Nanda Enfermagem
Jannet Nevels
To identify possible nursing diagnoses according to the NANDA-International classification present in critically ill adult patients with COVID-19 based on diagnostic clues described in the scientific literature.
From the reading of 20 studies, 51 diagnostic clues were selected and grouped into 11 Psychobiological Basic Human Needs. After three rounds of analysis by the experts, a correspondence of 51 diagnostic clues with 26 NANDA-International nursing diagnosis titles was identified. The domains of this classification with the highest number of diagnoses were: activity/rest (n=9); safety/protection (n=7) and nutrition (n=4). It is noteworthy that 45.1% of the diagnostic clues corresponded to more than one diagnostic title. Moreover, most nursing diagnoses (60.0%) refer to real problems and 40.0% to potential problems.
The results obtained allowed the identification of diagnostic clues present in critically ill adult patients with COVID-19 and to verify their equivalence with 26 diagnostic titles from NANDA-International.
Identificar possveis diagnsticos de enfermagem conforme a classificao da NANDA-International presentes em pacientes crticos adultos portadores de COVID-19 a partir de pistas diagnsticas descritas pela literatura cientfica.
Os resultados obtidos permitiram a identificao de pistas diagnsticas presentes em pacientes crticos adultos portadores de COVID-19 e verificar sua equivalncia com 26 ttulos diagnsticos da NANDA-International.
Identificar posibles diagnsticos en enfermera segn la clasificacin de NANDA-International presentes en pacientes crticos adultos con COVID-19 a partir de pistas diagnsticas que se describen en la literatura cientfica.
A partir de la lectura de 20 estudios, se eligieron 51 pistas diagnsticas que se agruparon en 11 Necesidades Humanas Bsicas Psicobiolgicas. Despus de tres rondas de anlisis de los expertos se identific la correspondencia de las 51 pistas diagnsticas con 26 ttulos diagnsticos de enfermera de NANDA-International. Los dominios de esa clasificacin con un mayor nmero de diagnsticos fueron: actividad/reposo (n=9); seguridad/proteccin (n=7) y nutricin (n=4). Se destaca que 45,1 % de las pistas diagnsticas presentaron correspondencia con ms de un ttulo diagnstico. Adems, la mayora de los diagnsticos de enfermera (60,0 %) se refiere a problemas reales y el 40,0 % a problemas potenciales.
Los resultados alcanzados permitieron la identificacin de pistas diagnsticas presentes en pacientes crticos adultos con COVID-19 y verificar su equivalencia con 26 ttulos diagnsticos de NANDA-International.
The survey of ND must be based on diagnostic reasoning that considers the so-called diagnostic clues. These can be understood as patient manifestations that represent signs, traces, signs, indications or characteristics of an ND.(55. Matos FG, Cruz DA. Development of an instrument to evaluate diagnosis accuracy. Rev Esc Enferm USP. 2009; 43(Spe):1087-95.)
In this context, with a view to improving the quality of nursing care for critically ill patients with COVID-19, it is essential to recognize which priority NDs are. In addition to this, the importance of documenting nursing care is emphasized, based on a standardized language, with a view to monitoring the clinical evolution of patients with COVID-19, for the implementation of evidence-based nursing interventions. Thus, this study aimed to identify possible ND according to the NANDA-I classification present in adult critical patients with COVID-19, based on diagnostic clues described in the scientific literature.
The inclusion criteria used for sample selection were: review articles (narrative, integrative, systematic, scoping or umbrella) published between the years 2019 to 2020, available in full, that discussed diagnostic clues present in critically ill patients with COVID-19. Considering that the topic addressed is recent in the scientific community, the choice of review articles was chosen, as this design allows obtaining comprehensive information on the clinical manifestations of COVID-19 in the world context. Reviews that targeted children and pregnant women were excluded.
To remove duplicate studies, they were imported from the databases into Endnote. Subsequently, the screening of titles and abstracts was performed using Rayyan QCRI, independently by two researchers (Doctor 1 and 2) and the divergent cases were evaluated by a third researcher (Doctor 3).
