Nidia María Uc-Chi,1 Reina Hermelinda Cauich-Cob,1 Simón Gabriel Vázquez-Cauich,2 Nixon Erik López-Navarro3
1Jefatura de Enfermería, Unidad Médica de Alta Especialidad, Mérida, Yucatán.
2Jefatura de Enfermeras, Hospital General Regional No. 12 “Lic. Benito Juárez”, Mérida, Yucatán;
3Hospital General Regional No. 17, Cancún, Quintana Roo. Instituto Mexicano del Seguro Social, México
Corrrespondence: Nidia María Uc Chi
Received: May 22nd 2013
Judged: May 21st 2014
Accepted: July 16th 2014
Introduction: Nursing diagnosis is the result of thoughtful analysis and critical interpretation of the data set collected during the assessment. In the Neonatal Intensive Care Unit, the cefalocaudal assessment is made based on the criteria of the physical examination, however although there are diagnostic labels and nursing interventions established, nursing care is based on perceived and patient emerging needs.
Objective: To establish methodological consistency between the cefalocaudal assessment and certain nursing diagnoses in Neonatal Intensive Care Unit inpatient.
Methods: using a simple random sampling 58 patients were selected. Cefalocaudal assessment was performed, report of signs and symptoms detected and nursing diagnoses from the report sheet. After obtaining patient assessment and nursing diagnoses, they were compared to verify that diagnostic labels correspond to the observed symptoms. Association analysis was used by logistic regression (LR) multivariate binary.
Results: Prevail of 51.7 % in the domain of Safety and Security. The nursing diagnosis most often used was ineffective airway clearance with 15.5 % (9). By associating the cefalocaudal assessment by body systems with affected domains it was possible to observe statistical significance at p < 0.05.
Conclusion: In the cefalocaudal assessment and diagnostic labels respiratory system is the most reported as affected.
Keywords: Nursing process; Nursing diagnosis; Intensive care
The role of the nurse in primary care is the care of the sick or healthy individual. Scientific nursing practice and the level of development that the discipline has achieved has as theoretical reference the model of care and as methodological element and the nursing process.1,2
The application of the nursing process (NP) and taxonomies, as methodological strategy and disciplinary languages, allows a scientific and humanistic provision of care; they are based on human interaction and the elements of the philosophy of nursing. NP emerged in the mid-twentieth century and it is Hall who first considered all nursing care as a process. Since then, different authors (Johnson, Orlando, Roy Aspinall and others) have been perfecting it.3,4
Meanwhile, since 1983 Carpenito was already working with a practice model that describes the clinical focus of professional nursing (bifocal clinical practice model).5
Patient assessment can be done from different nursing models, including that of Virginia Henderson,6 which is based on 14 basic human needs, and that of Marjory Gordon, based on functional health patterns and identifying the most prevalent diagnoses according to NANDA taxonomy (North American Nursing Diagnosis Association).7
Another assessment is cephalocaudal, which aims to find injuries or illnesses that have not yet been discovered. It has been suggested that physical assessment not take more than 2 or 3 minutes, and it is recommended that the test start with the head and follow methodically towards the feet.8
From this assessment, conclusions are drawn in relation to the needs, problems, concerns, and human responses of the client, so that a diagnostic taxonomy is created.9
These diagnoses have a methodological structure in their process. According to the Fehring model, four facets of content validity were proposed, which are called "intrinsic validity of diagnostic labels".10
In practice and according to various authors there are difficulties in making a nursing diagnosis although it must come from data collected during the assessment. Reppetto et al.11 mentioned difficulties with diagnosis and expected results; for Moraes et al.12 nursing diagnosis is recorded and physical examination is poorly described, particularly in relation to cardiovascular and respiratory systems; for Mena et al.,13 professionals rarely use the diagnostics; for Perez et al.,14 the main barriers to implementing NP is work overload, lack of human and material resources, lack of knowledge on the subject and lack of interest of nurses; Rojas15 established that a high proportion of those working in intensive care units (ICU) of Medellín carried out 80 % of phase activities; however, there is no homogeneity in the performance of these. Regarding the diagnostic phase, a dual position is reflected: first, the nursing diagnoses guide care, and second, nurses say they are not useful and they do not apply them for lack of time, interest, records, large numbers of patients, and delegating other responsibilities.
