Luciana Bento

A experiência do enfermeiro obstetra em um hospital de emergência

A prática do acolhimento não pode ser analisada de modo pragmático, como uma mera objetivação de ações recomendadas, mas sim como uma atividade conscientemente orientada, uma totalidade teórico-prática indissociável, que tem um lado ideal, teórico, e um lado material, propriamente prático, que não podem ser isolados um do outro.

Definição

Acolhimento é, antes de tudo, uma diretriz política e operacional do SUS. É postura ética, uma atitude em relação à garantia de acesso aos serviços de saúde, à qualidade e integralidade da atenção. Traduz-se em recepção do usuário nos serviços de saúde, desde a sua chegada, responsabilizando-se integralmente por ele, ouvindo sua queixa, permitindo que ele expresse suas preocupações. Implica prestar um atendimento com resolutividade e responsabilização, orientando, quando for o caso, o paciente e a família, garantindo a articulação com os outros serviços de saúde para a continuidade da assistência quando necessário.

Objetivos do acolhimento

  • Humanizar o atendimento mediante escuta qualificada da mulher no ciclo gravídico puerperal que busca os serviços de urgência/emergência dos hospitais
  • Organizar o processo de trabalho e ambiência hospitalar
  • Melhorar a informação para as usuárias e seus familiares sobre sua situação de saúde e sua expectativa de atendimento e tempo de espera
  • Classificar, mediante protocolo, as queixas das usuárias que demandam os serviços de urgência/emergência dos hospitais, visando identificar as que necessitam de atendimento médico mediato ou imediato
  • Fomentar a rede de atenção de saúde, articulando a atenção básica e maternidades com vistas à atenção integral

Aplicação

É um processo dinâmico de identificação das gestantes que necessitam de intervenção médica e de cuidados de enfermagem, de acordo com o potencial de risco, agravos à saúde ou graus de sofrimento.  Esse processo se dá mediante escuta qualificada e tomada de decisão baseada em protocolo, aliadas à capacidade de julgamento crítico e experiência do enfermeiro.

Ao chegar à maternidade demandando necessidade aguda ou de urgência, a usuária é acolhida pelos funcionários da portaria/recepção ou estagiários e encaminhada para confecção da ficha de atendimento.

Após a sua identificação, a usuária é encaminhada ao espaço destinado ao Acolhimento com Classificação de Risco onde serão aferidos os dados vitais pela equipe de enfermagem e será acolhida pelo enfermeiro (devidamente treinado para esta prática), apoiado pelo médico que, utilizando informações da escuta qualificada e da tomada de dados vitais, se baseia no protocolo e classifica a usuária em:

  • 1º Grupo – Prioridade Máxima (Vermelha) – Emergência:
    •  Atender imediatamente e encaminhar diretamente para atendimento médico, no Pré-parto ou Bloco Obstétrico
  • 2º Grupo – Prioridade I (Laranja) – Muito Urgente:
    • Atender em até 10 minutos e encaminhar para consulta médica priorizada
  • 3º Grupo – Prioridade II (Amarelo) – Urgente:
    • Atender em até 30 minutos e encaminhar para consulta médica priorizada. Reavaliar periodicamente
  • 4º Grupo – Prioridade III (Verde) – Pouco urgente:
    • Atender em até 120 minutos e encaminhar para consulta médica sem priorização. Informar expectativa do tempo de atendimento e reavaliar periodicamente. Pacientes classificados como VERDE podem também receber encaminhamento à unidade básica de referência pelo serviço social, via contato telefônico, com garantia de consulta médica e/ou cuidados de enfermagem, situação que deve ser pactuada previamente
  • 5º Grupo – Prioridade IV (Azul) – Não urgente:
    • Atender em até 4 horas e informar a possibilidade de encaminhamento para a Atenção Básica (UBS). Pacientes classificados como AZUL poderão ser encaminhados, por meio de documento escrito, para o acolhimento na Unidade Básica de Saúde de referência ou terão seus casos resolvidos pela Equipe de Saúde

A importância do enfermeiro obstetra no serviço de classificação de risco

Para avaliação do estado de saúde do paciente, o enfermeiro coleta informações, baseando-se, principalmente, na escuta dos antecedentes clínicos e da queixa principal, e realiza o exame físico, a fim de se identificar os sinais e sintomas, possibilitando o reconhecimento de padrões normais ou alterados e o julgamento de probabilidade do risco.

