Clinical profile, nursing diagnoses and nursing care for postoperative bariatric surgery patients

Nathalia Helene Steyer Magáli Costa Oliveira Mara Regina Ferreira Gouvêa Isabel Cristina Echer Amália de Fátima Lucena About the authors

RESUMO

Objetivo

Analisar o perfil clínico, os diagnósticos e os cuidados de enfermagem estabelecidos para pacientes em pós-operatório de cirurgia bariátrica.

Método

Estudo transversal realizado em um hospital do Sul do Brasil, com amostra de 143 pacientes. Os dados foram coletados retrospectivamente entre 2011-2012 no prontuário eletrônico dos pacientes, os quais foram analisados estatisticamente.

Resultados

Identificaram-se pacientes femininas adultas (84%) com obesidade grau III (59,4%) e hipertensas (72%), com 35 diagnósticos de enfermagem, sendo os mais frequentes: Dor aguda (99,3%), Risco de lesão pelo posicionamento perioperatório (98,6%) e Integridade tissular prejudicada (93%). Dentre os cuidados de enfermagem prescritos, os mais utilizados foram: usar mecanismos de proteção no posicionamento cirúrgico do paciente, registrar a dor como 5° sinal vital e verificar sinais vitais. Foi observada associação entre a idade e as comorbidades.

Conclusão

Os diagnósticos de enfermagem subsidiaram a prescrição de cuidados, possibilitando qualificar a assistência de enfermagem.

Cirurgia bariátrica; Diagnóstico de enfermagem; Cuidados de enfermagem

RESUMEN

Objetivo

Analizar el perfil clínico, diagnósticos de enfermería y cuidados de enfermería establecidos para los pacientes en postoperatorio de cirugía bariátrica.

Método

Estudio transversal con la muestra de 143 pacientes. El estudio se realizó entre 2011-2012, en un hospital en el sur de Brasil. Los datos fueron recolectados retrospectivamente de los registros médicos electrónicos y analizados estadísticamente.

Resultados

Se identificaron pacientes femeninas adultas (84%), con obesidad clase III (59,4%), hipertensión (72%) y con 35 diagnósticos de enfermería, siendo los más frecuentes: el Dolor agudo (99,3%), Riesgo de lesión perioperatoria de posicionamiento (98,6%) y la Integridad del tejido deteriorado (93%). Entre los cuidados de enfermería prescritos los más utilizados fueron: utilizar los mecanismos de protección en el posicionamiento quirúrgico del paciente, registrar el dolor como quinto signo vital y verificar los signos vitales. Se observó una asociación entre la edad y las comorbilidades.

Conclusión

Los diagnósticos de enfermería apoyaron la prescripción de los cuidados de enfermería, lo que permite calificar la asistencia de enfermería.

Cirugía bariátrica; Diagnóstico de enfermería; Atención de enfermería

ABSTRACT

Objective

To analyze the clinical profile, nursing diagnoses, and nursing care established for postoperative bariatric surgery patients.

Method

Cross-sectional study carried out in a hospital in southern Brazil with a sample of 143 patients. Data were collected retrospectively from electronic medical records between 2011 and 2012 and analyzed statistically.

Results

We found a predominance of adult female patients (84%) with class III obesity (59.4%) and hypertension (72%). Thirty-five nursing diagnoses were reported, among which the most frequent were: Acute Pain (99.3%), Risk for perioperative positioning injury (98.6%), and Impaired tissue integrity (93%). The most frequently prescribed nursing care were: to use protection mechanisms in the surgical patient positioning, to record pain as 5th vital sign, and to take vital signs. There was an association between age and comorbidities.

Conclusion

The nursing diagnoses supported the nursing care prescription, which enables the qualification of nursing assistance.

Bariatric surgery; Nursing diagnosis; Nursing care

INTRODUCTION

Obesity is an abnormal or excessive fat accumulation that may impair health and is directly associated with the presence of comorbidities. In 2008, 35% of the adults above 20 years of age were diagnosed with overweight worldwide; additionally, 10% of men and 14% of women had a body mass index (BMI) greater than 30 Kg/m(11. World Health Organization (CH). Obesity and overweight. Geneva, 2013.). In Brazil, the rates of obesity have also increased from 11.4% in 2006 to 17.4% in 2012. Moreover, 51% of the Brazilian population are overweight(22. Ministério da Saúde (BR). Vigitel Brasil 2012. Brasília; 2011.).

