Relationships between nursing diagnoses and the level of dependence in activities of daily living of elderly residents

Dias, Karina Mello; Herdman, Tracy Heather; Ferretti-Rebustini, Renata Eloah de Lucena; Lopes, Camila Takao; Santos, Eduarda Ribeiro dos

doi:10.31744/einstein_journal/2020AO5445

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Original Article • Einstein (São Paulo) 18 • 2020 • https://doi.org/10.31744/einstein_journal/2020AO5445 copy

Relationships between nursing diagnoses and the level of dependence in activities of daily living of elderly residents

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To identify and validate nursing diagnoses of elderly residents, and determine their relationship with the level of dependence in activities of daily living.

Methods:

One hundred thirty-five older adults were assessed using medical history and physical examination. Twelve validated gerontological instruments were administered to assess delirium, nutritional status, risk for falls, risk for pressure injury, dementia, cognitive losses, depression, and level of dependence in daily living and instrumental activities of daily living. Nursing diagnoses were identified and validated by experienced, doctorally-prepared nurses. The association between the presence of a nursing diagnosis and the level of dependence was assessed by a test for trend in proportions. The Kruskal-Wallis hypothesis test was used to investigate the association between the number of nursing diagnoses and the level of dependence of the elderly.

Results:

Most older adults were at risk for malnutrition, at high risk for falls, cognitively impaired, totally dependent for daily living and activities of daily living. In addition, they had very mild dementia and most did not have risk for pressure injuries. Depression was noted among those with dementia, but was absent in those without dementia. A total of 52 nursing diagnoses were validated. Of these, 11 were associated with the level of dependence in daily living.

Conclusion:

These results can be reproduced in other skilled nursing facilities for older adults, and these may allow the planning of interventions to alleviate etiologies and signs/symptoms of nursing diagnoses, rather than simply directing care toward a general category of dependence. Therefore, guaranteeing individualized nursing care to meet the specific needs of each resident.

Keywords:
Aged; Geriatric nursing; Homes for the aged; Nursing diagnosis; Nursing processes

