Identificación de la infección de sitio quirúrgico después de la cesárea: consulta de enfermería

Cunha, Marcia Regina; Padoveze, Maria Clara; Melo, Célia Regina Maganha e; Nichiata, Lucia Yasuko Izumi

doi:10.1590/0034-7167-2017-0325

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RESEARCH • Rev. Bras. Enferm. 71 (suppl 3) • 2018 • https://doi.org/10.1590/0034-7167-2017-0325 linkcopiar

Identificación de la infección de sitio quirúrgico después de la cesárea: consulta de enfermería

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo: Describir el perfil de las mujeres en relación con sus condiciones de vida, de salud, así como el perfil sociodemográfico, que correlacionan con la presencia de signos y síntomas sugestivos de infección del sitio quirúrgico post-cesárea; identificar informaciones a ser consideradas en la consulta de puerperio realizada por el enfermero y proponer un itinerario para la sistematización de la asistencia.

Método: Investigación cuantitativa, exploratoria, descriptiva, transversal y retrospectiva de revisión de prontuarios de mujeres que tuvieron parto cesárea en 2014, en el municipio de São Paulo.

Resultados: Se analizaron 89 prontuarios, 62 de ellos con informaciones incompletas. En 11 de ellos, hubo la presencia de al menos uno de los signos y síntomas sugestivos de infección.

Conclusión: Ante los resultados del estudio, la sistematización de la consulta puerperal es indispensable. El itinerario es un instrumento que puede potencialmente mejorar la calidad de la atención y el registro de las informaciones.

Descriptores:
Atención Primaria a la Salud; Cesárea; Infección Puerperal; Papel del Profesional de Enfermería; Salud de la Mujer

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Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[TFN1] Notes: SUS- Unified Health System; CNS-Social Security Card; BP- Blood Pressure; LL- Lower Limbs; ICNPCH- International Classification of Nursing Practices in Collective Health; ICPC- International Classification of Primary Care; BD- Birth Date.

ROADMAP FOR POST-CESAREAN POSTPARTUM NURSING CONSULTATION
Name:			BD
SUS/ CNS Card			Records:
Date:
NURSING HISTORY
Childbirth date:
Hospital name/ maternity of childbirth:
Duration of labor: _____hours
Premature rupture of membranes		□ yes	□no	□ no information
If yes, how long has elapsed between rupture and childbirth: ___hours				□ no information
Appearance of amniotic fluid:		□ normal	□ presence of meconium	□ no information
Time of hospitalization: ___days
Cesarean section performed urgently:		□ yes	□ no	□ no information
Reason for urgent Cesarean section:	□ maternal hypertension	□ fetal distress/meconium	□ umbilical cord prolapses	□ no information
Gestation	□ single	□ twin
Gestational age at childbirth: ___weeks
Intercurrences in labor and childbirth:			□ yes	□no
If yes, which ones:
HEALTH EDUCATION GROUPS
PREGNANT WOMEN GROUP
Participation in the group	□ yes	□no	How many meetings have you had?
SEXUAL AND REPRODUCTIVE PLANNING
Participated in the sexual and reproductive planning group			□ yes	□no
Contraceptive counseling			□ yes	□no
Contraceptive prescription			□ yes	□no
If yes, what method prescribed:
PUERPERIUM
Puerperium consultation	□ by 7 days	□ from 8 to 30 days	□ from 31 to 42 days	□ above 42 days
Feeding *	□ appropriate	□ inappropriate
Ferrous Sulfate Supplementation			□ yes	□ no
Emotional state	□ normal	□ depressed	□ bored	□ sad
Hygiene	□ daily bath	□ intimate hygiene once a day	□ sit baths
Hygiene	□ tidy	□ not tidy
Sex in the puerperium		□ yes	□ no
COMPLAINTS
Fever	□ yes	□ no
Pain underbelly	□ yes	□ no
Surgical site pain	□ yes	□ no
Urinary alterations (dysuria, polyuria...)		□ yes	□ no
Vaginal secretion (appearance)	□ yellow	□ green	□ colorless	□ not applied
Another:
OBSTETRIC PHYSICAL EXAMINATION
General Vital Signs	BP:	Heartbeat:
LL Edema	□ yes	□ no	If yes, how much +?
Breasts	□ symmetrical	□ asymmetrical	□ turgid	□ ingurgitated
Nipples	□ flat	□ protruding	□ inverted	□ sores
Abdomen	□ flaccid	□ distended
Involution of the uterus (according to the time of puerperium)		□ appropriate	□ inappropriate	□ not palpable
Surgical site	□ without signs of inflammation	□ local warm	□ edema	□ dehiscence
Surgical site secretion		□ yes	□ no
Secretion appearance	□ serous	□ yellow/purulent	□ with blood
Gynecological examination	□ normal (cervix intact)	□ altered (presence of lesion, warts)	□ not done	□ not applied
Lochia Appearance	□ red (dark, after 2 days)	□ yellow (after 10 days of delivery)	□ white or serous (16^th day postpartum)	□ purulent (pathological)
Other findings:
NURSING DIAGNOSIS- ICNPHC
Vaginal discharge	□ present
Underbelly pain	□ present
Urinary elimination	□ appropriate	□ affected
Body hygiene	□ appropriate	□ altered
Food intake	□ appropriate	□ altered
Breast Engorgement		□ present
Mastitis	□ present
Rest	□ altered
Skin trauma	□ present
Mom-child bond	□ preserved	□ affected
Other diagnoses:
INTERNATIONAL CLASSIFICATION OF PRIMARY CARE- ICPC
□ Medical examination/health evaluation/complete
□ W17 Postpartum bleeding (postpartum bleeding criteria: frank bleeding during or up to 6 weeks postpartum).
□ W19 Signs/symptoms of breast/lactation (galactorrhea, ablation, weaning).
□ W70 Sepsis/puerperal infection (criteria: infection of the birth canal or reproductive organs up to 6 weeks postpartum).
□ W71 Infections that complicate pregnancy (maternal infections that complicate pregnancy or the puerperium).
□ W92 Birth of live birth (assisted delivery, pelvic delivery, cesarean section, dystocia, induced delivery, lesions caused by delivery, low-lying placenta during delivery).
□ W94 Puerperal mastitis (breast abscess; criteria: pain, inflammation of the breast at 6 weeks postpartum or during lactation).
□ W95 Other problems of the breast during pregnancy/puerperium (problems of the breast during the puerperium, sored nipple).
Other Classifications:
NURSING PRESCRIPTION



REFERRALS



Signature and stamp of professional:
STITCHES REMOVAL
Date of stitches removal:
Surgical site appearance:

Referrals:


Evaluation of the surgical site for stitches removal:
Signature and stamp of professional:
*Feeding: take into account food routine recommended by the 10 steps of a healthy diet, with 3 meals daily (breakfast, lunch and dinner) plus two healthy snacks per day, following the recommendations by groups.
Recommendation: eat rice and beans every day of the week (at least 5 times a week). Drink 2 liters of water a day (6 to 8 glasses). Avoid industrialized products and salt.