacteri= al vaginosis and urinary tract infection. Nursing diagnoses (results) were lis= ted: Acute pain (Analgesic administration as prescribed); Disturbed mother-fetus binomial risk (fetal monitoring); Anxiety (Promotion of comfort and reducti= on of anxiety). Final considerations: The experience allowed the improvement of clinical reasoning skills and SNC implementation.=

Keywo= rds: Obstetric Nursing; Nursing <= span class=3DSpellE>Process; Obstetric Labor,= Premature.

=

RESUM= O

Objet= ivo: Relatar a experiência da elaboração da Sistematização da Assistência de Enfermagem (SAE) a uma pacie= nte com diagnóstico de Trabalho de Parto Prematuro (TPP). Método: Trata-= se de um relato de experiência, realizado em janeiro de 2020 em um hospital terciário localizado no Estado do Ceará. Para coleta dos dados seguiu-se as etapas do processo de enfermagem. Na primeira etapa (histórico de enfermage= m) foi realizada consulta ao prontuário, anamnese e exame físico. Para as dema= is etapas do processo (diagnósticos, planejamento, implementação e avaliação), utilizou-se as taxonomias NANDA-I, NIC e NOC, respeitando os aspectos ético= s. Resultados: Gestante com idade gestacional de 34 semanas, internada por TPP, com vagino= se bacteriana e infecção do trato urinário. Elencaram-se os diagnósticos (resultados) de Enfermagem: Dor aguda (Administração de analgésico conforme prescrição); Risco binômio mãe-feto perturbado (Monitorização fetal); Ansie= dade (Promoção de conforto e redução da ansiedade). Considerações finais:= A experiência permitiu o aprimoramento das habilidades de raciocínio clínico e implementação da SAE.

Palav= ras-chaves: Enfermagem Obstétrica; Cuida= dos de Enfermagem; Trabalho de Parto Prematuro.

=

RESUM= EN

Objet= ivo: Relatar la experiencia de elaboración de la Sistematización de la Atención de Enfermería (SAE) a una paciente diagnosticada con Trabajo de Parto Prematuro (TPP). Método:= Se trata de un relato de experiencia, realizado en enero de 2020 en un hospita= l de tercer nivel ubicado en el Estado de Ceará. Para la recolección de datos, se siguieron los pasos del proceso de enfermería. En la primera etapa (historia de enfermería), se consultaron historias clín= icas, anamnesis y examen físico. Para las demás etapas del proceso (diagnóstico, planificación, implementación y evaluación) se utilizaron las taxonomías NANDA-I, NIC y NOC, respetando los aspectos éticos. Resultados: Embarazada con edad gestacional de 34 semanas, hospitalizada por TPP, con vaginosis bacteriana e infección de vías urinarias. Fueron listados los diagnósticos de enfermería (resultados): Dolor agudo (Administración de analgésicos según prescripción); Riesgo binomio madre-feto perturbado (monitoreo fetal); Ansiedad (Promoción del confort y reducción de la ansied= ad). Consideraciones finales: La experiencia permitió la mejora de las habilidades de razonamiento clínico y la implementación de SAE.<= /span>

Palab= ras clave: Enfermería Obstétrica; Proceso de Enfermería; Trabajo de Parto Prematuro.

INTRODUCTION

Pregnancy is a physiological process that normally lasts between 37 completed weeks to 42 incomplete weeks. During this period, the woman undergoes physical and psychological changes and may present some complications or complications, requiring referral to specialized care for high-risk pregnant women.⁽¹⁾Among these complications, Premature Labor (PL) or preterm delivery stands out. term, defined as a syndrome that occurs between 22 and 37 weeks of gestation and is associated with increased neonatal morbidity.⁽²⁾

