ICNP® nursing diagnoses, outcomes and interventions for community elderly

Rev Bras Enferm. 2019;72(Suppl 2):191-8. http://dx.doi.org/10.1590/0034-7167-2018-0540 ABSTRACT Objective: To construct a nomenclature of nursing diagnoses, outcomes and interventions for elderly people under follow-up in the Family Health Strategy by using the International Classification for Nursing Practice and the theoretical reference of Virginia Henderson. Method: Methodological study developed according to guidelines of the International Council of Nurses. Results: A total of 127 concepts of nursing diagnoses/outcomes were constructed and distributed according to nursing care components in the subcategories of Biological/Physiological, Psychological, Social and Spiritual/Moral components. For these diagnoses, were proposed 551 nursing interventions. Conclusion: The concepts constructed may favor integral care for the elderly in the Family Health Strategy and the structuring of a terminological subset for this clientele. Descriptors: Aged; Terminology; Classification; Nursing; Family Health Strategy.


INTRODUCTION
The rapid and intense growth of the number of elderly people, especially in developing countries such as Brazil, has stimulated discussions about the need to expand access to health services and equipment for this population, in view of their greater vulnerability to diseases and disabilities (1) .Actions in the Family Health Strategy (FHS) can be reoriented towards the elderly's health needs, and contextualized with the reality experienced by the population in the family and community, thereby resulting in integral health care (2) .
Nurses play an important role in caring for the elderly in the FHS.This activity must be accomplished by adopting the Nursing Process, which is the main methodological instrument for the systematic performance of nurses' professional practice.Its use in clinical practice enables the application of Nursing theoretical foundations, the organization and orientation of individualized, personalized and humanized care (3) .
Nurses have several conceptual models for the operationalization of the Nursing Process in the development of scientific knowledge based actions.Among them, the Nursing Care Model (NCM) presented by Virginia Henderson emphasizes the use of scientific knowledge for problem solving in professional practice with actions based on integral and individualized care.According to the theory, every person is a unique and complex being with fundamental needs expressed in the biological/physiological, psychological, social and spiritual/moral components.These are common needs to any human being, and even though they do not represent health problems, they can be problematic areas.Hence, they are also the focus of nursing practice, where the purpose is to maintain or recover the autonomy and independence of subjects as quickly as possible (4) .
The use of the Nursing Process favored the establishment of nursing classification systems, among which, the International Classification for Nursing Practice (ICNP ® ).This classification brings together the terms and concepts of professional practice, enables clinical reasoning and documentation of nursing records.In addition, it favors the development of terminological subsets, which are groupings of concepts of nursing diagnosis, outcomes and interventions directed to specific areas of nursing care.The subsets allow a unified professional language and the evaluation of elements describing its practice (5) .
Using the scientifically-based Nursing Process with a standardized language leads to a reflective performance, better care provision, broadens professional autonomy, and facilitates the communicative process among nursing professionals and with other health team professionals.In an integrative review, it was found that FHS nursing practices are usually developed in an unsystematic way and/or do not follow a guiding theory, which makes continuity of care actions for the elderly and their family difficult.The authors emphasized the need for studies addressing systematized nursing care for the elderly based on Nursing theoretical and methodological frameworks (6) .
The aim of the present study is to fill these gaps in compliance with international recommendations for the development of ICNP ® terminological subsets (7) .Proposing a technological instrument that facilitates the systematized nursing practice supported by an appropriate theoretical framework to the context of care, clinical reasoning and standardized nursing vocabulary, will contribute to professional recognition resulting from the registration and quality of care in the FHS nursing practice.

OBJECTIVE
To develop a nomenclature of nursing diagnoses, outcomes and interventions for elderly people in follow-up in the FHS by using the ICNP ® and the theoretical reference of Virginia Henderson.

Ethical aspects
The study was approved by the Research Ethics Committee of the Universidade Estadual do Ceará.All participants signed the Informed Consent form (IC).

Design, place of study and period
Methodological study resulting from a Master's thesis developed in the Postgraduate Program in Nursing and Health Clinical Care of the Universidade Estadual do Ceará, in 2014.The study was developed in sequenced steps by adopting the guidelines of the International Council of Nurses (ICN) for the development of terminological subsets (7)(8) , namely: 1) identification and validation of relevant terms for the health priority and clients elected; 2) cross-mapping of terms identified with terms of the ICNP ® Version 2013; 3) development of concepts of nursing diagnoses, outcomes and interventions based on the validated terms and in Henderson's NCM.

