O serviço de atendimento pré-hospitalar móvel de urgência presta atendimento a toda e qualquer solicitação de ajuda fora do âmbito hospitalar visando a manutenção da vida e minimização de sequelas, exigindo do enfermeiro conhecimentos e habilidades específicas. Este estudo teve como objetivo identificar os diagnósticos de enfermagem em vítimas de trauma atendidas em um Serviço Avançado Móvel de Urgência (SAMU) do interior do estado de São Paulo. Foi elaborado e validado um instrumento de coleta de dados, segundo o modelo conceitual de Horta; os dados coletados foram validados por peritos na temática. O projeto foi aprovado por Comitê de Ética e Pesquisa. Foram avaliadas 23 vítimas de trauma, sendo 17 (73,9%) homens, 16 (69,5%) com idade entre 18 e 30 anos e 14 (60,1%) vítimas de acidentes de transito. Os diagnósticos de enfermagem mais frequentes foram: Risco para infecção (91%), Risco para trauma (82%), Dor aguda (74%), Integridade tissular prejudicada (65%), Volume de líquidos deficiente (43%) e Risco para volume de líquido deficiente (43%). Este estudo permitiu identificar os principais diagnósticos de enfermagem nesta clientela específica, os quais poderão fornecer importantes subsídios para futuras investigações, sobretudo abordando intervenções de enfermagem.

The aim of this study was to identify the nursing diagnoses of adult trauma victims in the pre-hospital attendance. The research methodology used was a descriptive, qualitative, case study strategy. It was based on Horta's Conceptual Model and the ATLS (Advanced Trauma Life Support) theoretical framework. The researcher collected data in the SAMU-192 pre-hospital intensive care ambulance, from the Advanced Vital Support Unit, in Ribeirão Preto (SP), Brazil during the period of January to June 2004, using a previously validated instrument for data collection. The sampling was made up of 23 adult trauma victims, of 18 years or older. After data collection the nursing diagnostics were identified through a rational thought process and forming of diagnostic categories based on the NANDA (North American Nursing Diagnosis) taxonomy II. Both the collected data and nursing diagnoses elaborated by the researcher were analyzed by five other nurses with experience in trauma care and specific Knowledge of nursing diagnosis and afterwards, the suggestions made were reviewed and accepted. During the advanced mobile prehospital assistance 24 nursing diagnoses were identified, 15 of which were actual problems and 9 were at risk of occurring.Of the latter, the factors with a 50% or higher at risk status were infection, trauma, acute pain and tissue integrity damage. The other diagnoses that were established included: ineffective airway clearance (17%), ineffective breathing pattern(30%), risk for aspiration (22%), risk for altered breath pattern (13%), fluid volume deficit (43%), risk for fluid volume deficit (43%), altered peripheral tissue perfusion (13%),. altered cerebral tissue perfusion (30%), altered gastrointestinal tissue perfusion (8%), risk for peripheral neurovascular dysfunction (39%), visual sensory/perceptual alterations (4%), tactile and kinesthetic sensory/perceptual alterations (22%), acute confusion (17%),risk for altered corporal temperature (34%), damaged skin integrity (22%), impaired physical mobility (22%),risk for falling, anxiety (43%), fear (4%) and risk for self directed violence (4%). We verify that the group of disgnostic represents the gravity of the victim for identifying alterations in vital organic systems.

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