Cross mapping between clinical indicators for assistance in intensive care and nursing interventions

Objective: Identify the main clinical indicators for assistance in the Intensive Care Unit (ICU) and map them in the nursing interventions described by the Nursing Interventions Classification (NIC). Methods: Integrative literature review study, followed by cross-mapping between clinical indicators for assistance in the ICU care and NIC nursing interventions and activities. Results: 36 articles were identified, which resulted in 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso tube / oroenteral and diarrhea the clinical indicators for as- sistance in the ICU the most prevalent. These were mapped in 12 Nursing Interventions Classification interventions and 130 nursing activities. Final considerations: It is concluded that the clinical indicators for ICU care associated with Nursing Interventions Classification are concrete data that assist intensive care nurses in their clinical practice. Descriptors: Signs and Symptoms; Intensive Care Units; Nursing Care; Health Status Indicators; Standardized Nursing Terminology. RESUMO Foram


INTRODUCTION
The Intensive Care Unit (ICU) is the hospitalization sector that has specialized equipment and technologies for maintaining vital functions, continuous monitoring and uninterrupted assistance from health professionals, in order to provide care to critical patients (1) . This type of patient is characterized by a serious or risky clinical situation and may present instability and imbalance in one or more systems of the body, which are identified through changes in signs and symptoms (2) .
The signs and symptoms are observable characteristics that reflect the health situation of an individual and are present in specific changes in the organism, directing the actions to be provided by the health team, thus being considered important clinical indicators for health care (2,3) . In nursing care, clinical indicators, also called "defining characteristics", support nursing diagnoses and guide interventions to be provided to critical patients (4) .
A survey carried out in the South of Brazil, considering the specificities of the ICU, aimed to identify the priority nursing diagnoses and outline a specific care plan to the real needs of patients with cardiovascular problems, by surveying the main signs and symptoms of this clientele. The authors concluded that nursing diagnoses based on signs and symptoms allow a prioritization of actions; hence, it is inferred that such diagnoses are also the basis for planning interventions (4) .
Nursing interventions are composed of a set of systematized and standardized actions and can be implemented by direct and indirect care (5) . However, initially, the nurse needs to identify and interpret the patient's clinical indicators, making an accurate diagnosis that will support the planning of these interventions according to the identified needs, ensuring a holistic and agile care (6)(7) .
Among the different taxonomies for nursing practice, the Nursing Interventions Classification (NIC) stands out, which is widely used in Brazil and worldwide. The NIC presents standardized language to describe the treatments performed by nurses, which allows the identification, organization and documentation of nursing actions, in addition to enabling the recognition of the main interventions prescribed to a group of patients (5) .
Several studies have evaluated and validated the applicability of NIC nursing interventions in different care settings. Examples: study carried out in the chemotherapy sector of a public hospital in São Paulo that validated 35 NIC interventions and 48 nursing activities (8) ; another research carried out in the surgical center of a public hospital in São Paulo concluded that the NIC is a sensitive tool to measure the nursing workload (9) ; in Spain, researchers identified the main nursing interventions and validated the time needed to perform them in the ICU, concluding that the NIC is a taxonomy appropriate to this reality (10) "given":"Mireia"},{"family ":"Mila-Villarroel", "given":"Raimon"}], "issued":{"date-parts": [["201 7",12]]}}}], "schema":"https://github.com/citation-style-language/ schema/raw/master/csl-citation.json"} .
However, there are still several places in which, although steps in the nursing process are used for the organization of care, standardized languages such as NIC are not yet used to name their actions. In this context, identifying the main clinical indicators for the care of a specific clientele, such as the ICU, and mapping them with the nursing interventions of the NIC can favor the systematization of health actions, considering the needs of the patient, in addition to assisting in the forecast and provision of human and material resources (5,9) .

OBJECTIVE
Identify the main clinical indicators for ICU care and map them in the nursing interventions described by the NIC.

