DOI: 10.15253/2175-6783.2015000600008 www.revistarene.ufc.br

Original Article

Frequency of nursing diagnoses in a surgical clinic Frequência de diagnósticos de enfermagem em uma clínica cirúrgica Frecuencia de diagnósticos de enfermería en una clínica quirúrgica

Andreza Cavalcanti Vasconcelos1, Cláudia Germania Alencar de Castro1, Durcival Francisco da Silva1, Vanessa Juvino de Sousa1

Objective: to identify the frequency of Nursing Diagnoses of patients in a surgical clinic. Methods: cross-sectional study, performed with 99 patients in the postoperative of general surgery. Data were collected through a questionnaire validated according to domains of NANDA International, including physical and laboratory examination. Results: 17 nursing diagnoses were found; eight had a frequency higher than 50.0% (infection risk, impaired tissue integrity, constipation risk, anxiety, bleeding risk, acute pain, delayed surgical recovery, dysfunctional gastrointestinal motility). It was observed in all patients the Nursing Diagnostics: risk of infection, impaired tissue integrity and risk of constipation. Conclusion: the frequency of the most prevalent diagnosis is inserted in the domains safety/protection and nutrition, which determines the need to redirect nursing care, prioritizing the patient’s clinic. Descriptors: Nursing Diagnosis; Perioperative Period; Nursing. Objetivo: identificar a frequência dos Diagnósticos de Enfermagem em pacientes de uma clinica cirúrgica. Métodos: pesquisa transversal, realizada com 99 pacientes em pós-operatório de cirurgia geral. Os dados foram coletados através de um questionário validado segundo os domínios da NANDA Internacional, incluindo exame físico e laboratorial. Resultados: foram encontrados 17 diagnósticos de enfermagem, oito apresentaram frequência maior que 50,0% (Risco de infecção, Integridade tissular prejudicada, Risco de constipação, Ansiedade, Risco de sangramento, Dor aguda, Recuperação cirúrgica retardada, Motilidade gastrointestinal disfuncional). Observou-se em todos os pacientes os Diagnósticos de Enfermagem de: Risco de infecção, Integridade tissular prejudicada e risco de constipação. Conclusão: a frequência dos diagnósticos mais prevalentes encontra-se inseridos nos domínios segurança/proteção e nutrição, o que determina a necessidade de redirecionar os cuidados de enfermagem, priorizando a clínica do paciente. Descritores: Diagnóstico de Enfermagem; Período Perioperatório; Enfermagem.

Objetivo: identificar la frecuencia de diagnósticos de enfermería en pacientes de una clínica quirúrgica. Métodos: estudio transversal, realizado con 99 pacientes en el postoperatorio de cirugía general. Datos recolectados a través de un cuestionario validado según los dominios de la NANDA Internacional, incluyendo examen físico y de laboratorio. Resultados: se encontraron 17 diagnósticos de enfermería, ocho tenían frecuencia superior a 50,0% (Riesgo de infección, Integridad del tejido perjudicado, Riesgo de estreñimiento, Ansiedad, Riesgo de sangrado, Dolor agudo, Recuperación quirúrgica demorada, Motilidad gastrointestinal disfuncional). Se observó en todos los pacientes de los Diagnósticos de Enfermería: Riesgo de infección, Integridad del tejido perjudicado y riesgo de estreñimiento. Conclusión: la frecuencia de los diagnósticos más frecuentes se introduce en los dominios de seguridad/protección y nutrición, lo que determina la necesidad de desviar la atención de enfermería, priorizando clínica del paciente. Descriptores: Diagnóstico de Enfermería; Periodo Perioperatorio; Enfermería.

Hospital Regional do Agreste. Caruaru, PE, Brazil.

1

Corresponding author: Claudia Germania Alencar de Castro Av. Brasil, 580 – Portal do Sol Condominium. Zip Code: 55016-360, University Neighborhood, Caruaru, PE, Brazil. E-mail. claudia_alencastro@ hotmail.com

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Received: Aug. 15th 2015; Accepted: Nov. 5th 2015.

