Elaboração de protocolo de avaliação de enfermagem frente à sepse no pós-operatório cardíaco

Abstract

Sepsis in the postoperative period of cardiac surgery is a rare but potentially fatal complication, requiring early recognition and rapid intervention to minimize morbidity and mortality. Due to the clinical complexity of these patients, frequently exposed to invasive devices, extracorporeal circulation, and an intensified inflammatory response systematic nursing assessment plays a crucial role in identifying early signs of deterioration. This study aimed to develop a nursing assessment protocol for the early identification of sepsis in postoperative cardiac surgery patients, based on an integrative literature review. Articles published between 2010 and 2025 were analyzed through, LILACS, SciELO, PubMed, and BDENF databases to identify risk factors, pathophysiological changes, clinical tools, and effective nursing strategies. The findings revealed persistent barriers such as insufficient clinical monitoring, lack of standardized care, and communication failures within the healthcare team, all contributing to delayed sepsis diagnosis. Based on the synthesized evidence, a structured protocol was developed following the Nursing Process and grounded in the NANDA-I 2024-2026 Taxonomy II. The protocol includes a practical checklist for initial assessment and immediate interventions, guided by qSOFA criteria and relevant clinical and laboratory indicators. The study concludes that this protocol has the potential to enhance nursing response time, improve clinical decision-making, and reduce sepsis-related complications. Clinical validation is recommended to determine its effectiveness in real-world settings and its contribution to improved patient outcomes.