Bariatric surgery has been an option for the prophylaxis and treatment of complications resulting from class III obesity. Patients eligible for the procedure should be assessed by specialized physicians and meet the following criteria: BMI greater than 40 Kg/m2 (or greater than 35Kg/m2 in the presence of severe comorbidities) and failure to lose weight with non-surgical techniques(33. Branco-Filho AJ, Nassif LS, Menacho AM, Aurichio ERA, Siqueira DED, Fernandez RM. Tratamento da obesidade mórbida com gastrectomia vertical. ABCD Arq Bras Cir Dig. 2011;24(1):52-54.).

In the hospital where this study was performed, patients eligible for bariatric surgery are referred to a group of pre-surgical patients for multidisciplinary evaluation, and the procedure is performed via the Brazilian Unified Health System using the open surgery technique and gastric bypass. Patients receive follow-up care at the outpatient clinic for 2 years after surgery, in order to help them to acquire healthy habits.

In the middle postoperative period starting 24 hours after surgery and ending with hospital discharge(44. Moraes LO, Peniche ACG. Assistência de enfermagem no período de recuperação anestésica: revisão de literatura. Rev Esc Enferm USP. 2003;37(4):34-42.), patients require special care, in which nurses play a key role. To perform this task, they need to have knowledge and technical and interpersonal skills that allow them to think critically and make a clinical judgment for decision making by establishing nursing diagnoses (NDs) and appropriate interventions to achieve positive results.

With this purpose, the nursing process (NP) and systems to classify nursing practice have been used in the hospital where the present study was performed. In this institution, the NP is based on Horta’s theory associated with the diagnostic terminology of NANDA-International (NANDA-I)(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.-66. Pruinelli L, Severo IM, Almeida MA, Lucena AF, Santos GG. Operacionalização do processo de enfermagem no HCPA. In: Almeida MA, et al. Processo de enfermagem na prática clínica: estudos clínicos realizados no Hospital de Clínicas de Porto Alegre. Porto Alegre: Artmed; 2011. p. 53-62.). The nursing care prescribed is grounded in the literature and in the Nursing Interventions Classification (NIC)(77. Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. Nursing Interventions Classification (NIC). 6th ed. St. Louis: Mosby-Elsevier; 2013.).

However, studies on nursing care to bariatric surgery patients remain little explored in our institution, since this surgical procedure is relatively recent. In addition, few publications have addressed this topic in the field of nursing(88. Moreira RAN, Caetano JA, Barros LM, Galvão MTG. Diagnósticos de enfermagem, fatores relacionados e de risco no pós-operatório de cirurgia bariátrica. Rev Esc Enferm USP. 2013;47(1):168-75.-99. Jóia-Neto L, Lopes-Junior AG, Jacob CE. Alterações metabólicas e digestivas no pós-operatório de cirurgia bariátrica. ABCD Arq Bras Cir Dig. 2010;23(4):266-9.), which reveals that there is a knowledge gap on NDs and appropriate care to these patients. Hence, the leading question of the present study was: who are the patients undergoing bariatric surgery and which NDs and nursing care are established in clinical practice?

Thus, the aim of this study was to analyze the clinical profile and the NDs of bariatric surgery patients, as well as nursing care to bariatric surgery patients in the postoperative period, in order to contribute to knowledge on the procedure and qualify nursing care for this population.

METHODS

This is a cross-sectional study(1010. LoBiondo-Wood G, Haber J. Desenhos não-experimentais. In: LoBiondo-Wood G, Haber J. Pesquisa em enfermagem: métodos, avaliação crítica e utilização. 4. ed. Rio de Janeiro: Guanabara-Koogan; 2001. p.114.) carried out in a university hospital in southern Brazil with a sample of 143 patients who underwent bariatric surgery from November/2008 to August/2011, the period when bariatric surgeries started to be performed in the hospital. Data were collected retrospectively from electronic medical records between September/2011 and March/2012. The data collection instrument was built on Microsoft Excel for Windows and included: patient name; medical record number; BMI(11. World Health Organization (CH). Obesity and overweight. Geneva, 2013.) (as defined by the World Health Organization); gender; age; date of admission, surgery, and discharge; smoking status; comorbities; NDs and nursing care in the middle postoperative period. Statistical data analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 18.0. Continuous variables were analyzed with tests for comparison of means or medians (t-test of Mann-Whitney test) and categorical variables were analyzed with the chi-square test; the significance level was set at p≥0.05.