Approximately 15 million preterm children are born world= wide each year.⁽³⁾In Brazil, one in four infant deaths occurs in the first 24 hours of life, with prematurity being the cause of 70% of these deaths.⁽⁴⁾Escola Nacional de Saúde Pública (ENSP/Fiocruz) carri= ed out a survey and found that the Brazilian prematurity rate is 11.5% of birt= hs. In 2017, 2.87 million births were recorded in Brazil, in which more than 330,000 babies were born before 37 weeks that year.(⁵⁾

Although the etiology of PL is not fully understood, it = can be associated with several risk factors, such as a history of preterm birth, anemia, smoking, premature rupture of membranes, arterial hypertension, transvaginal bleeding, the absence of prenatal control, inadequate prenatal control, maternal age over 35 years, urinary tract infection (UTI), oligohydramnios, among others.^(2,6)

Therefore, it is emphasized that a maternal infection, whatever its origin or location, decisively influences preterm birth, espec= ially those that affect the genital organs. It should also be noted that most pre= term births may be related to infections.⁽= ⁷⁾

In this context, due to its intrinsic relationship with maternal and child mortality, PL is considered one of the main global conce= rns and a challenge for public health. Reducing this index depends on the preparation of the health service and qualified professionals to provide adequate prenatal care, with early identification of signs and symptoms indicative of PL, as well as effective decision-making in emergency situations.⁽⁸⁾=

Among the professionals who provide care to patients wit= h PL, nurses stand out, due to their competence to identify early signs of PL and manage the nursing team to carry out evidence-based therapeutic approaches. With the assistance provided, the objective is to provide care and promote comprehensive care for the pregnant woman and the fetus, and thus contribut= e to the reduction of the incidence of perinatal morbidity and mortality.⁽⁹⁾

Considering the organization of professional Conselho Nacional de Enfermagem (COFEN) established Resolution nº 358/2009, which provides for the Systematization of Nursing Care (SNC) and the implementati= on of the Nursing Process (NP). The SNC refers to the organization of professi= onal performance with regard to the method, personnel and instruments, aspects t= hat enable the operationalization of the NP, a methodological instrument that guides the assistance and documentation of nursing actions. Therefore, the = SNC and NP direct nursing care according to the patient's needs, whether in pub= lic or private environments, ensuring visibility and professional recognition.⁽¹⁰⁾

In this sense, the SNC is an important tool used by nurs= es to promote a holistic, safe and systematized patient care, as it provides scientific, technical and human resources for the operationalization of the= NP. Taking into account the context above, this study aims to report the experi= ence of elaborating the SNC to a patient diagnosed with PL.

METHODS

This is a descriptive study, with a qualitative approach= , of the experience report type, based on the elaboration of the SNC for a patie= nt with a clinical picture of PL. It was carried out in January 2020 in a Hosp= ital in the State of Ceará, by nursing students, during the curricular internshi= p of the discipline Process of Care in Sexual and Reproductive Health of the Nur= sing course at the Universidade da Integração Internacional da Lusofonia Afro-Brasileira.

For data collection and analysis, we chose to follow the steps of the NP, which, according to COFEN Resolution nº 358/2009, consists= of five steps: Nursing history, which includes data collection and physical examination; Nursing Diagnosis, formulated from the problems identified dur= ing the anamnesis; Nursing Planning, based on the needs observed in the previous phase; Nursing Implementation, a stage that consists of performing the list= ed care; and Nursing Assessment, which is based on the analysis of the patient= 's evolution after the assistance provided.⁽¹⁰⁾

Data collection took place with the aid of a semi-struct= ured instrument organized into three components, namely: 1. collection of information from the patient's medical record, with the aim of knowing the history of current disease, the results of laboratory tests performed and clinical evolution; 2. anamnesis, which made it possible to identify the current health history, possible complaints and the patient's profile; and = the cephalocaudal physical examination, in order to assess the functioning of t= he physiological systems and detect eventual alterations.