In the ICU the gravity of patient conditions requires performing complex interventions. According to Beltran, this implies a high level of technical and scientific skill, analytical skill and problem solving, self-control, sense of humanity, morality and ethics.16 Patient assessment in these units should have a conceptual scheme of the characteristics of organ and system dysfunction that are common to critical changes. In the first minutes of assessment, functional abnormalities that endanger life are identified.17
Signs and symptoms detected in patient assessment should be transcribed. Incomplete or misleading entries hinder continuity of care and communication between professionals. According to the Secretaría de Salud a project done in 1998 on Norma Oficial Mexicana NOM-168-SSA1-1998, the clinical record sheet must be prepared by the nursing staff on shift.18
The nursing record should mirror the NP; therefore, it must be designed and structured in a way that reflects each and every one of the steps.19 Gonzales found several factors that interfere with the correct filling of clinical nursing record sheets, including workload, the lack of unified criteria, the lack of control regarding the training provided to staff, and, finally, the lack of guidelines established in the official law.20
In the ICU, nursing actions are immediate. The patient's conditions make assessment by functional patterns difficult; often the assessment is done with the criteria of the physical examination and cephalocaudal assessment. Although there are risk diagnoses and related diagnoses, in most cases attention is based on the real and immediate needs of the patient. Therefore, the purpose of the study is to establish methodological consistency between the cephalocaudal assessment and the accuracy of nursing diagnoses.
In the city of Merida, Yucatan, with prior authorization from the Local Research Committee, a descriptive prospective survey was done. By random sampling 58 patients who underwent cephalocaudal assessment were selected, and their nursing report reviewed. Patients of either gender were included, and patients with nursing reports in a different format or who came from an outpatient clinic were not included; hardly legible or dubious reports were eliminated.
The researchers conducted the cephalocaudal assessment and recorded signs and symptoms detected. They then examined the nursing diagnosis area of the note sheet, and wrote it down in the data collection sheet. Once the patient assessment and the nursing diagnoses were obtained, they were compared to verify that diagnostic labels corresponded to the symptoms observed and to the criteria for making nursing diagnoses according to Gordon’s functional health patterns.21
Data were emptied into a collection sheet developed based on the literature and analyzed using SPSS version 15 in Spanish. From the descriptive statistics (frequencies and percentages) demographics of the patients were described. Content validity of the diagnosis was measured according to the criteria proposed by the NANDA and reported in the book "Nursing Diagnoses 2009-2011: Definitions and Classifications."22
For the association of the variables multivariate binary logistic regression (LR) was used.
The results were presented in tables and figures.
Development of the measuring instrument
For the preparation of the measuring instrument, the different items involved in the research framework were taken as reference; the feature of these articles was that they mentioned the necessary elements for carrying out the cephalocaudal assessment. For content or face validity, the different systems were enumerated starting with the nervous system; the Glasgow,23 Silverman,24 and Ramsay scales were included in the instrument.
Construct validity included re-checking data and specifying the theoretical relationship between signs and symptoms given by other authors and the concepts of the framework. When the instrument was completed, the Delphi technique was used. Five experts were presented the subject and a consensus of 80 % was achieved among them. The data were emptied into a sheet prepared specifically for the purpose.
58 patients were studied of which 51.7 % were male and the remaining 48.3 % female.
In assessing the nursing diagnoses reported in the nursing notes, it was seen that in 52% mastery of safety and security prevailed, activity and rest 17 %; another highlight is the mastery of nutrition, with 14 % (Figure 1).
Figure 1. NANDA domains according to nursing diagnoses reported in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
The most frequent nursing diagnosis was ineffective cleaning of the airways, followed by ineffective thermoregulation, risk of infection, and others.
According to the cephalocaudal assessment made, it was determined that 35 % had involvement of the respiratory system, and 55 of the circulatory, cardiac and the integumentary system (Figure 2).
Figure 2. Systems affected according to nursing assessment in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
By associating the cephalocaudal assessment by system with the affected domains, a statistical significance with p < 0.05 was observed.
According to the nervous system assessment, the signs present were: 16 % drowsy patients, 22 % alert, 3.4 % patients in coma, 30 % hypoactive patients and 13 and 6 % very restless and irritable (Figure 3).
Figure 3. Nervous system symptoms according to nursing assessment in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
In the respiratory system, 28 % had bronchial wheezing, 11 % hypoventilation and 11 % distal and perioral cyanosis (Figure 4).
Figure 4. Respiratory system symptoms according to nursing assessment in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
Regarding the heart and circulatory system 50 % of patients had tachycardia (Figure 5).
Figure 5. Cardiovascular system symptoms as nursing assessment in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
In the integumentary system 10 % had cold skin, 9 % warm skin, 20 % dry, 36 % skin firmness, 20 % pale skin and 10 % dehydration (Figure 6).
Figure 6. Integumentary system (skin) symptoms according to nursing assessment in the Neonatal Intensive Care Unit. Source: survey conducted in the intensive care unit of the UMAE in Merida, Yucatan
The globular belly was a relevant datum in the gastrointestinal system in 39.7 %; 6.9 % of patients had abdominal distension; of patients with gastric tube 6.9 % had dark brown discharge; another significant finding was that 67.2 % had no evacuation.