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Frequency of nursing diagnoses in a surgical clinic

Introduction The Systematization of Nursing Care is a nurse working tool, enabling a care plan directed to the individual evidenced problems, family and community(1-2) and has been implemented as a way to raise the quality of care, make agile and organize the work of the nursing staff and benefit the individual. The Nursing Process is an organized way to provide care to the customer and consists of six steps that must be previously established(3). Among these steps, there is the Nursing Diagnosis, comprising the clinical trial about the individual, family or community answers, directed to health problems/real or potential life processes(4). Thus constitutes the basis for selection of nursing interventions through a method and scientific work strategy to achieve the expected results, which priority and responsibility are of nurses(5-6). Thereby, for applicability of the Nursing Process and identification of nursing diagnoses, the first step is the nursing history. Then emerges the classification of nursing diagnoses, which is evidenced by clinical reasoning about the data collected by clinical interview and physical examination(7). In the hospital, the nurses also use this reasoning in patient care, because at this moment they need a special attention to their health. When the patient needs surgery, whether elective or emergency, it is considered a stressful situation for them and their family, regardless of the purpose, as from admission the patient is surrounded by a number of factors that cause changes in their lifestyle, and can trigger an emotional, explicit or implicit reaction(8). The surgical procedure, regardless of the surgery type, it is always a crisis for patients and their families. Even in small interventions, some situations can lead to fear, anxiety and be interpreted as life threatening. The effects or consequences of surgery are not limited only to the excision and/or functional

changes in an organ, involve numerous changes in the daily lives of their personal, family, professional and social life, generating some emotional reaction (explicit or implicit). From this perspective, nursing professionals create expectations and perspectives in taking care of the surgical patient(8). The postoperative period is the period of patient’s recovery. In this period, nursing care is related to interventions to prevent or treat complications and provide to the patient the return to daily activities(7). The care provided to patients during the phases of pre, during and post surgery should be planned based on scientific evidences and determined by the client’s health status, type of surgery, hospital stay, rules and routines implemented in the institution, and especially, by the emergence of specific needs, since standardized by an instrument of practical language that contributes to the continuity of nursing care(9). Thus, the Nursing Process is a scientific and dynamic working method, systematized and interrelated by actions enabling greater interaction with the staff. Among the instruments, we can highlight the Diagnosis Classification System NANDA International, Inc.(4), which is widely used in the practice of nursing care, allowing the understanding of professionals through a standardized language, which proposes a facilitator for the interpretation of the real situation of the individual and the communication between the nursing staff that assists them(7,10). Seeking the improvement of nursing care through a dynamic process to better qualify the assistance to patients exposed to some type of surgical procedure, and value observations of the nursing staff for the health of these people, this study becomes relevant to identify the frequency of nursing diagnoses in a surgical clinic, according to the taxonomy II of NANDA International, Inc.(4), allowing to expand knowledge in this area and better target assistance to those individuals.

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Method The research was a documentary type, prospective with a quantitative approach(11), developed from February to May 2012. The population of the study consists of patients in the postoperative of general surgery, characterized mainly by surgeries of the respiratory and gastrointestinal tract. All patients in immediate and mediate postoperative were included, of elective and non-emergency surgery, regardless of gender and age; who remained in the sector for more than 24 hours; did not present any cognitive disorder and underwent surgery of the respiratory and gastrointestinal tract. As exclusion criteria were the patients with verbal communication or written disability, due to the severity process of the disease (comatose, intubated, etc.) and psychosocial changes; those undergoing emergency surgery and transferred from the sector. By such inclusion and exclusion criteria, 99 patients participated in the study. For data collection, was adopted a questionnaire validated in Brazil(12), whose variables (socio-demographic, comorbidities and changes in the body’s systems) attend the research objectives and through secondary data obtained from medical records, through analysis of the changes description of physical examination and laboratory tests. To attend the research requirements broadly, information on the characteristics of respondents and the diagnoses were collected, according to domains of the Nursing Diagnosis Classification System NANDA International(4). Were used as variables (infection, tissue and skin integrity, constipation, pain, mobility, anxiety, nutritional status, fear, body image) changes inherent in the systems of the human body (neurological, cutaneous, cardiovascular, respiratory, gastrointestinal, genitourinary, skeletal muscle). For every alteration found was verified association with

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the type of surgical procedure. The measurement was determined by the correlation between the type of surgery and the alterations presented by the patient. Nursing Diagnoses were elaborated according to the changing needs. After collecting data, preceded the identification of the most frequent Nursing Diagnoses, used to build a database of Microsoft Excel program. For validation of diagnoses, there were three guests with experience in caring for surgical patients and systematization of nursing care. Each guest evaluated which changes were associated with certain surgery and if these changes were repeated on another patient underwent to the same procedure, observing the length of stay, age group, preexisting conditions. After repeating three times over these changes is verified, the diagnosis was evidenced and validated. The diagnoses titles were described according to the Brazilian publication 2013 of Nursing Diagnosis Classification System, NANDA International, Inc.(4) because this was the edition used by nurses to develop and validate the diagnoses at the time of the study. Will be discussed diagnoses with a frequency greater than 50.0%. This study was approved by the Ethics Committee of the Caruaruense Association of Higher Education - Opinion No. 162/2011.