In possession of the information, the care plan was established. The NANDA-I Nursing Diagnoses taxonomies were used to define t= he nursing diagnoses, Classification of Nursing Interventions (NIC) for interventions to be performed by the team and Classification of Nursing Outcomes (NOC) for the expected results and evaluation of the assistance.⁽^11-13)

After that, the care planning was attached to the patien= t's chart, so that the established care could be implemented according to the patient's needs and the routine of the health institution. Finally, the assessment of care was performed based on the observation of the patient's evolution according to the care provided.

The ethical aspects present in Resolution nº 466/2012 of= the National Health Council were respected, as well as the conducts set out in = the Code of Ethics for Nursing= Professionals.⁽^14,15)

RESULTS

The nursing process was carried out in the present study, starting with the nursing history stage, from the anamnesis and physical examination and consultation of the patient's multiprofessional chart. Some relevant aspects were highlighted during the anamnesis, such as: patient wi= th 34 weeks of gestation; reported prematurity in a previous pregnancy and low= adherence to prenatal care in the current pregnancy; sought health care when experien= cing severe pain in the lumbar region, radiating to the abdomen and lower abdome= n, with PL prodomes, rhythmic contractions, signs of imminence, loss of liquid= s, nausea and vomiting.

According to the medical records, the vaginal examination revealed a posterior cervix, in effacement, with an intact pouch and dilata= tion of 2 to 3 cm. Tocolysis was performed and corticosteroids and antibiotics w= ere administered. In addition, the tests performed identified UTI and Bacterial Vaginosis, and obstetric ultrasound showed adequate fetal growth. Regarding= the clinical picture, the patient progressed in good general condition, however, she complained of stabbing pain in the right and left lower quadrants of the abdomen, which ceased with time. She reported loss of mucus plug, with no o= ther vaginal losses. She presented anxiety and restlessness regarding her health condition and that of the fetus.

Thus, the Nursing Diagnoses and Nursing Planning were established, which involves the necessary interventions and their respective expected results, following the steps of the NP, as shown in Frame 1.<= /o:p>

The listed care was based on the need to implement a holistic c= are plan aligned with the patient's particularities. With the implementation of Nursing care, the patient reported being more comfortable and with less pai= n, she was more calm and confident about her safety and that of her baby. In addition, guidelines were provided on breastfeeding and care for the newbor= n. It is noteworthy that these results were analyzed immediately after the interventions were applied, in the Nursing Assessment phase, when the professional investigates the evolution of the patient's clinical condition according to the care provided.

The operationalization of the NP through the SNC provide= d a coordinated, holistic and humanized assistance. The experience was successf= ul, since the care plan developed by the academics resulted in improvements in = the patient's clinical condition, thus achieving the proposed objective with the implementation of the SNC. In addition, the experience provided the academi= cs with the improvement of a clinical and comprehensive view of the health-dis= ease process, as well as experience in the construction of a cohesive and individualized strategy to be adopted by the nursing team during the follow= -up of the patient.

The activity also enabled the acquisition of new knowled= ge and the theoretical-practical alignment of this methodology, which generates value and scientificity to professional practice, due to the proximity of t= he academic to the working environment. Teamwork was also one of the improved aspects, since the elaboration of the care plan allowed the discussion of t= he clinical case with other interns and with professionals from the multidisciplinary team, which contributed to the expansion of knowledge abo= ut the health condition presented by the patient. patient. However, the best benefit gained from the experience was the opportunity to closely observe t= he activities developed by the Nurse from the application of the NP, to later reproduce them, especially in the face of a critical situation, such as the= PL.