The study was approved by the institutional Research Ethics Committee (Protocol n° 11-0613) and a term of commitment for use of data was signed by the authors, according to Resolution 466/12 from the Brazilian National Health Council.

RESULTS

As for the clinical profile of the sample, there was a majority of women (84%), non-smokers (83.2), and cases of class III obesity (59.4%) and hypertension (72%) (Table 1). Mean age was 39.9 years (±10.1).

Table 1
– Clinical profile of patients undergoing bariatric surgery. Porto Alegre, 2014

The association between BMI and comorbidities was not statistically significant (p>0.05). However, there was an association between age and comorbidities, i.e., older patients showed a higher prevalence of hypertension, diabetes, anxiety/depression, and dyslipidemia (p<0.05). Osteoarticular disorders were also associated with age (p=0.06).

As for smoking status, smokers were more likely to have ventilatory disorders than non-smokers and abstinent smokers (p<0.05). Moreover, smoking status was associated with anxiety/depression (p=0.05).

Thirty-five different NDs were found in the study sample, with 48 different etiologies. Table 2 shows the ten most frequent NDs, six of which were actual diagnoses and four were risk diagnoses.

Table 2
– Nursing diagnoses and its etiologies for postoperative bariatric surgery patients. Porto Alegre, 2014

Fifty-one different nursing care were prescribed for patients with actual NDs(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.)and 31 to patients with risk NDs(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.).

Table 3 shows the nursing care prescribed for patients with actual NDs

Table 3
– Nursing care prescribed for postoperative bariatric surgery patients with actual NDs. Porto Alegre, 2014 (continue)

Table 4 shows nursing care prescribed for patients with risk NDs.

Table 4
– Nursing care prescribed for postoperative bariatric surgery patients with risk NDs. Porto Alegre, 2014

DISCUSSION

Patients’ clinical profile was mainly characterized by adult women with class III obesity and associated comorbidities. Hypertension was the most frequent comorbidity, followed by osteoarticular disorders. Brazilian studies with similar populations also found a predominance of young females with class III obesity and comorbidities, especially hypertension(88. Moreira RAN, Caetano JA, Barros LM, Galvão MTG. Diagnósticos de enfermagem, fatores relacionados e de risco no pós-operatório de cirurgia bariátrica. Rev Esc Enferm USP. 2013;47(1):168-75.-99. Jóia-Neto L, Lopes-Junior AG, Jacob CE. Alterações metabólicas e digestivas no pós-operatório de cirurgia bariátrica. ABCD Arq Bras Cir Dig. 2010;23(4):266-9.).

It should be highlighted that, in the present study, 85 (59.4%) of patients had a BMI above 40Kg/m2, with high levels of morbid obesity. However, bariatric surgery is beneficial for cases of class I and II obesity and even overweight when there are associated comorbidities. This is reinforced by investigations on the metabolic effects of bariatric surgery in patients with BMI above 35Kg/m2 and type 2 diabetes mellitus revealing that the surgical option is an important therapeutic modality for the control of this disease(1111. Li Q, Chen L, Yang Z, Ye Z, Huang Y, He M, et al. Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2. Diabetes Obes Metab. 2012;14(3):262-70.).

The mean length of hospital stay of our patients was 6.3 days. Two other studies, one of which with sleeve gastrectomy patients and another with patients treated with adjustable gastric banding, found shorter lengths of stay(33. Branco-Filho AJ, Nassif LS, Menacho AM, Aurichio ERA, Siqueira DED, Fernandez RM. Tratamento da obesidade mórbida com gastrectomia vertical. ABCD Arq Bras Cir Dig. 2011;24(1):52-54.,1212. Pajecki D, Mancini MC, Halpern A, Zilberstein B, Garrido Jr AB, Cecconello I. Abordagem multidisciplinar de pacientes obesos mórbidos submetidos a tratamento cirúrgico pelo método da banda gástrica ajustável. Rev Col Bras Cir. 2010;37(5):328-32.). However, it is important to consider the differences in the procedures, because open surgery requires a longer patient’s recovery period.