Criteria for the inclusion of specialists
For the content validation of relevant terms to the chosen priority, was selected a group of experts through advanced search in the Lattes Platform of the National Council of Scientific and Technological Development (CNPq) website.Nurses elected as specialists should hold at least a Master's degree, work with the Nursing Process and the ICNP ® focused on the elderly population served in Primary Health Care, care, teaching and/or research.Out of the 15 nurses who met the inclusion criteria, only five accepted to participate in the study.They returned the completed form, signed the IC form and composed the final sample.

Study protocol
In the first stage, were analyzed the official documents on elderly people published in Brazil (9)(10)(11)(12)(13) in order to identify the clinically and culturally relevant terms for the FHS nursing practice.These documents were read in full for extracting the terms, which were decomposed in simple terms (nouns, verbs, adverbs and adjectives) that generated a list of 880 terms.Next, the terms related to medical procedures, diseases and medicines were excluded, and was formed a list of 616 terms.These underwent a normalization and standardization process with removal of duplicates, graphic corrections and gender and number adjustments, thereby reaching the total of 373 terms.
The relevant terms were included in a form and underwent content validation by a group of experts selected according to the previously mentioned inclusion criteria and by considering the literature recommendations (14) .Participants completed the validation instrument and indicated agreement or disagreement with the relevance of terms identified for clinical nursing practice with elderly people under follow-up in the FHS.In the end, there was space for comments and suggestions.
Then, was calculated the Concordance Index (CI) among participants for each term through the formula: CI = CN/(CN+DN), where CN = concordance number and DN = discordance number (15) .Terms with a CI ≥ 0.80 were considered valid (16) , and 332 terms were validated.Unvalidated terms belonged to components of the body system and were included in more comprehensive terms.No further rounds of evaluation were required.
In the second step, validated terms were imported into Microsoft Office Access ® spreadsheets, and was performed the cross-mapping process with terms of the Seven Axis Model, ICNP ® Version 2013 (17) .As a result of this process, were obtained 271 constant terms and 61 terms not included in this terminology, which were grouped in alphabetical order, and formed the bank of terms of this study.
In the third step, were developed the concepts of nursing diagnosis, outcomes and interventions from the developed and validated terms in the previous steps and guidelines of the ICN embodied in the ISO 18104.In the development of concepts of nursing diagnoses/outcomes, were included a term of the Focus axis and a term of the Judgment axis, as well as additional terms of other axes, as necessary.In the development of concepts of interventions, was used a term of the Action axis and a Target term.The latter was any term of the other axes, except for the Judgment axis.Additional terms could be included, if necessary (17) .

Analysis of results
The concepts of nursing diagnosis/outcomes and interventions were organized in charts in alphabetical order, and categorized according to Henderson's NCM.
The results were discussed based on the theoretical framework adopted and the relevant literature.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.