METHODS
This is an integrative literature review study, followed by cross-mapping.
Literature review is a research method to synthesize previous studies, through a critical and methodological analysis divided into six phases: elaboration of the research question, sample selection, categorization of studies, critical analysis, interpretation of results and presentation of the review to in order to explain the investigated phenomena (11) .
To direct the review, the following research question was used: What are the main clinical indicators in the ICU that guide nursing interventions to critical patients? Clinical indicators, signs and symptoms as well as nursing care in the ICU were considered.
The sample included articles published in full, in the time frame from 2013 to 2018, in Portuguese, English and Spanish and that answered the research question. Contents of theses, dissertations, books, review articles and research carried out in the areas of pediatrics and neonatology were excluded.
Data collection was carried out independently and paired by two researchers in November 2018, with the aid of an instrument that contained the data identifying the article, method and results.
The databases accessed were Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Health Sciences Information Literature (LILACS) and Cummulative Index to Nursing and Allied Health Literature (CINAHL). The articles indexed in CINAHL were accessed through the CAPES portal; those published in LILACS were searched by the Virtual Health Library (VHL); and MEDLINE studies were researched through the VHL and PubMed. Thus, in Portuguese and Spanish, the Health Science Descriptors (DeCS) and, in English, the Medical Subject Headings (MeSH) were used, with the Boolean AND resource, which took place between the first, second, third and fourth descriptor: "signs and symptoms", "intensive care units", "nursing care" and "critical care".
The analysis and interpretation of the results were carried out in an organized and synthesized manner in a synoptic table with the following items: article number, year of publication, database and journals, methodology and clinical indicators for ICU care.
Clinical indicators were identified and selected in the item "Results" of the articles, being typed and stored in a Microsoft Office Excel ® 2013program spreadsheet. Then, cross-mapping was performed between the main clinical indicators for ICU care and the nursing interventions/ activities described in the NIC (5) .
Cross-mapping is a method of identifying terms that can be used, compared or understood from a standardized language. It allows comparing different nursing records to standardized nursing classifications (12) .
For cross-mapping, six rules were determined based on the characteristics of the data obtained and the classification used (13) , adapted from the Moorhead and Delaney (1997) and Lucena and Barros (2005) references: 1) select, at least, one NIC nursing intervention for each clinical indicator for ICU care found in the integrative review; 2) determine a keyword that clearly describes the clinical indicator that will assist in identifying the most appropriate NIC intervention; 3) select NIC interventions based on their similarity to the clinical indicator or its definition, according to the dictionaries of health care practices; 4) list the activities corresponding to the NIC interventions based on the similarity between these and the clinical indicator or the keyword and that describe the reality of nursing care practice in the ICU; 5) map the clinical indicator in different NIC interventions, when the actions and or results are different; 6) identify the clinical indicator that, for whatever reason, cannot be mapped.

RESULTS
Of the 1,084 articles found in the databases, 36 were selected to compose the integrative literature review, according to the flowchart described in Figure 1.
As for the databases, two (6%) of the studies were found in LILACS, 10 (28%) in CINAHL and 24 (66%) in MEDLINE. Among the journals, Intensive and Critical Care Nursing stood out, with six (25%) indexed surveys and the UFPE Online Journal of Nursing with four (17%). Of the 24 journals accessed in this review, 13 (54%) were specific to the nursing area.
Regarding the methodology, 35 (97%) articles had a quantitative approach. Nine (25%) articles were based on the cross-sectional method, seven (19%) in descriptive research, six (17%) in a cohort, five (14%) in observational studies, two (6%) in clinical trials, two (6%) in randomized research, and the other studies were based on quasi-experimental, documentary, methodological, exploratory and multicenter methods.
In this review, 285 clinical indicators for ICU care were identified, with a total of 141 different terms. The most common clinical indicators found in the 36 articles were: mechanical ventilation assistance (MVA) present in 17 (47%) articles; pain, in 10 (28%); sedation, in nine (25%); psychomotor agitation and delirium, in eight (22%); anxiety and altered heart rate, in seven (19%); and diet by naso / oroenteral tube as well as diarrhea, in six (16%) (Chart 1). After