As for smoking status, smokers were found to be more likely to have ventilatory disorders than non-smokers and abstinent smokers (p<0.05). An association between smoking status and anxiety/depression was also observed in the present study, since these comorbidities were more frequent in smokers than in nonsmokers and abstinent smokers (p=0.05). Smoking is known to have several harmful effects, such as ventilatory disorders that include sleep obstructive sleep apnea-hypopnea syndrome, which are frequent in individuals with class III obesity(1313. Faria CS, Botelho C, Silva RMVG, Ferreira MG. Tabagismo e obesidade abdominal em doadores de sangue. J Bras Pneumol. 2012;38(3):356-63.-1414. Dias-Junior SA, Pinto RC, Angelini L, Fernandes FLA, Cukier A, Stelmach R. Prevalência de tabagismo ativo e passivo em uma população de asmáticos. J Bras Pneumol. 2009;35(3):261-5.). Therefore, the prevention of smoking initiation and smoking cessation are beneficial in the reduction of comorbidities, complications, and mortality, and health care professionals are responsible for detecting, guiding, and treating patients at risk for smoking-related diseases.

There is a scarcity of studies on which to base the analysis of the ten NDs more frequently established for bariatric surgery patients. However, available studies showed results similar to those of the present study, especially investigations on the ND Acute pain, which is one of the most established for surgical patients(88. Moreira RAN, Caetano JA, Barros LM, Galvão MTG. Diagnósticos de enfermagem, fatores relacionados e de risco no pós-operatório de cirurgia bariátrica. Rev Esc Enferm USP. 2013;47(1):168-75.,1515. Pereira LV, Sousa FAEF. Psychophysical evaluation of the descriptors of pain in the postoperative. Rev Latino-Am Enfermagem. 2007;15(3):474-9.-1616. Rocha LA, Maia TF, Silva LF. Diagnósticos de enfermagem em pacientes submetidos à cirurgia cardíaca. Rev Bras Enferm. 2006;59(3):321-6.).

The ND Acute pain(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.) was established for 99.3% of patients in our study and have been investigated in several practice scenarios for nurses, who are responsible for diagnosing accurately, intervening appropriately and reassess the results obtained at a later time. The most prevalent care interventions for this ND was to record pain as the 5th vital sign, which is essential for the evaluation of the presence or absence of pain caused by tissue injury and by activation of nociceptive transducers at the site of the surgical injury. This care requires attention from nurses, who should ask patients whether they are in pain and observe their facial expression, movements, and positioning, in order to better characterize, locate, and assess the intensity of pain(1717. Mello BS, Massutti TM, Longaray VK, Trevisan DF, Lucena AF Applicability of the Nursing Outcomes Classification (Noc) to the evaluation of cancer patients with acute or chronic pain in palliative care. App Nurs Res. Forthcoming 2015. doi:10.1016/j.apnr.2015.04.001).

The second most frequent ND was Risk for perioperative positioning injury, which requires preventive interventions, especially when the patient is in the operating room. Since bariatric surgery patients have large body dimensions, they are more likely to experience injuries related to the procedure are at greater surgical and anesthetic risk(1818. Tanaka DS, Peniche ACG. Assistência ao paciente obeso mórbido submetido à cirurgia bariátrica: dificuldades do enfermeiro. Acta Paul Enferm. 2009;22(5):618-23.). Nursing care for this ND includes the appropriate use of body protection equipment to prevent injuries, especially skin and tissue injuries.

Impaired tissue integrity and Risk for infection were respectively the third and fourth more frequent NDs for the patients analyzed. These NDs, which were also pointed out in a study of surgical patients(1616. Rocha LA, Maia TF, Silva LF. Diagnósticos de enfermagem em pacientes submetidos à cirurgia cardíaca. Rev Bras Enferm. 2006;59(3):321-6.), are a consequence of tissue injury and the risk for infection resulting from the invasive procedure. Therefore, the care for these NDs evidenced the importance of monitoring bleeding and observing signs of infection when changing dressings.

Imbalanced nutrition: more than body requirements(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.)was the fifth more frequent ND, although bariatric surgery was the reason for admission of these patients. It can be inferred that this ND was not established by some nurses because they believed that postoperative patients did not have this ND anymore, since they did not receive nutrition above their body requirements. However, it is important to consider that one of the factors that led the patient to undergo bariatric surgery was exactly overconsumption of food.

Nursing care prescribed for this ND, including taking patients’ weight, stimulating patients to walk, and instructing them about their new diet, was considered important for surgical recovery. It is worth highlighting that guidance about changes in lifestyle, especially about a diet balanced with body requirements, is essential to operated patients.