= DISCUSSION=

Nursing practice is based on SNC, being guided by technical-scientific methods. This process is configured as a work instrument whose purpose is to guide nursin= g professionals to perform care in a methodical, organized, planned and holistic way.⁽¹⁶⁾

The execution of this flow provides the nursing work process with a foundation = for humanized care, capable of promoting numerous benefits, such as: effective planning, implementation and evaluation of nursing actions, individualized = care and reduction of the hospitalization period, which provides savings of human and material resources, in addition to generating visibility and autonomy f= or the class.⁽¹⁶⁾

Thus, implementing the SNC is to adopt scientific nursing capable of directing care to the main needs of the patie= nt, whether the patient has a critical or stable clinical condition.^{(17) <=
/sup>From
this perspective, the implementation of SNC for a patient undergoing PL is =
of paramount
importance. , since this complication is one of the main gestational
complications that causes mortality in newborns.}

Nurses a= re able to identify a PL condition, as they are able to recognize that the presence of painful uterine contractions (1-2/10 minutes), presence of cerv= ical dilatation equal to or greater than 2 cm, cervical effacement of 80% or more and a gestational age greater than or equal to 20 weeks and less than 37 we= eks are considered clinical signs of this gestational complication.^{(18, 19=
)}

In addit= ion, the professional must know the various causes of this complication. The pat= ient in this study had signs of UTI, bacterial vaginosis and vaginal fluid loss.= The anatomical and physiological changes imposed on the urinary tract by pregna= ncy predispose the proliferation of bacteria, which can cause symptomatic or asymptomatic infections. UTI is a relevant complication of the gestational period, which can worsen both maternal and perinatal prognosis. Among the m= ost common complications resulting from this infection during pregnancy are intrauterine growth restriction, low birth weight, premature rupture of amniotic membranes, cerebral palsy, PL, perinatal death and fetal mortality.⁽²⁰⁾=

It is al= so noteworthy that during pregnancy the woman undergoes hormonal changes that = lead to an imbalance of the vaginal microbiota, favoring the appearance of signs= and symptoms characteristic of vaginosis, such as white, greenish or grayish discharge, with a strong smell and a burning sensation when urinate. Like U= TI, vaginosis can cause complications such as premature delivery, premature rup= ture of membranes, low birth weight, miscarriage and neonatal death.⁽²¹⁾

Prematur= e Rupture of Membranes (PRM) is considered to be the loss of amniotic fluid prior to = the onset of labor, regardless of gestational age. When it occurs before the 37= th week of gestation, it is classified as Premature Membrane Rupture (PMR).⁽²²⁾

Thus, it is observed that the UTI and bacterial vaginosis may have contributed to the PL of the patient in th= is study, in addition, the association of the two conditions may have caused t= he PMR. Thus, it is inferred that the occurrence of PL assisted by the researchers resulted from the relationship between several clinical complications, comm= on in pregnancy, but which did not receive the necessary attention due to low adherence to prenatal care and thus culminated in a PL.

It is noteworthy that although P= L is not considered a pathology, it is a condition in which nurses must maintain= a state of alert, as this situation can cause maternal-fetal morbidity and mortality. Therefore, nurses play an essential role, whose main objective i= s to develop a care plan aimed at the well-being of this bin= omial.⁽²³⁾In view of the clinical picture presented by the patient in the prese= nt study, three priority diagnoses were listed: Acute pain; Risk of the distur= bed mother-fetus binomial; Anxiety.

It is known that labor is a physiological process, of a subjective nature, subject to the influence of numerous sensory stimuli and is intrinsically related to physical elements = and environmental factors. Among the sensory stimuli present in this process, a= cute pain stands out as an experience sometimes reported as inexplicable, horrib= le or even unbearable by parturients. Therefore, from the report of acute pain= by the patient in the present study, this diagnosis was based, since its defin= ing characteristics are: change in blood pressure, change in heart rate, change= s in uterine dynamics and verbal reports of pain. ^{(24, 25)}=

Preterm newborns (PN) are subjec= t to the most varied neonatal complications due to their premature exposure to an environment to which they were not prepared to interact.⁽²⁶⁾Amo= ng the possibilities of intrauterine complications that the fetus can develop, highlights Lower tolerance to acidosis, higher frequency of anomalous presentations, risk of fetal trauma, risk of intracranial hemorrhage and ri= sk of sepsis. After birth, they may present difficulties in sucking, weight ga= in, temperature control, as well as respiratory problems.(²⁷⁾

Given the above, monitoring the fetus during labor becomes essential, as the constant verification of physiological patterns can point out possible complications. From this cont= ext, the risk diagnosis of the disturbed mother-fetus binomial was listed, in or= der to perform care that safely met the needs of the mother and baby during lab= or, in an attempt to prevent other complications.

