ICNP<sup>®</sup> terminological subgroup for palliative care patients with malignant tumor wounds

Castro, Maria Cristina Freitas de; Fuly, Patrícia dos Santos Claro; Garcia, Telma Ribeiro; Santos, Mauro Leonardo Salvador Caldeira dos

doi:10.1590/1982-0194201600047

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Original Article • Acta Paul Enferm. 29 (3) • May-Jun 2016 • https://doi.org/10.1590/1982-0194201600047 linkcopy

ICNP^® terminological subgroup for palliative care patients with malignant tumor wounds

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective To develop and validate a terminological subgroup using the International Classification for Nursing Practice for palliative care patients with malignant tumor wounds.

Methods A methodological study with an integrative literature review that searched empirical evidence related to malignant tumor wounds and nursing interventions for the management of symptoms in MEDLINE, CINAHL, LILACS and COCHRANE, time frame from 2002 to 2015. After crossing the evidence with 2013 ICNP® terms based on the Model 7 Axis, statements were prepared as diagnoses and nursing interventions, distributed according to basic human needs of the conceptual framework of Wanda Horta, and evaluated by experts.

Results From 51 affirmative diagnoses and 134 nursing interventions, 84.31%, and 91.04% were validated, respectively, establishing the subgroup.

Conclusion The instrument may constitute an easy access reference for nurses, providing wound care based on evidence and a unified nursing language.

Nursing care; Palliative care; Nursing diagnosis; Wounds and injuries; Nursing process; Patient care bundles

Physiological needs
Subgroup	ICNP® Diagnosis
Perception of sensory organs	Wound pain
	Cancer pain
	Nausea
	Foul odor
	Itching
Oxygenation	Upper airway obstruction risk
Vascular regulation	Bleeding
	Bleeding risk
	Hemorrhage
	Hemorrhagic risk
Hydration	Peripheral edema
Feeding	Impaired appetite
	Malignant wound
	Maceration of the skin surrounding the wound
Physical integrity	Risk of maceration of the skin surrounding the wound
Physical activity	Fatigue
	Impaired mobility
Body care	Impaired ability to perform hygiene
Physical security / Environment	Infection
	Infection risk
	Septic shock
	Wound with secretion
	Tumor wound infestation by fly larvae
Sexuality	Sexual behavior impaired
Regulation: cell growth	Healing
	Impaired Wound
	Necrosis
Sleep and rest	Impaired Sleep
Therapeutics	Complex Care Provider Role
	Caregiver Stress Risk

Psychosocial needs
Subgroup	ICNP® Diagnosis

Leisure	Social isolation
	Impaired socialization
Emotional security	Anxiety
	Low confidence
	Fear
	Anger
Love and acceptance	Stigma
	Lack of social support
	Impaired family relationship
Self-esteem, self-confidence and self-respect	Low self-esteem
	Negative Self-Concept
	Impaired Coping Process
	Depression
	Hopelessness
	Disturbed body image
	Suffering
	Impaired Psychological condition
	Shame
Liberty and participation	Helplessness
Health education/learning	Health Knowledge Deficit
Autorrealização	Impotence

Psycho-spiritual needs
Subgroup	ICNP® Diagnosis

Religiosity/Spirituality	Spiritual Distress

ICNP® Nursing interventions for the diagnosis, “foul odor”
1- Apply wound dressing.
2- Do debridement.
3- Assess the need for debridement surgery.
4- Gently rub the wound with gauze dressing and saline.
5- Gently rub the wound with gauze dressing and solution to clean.
6- Irrigate the wound with saline solution in syringe with needle.
7- Authorize bathing the wound in the shower.
8- Apply topical antibiotic therapy.
9- Apply occlusive dressing wound.
10- Guide the wound exchange dressing every day.
11 - Instruct on wound care.
12- Manage the control of the foul odor at the wound site.
13- Implement aromatherapy at the wound site.
14- Encourage ability to perform hygiene.
15- Guide patient and family about the disposal of bandages after changing.
16- Instruct on odor control at home.
17- Ventilate the house when changing the dressing.
18- Evaluate the need to administer antibiotics.
19- Avoid demonstrating discomfort with the foul odor.
20- Provide instructional material on control of the foul odor at the wound site.