Risk for imbalanced nutrition: more than body requirements was the sixth more frequent ND, although it was not described in another investigation(88. Moreira RAN, Caetano JA, Barros LM, Galvão MTG. Diagnósticos de enfermagem, fatores relacionados e de risco no pós-operatório de cirurgia bariátrica. Rev Esc Enferm USP. 2013;47(1):168-75.) with bariatric surgery patients. Nonetheless, this ND is considered accurate, because these patients remain vulnerable to the excess consumption of nutrients after surgery. Nursing care prescribed for this ND involved health education about a new lifestyle and the need for an adequate diet to complement the success of the surgical procedure and thus the improvement in patient’s health.

Impaired physical mobility, the seventh more frequent ND, was related to excess weight and comorbidities such as osteoarthritis. Additionally, common postoperative findings such as musculoskeletal impairment, reluctance to initiate movements, and pain(55. NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.)may hamper patient’s locomotion, mobility, and rehabilitation, indicating interventions directed to control pain and facilitate gradual movements associated with exercise and exiting bed early.

Impaired comfort was the eighth more frequent ND and the most used etiology in the postoperative period. Hospitals cause feelings of fear and insecurity and bring people close to disease, feelings that affect postoperative patients as well. Hence, the nursing staff should calm down these patients so as to promote safety and comfort and make the hospitalization period the least painful as possible both physically and emotionally.

Risk for imbalanced fluid volume was the ninth more frequent ND and require nursing care related to hydration and hemodynamic balance, such as monitoring of fluid intake and output and control of vital signs, as corroborated by the literature(1919. Felix, LG, Soares, MJGO, Nóbrega, MML. Protocolo de assistência de enfermagem ao paciente em pré e pós-operatório de cirurgia bariátrica. Rev Bras Enferm. 2012 jan-fev;65(1):83-91.).

Bathing/hygiene self-care deficit, the tenth more frequent ND, required nursing care for daily activities such as bathing and performing oral hygiene, since the ability of self-care and mobilization is limited in patients with this ND.

An analysis of the association between comorbidities and NDs showed that all patients had at least one comorbidity (hypertension, diabetes mellitus, anxiety/depression, ventilatory disorders, dyslipidemia, osteoarticular disorders, and biliary lithiasis) and at least one of the following NDs: Acute pain, Risk for perioperative positioning injury, Impaired tissue integrity, and Risk for infection. This finding demonstrate the extent of nursing care required by bariatric surgery patients, since surgical treatment interferes with their physical and psychological status(2020. Oliveira, DM, Merighi, MAB, Jesus, MCP. A decisão da mulher obesa pela cirurgia bariátrica à luz da fenomenologia social. Rev Esc Enferm USP. 2014;48(6):970-6.).

Thus, nurses need to understand the decision making process through which patients decide to undergo bariatric surgery and provide them which comprehensive care(2020. Oliveira, DM, Merighi, MAB, Jesus, MCP. A decisão da mulher obesa pela cirurgia bariátrica à luz da fenomenologia social. Rev Esc Enferm USP. 2014;48(6):970-6.), which goes beyond the hospitalization period, with educational guidance and behaviors that favor successful recovery of their health(2020. Oliveira, DM, Merighi, MAB, Jesus, MCP. A decisão da mulher obesa pela cirurgia bariátrica à luz da fenomenologia social. Rev Esc Enferm USP. 2014;48(6):970-6.).

CONCLUSIONS

The present study has shown that patients undergoing bariatric surgery were mostly adult women with class III obesity and at least one associated comorbidity, the most prevalent of which was hypertension. The research also found that the higher the patient age the higher the incidence of hypertension, diabetes mellitus, and anxiety and/or depression. In addition, smokers had more ventilatory disorders than nonsmokers or abstinent smokers, being imperative that these patients receive guidance on and treatment for smoking cessation before the surgical procedure.

Acute pain and Impaired tissue integrity were the most frequent actual NDs reported in this study, and Risk for perioperative positioning injury and Risk for infection were the most frequent risk NDs. These NDs required nursing care such as controling vital signs, reporting pain as the fifth vital sign, and using protective mechanisms in patient surgical positioning, in addition to monitoring weight daily and guiding and comforting the patient.

The shortage of nursing studies on bariatric surgery has brought limitations to the discussion of data while corroborating the need to expand research on the topic. This is a relatively new field of knowledge in Brazil, which gives relevance to the results of the present study in terms of improving clinical practice, teaching, and research.