A study carried out in a hospita= l in the city of São Paulo observed that 52.1% of the parturients who went throu= gh the experience of a risky delivery reported concern for themselves and their baby's health during the delivery process, mentioning anxiety resulting fro= m a danger. real, perceived or imaginary.⁽²⁸⁾In view of this, the diagnosis of anxiety was listed based on the rep= ort of the parturient's concern with the conditions of delivery, with care being listed in order to promote comfort to the patient.

Based on this experience, it was noticed through the application of the SNC, that the nurse participates ful= ly in the care provided to the parturient, which is extremely relevant, as it allows organizing and directing the decision-making of the professional in = the face of the real needs of the woman. patient, collaborating for the promoti= on, prevention, recovery and rehabilitation of individual and collective health= . In addition, nurses have the possibility to strengthen bonds with the pregnant woman, providing qualified, welcoming and holistic care= .⁽^29-31)

Observing the role of nurses provided the academics with practical experiences in care during labor, contributing to the acquisition of professional skills and competences, sin= ce the completion of internships during the Nursing undergraduate course provi= des the student with the opportunity to practice the content obtained from theoretical form.⁽³²⁾However, despite the significant experienc= es obtained during the internship with the implementation of the SNC, the stud= ents were not able to assess whether the expected results were satisfactorily achieved, due to the short period of time that the academics remained in the unit of health.

This study brought important res= ults to be discussed in the academic and professional scope. The findings show t= hat it is necessary to develop research that provide better subsidies for the w= ork of nurses, as well as indicating that the use of SNC enhances the quality of care provided, especially in the face of an intercurrence such as PL, which directly impacts the incidence of maternal morbidity and mortality. and neonatal.

Thus, the results show that it is necessary for nurses and the multiprofessional health team to have knowledg= e on the subject and be able to provide quality care in the face of PL. The limitations of this study involve the difficulty of a prolonged follow-up of the patient's clinical evolution until her discharge from hospital, due to = the rotation of academics in the internship field.

FINAL CONSIDERATIONS

It is concluded that the study made it possible to discu= ss and expand the theoretical knowledge of academics about important obstetric complications, such as PL. In this way, the experience made it possible for= the academics to improve their clinical reasoning skills necessary for the elaboration of the SNC. The assistance provided also made it possible to re= flect on the nurse's practice regarding individualized patient care, favoring a better view of the importance of working based on technical-scientific knowledge.

The application of the SNC by academics provided the expansion of their understanding of the relevance of a systematized care, b= oth in the care and management aspects, in order to obtain the best results for= the patient and also provide the optimization of the work of the nursing team. Through the practical application of SNC, it was possible to provide quality nursing care, which provided the patient with efficient, holistic and human= ized care.

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: 2021-11-10

: 2022-01-19

Diagnosis	Expected results	Interventions carried out
Acute pain, related to uterine contractions, evidenced by self-reported pain intensity and expression.<= /o:p>	Control of pain and discomfort levels.	Administration of analgesics as prescribed by a physic= ian; shower; emotional support; improved positioning in bed; active listening.=
Disturbed mother-fetus binomial risk related to preterm labor.	Maintenance of the health of the mother and fetus.	Promotion of care in high-risk pregnancy; electronic f= etal monitoring; medication control; supervision.
Anxiety related to labor, evidenced by a report of con= cern about the conditions of delivery.	Reduction of anxiety levels, maintenance of coping and increase in self-control and concentration in other activities.	Comfort promotion; anxiety reduction; pain and environ= ment control.