DISCUSSION
This research promoted the identification of 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso/ oroenteral tube and diarrhea the most prevalent, which were mapped with similarities in 12 NIC interventions and 130 nursing activities.
Nursing interventions for critical patients in the ICU described in the literature predominantly involve actions aimed at physical and homeostatic functioning (5,10,(48)(49) , with few, if any, approaches to psychosocial needs, lifestyle and protection from harm. Thus, nursing interventions in the ICU were found in greater numbers in the "Physiological: Complex" domain, highlighting the "Class K -Respiratory Management" with two interventions and 37 mapped nursing activities, data corroborated by NIC studies (48)(49) .
Forty-eight clinical indicators for ICU care, identified in the review, were linked to Respiratory Management, in relation to which nursing interventions aim to promote airway permeability and gas exchange. Of these, 24 were specific for mechanical ventilatory assistance, and the main interventions mapped in the NIC for this indicator were: Artificial Airway Management, Mechanical Ventilation Management: Invasive (5) . -Monitor bowel movements including frequency, consistency, shape, volume, and color, as appropriate.
-Monitor for signs and symptoms of diarrhea, constipation, and impaction.

Class D: Nutrition Support
Clinical Indicators
-Apply anchoring substance to the skin and secure feeding tube with tape.
-Monitor for proper placement of the tube by inspecting oral cavity, checking for gastric residual, or listening while air is injected and withdrawn, according to agency protocol.
-Elevate head of the bed 30 to 45 degrees during feedings.
-Discontinue feeding 30 to 60 minutes before putting in a head down position. -Turn off the tube feeding one hour prior to a procedure or transport if the patient needs to be less than 30 degrees.
-Irrigate the tube every 4 to 6 hours as appropriate during continuous feedings and after every intermittent feeding.
-Use clean technique in administering tube feeding.
-Check gravity drip rate or pump rate every hour.
-Slow tube feeding rate and/or decrease strength to control diarrhea.
-Hold tube feedings if residual is greater than 150 cc or more than 110% to 120% of the hourly rate in adults.
-Keep cuff of endotracheal or tracheostomy tube inflated during feeding, as appropriate.

Nursing Interventions Activities
Pain Pain Management -1400 -Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors.
-Observe the nonverbal cues of discomfort, especially in those unable to communicate effectively.
-Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient's response to pain.
-Provide information about the pain, such as causes of the pain, how long it will last, and anticipated discomforts from procedures.
-Control environmental factors that may influence the patient's response to discomfort.
-Select and implement a variety of measures (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate.
-Provide the person optimal pain with prescribed analgesics.
-Assure pretreatment analgesia and/or nonpharmacologic strategies prior to painful procedures -Determine pain location, characteristics, quality, and severity before medicating patient.
-Check medical order for drug, dose and frequency of analgesic prescribed.
-Choose the appropriate analgesic or combination of analgesic when more than one is prescribed.
-Determine analgesic selection, based on the type and severity of pain.
-Determine the preferred analgesic, route of administration, and dosage to achieve optimal analgesia. -Choose the IV route, rather than IM, for frequent pain medication injections, when possible.
-Monitor vital signs before and after administering narcotic analgesic with first-time dose or if unusual signs are noted.
-Attend to comfort needs and other activities that assist relaxation to facilitate response to analgesia.
-Administer analgesics around the clock to prevent peaks and troughs of analgesia, especially with severe pain.
-Administer adjuvant analgesics and/or medications when needed to potentiate analgesia.
-Consider use of continuous infusion, either alone or in conjunction with bolus opioids, to maintain serum levels.
-Institute safety precautions for those receiving narcotic analgesic, as appropriate.
-Instruct to request PRN pain medication before the pain is severe.
-Evaluate the effectiveness of analgesics at regular frequent intervals after each administration, but, especially after the initial doses, also observing for any signs and symptoms of untoward effects.
-Document response to analgesic and any untoward effects.
-Evaluate and document level of sedation for patients receiving opioids.
-Implement actions to decrease untoward effects of analgesics.