References

  • 1
    World Health Organization (CH). Obesity and overweight. Geneva, 2013.
  • 2
    Ministério da Saúde (BR). Vigitel Brasil 2012. Brasília; 2011.
  • 3
    Branco-Filho AJ, Nassif LS, Menacho AM, Aurichio ERA, Siqueira DED, Fernandez RM. Tratamento da obesidade mórbida com gastrectomia vertical. ABCD Arq Bras Cir Dig. 2011;24(1):52-54.
  • 4
    Moraes LO, Peniche ACG. Assistência de enfermagem no período de recuperação anestésica: revisão de literatura. Rev Esc Enferm USP. 2003;37(4):34-42.
  • 5
    NANDA International. Diagnósticos de enfermagem da NANDA: definições e classificação 2012-2014. Porto Alegre: Artmed; 2013.
  • 6
    Pruinelli L, Severo IM, Almeida MA, Lucena AF, Santos GG. Operacionalização do processo de enfermagem no HCPA. In: Almeida MA, et al. Processo de enfermagem na prática clínica: estudos clínicos realizados no Hospital de Clínicas de Porto Alegre. Porto Alegre: Artmed; 2011. p. 53-62.
  • 7
    Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. Nursing Interventions Classification (NIC). 6th ed. St. Louis: Mosby-Elsevier; 2013.
  • 8
    Moreira RAN, Caetano JA, Barros LM, Galvão MTG. Diagnósticos de enfermagem, fatores relacionados e de risco no pós-operatório de cirurgia bariátrica. Rev Esc Enferm USP. 2013;47(1):168-75.
  • 9
    Jóia-Neto L, Lopes-Junior AG, Jacob CE. Alterações metabólicas e digestivas no pós-operatório de cirurgia bariátrica. ABCD Arq Bras Cir Dig. 2010;23(4):266-9.
  • 10
    LoBiondo-Wood G, Haber J. Desenhos não-experimentais. In: LoBiondo-Wood G, Haber J. Pesquisa em enfermagem: métodos, avaliação crítica e utilização. 4. ed. Rio de Janeiro: Guanabara-Koogan; 2001. p.114.
  • 11
    Li Q, Chen L, Yang Z, Ye Z, Huang Y, He M, et al. Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2. Diabetes Obes Metab. 2012;14(3):262-70.
  • 12
    Pajecki D, Mancini MC, Halpern A, Zilberstein B, Garrido Jr AB, Cecconello I. Abordagem multidisciplinar de pacientes obesos mórbidos submetidos a tratamento cirúrgico pelo método da banda gástrica ajustável. Rev Col Bras Cir. 2010;37(5):328-32.
  • 13
    Faria CS, Botelho C, Silva RMVG, Ferreira MG. Tabagismo e obesidade abdominal em doadores de sangue. J Bras Pneumol. 2012;38(3):356-63.
  • 14
    Dias-Junior SA, Pinto RC, Angelini L, Fernandes FLA, Cukier A, Stelmach R. Prevalência de tabagismo ativo e passivo em uma população de asmáticos. J Bras Pneumol. 2009;35(3):261-5.
  • 15
    Pereira LV, Sousa FAEF. Psychophysical evaluation of the descriptors of pain in the postoperative. Rev Latino-Am Enfermagem. 2007;15(3):474-9.
  • 16
    Rocha LA, Maia TF, Silva LF. Diagnósticos de enfermagem em pacientes submetidos à cirurgia cardíaca. Rev Bras Enferm. 2006;59(3):321-6.
  • 17
    Mello BS, Massutti TM, Longaray VK, Trevisan DF, Lucena AF Applicability of the Nursing Outcomes Classification (Noc) to the evaluation of cancer patients with acute or chronic pain in palliative care. App Nurs Res. Forthcoming 2015. doi:10.1016/j.apnr.2015.04.001
  • 18
    Tanaka DS, Peniche ACG. Assistência ao paciente obeso mórbido submetido à cirurgia bariátrica: dificuldades do enfermeiro. Acta Paul Enferm. 2009;22(5):618-23.
  • 19
    Felix, LG, Soares, MJGO, Nóbrega, MML. Protocolo de assistência de enfermagem ao paciente em pré e pós-operatório de cirurgia bariátrica. Rev Bras Enferm. 2012 jan-fev;65(1):83-91.
  • 20
    Oliveira, DM, Merighi, MAB, Jesus, MCP. A decisão da mulher obesa pela cirurgia bariátrica à luz da fenomenologia social. Rev Esc Enferm USP. 2014;48(6):970-6.

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    10 Sept 2014
  • Accepted
    30 June 2015
Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
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