O enfermeiro interpreta os sinais psicológicos, interpessoais e comunicativos do paciente, para acolher e verificar a credibilidade da informação clínica. Nesse sentido, o trabalho do enfermeiro na classificação de risco também é influenciado por aspectos sociais e pelo contexto de vida em que o usuário se encontra. Assim, o enfermeiro utiliza a avaliação intuitiva para exercer a classificação a partir da aparência física e do modo que o paciente apresenta o seu problema.

A partir da coleta dos dados e do exame físico do usuário, o enfermeiro realiza a tomada de decisão, em que a escuta qualificada e o julgamento clínico e crítico das queixas induzem a um raciocínio lógico que determinará a priorização do atendimento. Para a tomada de decisão, o enfermeiro pode utilizar guias e protocolos como suporte e auxílio na classificação do risco do usuário. Os estudos mostram que é fundamental que os enfermeiros que atuam na avaliação e classificação do risco tomem decisões precisas, pois trata-se de identificar e diferenciar aquelas pessoas que não podem esperar por atendimento médico daquelas que podem, portanto, influenciando a dinâmica do serviço de urgência.

O enfermeiro deve estar preparado para classificar e, se necessário, reclassificar a prioridade de atendimento do usuário ao longo do período de espera. Para isso, a avaliação do enfermeiro deve ser cíclica, ou seja, requer contínuo planejamento e reavaliações dos usuários.

Com relação ao tema de conhecimentos e habilidades necessários para classificação de risco, o conhecimento teórico é apresentado como fundamental para se realizar a classificação de risco. O enfermeiro precisa conhecer extensamente as condições clínicas, cirúrgicas e psicossociais da população, em função da diversidade de problemas presentes no contexto do serviço de urgência. O profissional deve ter conhecimento sobre o perfil epidemiológico dos usuários que procuram o serviço de urgência, assim como a fisiologia e patologia das alterações mais frequentes para se estabelecer uma prioridade mais adequada.

Por outro lado, o conhecimento da organização e funcionamento do serviço é também essencial para o enfermeiro que trabalha na avaliação e classificação do risco.  O profissional deve conhecer amplamente a área física do serviço, assim como os recursos humanos e materiais, a fim de dimensionar o fluxo de usuários e espaço disponível, regulando o tempo de espera para o atendimento.

Em uma revisão integrativa sobre a organização de serviços de urgência hospitalar, identificou-se que o processo de classificação de risco envolve organização da área física, recursos materiais e, principalmente, de pessoal competente e suficientemente capacitado.

Classificação de risco

É importante a experiência dos enfermeiros para a definição da classificação de risco, pois as decisões para a priorização podem ser simples ou complexas e dependem da experiência do profissional. Os enfermeiros experientes transmitem segurança para a equipe de classificação de risco, já que os profissionais menos experientes os procuram para auxílio e suporte quando têm dúvidas.

A intuição é outra habilidade que é utilizada em algumas situações para se estabelecer a prioridade quando não há sinais facilmente identificados, já que a avaliação intuitiva é uma impressão imediata, subjetiva, que é centrada em manifestações que indicam um elevado nível de estresse. Ainda, são utilizadas para a triagem/classificação de risco a racionalidade, a confiança e a coragem, principalmente quando se trata da tomada de decisão do enfermeiro para a priorização do atendimento.

Perfil do enfermeiro para que possa atuar nessa área

  • Habilidade em associar o conhecimento teórico com a avaliação do paciente – para isso, é necessário se ter uma educação clínica e suporte ao enfermeiro, a fim de qualificar a classificação de risco. A preparação específica para classificação aumenta a consistência das decisões dos enfermeiros para a priorização, indicando que o conhecimento teórico é importante para a tomada de decisão
  • Habilidade em comunicação – orientar ou referenciar os pacientes com queixas classificadas como não urgentes a serviços ambulatoriais de saúde. Ainda, esse profissional deve estar disposto à conversa e ao diálogo, permitindo entender as necessidades de saúde apresentadas pelo usuário, buscando a solução do problema e criando a possibilidade do fortalecimento da rede de atenção, à medida que encaminha para outros serviços de saúde mais apropriados para cada situação apresentada
  • Habilidade em relações interpessoais – o profissional está acolhendo o usuário, ouvindo suas queixas e dando respostas a seus questionamentos. Com isso, o enfermeiro estabelece uma relação empática com o indivíduo, minimizando muitas vezes os sentimentos como a ansiedade, a agressividade ou a impaciência que possam surgir no decorrer do atendimento no serviço.