Results

To identify the most frequent Nursing Diagnoses, the data were organized as the characterization of the participants and the frequency of these diagnoses. The prevalent age group of participants was the group above 60 years (29.0%), female. The majority of participants lived in other cities in the rural of Pernambuco (65.0%); as marital status, married prevailed (52.0%); and most had undergone previous hospitalizations (79.0%). These suffered from anxiety at some moment before and after surgery (74.0%)

Frequency of nursing diagnoses in a surgical clinic

and suffered from other diseases, such as diabetes and hypertension (62.0%). The medical diagnostic found that lead to gastrointestinal surgical procedures were: cholelithiasis (62.0%), hernia (45.0%) and bowel tumors (42.0%).

Table 1 - Characterization of the patients in the postoperative period Confidence Interval (95%)

n (%)

67 - 71

69 (69.6)

20 - 29

08 - 12

10 (10.1)

40 – 49

23 - 27

25 (25.2)

Variables Gender

Female Male

Age (years) 30 – 39 50 – 59

28 - 32 14 - 18

16 (16.1)

Confidence Interval

n(%)

Infection risk

97 – 100

99 (100.0)

Constipation risk

65 – 69

67 (67.6)

Nursing diagnosis*

Impaired tissue integrity Anxiety

Bleeding risk

57 – 59

Acute pain

Delayed-surgical recovery

Dysfunctional gastrointestinal motility Stress syndrome risks by changes Glucose risk

Impaired comfort

Impaired skin integrity risk Fear

Imbalanced nutrition: less than nutritional needs

32 - 36

34 (34.3)

Imbalanced of the liquid volume risk

Married

50 - 54

52 (52.5)

Widower

4-8

6 (6.0)

Residency

City of the research Other cities

Marital status Single

Others

Psychosocial needs, fear, and anxiety

27 - 31 63 - 67 33 - 37 4-8

29 (29.2) 65 (65.6) 35 (35.3) 6 (6.0)

72 - 76

74 (74.7)

Diabetes

25 - 29

27 (27.2)

Others

35 - 39

37 (37.3)

Other pathologies

Arterial hypertension Surgery of the digestive tract

33 - 37

35 (35.3)

Cholelithiasis

36 - 40

38 (38.3)

Intestinal tumors

19 - 23

21 (21.2)

Hernias Others

27 - 31 9 - 13

29 (29.2) 11 (11.1)

97 – 100 60 – 64

19 (19.1)

≥ 60

17 - 21

30 (30.3)

Table 2 - Frequency distribution (N=99) of the identified nursing diagnosis

Situational low self-esteem risk Disturbance in body image

44 – 46 35 – 39 24 – 28 11 – 15 9 – 13 5–9 3–7 2–6 2–6 1–5 0–4 0–4

*A patient may present one or more nursing diagnosis

99 (100.0) 62 (62.6) 55 (55.5) 42 (42.2) 37 (37.3) 26 (26.2) 13 (13.1) 11 (11.1) 7 (7.0) 5 (5.0) 4 (4.0) 4 (4.0) 3 (3.0) 2 (2.0) 2 (2.0)

17 Nursing Diagnoses were found. Of these, eight have a higher frequency than 25.0%. The most prevalent were infection risk (100.0%), impaired tissue integrity (100.0%), constipation risk (68.0%), anxiety (63.0%), bleeding risk (55.0 %), acute pain (4.0%), delayed-surgical recovery (37.0%) and, dysfunctional gastrointestinal motility (26.0%).

Discussion

The implementation of the Nursing Process, in a systematic and deliberate manner, elucidates the needs, directs the care and documents the results obtained from the action/intervention performed. Therefore, it was evidenced 17 Nursing Diagnoses