Scale Name	Focus of assessment	Who conducted assessment	From whom data was obtained	Characteristics considered	Scoring
Confusion Assessment Method for Intensive Care Unit⁽⁷7. Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the portuguese version of the confusion assessment method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59(2 A):175-9.⁾	Delirium	Nurse researcher	Resident	1. Acute onset and fluctuating course of delirium symptoms 2. Inattention 3. Altered level of consciousness 4. Disorganized thinking	When features 1 and 2 are both present and either features 3 or 4 are present: Confusion Assessment Method for Intensive Care Unit is positive, delirium is present
Mini Nutritional Assessment^®(8)	Nutritional status	Nurse researcher	Resident	18 items encompassing anthropometry, dietary assessment, global clinical evaluation and self-perception of health and nutritional status	24-30 points: normal nutritional status 17-23.5 points: at risk of malnutrition 17 points: malnourished
Downton Fall Risk Index⁽⁹9. Downton J. Falls in the Elderly. Great Britain: Edward Arnold; 1993.⁾	Fall risk	Nurse researcher	Resident, medical records and family members	Past history of falls, medications, sensory deficits, mental state, and walking activities	Each factor can obtain a score of 1 point, with scores ≥3 identifying patients at risk
Braden scale⁽¹⁰10. de Souza DM, Santos VL, Iri HK, Sadasue Oguri MY. Predictive validity of the Braden Scale for Pressure Ulcer Risk in elderly residents of long-term care facilities. Geriatr Nurs. 2010;31(2):95-104.⁾	Pressure injury risk	Nurse researcher	Resident	6 subscales, namely: sensory perception, activity, mobility, moisture, nutrition, friction or shear	Total score can vary from 6-23 points, and the patients are classified as follows: very high risk of pressure injury (≤9 points), high risk (10-12), moderate risk (13-14), low risk (15-18) and no risk (19-23)
Clinical Dementia Rating⁽¹¹11. Montaño MB, Ramos LR. Validity of the Portuguese version of Clinical Dementia Rating. Rev Saude Publica. 2005;39(6):912-7.⁾	Cognitive and functional performance in dementia	Researcher and a physician	Resident and/or family member	6 domains: memory, orientation, judgment & problem solving, community affairs, home & hobbies, and personal care	Five-point scale. An overall score is calculated through the use of an algorithm – 0: normal – 0.5: very mild dementia – 1: mild dementia – 2: moderate dementia – 3: severe dementia
Mini-Mental State Examination⁽¹²12. Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saude Publica. 2006;40(4):712-9.⁾	Cognitive impairment	Nurse researcher	Resident	30-point questionnaire grouped into 7 categories, each representing a different cognitive domain/function: orientation to time (5 points), orientation to place (5 points), registration of 3 words (3 points), attention and calculation (5 points), recall of 3 words (3 points), language (8 points) and visual construction (1 point)	The cutoff points for cognitive impairment vay according to the level of education: – 18: illiterate – 21: 1 to 3 years of education – 24: 4 to 7 years of education – 26: over 7 years of education
Semantic Verbal Fluency⁽¹³13. Rodrigues AB, Yamashita ÉT, Chiappetta AL. Teste de fluência verbal no adulto e no idoso: verificação da aprendizagem verbal. Rev CEFAC. 2008;10(4):443-51.⁾	Cognitive impairment	Nurse researcher	Resident	Tracks the storage capacity of the semantic memory system, the ability to retrieve information stored in memory, and the processing of executive functions. This test includes reporting as many animal names as possible within a 1-minute period, and assigns 1 point per animal named	Results are scored as follows: 9 points: illiterate; 12 points: 1 to 8 years of study; 13 points: 9 years or more of study.
Clock Drawing Test⁽¹⁴14. Atalaia-Silva KC, Lourenço RA. Translation, adaptation and construct validation of the Clock Test among elderly in Brazil. Rev Saude Publica. 2008;42(5):930-7⁾	Cognitive impairment	Nurse researcher	Resident	Residents were given a blank sheet of paper and a pen, and were then asked to follow the instructions: “First, draw a clock with all the numbers on it. Second, put hands on the clock to make it read 2:45”	10-6 points: drawing of clock face with circle and numbers is generally intact 5-1 point: drawing of clock face with circle and numbers is not intact Scores <6 are classified as cognitive impairment
Geriatric Depression Scale: Short Form⁽¹⁵15. Pereira KR. Adaptação transcultural e validação da Escala de Depressão Geriátrica GDS-15 [Dissertação]. Uberaba: Universidade Federal do Triângulo Mineiro; 2017.⁾	Depression in elderly without dementia	Nurse researcher	Resident	15-item scale, in which 10 items indicate the presence of depression when answered positively, whereas 5 items indicate depression when answered negatively	− 0-5: absence of depression – 6-10: mild depression – 9-11: moderate depression – 11-15: severe depression
Cornell Scale⁽¹⁶16. Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, Okamoto I, Caramelli P, Bertolucci PH, et al. Versão brasileira da escala cornell de depressão em demência (cornell depression scale in dementia). Arq Neuropsiquiatr. 2007;65(3 B):912-5.⁾	Depression in elderly with dementia	Nurse researcher	Caregiver interview	19 items, each of which is evaluated for severity, on a scale of 0-2: – 0: absent – 1: slight or intermittent – 2: severe	Total score ≤9 equates to absence of depression; 10-17 indicates probable depression; 18 correlates to depression
Katz Index⁽¹⁷17. Lino VT, Pereira SR, Camacho LA, Ribeiro Filho ST, Buksman S. Adaptação transcultural da Escala de Independência em Atividades da Vida Diária (Escala de Katz). Cad Saude Publica. 2008;24(1):103-12.⁾	Autonomy in ADL	Nurse researcher	Resident, medical records and family member	Assess by ranking adequacy of performance in bathing, dressing, toileting, transferring, continence, and feeding. In each activity, the residents were scored “yes” or “no” for independence	Classified as totally dependent when ≤2 yes scores were obtained; partially dependent (3 or 4 points); totally dependent (5 or 6 points)
Lawton & Brody Scale⁽¹⁸18. Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. RBPS. 2008;21(4):290-6.⁾	Independence in IADL	Nurse researcher	Resident and family member	8 domains: ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications and ability to handle finances	- Score of 0-1: total dependence – 2-3: severe dependence – 4-5: moderate dependence – 6-7: mild dependence – 8: independent

Variables		Mean±SD
Age (years old)		85.7±8.0
		n (%)
Gender
	Female	107 (79.3)
	Male	28 (20.7)
Religion: Judaism		135 (100.0)
Marital status
	Widow(er)	81 (60.0)
	Single	28 (20.7)
	Married	20 (14.8)
	Divorced	6 (4.4)
Occupation before living in the institution
	Housewife	59 (43.7)
	Tradesman/Tradewoman	30 (22.2)
	Teacher	9 (6.7)
	Secretary	9 (6.7)
	Other	28 (20.7)
Habits
	Smoking	3 (2.2)
	Alcohol use	2 (1.5)
	Use of sleeping pills	102 (75.6)
Feeding method
	Oral	126 (93.3)
	Gastrostomy	9 (6.7)
Food acceptance
	Good	109 (86.5)
	Fair	15 (11.9)
	Bad	2 (1.6)
Use of oral supplements		36 (26.7)
Visual deficit		102 (75.6)
Hearing loss		56 (41.5)
Speech impairment		4 (3.0)
Unsteady gait		103 (76.3)
Mobility device requirement
	Wheelchair	64 (45.9)
	None	34 (26.7)
	Walker	33 (24.4)
	Cane	4 (3.0)

