Diagnósticos, resultados e intervenciones de enfermería de la CIPE <sup>®</sup> para ancianos comunitarios

Clares, Jorge Wilker Bezerra; Nóbrega, Maria Miriam Lima da; Guedes, Maria Vilaní Cavalcante; Silva, Lúcia de Fátima da; Freitas, Maria Célia de

doi:10.1590/0034-7167-2018-0540

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 72 (suppl 2) • Nov 2019 • https://doi.org/10.1590/0034-7167-2018-0540 copiar

Diagnósticos, resultados e intervenciones de enfermería de la CIPE ^® para ancianos comunitarios

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

Construir una nomenclatura de diagnósticos, resultados e intervenciones de enfermería para ancianos acompañados en la Estrategia Salud de la Familia, utilizando la Clasificación Internacional para la Práctica de Enfermería y el referencial teórico de Virginia Henderson.

Método:

Estudio metodológico desarrollado conforme a las directrices preconizadas por el Consejo Internacional de Enfermeros.

Resultados:

Se construyeron 127 conceptos de diagnósticos/resultados de enfermería, distribuidos según componentes de los cuidados de enfermería en las subcategorías de los Componentes Biológicos/Fisiológicos, Psicológicos, Sociales y Espirituales/Morales. Para estos diagnósticos se propusieron 551 intervenciones de enfermería.

Conclusión:

Los conceptos construidos pueden favorecer el cuidado integral a los ancianos en la Estrategia Salud de la Familia, y la estructuración de un subconjunto terminológico para esa clientela.

Descriptores:
Anciano; Terminología; Clasificación; Enfermería; Estrategia de Salud Familiar

BIOLOGICAL/PHYSIOLOGICAL COMPONENTS
Need to breathe: Improved breathing; Impaired breathing; Dry cough; Productive cough; Use of tobacco.
Need to eat and drink: Adherence to diet; Improved appetite; Ability to prepare food effectively; Ability to prepare food; Impaired swallowing; Impaired dentition; Lack of adherence to dietary regime; Proper hydration; Insufficient food intake; Impaired fluid intake; Appropriate body weight; Increased body weight; Decreased body weight.
Need to eliminate: Constipation; Diarrhea; Disposition for improved bowel elimination; Disposition for improved urinary elimination; Improved bowel elimination; Improved urinary elimination; Bowel incontinence; Urinary incontinence; Urge incontinence of urine; Urinary retention.
Need to sleep and rest: Fatigue; Improved sleep; Impaired sleep.
Need to move and maintain proper posture: Effective ability to transfer; Impaired ability to transfer; Effective ambulation; Impaired ambulation; Intolerance to physical activity; Impaired physical mobility.
Need to dress and undress: Ability to dress and undress effectively; Impaired ability to dress and undress; Ability to groom effectively; Impaired ability to groom.
Need to maintain normal body temperature: Fever; Hyperthermia; Hypothermia; Proper body temperature.
Need to stay clean, care and protect the skin: Ability to bathe effectively; Impaired ability to bathe; Ability to perform self-care effectively; Impaired ability to perform self-care; Ability to perform oral hygiene effectively; Impaired ability to perform oral hygiene; Peripheral edema; Improved peripheral edema; Impaired skin integrity; Impaired oral mucous; Skin integrity; Dry skin; Itching (specify location); Risk for pressure injury; Risk for impaired skin integrity; Pressure injury (specify stage and location).
Need to avoid dangers: Adherence to therapeutic regime; Anxiety (specify); Death-related anxiety; Low self-esteem; Acute confusion; Chronic confusion; Effective pain control; Ineffective pain control; Depression; Disposition for maintaining improved health; Acute pain (specify intensity and location); Chronic pain (specify intensity and location); Ineffective coping; Improved coping; Lack of adherence to therapeutic regime; Clear frailty; Hyperglycemia; Hypoglycemia; Intake of alcoholic beverage; Impaired health maintenance; Fear; Adequate blood pressure; Altered blood pressure; Fall; Risk for depression; Risk for frailty; Risk for drug intoxication; Risk for fall; Risk for caregiver burden; Risk for trauma; Risk for violence directed at third parties; Risk for disuse syndrome; Risk for domestic violence; Caregiver burden.
PSYCHOLOGICAL COMPONENTS
Need to communicate: Decreased hearing ability; Impaired verbal communication; Impaired sexual functioning; Disposition for improved communication; Impaired social interaction; Social isolation; Ineffective sexuality pattern; Impaired family process; Satisfactory family process; Risk for social isolation; Risk for loneliness; Altered sensitivity (specify location); Chronic sadness.
Need to learn: Poor caregiver knowledge about elderly care; Poor caregiver knowledge about therapeutic regime of the elderly; Poor knowledge about health status; Poor knowledge about therapeutic regime; Effective memory; Impaired memory.
SOCIAL COMPONENTS
Need to work and self-realization: Ineffective role performance; Impotence.
Need to get distracted: Deficient leisure activities; Ability to perform leisure activity effectively; Impaired ability to perform leisure activity; Improved disposition for leisure activity.
SPIRITUAL/MORAL COMPONENTS
Need to live according to beliefs and values: Spiritual distress; Conflicting religious belief; Hopelessness; Disposition for facilitating religious belief; Anticipatory grief process; Dysfunctional grief process; Suffering (specify).