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present in the 99 study participants, which are: Infection risk such as increased risk of invasion of pathogens. This diagnosis is commonly identified in persons subjected to any surgical procedure. In this research, 100.0% of the patients presented this Nursing Diagnosis, which may be related to invasive procedures, such as a delayed urinary catheter, peripheral venous access, and drains. Corroborating this finding, a study performed in Fortaleza with postoperative cardiac surgery patients also showed 100.0% of this diagnosis in its sample(7). In another study performed in Minas Gerais with Intensive Care Unit patients, this diagnosis also had 100.0% frequency(13). Therefore, it can be inferred that the patient who goes through a relocation process has a high risk for infection, especially if subjected to surgery or if needs intensive care due to the use of invasive procedures. The Nursing Diagnosis Integrity of impaired skin, defined as the change in the dermis and/or epidermis(4), was present at 100.0% of the patients in this study. Another similar study in Fortaleza(14) in the postoperative period of cardiac surgery, also obtained the frequency of 100% of this diagnosis. All participants had the integrity of impaired skin as a result of secondary mechanical factors the procedure (surgical incision). The Diagnosis of Risk Nursing for constipation is defined as the risk to decrease the normal frequency of evacuation, increased the difficulty resulting from the passage of stool(4). 67.0% of the participants showed constipation risk and had the functional factors as risk (insufficient physical activity) and physiological (change in their usual patterns of food and feed, as well as decreased motility of the gastrointestinal tract). The Diagnosis risk for constipation appeared in a study conducted in Rio Grande do Sul(7), but with a frequency of 96.0%, different the present study. It follows that the constipation risk Diagnosis has high frequency due to decreased food intake and intestinal peristalsis. Acute pain means unpleasant sensory and

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emotional experience, which may be a sudden beginning or slow, with mild to severe intensity(4). This diagnosis indicated as defining the characteristic facial expression of pain when coughing and moving. It is justified by the “broken” epithelial barrier and is caused by tissue damage. In another study(7,13), the acute pain was one of the most common diagnoses found in cardiac surgery and Intensive Care Unit patients. It is important to pay attention to the patient’s complaints of pain because the lack of necessary care can trigger anxiety, later changing vital signs and increased energy expenditure. The pain relief is important because pain leads patients to reduce the movement, breathe shallowly and find it difficult to reconcile sleep and rest, causing physical wear and lower motivation for treatment, negatively interfering with the recovery of the patient(14). It is understood by Anxiety, concern or fear related death(4). This diagnosis proved to be evident, with a frequency of 62% due to the environment change, the fear of death in the surgical procedure, distance from family and being with society, financial and family concerns. In a similar study in patients undergoing cardiac surgery(7), the frequency was 68%. Thus, as in the present investigation, this diagnosis related to this vague uncomfortable feeling of discomfort or dread accompanied by an autonomic answer; a feeling of apprehension or danger(15). The phone consultation can be alleviated by assistance to exams. Every surgical procedure, being deep or shallow, no matter how small, has risks. The bleeding risk is one of them, and, if not contained, will often result in death risk to the patient. This study showed more than 50.0% probability of this risk occurs. In other research, it was not observed this Nursing Diagnosis, because the used literature was the latest version of NANDA International, Inc.(4) and there are few studies that address the Systematization of Nursing Care and difficult the discuss of this diagnosis. It is understood as diagnosis, delayed surgical recovery, the extension of the number of days

Frequency of nursing diagnoses in a surgical clinic

postoperative necessary to initiate and perform activities to sustain life, health, and welfare related to prolonged surgical procedure(4), in this survey the diagnosis was 37.7% of frequency and was not observed in other studies. The dysfunctional gastrointestinal motility diagnosis was present in 26.6% of patients and found diminished by the lack of food and/or water intake, prolonged fasting, bed rest and consequently decreased peristalsis. Risk factors are those that increase vulnerability to the occurrence of an event, as the related factors have standardized relation to the Nursing Diagnosis(4). Although most diagnoses have risk factors and related factors, others do not have either. Among the identified related factors, the most common were pain, anxiety, fear, smoke, harmful agents.

Conclusion

The clinical evolution of a patient undergoing a surgical procedure should be observed from the preoperative period as influences greatly on changes that may be present in the period after the procedure. The nursing diagnoses identified in this study establishes a parameter of the conduct of the nursing staff to be observed during the postoperative period following any surgery, especially of the respiratory and gastrointestinal tract. In surgical nursing care, the frequency of the most prevalent diagnosis is entered in the domains safety/protection and nutrition, which determines the need to redirect nursing care, prioritizing the patient’s clinical. It was observed that the diagnosis, infection risk and integrity of damaged skin, were present in all patients, which makes necessary preventive measures to control infection before, during and after any surgical procedure.

Collaborations

Vasconcelos AC contributed to the design, collection, analysis and interpretation of data, article writing and final approval of the version to be published. Castro CGA, Silva DF and Sousa VJ contributed monitoring, adjustments and revisions at all stages.

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