Assessment		n (%)
Nutritional status according to the Mini Nutritional Assessment^® (n=135)
	Malnourished	25 (18.5)
	At risk of malnutrition	66 (48.9)
	Normal nutritional status	44 (32.6)
Risk for falls according to the Downton Fall Risk Index (n=135)
	High risk for falls	122 (90.4)
	Low risk for falls	13 (9.6)
Risk for pressure injury according to the Braden scale (n=135)
	High risk	19 (14.1)
	Moderate risk	17 (12.6)
	Low risk	26 (19.3)
	No risk	73 (54.1)
Level of dementia according to the Clinical Dementia Rating (n=135)
	Severe dementia	30 (22.2)
	Moderate	22 (16.3)
	Mild dementia	24 (17.8)
	Very mild dementia	31 (23.0)
	Normal	28 (20.7)
Cognitive status according to the Mini-Mental State Examination (n=135)
	Cognitive impairment	54 (40.0)
	No cognitive impairment	58 (23)
	Refused to respond	23 (17.0)
Cognitive status according to the Semantic Verbal Fluency test (n=135)
	Cognitive impairment	90 (66.7)
	No cognitive impairment	18 (27)
	Refused to respond	27 (20.0)
Cognitive status according to the Clock Drawing Test (n=135)
	Cognitive impairment	56 (41.5)
	No cognitive impairment	37 (42)
	Refused to respond	42 (31.1)
Depression according to the Cornell Scale (n=76)
	No depression	73 (96.1)
	Probable depression	3 (3.9)
Depression according to the Geriatric Depression Scale: Short Form (n=59)
	No depression	41 (69.5)
	Depression	16 (27.1)
	Severe depression	2 (3.4)
Level of dependence in activities of daily living according to the Katz Index (n=135)
	Total dependence	63 (46.7)
	Partial dependence	28 (20.7)
	Independent	44 (32.6)
Level of dependence in instrumental activities of daily living according to the Lawton & Brody Index (n=66)
	Total dependence	29 (43.9)
	Severe dependence	17 (25.8)
	Mild dependence	11 (16.7)
	Mild dependence	7 (10.6)
	Independent	2 (3.0)