Sedation
Sedation Management -2260 -Check for drug allergies.
-Instruct the patient and/or family about effects of sedation.
-Evaluate the patient's level of consciousness and protective reflexes before administering sedation.
-Administer medication as per physician's order or protocol, titrating carefully, according to patient's response.
-Monitor the patient's levels of consciousness and vital signs, oxygen saturation, and EKG, as per agency protocol.
-Monitor the patient for adverse effects of medication, including agitation, respiratory depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or exacerbation of a preexisting condition.

Nursing Interventions Activities
Mechanical ventilatory assistance Mechanical Ventilation Management: Invasive -3300 -Monitor for conditions indicating a need for ventilation support.
-Monitor for impending respiratory failure.
-Initiate setup and application of the ventilator.
-Ensure that ventilator alarms are on.
-Routinely monitor ventilator settings, including temperature and humidification of inspired air.
-Check all ventilation connections regularly.
-Monitor for factors that increase the patient/ventilator work of breathing (e.g., morbid obesity, pregnancy, biting ET).
-Monitor for symptoms that indicate increased work of breathing.
-Monitor the effectiveness of mechanical ventilation on patient's physiological and psychological state.
-Provide patient with a means for communication (e.g., paper nad pencil, alphabet board).
To be continued  -Monitor ventilator pressure readings, patient/ventilator synchronicity, and patient breath sounds.
-Perform suctioning based on presence of adventitious breath sounds and/or increased inspiratory pressure.
-Monitor pulmonary secretions for amount, color and consistency and regularly document findings.
-Monitor for mucosal damage to oral, nasal, tracheal or laryngeal tissue from pressure from artificial airway, high cuff pressure, or unplanned extubations.
-Use commercially tube holders rather than tape or strings to fixate artificial airways to prevent unplanned extubations.
-Position to facilitate ventilation/perfusion matching, as appropriate.
Artificial Airway Management -3180 -Provide an oropharyngeal airway or bite block to prevent biting on the endotracheal tube, as appropriate.
-Inflate endotracheal/tracheostomy cuff using minimum occlusive volume technique or minimal leak technique.
-Maintain inflation of the endotracheal/tracheostomy cuff at 15 to 25 mm Hg during mechanical ventilation and during and after feeding.
-Monitor cuff pressure every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and manometer.
-Check cuff pressure immediately after delivery of any general anesthesia or manipulation of endotracheal tube.
-Change the endotracheal tapes/ties every 24 hours, inspect the skin and oral mucosa, and reposition the endotracheal tube to the other side of the mouth.
-Loosen commercial endotracheal tube holders at least once a day, and provide skin care.
-Auscultate for presence of lung sounds bilaterally after insertion and after changing endotracheal/tracheostomy ties.
-Note the centimeter reference marking on endotracheal tube to monitor for possible displacement.
-Assist with chest x-ray examination, as needed, to monitor the position of tube.
-Minimize leverage and traction on the artificial airway by suspending ventilator tubing from overhead supports, using flexible catheter mounts and swivels, and supporting tubes during turning, suctioning, and ventilator disconnection and reconnection.
-Monitor for presence of crackles and rhonchi over large airways.
-Monitor secretions color, amount and consistency.
-Perform oral care, as needed.
-Monitor for decrease in exhale volume and increase in inspiratory pressure in patients receiving mechanical ventilation.
-Institute measures to prevent spontaneous decannulation (i.e., secure artificial airway with tapes or ties, administer sedation and muscle paralyzing agent, use arm restraints), as appropriate.
-Provide trachea care every 4 or 8 hours as appropriate: Clean inner cannula, clean and dry the area around the stoma, and change the tracheostomy tie.
-Inspect skin around the tracheal stoma for drainage, redness, irritation, and bleeding.
-Shield the tracheostomy from water.

Nursing Interventions Activities
Altered heart rate Hemodynamic Regulation -4150 -Perform a comprehensive appraisal of hemodynamic status (i.e., check blood pressure, heart rate, pulse, jugular venous pressure, central venous pressure, right and left atrial and ventricular pressures, and pulmonary artery pressure), as appropriate.
-Monitor and document blood pressure, heart rate, rhythm, and pulse.
-Monitor pacemaker function, if appropriate.
-Monitor the effects of medications.