ICNP® nursing interventions for the diagnoses: “Anxiety”, “Low Self-Esteem,” “ Negative Self-Concept “, “Low Confidence”, “ Impaired Coping process”, “Depression”, “Helplessness”, “Hopeless”, “Stigma” “Lack of Social Support”, “Disturbed Body Image “, “Impotence”, “Fear”, “Anger”, “Impaired Socialization”, “Suffering”, “Impaired Psychological Condition” and “Shame”

1- Protect the patient’s autonomy.
2- Engage the patient in the decision-making process.
3- Develop ability to communicate with the patient.
4- Develop ability to communicate with family members.
5- Explain about the wound.
6- Refer to social services.
7- Refer for support group therapy.
8- Guide in relaxation technique.
9- Guide in music therapy.
10- Assess social support.
11- Promote social support.
12- Wound care.
13- Teach about the wound care.
14- Assess the psychosocial response to the instruction on the wound.
15- Provide emotional support.
16- Assess exhaustion.
17- Palliate.
18- Advise on hope.
19- Assess fear.
20- Assess self-image.
21- Assess psychological well-being.
22- Assess coping capacity.
23- Assess depression.
24- Assess expectations.
25- Advise on fear.
26- Assess suffering.
27- Assess stigma.
28- Teach adaptation techniques.
29- Identify psychosocial status.
30- Maintain dignity and privacy.
31- Promote self-esteem.
32- Promote social welfare.
33- Promote hope.
34- Reinforce personal identity.
35- Encourage socialization.

ICNP® nursing interventions for the diagnosis, “Wound with secretion”

1- Apply wound dressing.
2- Apply a drainage bag.
3- Maintain integrity of skin proximal to the wound site.
4- Apply topical antibiotic therapy.
5- Clean the wound with appropriate solution.
6- Manage control of secretion at the wound site.
7- Assess the need to administer antibiotics.
8- Instruct on wound care.

Nursing interventions for the diagnosis, “Bleeding”

1- Prevent bleeding at the wound site.
2- Apply a non-adherent wound dressing.
3- Compress with wound dressing.
4- Press the wound site.
5- Apply hemostatic agent at the wound site.
6- Apply cold compress on the wound.
7- Apply cold saline in the wound.
8- Implement care technique with malignant wound.
9- Instruct about wound care.
10- Instruct the patient how to prevent bleeding at the wound site.
11- Instruct family on how to prevent bleeding at the wound site.
12- Instruct the patient to control bleeding at the wound site.
13- Instruct the family to control bleeding at the wound site.
14- Provide instructional material on bleeding control at the wound site.
15- Plan action for bleeding at the wound site.
16- Assess the need for blood therapy.
17- Refer to the physician.
18- Refer to emergency service.

Nursing interventions for the diagnosis, “Wound pain”

1- Administer pain medication before caring for the wound.
2- Care for the malignant wound.
3- Moisturize the gauze dressing with saline before removal.
4- Clean the wound with saline solution in syringe with needle.
5- Use saline solution at a comfortable temperature for the patient.
6- Keep the wound moist.
7- Assessing the need for pain medication at the wound site.
8- Apply cold compress pad to the wound site.
9- Maintain the integrity of skin proximal to the wound site.
10- Treat condition of skin proximal to the wound site.
11- Control foul odor in the wound.
12- Assessing infection at the wound site.
13- Avoid handling wound if not necessary.
14- Teach about wound care.
15- Assess pain when changing wound dressing.
16- Provide instructional material for pain control at the wound site.

Nursing interventions for the diagnosis, “Cancer pain”

1- Evaluate the pain.
2- Evaluate the need for pain medication.
3- Assess response to pain management.
4- Guide the patient about pain management.
5- Guide patient-controlled analgesia use.
6- Guide the family about pain management.
7- Promote the use of devices to aid memory.
8- Assess adherence.
9- Encourage family and patient participation in pain control.
10- Guide relaxation technique.
11- Guide music therapy.
12- Refer for physiotherapy.
13- Report to physician about pain control.
14- Provide instructional material on pain control. To be continued

Nursing interventions for the diagnosis, “Infection” Continuation

1- Apply wound dressing.
2- Implement aseptic technique when caring for malignant wound.
3- Apply topical therapy with appropriate solution.
4- Perform debridement.
5- Apply topical antibiotic therapy in wound.
6- Assess the susceptibility for wound infection.
7- Assess the need to administer antibiotics.

Nursing interventions for the diagnosis, “Necrosis”

1- Assess the need for debridement.
2- Perform debridement.
3- Apply wound dressing.
4- Assess the need to administer antibiotics.

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Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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ICNP® terminological subgroup for palliative care patients with malignant tumor wounds

Abstract

ICNP^® terminological subgroup for palliative care patients with malignant tumor wounds