Nursing diagnosis/outcome	Nursing interventions
Impaired ability to dress and undress	Evaluate the need for adaptation resources to dress and undress; Encourage the elderly's independence to dress and undress by respecting their limitations; Guide family members and caregivers about easy-to-wear clothing (prefer loose, button-down clothing); Perform clothing training with the elderly.
Constipation	Identify the causes of bowel constipation; Investigate the bowel habit of the elderly and characteristics of feces; Teach techniques for bowel management (abdominal massage, manual stool extraction, use of suppositories when necessary); Stimulate the adjustment of fluid intake by the elderly; Guide the selection of a high fiber diet.
Impaired dentition	Evaluate the elderly's oral cavity during nursing visits; Guidance on oral hygiene after meals and whenever necessary; Guidance on the correct technique of tooth brushing and/or hygiene of dental prostheses; Encourage regular follow-up with the dentist.
Lack of adherence to therapeutic regime	Assess barriers to adherence to therapeutic regime; Encourage adherence to therapeutic regime; Guidance on the benefits of therapeutic regime for the elderly's quality of life; Guide the elderly about health complications when they fail to follow the therapeutic regime.
Fever	Monitor the temperature curve; Guide the use of physical means for fever control; Encourage fluid intake; Administer antipyretic medication if necessary; Observe disorientation/confusion reactions.
Urinary incontinence	Investigate the causes of urinary incontinence; Stimulate adequate fluid intake; Investigate the use of medications that may contribute to incontinence (diuretics, antidepressants); Provide guidance regarding urination at scheduled intervals and respect the first desire to urinate; Orient the elderly and/or caregiver on the use of diapers and/or external collector at night; Provide guidance on strengthening exercises for pelvic floor muscles.
Risk for impaired skin integrity	Perform skin inspection during the nursing visit; Explain the damage of skin lesions to the elderly's quality of life; Guidance on skin care; Guidance on skin hydration.
Risk for fall	Track the risk for falls and other accidents at home; Encourage the use of resources that facilitate locomotion; Guidance on the type of appropriate footwear; Provide guidance for elderly subjects and/or family members on preventive measures of falls and adaptations at home.
Impaired sleep	Evaluate the habitual sleep pattern of the elderly; Advise the reduction of the intake of stimulant foods (caffeine, chocolate, carbonated drinks); Teach the elderly and/or family/caregiver about comfort measures and muscle relaxation techniques; Guidance on the importance to follow a sleep and rest routine; Plan the environmental organization by promoting comfort and providing adequate conditions to promote sleep.

Nursing diagnosis/outcomes	Nursing interventions
Poor knowledge about the therapeutic regime	Provide guidance on the therapeutic regime and its importance for health; Recommend regular follow-up in primary health care unit and/or available health services; Encourage the elderly to follow the guidelines at home; Encourage family involvement in the care plan.
Impaired memory	Evaluate the causes and degree of limitation of memory deficit; Apply the mini mental state examination during nursing consultations; Use a feedback technique to stimulate the memorization of guidelines given to elderly people; Teach the elderly about the memory training technique; Refer the elderly for psychological/cognitive assessment if necessary.
Ineffective sexuality pattern	Consider the importance of sexual activity for the elderly; Guidance on anatomy and the impact of aging on sexuality; Listen and appreciate the elderly 's feelings about the altered sexual pattern; Identify alternative acceptable forms of sexual expression to the elderly/partner; Develop strategies together with the elderly for coping with the situation.
Impaired family process	Evaluate the dynamics of family relationships/functioning; Help the family to identify and solve conflicting situations; Observe family communication patterns; Help the elderly to identify a network of supportive people and resources outside the family.
Risk for social isolation	Assess the risk for social isolation; Identify the support systems available for the elderly; Help the elderly to identify a network of supportive people and resources; Promote socialization; Encourage participation in leisure activities.
Changed sensitivity (specify location)	Evaluate the degree of limitation resulting from sensitivity changes (specify location); Explain about changes in sensory perception arising from the aging process; Listen and appreciate the elderly's feelings and expressions about sensorial alterations; Promote the elderly's sensorial stimulation.
Chronic sadness	Evaluate the factors causing/contributing to sadness; Stimulate the elderly to verbalize the situation; Listen and appreciate the elderly's feelings and concerns; Provide emotional and spiritual support to the elderly; Refer the elderly to psychology/psychiatry service, if necessary.