Nursing Interventions Activities
Anxiety Anxiety Reduction -5820 -Use a calm, reassuring approach.
-Explain all procedures, including sensations likely to be experienced during the procedure.
-Stay with patient to promote safety and reduce fear.
-Encourage verbalization of feelings, perceptions, and fears.
-Identify when level of anxiety change.
-Help patient identify situations that precipitate anxiety.
-Administer medication to reduce anxiety, as appropriate.
-Assess for verbal and nonverbal signs of anxiety. -Acknowledge the patient's fears and feelings.

Domain 4 -Safety
-Allow the patient to maintain rituals that limit anxiety.
-Administer PRN medications for anxiety or agitation, but limit those with anticholinergic side effects.
-Reduce sedation in general, but do control pain with analgesics, as indicated.
-Remove stimuli, when possible, that create excessive sensory stimuli.
-Maintain a well-lit environment that reduces sharp contrasts and shadows.
-Maintain a hazard-free environment.
-Use physical restrictions, as needed.
-Inform patient of person, place, and time, as needed.
-Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation.
Despite the higher prevalence of nursing interventions in the NIC Physiological Complex domain, a significant number of interventions located in the Physiological Basic domain were also identified, which aims to support the individual's physical functioning. In this domain, the "Class B -Elimination Management" stood out, which aims to establish and maintain regular patterns of intestinal and urinary elimination and to control complications arising from altered patterns (5) .
Diarrhea was the most prevalent clinical indicator mapped in the Elimination Management intervention; is a symptom of severe gastrointestinal dysfunction in critically ill patients, associated with an increase in the malnutrition rate, in addition to predisposing to an increase in nursing workload and health costs (10,22) . In parallel, it is necessary to institute other interventions, such as Pressure Ulcer Prevention and Wound Care, since diarrhea is a risk factor for incontinence dermatitis and pressure injury (5,22,25,37,41) .
Regarding the Behavioral domain (which supports psychosocial functioning and facilitates changes in lifestyle) and the Safety domain (which aims to protect against harm), a nursing intervention was evidenced for each domain mapped to the clinical indicators of anxiety, psychomotor agitation and delirium. The intervention of the NIC mapped for anxiety was the Anxiety Reduction, whereas the intervention for psychomotor agitation and for delirium was the Delirium Management (5) .
In the ICU, the occurrence of anxiety, psychomotor agitation and delirium are frequent, as patients are constantly exposed to risk factors, such as invasive procedures, restricted mobilization, noisy unit, use of benzodiazepines and narcotics, changes in sleep pattern, changes electrolytic, among others (18)(19)26,36) . Therefore, it is essential to outline a care plan that favors the standardization of sleep and wakefulness, early mobilization, a pleasant environment and effective communication with the patient about the time, clinical condition and interventions to be performed by the health team (26,33,36) .

Study limitation
As for the limitations of this review, the authors delimited primary studies and restricted languages, that is, gray literature and articles in languages that did not meet the inclusion criteria were not included in the research.

Contributions to the field of nursing, health or public policy
It is necessary to recognize the pertinence in identifying the main clinical indicators for assistance of a certain population and, from these, elaborate care protocols through cross-mapping with the Nursing Classifications, in order to unify and standardize care. Thus, the results of this study serve as a tool for the development of nursing care protocols for critical patients in the ICU.

FINAL CONSIDERATIONS
It is concluded that the clinical indicators for ICU care are concrete data that help in identifying the clientele's care profile and, consequently, in the development of an appropriate intervention plan.
The cross-mapping process between these indicators and the NIC showed which interventions are related to them and pointed out a set of them to support care plans. Thus, it is also concluded that the NIC is a broad taxonomy that can assist intensive care nurses in their clinical practice.
Finally, it can be said that cross-mapping was effective in identifying the main nursing interventions in the ICU. However, new research can be carried out in order to identify and test interventions according to the needs of the assisted clientele, through studies with more robust designs.

FUNDING
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES) -Finance Code 001 in partnership with the Conselho Federal de Enfermagem.