As diagnostic clues, the manifestations of critically ill adult patients with COVID-19 that represent signs, traces, signs, indications or characteristics of a ND were considered.(55. Matos FG, Cruz DA. Development of an instrument to evaluate diagnosis accuracy. Rev Esc Enferm USP. 2009; 43(Spe):1087-95.) It is noteworthy that the identification of diagnostic clues was also performed by three researchers (Doctors 1, 2 and 3) independently. Then, the selected diagnostic clues were submitted to an approval process (Doctor 4) in order to discuss differences, being constantly checked to confirm the findings. Subsequently, diagnostic clues were grouped according to Basic Human Needs (BNH).(1212. Horta WA. Processo de enfermagem Castellanos. So Paulo: EPU; 1979.)The choice for this theoretical framework was based on the fact that the BNH Theory is the most widespread among Brazilian hospital institutions, especially in the context of critical care.(1313. Schmitz EL, Gelbcke FL, Bruggmann MS, Luz SC. Philosophy and conceptual framework: collectively structuring nursing care systematization. Rev Gacha Enferm. 2016;37(esp):e68435.)
In the second stage, the survey of NANDA-I ND was carried out, following the precepts of diagnostic reasoning of the Risner Model.(1414. Risner PB. Nursing diagnosis: diagnostic sistements. In: Christensen PJ, Kenney JW, editors. Nursing Process: application of conceptual modes. 4th ed. St. Louis: Mosby; 1996.) For the analysis stage, clinically relevant data extracted from the literature were categorized according to the BNH, which made it possible to identify gaps in information not covered in the bibliographic survey. For the synthesis process, the relevant diagnostic clues were grouped to compose the judgment of a diagnostic hypothesis by comparing the clues with normality standards.(1414. Risner PB. Nursing diagnosis: diagnostic sistements. In: Christensen PJ, Kenney JW, editors. Nursing Process: application of conceptual modes. 4th ed. St. Louis: Mosby; 1996.) Based on the taxonomic structure of NANDA-I, ND related to diagnostic hypotheses were sought. The definition of the diagnostic title and the correspondence of diagnostic clues with NANDA-I diagnostic indicators (related factor/risk factor, defining characteristics, associated conditions and population at risk) supported the selection of NDs using standardized language. It is noteworthy that this step was conducted by two researchers (Doctors 1 and 2) in a Microsoft Excel spreadsheet and later discussed with two other researchers (Doctors 3 and 4) to identify differences and propose a version only.
The following were sent to the expert nurses via e-mail: a professional profile characterization form; instrument referring to the survey of ND from the diagnostic clues described in the literature; invitation letter with detailed instructions related to filling out the instrument; file in PDF format with NANDA-I NDs; and the informed consent form.
The document sent to the experts for validation was structured by the authors in columnar format. In the first column, BNHs were described; in the second, the diagnostic clues extracted from the review articles that made up each BNH; in the next column, the diagnostic titles as well as the diagnostic indicators (defining characteristics, related and risk factors, associated conditions or population at risk) of NANDA-I. Thus, the diagnostic correspondence validation was based on the equivalence between the groups of diagnostic clues with NANDA-I title and diagnostic indicators.
Expert nurses were instructed to make their notes and suggestions in a space beside each NANDA-I ND. Each expert informed whether or not they agreed with the set of diagnostic clues identified for each BNH and NANDA-I ND. In case of disagreement, they were also asked to explain the reasons and possible suggestions for NDs.
In the first stage, 289 studies were found in electronic and manual searches. Since they are duplicated, 52 were removed from the listing. After reviewing titles and abstracts, 205 articles were excluded, remaining 32 for full text analysis. Of these, one study was not found and 11 were excluded. Thus, 20 articles were included in the study (Figure 1).
Among the limitations presented in this study, the inclusion of some medical diagnoses, such as pulmonary edema, cardiac insufficiency, acute renal failure, systemic inflammatory response syndrome, as diagnostic clues. The choice to maintain these medical diagnoses for the survey of ND was based on the fact that they were described by the studies included in the review as important clinical manifestations in critically ill patients with COVID-19. Furthermore, it is noteworthy that these are associated conditions described by NANDA-I.
Another limitation of this study is based on the survey of diagnostic clues based on secondary data from review studies. The choice for such a strategy is based on the fact that it is a newly discovered infectious disease, whose clinical aspects are being elucidated. However, the diagnostic clues listed in the studies allowed to reflect the reality experienced in clinical practice in different countries, which minimizes this limitation.
This study allowed us to identify diagnostic clues present in critically ill adult patients with COVID-19 and to verify their equivalence with 26 NANDA-I diagnostic titles. In clinical practice, the identified ND may support the construction of instruments for collecting nursing data for patients with COVID-19 hospitalized in ICU, in addition to favoring the creation of software to support the nursing process recording. Studies on classifications with standardized languages in Brazil, including NANDA-I, still focus primarily on the development of terminology; however, it is necessary to advance, including its documentation in electronic records so that the data can be analyzed, evidencing nursing care in practice.
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