Nesse sentido, o enfermeiro que realiza essa atividade é muitas vezes o primeiro profissional de saúde que famílias e pacientes veem quando chegam ao serviço. Portanto, é necessário que ele tenha essas habilidades para ajudar as pessoas em um momento tão vulnerável.

Perfil do futuro profissional – acadêmico

O estudante deverá demonstrar competências para:

  • Utilizar fundamentação teórico-prática na consulta de enfermagem no pré-natal, no pós-parto e na saúde da mulher
  • Resolver problemas relacionados ao papel do enfermeiro obstetra no âmbito da unidade obstétrica
  • Prestar cuidados no parto normal de risco habitual e puerpério
  • Identificar e encaminhar para maternidades de referência gestantes de risco no pré-natal
  • Apresentar postura humanista, ética e reflexiva nos cuidados com gestantes/familiares, parturientes e puérperas
  • Prestar cuidados imediatos ao recém-nascido na sala de parto
  • Elaborar e desenvolver projeto de pesquisa, demonstrando atitude investigativa
  • Ampliar conhecimentos já produzidos e organizados baseados em evidências na área de saúde materno-infantil

Capacitação dos enfermeiros e os passos que os interessados em atuar nessa área devem seguir

Apesar do trabalho de enfermeiro obstetra ser uma carreira em ritmo acelerado e desafiador, a recompensa de fazer o parto e receber recém-nascidos saudáveis é de valor inestimável.

Devido à ampla gama de funções que os enfermeiros obstetras têm diariamente, para se tornar um enfermeiro obstetra, é preciso se inscrever no programa educacional apropriado.

Considerando que, conforme previsto na Lei nº 7.498 de 25 de junho de 1986, o Enfermeiro Obstetra é o Enfermeiro titular do diploma ou certificado de Enfermeiro Obstetra que tem competência legal de realizar assistência obstétrica, além de todas as atividades de enfermagem; e que a Obstetriz é a titular do certificado de Obstetriz, com competência legal de realizar assistência obstétrica, e cuja graduação em obstetrícia tem ênfase na promoção da saúde da mulher e na assistência da mulher durante a gestação, o parto e o pós-parto; 

Considerando a Resolução COFEN nº 389/2011, de 18 de outubro de 2011, que atualiza no âmbito do Sistema Cofen/Conselhos Regionais de Enfermagem, os procedimentos para registro de títulos de pós-graduação lato e stricto senso;

Considerando a Resolução COFEN nº 477/2015 que dispõe sobre a assistência às gestantes, parturientes e puérperas, de 14 de abril de 2015.

Considerando a Resolução COFEN nº 478/2015 que normatiza a atuação e a responsabilidade civil do Enfermeiro Obstetra e Obstetriz nos Centros de Partos Normais e/ou Casas de Parto, e dá outras providencias, de 14 de abril de 2015;

Considerando que os portadores de diploma ou certificado de Enfermeiro Obstetra e Obstetriz estão autorizados a realizar parto normal, sem distócia, visando à redução da mortalidade materna e perinatal;

O título de Enfermeiro Obstetra e Obstetriz no Conselho Federal de Enfermagem além do disposto na Resolução COFEN nº 389/2011, de 20 de outubro de 2011, será condicionado a composição dos seguintes critérios mínimos de qualificação para os títulos de pós-graduação Stricto ou Lato Sensu, modelos de Residência em Enfermagem Obstétrica e Pós-Graduação em Enfermagem Obstétrica.

I- Realização de no mínimo, 15 (quinze) consultas de Enfermagem pré-natais;

II- Realização de no mínimo, 20 (vinte) partos com acompanhamento completo do trabalho de parto, parto e pós-parto;

III- Realização de, no mínimo, 15 (quinze) atendimentos ao recém-nascido na sala de parto.

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Profa. Dra. Cláudia Maria Messias

Professora da disciplina de Saúde da Mulher. Enfermeira Obstetra. Especialista em Docência em Saúde e do Ensino Superior. Enfermeira do Hospital Municipal Miguel Couto, no Rio de Janeiro e Hospital dos Servidores do Estado.

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