Nursing diagnoses		Total (n=135)	Total dependence (n=63)	Partial dependence (n=28)	Independence (n=44)	p value
Nursing diagnoses		n (%)	n (%)	n (%)	n (%)	p value
Domain 1. Health promotion
	Frail elderly syndrome	105 (77.8)	63 (100.0)	26 (92.9)	16 (36.4)	<0.001
	Ineffective protection	8 (5.9)	2 (3.2)	2 (7.1)	4 (9.1)	0.195
	Risk-prone health behavior	6 (4.4)	0 (0.0)	2 (7.1)	4 (9.1)	0.021
	Ineffective health management	3 (2.2)	1 (1.6)	1 (3.6)	1 (2.3)	0.779
	Sedentary lifestyle	1 (0.7)	0 (00)	0 (0.0)	1 (2.3)
Domain 2. Nutrition
	Overweight	48 (35.6)	23 (36.5)	11 (39.3)	14 (31.8)	0.646
	Obesity	43 (31.9)	12 (19.0)	10 (35.7)	21 (47.7)	0.002
	Impaired swallowing	22 (16.3)	22 (34.9)	0 (0.0)	0 (0.0)	<0.001
	Risk for unstable blood glucose level	21 (15.6)	6 (9.5)	8 (28.6)	7 (15.9)	0.285
	Risk for overweight	8 (5.9)	5 (7.9)	1 (3.6)	2 (4.5)	0.437
	Imbalanced nutrition: less than body requirements	3 (2.2)	2 (3.2)	0 (0.0)	1 (2.3)	0.701
Domain 3. Elimination and exchange
	Risk for constipation	48 (35.6)	26 (41.3)	9 (32.1)	13 (29.5)	0.202
	Functional urinary incontinence	24 (17.8)	9 (14.3)	6 (21.4)	9 (20.5)	0.387
	Constipation	7 (5.2)	4 (6.3)	1 (3.6)	2 (4.5)	0.654
	Urge urinary incontinence	3 (2.2)	1 (1.6)	1 (3.6)	1 (2.3)	0.779
	Bowel incontinence	2 (1.5)	2 (3.2)	0 (0.0)	0 (0.0)
	Stress urinary incontinence	2 (1.5)	0 (0.0)	0 (0.0)	2 (4.5)
	Impaired urinary elimination	2 (1.5)	0 (0.0)	1 (3.6)	1 (2.3)	0.299
Domain 4. Activity/Rest
	Impaired physical mobility	15 (11.1)	1 (1.6)	1 (3.6)	13 (29.5)	<0.001
	Insomnia	10 (7.4)	8 (12.7)	0 (0.0)	2 (4.5)	0.086
	Risk for decreased cardiac output	3 (2.2)	1 (1.6)	0 (0.0)	2 (4.5)	0.345
	Risk for ineffective peripheral tissue perfusion	3 (2.2)	1 (1.6)	2 (7.1)	0 (0.0)	0.701
	Impaired sleep pattern	2 (1.5)	0 (0.0)	0 (0.0)	2 (4.5)
	Wandering	2 (1.5)	1 (1.6)	1 (3.6)	0 (0.0)	0.560
	Impaired bed mobility	1 (0.7)	1 (1.6)	0 (0.0)	0 (0.0)
	Ineffective peripheral tissue perfusion	1 (0.7)	0 (0.0)	1 (3.6)	0 (0.0)
Domain 5. Perception/cognition
	Impaired memory	5 (3.7)	0 (0.0)	0 (0.0)	5 (11.4)
	Impaired verbal communication	5 (3.7)	0 (0.0)	0 (0.0)	5 (11.4)
Domain 6. Self-perception
	Low situational self-esteem	1 (0.7)	1 (1.6)	0 (0.0)	0 (0.0)
Domain 7. Role relationship
	Dysfunctional family processes	17 (12.6)	3 (4.8)	7 (25.0)	7 (15.9)	0.059
	Interrupted family processes	5 (3.7)	1 (1.6)	0 (0.0)	4 (9.1)	0.055
	Caregiver role strain	3 (2.2)	0 (0.0)	0 (0.0)	3 (6.8)
	Impaired social interaction	1 (0.7)	0 (0.0)	0 (0.0)	1 (2.3)
Domain 9. Coping/stress tolerance
	Anxiety	6 (4.4)	3 (4.8)	1 (3.6)	2 (4.5)	0.941
	Chronic sadness	1 (0.7)	1 (1.6)	0 (0.0)	0 (0.0)
	Readiness for enhanced resilience	1 (0.7)	0 (0.0)	0 (0.0)	1 (2.3)
Domain 11. Safety/protection
	Risk for falls	134 (99.3)	62 (98.4)	28 (100.0)	44 (100.0)
	Risk for Impaired skin integrity	78 (57.8)	52 (82.5)	14 (50.0)	12 (27.3)	<0.001
	Risk for pressure ulcer	57 (42.2)	49 (77.8)	4 (14.3)	4 (9.1)	<0.001
	Risk for aspiration	39 (28.9)	36 (57.1)	3 (10.7)	0 (0.0)	<0.001
	Risk for Impaired tissue integrity	12 (8.9)	9 (14.3)	3 (10.7)	0 (0.0)	0.012
	Impaired skin integrity	10 (7.4)	3 (4.8)	3 (10.7)	4 (9.1)	0.368
	Risk for Infection	10 (7.4)	9 (14.3)	0 (0.0))	1 (2.3)	0.014
	Impaired tissue integrity	5 (3.7)	3 (4.8)	1 (3.6)	1 (2.3)	0.502
	Risk for Injury	3 (2.2)	3 (4.8)	0 (0.0)	0 (0.0)
	Risk for other-directed violence	3 (2.2)	1 (1.6)	1 (3.6)	1 (2.3)	0.779
	Risk for bleeding	1 (0.7)	0 (0.0)	0 (0.0)	1 (2.3)
	Risk for suicide	1 (0.7)	1 (1.6)	0 (0.0)	0 (0.0)
	Risk for self-mutilation	1 (0.7)	0 (0.0)	1 (3.6)	0 (0.0)
	Risk for impaired oral mucosa	1 (0.7)	1 (1.6)	0 (0.0)	0 (0.0)
Domain 12. Comfort
	Chronic pain	12 (8.9)	2 (3.2)	2 (7.1)	8 (18.2)	0.008
	Acute pain	1 (0.7)	0 (0.0)	0 (0.0)	1 (2.3)

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[1] Corresponding author: Eduarda Ribeiro dos Santos Avenida Albert Einstein, 627/701 – Morumbi Zip code: 05652-900 – São Paulo, SP, Brazil Phone: (55 11) 2151-1001 E-mail: eduarda.santos@einstein.br