Construction of nursing diagnoses for people with spinal cord injury in rehabilitation

Clares, Jorge Wilker Bezerra; Guedes, Maria Vilaní Cavalcante; Freitas, Maria Célia de

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Revista da Escola de Enfermagem da USP

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Original Article • Rev. esc. enferm. USP 55 • 2021 • https://doi.org/10.1590/S1980-220X2020038403750 copy

Construction of nursing diagnoses for people with spinal cord injury in rehabilitation

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To construct nursing diagnosis statements of the International Classification for Nursing Practice (ICNP^®) for the spinal cord rehabilitation specialty based on the Callista Roy Adaptation Model.

Method:

Descriptive study developed in sequential steps of identification and cross-mapping of terms relevant to care with the health priority, construction and cross-mapping of nursing diagnosis statements based on the ICNP^®, and categorization of diagnoses according to adaptive modes.

Results:

Ninety-two statements of nursing diagnoses were developed, of which 66 were classified in the Physiological Mode, 12 in Functional Role Mode, 10 in Self-Concept Mode and four in Interdependence Mode.

Conclusion:

The nursing diagnoses developed portray focuses of attention for nursing care to people with spinal cord injury in rehabilitation and contribute to the direction of nursing care actions in a systematic, individualized and resolutive way.

DESCRIPTORS
Nursing; Nursing Diagnosis; Terminology; Classification; Rehabilitation; Spinal Cord Injuries

	PHYSIOLOGICAL MODE
Oxigenation	Effective breathing; Impaired breathing; Risk of impaired respiratory system function.
Nutrition	Improved fluid intake; Impaired fluid intake; Overweight; Underweight.
Elimination	Constipation, Bowel incontinence, Urinary incontinence, Stress incontinence of urine, Urge incontinence of urine, Impaired urination, Urinary retention, Risk for constipation; Risk for urinary retention.
Activity and rest	Impaired active range of motion; Musculoskeletal deformity present; Impaired self-feeding; Impaired self-toileting; Impaired ability to perform oral hygiene; Impaired ability to perform hygiene; Self-care deficit; Impaired ability to transfer to the wheelchair; Impaired ability to transfer to the bed; Impaired ability to transfer to the car; Impaired ability to overcome environmental barriers; Impaired ability to dress and undress lower body; Impaired ability to dress and undress upper body; Impaired walking; Impaired wheelchair mobility; Impaired mobility in bed; Risk for musculoskeletal deformity.
Protection	Fever; Impaired hygiene; Postural hypotension; Urinary infection; Pressure ulcer (specify stage and location); Fall-relate injury (specify location); Transfer injury (specify location); Thermal injury (specify location); Altered blood pressure; Fall; Risk for complications related to the use of orthoses; Risk for fracture; Risk for infection (specify); Risk for urinary infection; Risk for diaper rash; Risk for pressure ulcer; Risk for fall-related injury; Risk for transfer injury; Risk for falls; Risk for trauma; Risk for deep vein thrombosis.
Senses	Acute pain (specify intensity and location); Chronic pain (specify intensity and location); Musculoskeletal pain (specify intensity and location); Neuropathic pain (specify intensity and location); Sensory absence (specify location); Sensory deficit (specify type and location); Impaired vision.
Fluids and electrolites	Peripheral edema (specify degree and location).
Neurological function	Communication barrier, Autonomic dysreflexia, Spasticity (specify intensity and location); Risk for autonomic dysreflexia.

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Jorge Wilker Bezerra Clares, Universidade Estadual do Ceará, Programa de Pós-Graduação Cuidados Clínicos em Enfermagem e Saúde Av. Dr. Silas Munguba, 1700, Campus do Itaperi CEP 60714-903 – Fortaleza, CE, Brazil. jorgewilker_clares@yahoo.com.br