In the kidney-urinary system 82.8 % had spontaneous diuresis with light urine.
According to the cephalocaudal assessment, the respiratory system showed a significant correlation with the observed symptoms (p <0.05), 34 % had respiratory rattling, 13.7 % hypoventilation, and although there were statements or nursing diagnoses clinically related to hypoventilation and rattling, they were not statistically significant (Table I).
|Table I. Methodological congruence between assessment and nursing diagnostic label in Neonatal ICU|
|Risk of ineffective tissue perfusion|
|Distal and peripheral cyanosis
Slight intercostal retraction
|Ineffective airway cleaning
Ineffective breathing pattern
Impairment of gas exchange
Impairment of spontaneous ventilation
Risk of airway obstruction
|Fluid volume deficit
Fluid volume excess
Risk of vascular trauma
|Impaired skin integrity
Deterioration of the oral mucosa
Risk for impaired skin integrity
Risk of infection
Dysfunctional gastrointestinal motility
|Renal and urinary|
|Risk of ineffective renal perfusion|
|Source: ICU survey, UMAE Merida, Yucatan|
In cephalocaudal assessment on the integumentary level, what stands out is that skin color was pale in 32.7 % of patients, cyanosis was in 15.5 % with statistical significance of p <0.05 between the assessment and the integumentary signs. This assessment is not significantly associated with the nursing diagnoses, since at the integumentary level the predominant nursing diagnosis was neonatal jaundice (Table I)
According to the results it was observed that in the neonatal intensive care unit the NP and taxonomies as mentioned by Alfaro-Lefevre et al. are applied. In this unit the nursing report model includes this process and complies with NOM-168-SSA1-1998 on the clinical record, as the nursing sheet is prepared by the staff on duty.
Nursing diagnoses reported concurred with the taxonomy proposed by NANDA (North American Nursing Diagnosis Association). In reviewing the diagnostic labels one could see clarity of label, clarity of definition, consistency and capacity for intervention as suggested by Fehring et al.; however, sometimes the nursing diagnoses issued were seen as incomplete, since the related factor was missing.
Despite the nursing diagnoses, it can be seen that there are systems that present a great variety in symptomatology and few labels, which coincides with Reppetto et al., who mention difficulties with diagnosis.
In the results, what stands out is that the respiratory system presented the most symptoms and the most diagnostic labels; however, circulatory and digestive systems presented a wide array of symptomatology but not of nursing diagnosis labels, which is consistent with Pokorski, who says that nursing diagnosis is recorded and physical examination is poorly described.
The limited amount of diagnostic labels in the nervous, gastrointestinal and urinary-renal system, despite the varied symptoms found by the researchers, is consistent with the assertions of Mena et al., who describe that professionals rarely used nursing diagnoses, that patient assessment was done by researchers, and that the guide was an assessment sheet prepared according to system; this is probably why there are no diagnostic labels for these systems.
The reasons for the lack of diagnostic labels on systems with the most symptoms were not investigated. It is unknown if the cause is work overload, lack of human and material resources, or lack of knowledge on the subject and interest of nurses, as Perez et al. assert.
In the nervous system only one diagnostic label was found, but the symptoms were various; hypoactivity was a figure that prevailed. This item puts the patient at risk, but the only diagnosis was risk of tissue perfusion. This is consistent with Beltran et al. Patient care in the ICU requires a high level of qualification, as it is provided according to the characteristics of organ and system dysfunction.
In this study 63 diagnostic labels were presented in total, which are few compared with the number of patients and the great variety of symptoms reported, probably because, as Rojas mentions, there is a dual position regarding the diagnosis; on the one hand, they guide the care, and, on the other, it is said that they are not useful and that nurses perform only part of the activities of the process steps and there is no homogeneity in making the diagnosis. More research is needed to investigate why diagnostic labels are not made.
There is a correlation between cephalocaudal assessment, the symptoms presented by patients, and diagnostic labels described in the reports of nursing of patients treated at the neonatal intensive care unit.
According to the assessment it was observed that the most affected domain was safety / security, the most affected system was respiratory, and the most common diagnosis was ineffective cleaning of airways.
In this study we did not intend to revise the law of writing diagnostic labels, only to see that the statement corresponded to the symptoms presented; however, it was observed that sometimes, the nursing diagnoses issued were observed incomplete (the related factor was missing).
Systems with symptoms such as abdominal and nervous system were seen to have limited diagnostic labels.
The assessment stage is critical because care planning is based on it; nursing staff should encourage adequate cephalocaudal assessment of patients.
We must continue research protocols around the nursing process, especially if assessment is consistent with the planning of nursing actions; propose assessment systems accordingly for ICU patients; conduct protocols for the use of nursing diagnoses according to NANDA – and their functionality in the ICU - ; and ask why diagnoses were not made for all the observed symptoms.