A
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.
To be continued

DISCUSSION
In the present study, the expression nursing diagnosis/outcome was used for these two phenomena of professional practice.The difference between them is nurses' evaluation by considering that diagnosis is a decision regarding the clients' condition, problems and/or needs, and the outcome is the response obtained after implementing the interventions (13) .Its use in clinical practice will not replace the nurses' rationale and decision-making process, through which they judge the answers classified as nursing diagnoses and outcomes (7) .
Most concepts of nursing diagnoses/outcomes were related to the Biological/Physiological Components, according to Henderson's NCM.They were expressed in care demands derived from biofunctional changes inherent in the aging process that predispose the elderly to dependence and illness.These findings were already predicted, since in the theoretical model adopted, this component includes the greatest number of essential needs for maintaining a person's health and life, and they influence the satisfaction of other needs (4) .Similar results were found in a study with the objective of constructing statements of nursing diagnoses of the ICNP ® based on the Life Model.Among these statements, 54.3% were classified in the biological factors influencing the life activities of elderly subjects in Primary Health Care (18) .
The aging process is determined by biological, physiological, and anatomical changes that lead to greater limitations for performing individual bodily functions.They can also lead to adaptive difficulties, illness, and require health professionals' knowledge, especially from nurses, for performing actions for prevention of dependence and disability, and health promotion (19) .
Understanding the aging process beyond biophysiological aspects is critical.Care to the elderly must be focused on the real needs of this population and consider the biopsychosocial and spiritual aspects of aging in an integral approach (18) .According to the theoretical framework used in the present study, all fundamental needs are interdependent, interrelated and part of an indivisible whole in the constitution of human beings.Every need contains psychological, social, and cultural components, even those that seem only biophysiological at first glance.The satisfaction of these needs is different for each person and varies according to psychological, sociocultural and spiritual factors and the individual perception of health and illness (4) .The psychological, social and spiritual/moral components also supported the construction of the nomenclature of nursing diagnoses, outcomes and interventions, and their inclusion was appreciated in the care plan of elderly subjects.
In this nomenclature, nursing intervention proposals were developed according to diagnostic concepts.There was an expressive number of interventions linked to educational practices for the elderly's health promotion.This result is in line with the theoretical framework adopted (4) and the Primary Health Care model (20) , where individuals' empowerment is prioritized in health promotion for their greater control over how to maintain, improve or recover their health.Making human needs the foundation of nursing care can be a guide for FHS nurses in the health promotion of the population fin order to meet their basic needs and transmit information for behavior change, adoption of healthy lifestyles or health recovery.
Health promotion has been used as an alternative for the development of healthy changes and practices for individuals and collectivities.It enables a greater quality of health and life of the population, reduces vulnerabilities, and provides an understanding of the health-disease process as a social production (21) .The main purpose of health promotion actions for the elderly is to maintain a healthy and active life in their environment with autonomy and physical, psychic and social independence.In order that actions achieve the desired results, nurses must bond with the elderly, family and community, guarantee the provision of guidelines for the health-disease process, and the necessary resources to facilitate and implement learning.Individuals' autonomy is paramount in this co-participatory relationship, since it allows their integration into society and transforms elderly subjects into the main agents of their health-illness-care process, which corroborates the principles of gerontological care (18,22) .
The use of the nomenclature of nursing diagnoses, outcomes and interventions based on the theoretical assumptions of Henderson is an instrument that facilitates health promotion, humanization of care and the quality of professional practice.It enables the provision of elderly centered care by considering the values, interests and desires of the individual, family and community in the planning and implementation of clinical nursing practice.
The provision of systematized care for the elderly in the FHS is a huge challenge and responsibility for nurses.The process demands technical-scientific knowledge and reflection on professionals' own conceptions about the aging process and clinical practice with the objective of improving care strategies that mobilize responses to meet the specific needs of this group.Successful results obtained with implementation of the vocabulary inventory of the International Classification of Public Health Nursing Practices (Portuguese acronym: CIPESC ® ) in Primary Health Care units of Curitiba-PR prove and reinforce the possibility of using the Nursing Process and a standardized language based on theoretical references to systematize the clinical nursing practice.Consequently, it will increase the visibility of professionals at this level of health care to the population (23) .

Limitations of the study
As the concepts of nursing diagnosis/outcomes and interventions constructed in this study were not validated by specialists, other studies should be conducted for their content validation.Clinical validation should also be done through clinical case studies with elderly people in follow-up with FHS teams at home and in primary health care units with the objective to check its applicability.

Contributions to the area of nursing
The application of the results of this study in clinical practice will contribute to the implementation of the Nursing Process, the use of ICNP ® by FHS nurses, and the development of care actions based on scientific knowledge and standardized language, which will result in an individualized, humanized and resolutive care to the elderly.
Other contributions to the clinical nursing practice will be: identification of the specialized and peculiar language used by nurses in the clinical care to elderly people in the FHS; record of care actions performed, which facilitates the communicative process among nurses and other multiprofessional team members; possibility of including new terms and concepts in the ICNP ® , thereby contributing to its continuous development and improvement; greater visibility, recognition and professional autonomy; scientific, technological and innovative advances in Nursing.

CONCLUSION
The use of INCP ® terminology in this study for developing concepts of nursing diagnoses, outcomes and interventions has favored the specification of professional practice concepts in elderly care in the FHS, subsidized the operationalization of the Nursing Process at this level of care and generated information and knowledge to improve the quality of care, teaching and research.
The concepts of nursing diagnoses/outcomes and interventions contemplated do not finish the domain of this health priority.Other studies should be conducted in order to structure the ICNP ® terminology subset for elderly care in the FHS with attention to the importance of studies on nurses' role based on the scientific method and a standardized language.

BIOLOGICAL/PHYSIOLOGICAL COMPONENTS Need to breathe:
For the concepts of constructed diagnoses, were proposed 515 nursing interventions by taking into account the ICN guidelines, the clinical judgment and experience of authors.Some examples of concepts of nursing diagnosis/outcomes and interventions are presented in Charts 2, 3, 4 and 5 given the limited space in the article.Distribution of concepts of nursing diagnoses/outcomes for elderly subjects according to the nursing care components, Fortaleza, Ceará, Brazil, 2014 Improved breathing; Impaired breathing; Dry cough; Productive cough; Use of tobacco.

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 get distracted:
Deficient leisure activities; Ability to perform leisure activity effectively; Impaired ability to perform leisure activity; Improved disposition for leisure activity.

Chart 5 -
Examples of concepts of nursing diagnosis/outcomes and interventions for elderly subjects according to Spiritual/Moral Components, Fortaleza, Ceará, Brazil, 2014 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.