Implementation of the nursing process: case study in an Intensive Care Unit

Abstract

This descriptive case study, with qualitative design, aimed to implement the nursing process to a client in an Intensive Care Unit (ICU), based on Wanda Horta’s theory. An ICU-specific instrument, previously validated in the literature, was used for data collection. Nursing diagnoses were identified according to NANDA II taxonomy. The Nursing Interventions Classification (NIC) was used to outline the targets and aims of the study, as well as to develop the nursing interventions. The main diagnoses identified were: ineffective airway clearance, ineffective peripheral tissue perfusion, impaired skin integrity, excess fluid volume, risk for imbalanced body temperature, risk for infection and impaired tissue integrity. Results evidenced the importance of the nursing process as the driving force in the delivery of care to high complexity clients.