Nursing diagnosis/outcomes	Nursing interventions
Deficient leisure activities	Assess the factors causing/contributing to lack of interest in leisure/recreation activities; Encourage participation in leisure activities; Identify the elderly's favorite leisure activities; Encourage the elderly's participation in family gatherings that provide moments of joy/wellness; Guidance on the benefits of leisure for the quality of life; Guidance on family involvement in the planning of leisure/recreation activities for the elderly.
Ability to perform leisure activity effectively	Reinforce the benefits of leisure for the quality of life; Strengthen guidelines on family involvement in the planning of recreational/leisure activities for the elderly; Praise the elderly's performance when participating in leisure activities.
Impaired ability to perform leisure activity	Evaluate the causes of difficulty to perform leisure activities; Help the elderly in leisure activities by respecting their limitations; Guide the family involvement in the planning of leisure/recreation activities for the elderly.
Ineffective role performance	Determine the role of the elderly in the family; Help the elderly to develop strategies for dealing with changes of roles; Listen and appreciate the elderly's feelings and expressions about their current condition and change of roles; Identify and reinforce the strengths/personal abilities of the elderly; Encourage participation in domestic activities and/or reintegration into the labor market by respecting the elderly's limitations; Encourage participation in groups of support/vocational guidance.
Impotence	Investigate the factors causing/contributing to the feeling of impotence; Listen and appreciate the elderly's feelings and expressions about their current condition and future perspectives; Determine family relationship patterns and social behaviors; Identify and reinforce the strengths/personal abilities of the elderly; Promote the elderly's independence by respecting their limitations; Help the elderly to set realistic goals for the future.

Nursing diagnosis/outcome	Nursing interventions
Spiritual distress	Determine the factors causing/contributing to spiritual distress; Evaluate the religious/spiritual beliefs of the elderly; Listen and appreciate the elderly's feelings and opinions about their beliefs and values.
Hopelessness	Identify the factors causing/contributing to the feeling of hopelessness; Evaluate the level of hopelessness of the elderly; Provide emotional and spiritual support to the elderly; Encourage the elderly to develop and practice their spirituality/religiosity.
Disposition for facilitating religious belief	Encourage the elderly to maintain a facilitating religious belief; Strengthen participation in religious ceremonies; Encourage the caregiver/family member to stimulate the elderly's religious practice; Praise elderly subjects for exercising their religious practice.
Anticipatory grief process	Investigate the causes of anticipatory grief; Evaluate the impact of the elderly's subjective and previous experiences with death; Listen and appreciate the elderly's feelings and expressions about the feeling of anticipatory grief; Provide emotional and spiritual support to the elderly.
Dysfunctional grief process	Evaluate grief; Support the grieving process; Develop strategies to cope with grief together with the elderly; Provide emotional and spiritual support to the elderly; Help the elderly to identify a network of people and support resources; Refer the elderly to Psychology service if necessary.
Suffering (specify)	Investigate the causes of spiritual suffering in the elderly; Evaluate the elderly's spiritual beliefs; Determine the importance of spirituality in the elderly's life; Encourage the elderly to expand and practice their spirituality; Provide emotional and spiritual support to the elderly; Encourage participation in support groups.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding Author: Jorge Wilker Bezerra Clares E-mail: jorgewilker_clares@yahoo.com.br

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Diagnósticos, resultados e intervenciones de enfermería de la CIPE ® para ancianos comunitarios

RESUMEN

Objetivo:

Método:

Resultados:

Conclusión:

Diagnósticos, resultados e intervenciones de enfermería de la CIPE ^® para ancianos comunitarios