Application of anthropometric methods in the nursing process of nursing research.

OBJECTIVES
to identify anthropometric techniques and measurements related to nursing diagnoses and interventions, included in the NANDA International (NANDA-I) and Nursing Interventions Classification (NIC), respectively.


METHODS
descriptive study of the revision of the NANDA-I and NIC taxonomies by professors of Nursing of the Universidad Complutense de Madrid.


RESULTS
A total of 24 nursing diagnoses, 20 nursing interventions and 71 nursing activities were identified that require the use of anthropometric measurements.


CONCLUSIONS
anthropometric measurements are necessary in the conduct of numerous nursing diagnoses and nursing interventions that are commonly used in healthcare practice. It would be useful to systematize the use of anthropometric techniques in the application of the nursing process and to standardize this training process.


INTRODUCTION
The nursing process (or nursing methodology) consists of the application of the scientific method to the clinical practice of nursing. Alfaro Lefevre defines the nursing process as the systematic, humanistic and rational method for organizing and providing nursing care (1) .
This process is developed in five sequential phases (assessment, nursing diagnosis, planning, execution and evaluation), among which the nursing diagnosis stands out, which many authors consider the axis of the care plan (2) . NANDA International (NANDA-I) defines the nursing diagnosis as a clinical judgment about a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group or community (3) . A nursing diagnosis provides the basis for the selection of nursing interventions to achieve results for which the nurse is responsible (3) .
The use of the nursing process in general, and of the nursing diagnosis in particular, allows for differentiating the specific contributions of nurses from other professional actions (4) .
NANDA-I (3) , the Nursing Interventions Classification (NIC) (5) and the Nursing Outcomes Classification (NOC) (6) are standardized classifications of nursing diagnoses, nursing interventions and outcome criteria specific to nursing practice, respectively. The implementation of the three classification NNN interrelationships (nursing diagnosis, intervention and outcome classifications) in the electronic nursing documentation system helps nurses use the nursing process, contributes to improving diagnostic accuracy and facilitates the evaluation of the outcomes derived from the nursing intervention (7) .
Taxonomy II of NANDA-I provides a structure that classifies the 235 nursing diagnoses into seven domains and 47 classes (3) .
The nursing diagnoses approved by NANDA-I contain, in addition to the diagnostic label and its definition for all cases, the related factors and defining characteristics in the actual nursing diagnoses and the risk factors in the risk diagnoses.
The NIC (5) also consists of a structure of domains, classes and interventions. Each of the 550 interventions included in the classification has a title, definition, list of activities and bibliographic references. This structure favors the use of a standardized language in the process of making clinical and therapeutic decisions and facilitates the support of the process of documentation of professional practice (8) .
Anthropometry can be defined as the set of techniques that allows the characterization of human morphology, as well as body diversity, due to sexual, age or ethnic group differences. It also assesses the influence of the environment on body size and shape, including nutrition, health status and social or cultural customs (9) .
Specifically, the anthropometry of health analyzes the relationship between the morphological variability of the human being and the predisposition to contract diseases or suffer them directly. The most obvious example is the use of the waist-to-height ratio to determine cardiovascular risk.
The provision of nursing care and, by extension, the use of the nursing process requires numerous anthropometric techniques: direct measurements, such as weight, height and body fat percentage; and indirect measurements, of which the most commonly used is the body mass index (BMI). In addition, other indices, such as the waistheight index, are used to measure robustness and proportionality.
Neither the anthropometric techniques identified in the different stages of the nursing process nor the level of use of these techniques have been determined. It would be very useful to systematize their use and to identify in each case the most appropriate measure or anthropometric index for the nursing diagnosis or the most appropriate nursing intervention. In addition, objective data provided by anthropometric techniques may contribute to improving the validity and safety of nurses' determinations increasing diagnostic accuracy and facilitating the monitoring and evaluation of the whole nursing process.

OBJECTIVES
To identify anthropometric techniques and measurements related to nursing diagnoses and interventions, included in the NANDA-I and NIC classifications, respectively.

Ethical aspects
For the development of the research was considered an ethical structure to provide the information clearly and truthfully. Copyright of taxonomies NANDA and NIC taxonomies has been respected by incorporating the corresponding bibliographic references. None of the authors present a conflict of interest in the elaboration of the article.

Design, period and place of study
Descriptive study, carried out from January 2017 to January 2018 by professors of the Facultad de Enfermeria, Universidad Complutense de Madrid and consisted of the review of the NANDA-I 2015-2017 (3) and NIC 2012 (5) taxonomies.
The reference of the EQUATOR network used was STROBE for Observational studies.

Population or sample; criteria of inclusion and exclusion
The review of the NANDA-I 2015-2017 (3) and NIC 2012 (5) taxonomies, taking into account the following review criteria: All nursing diagnoses were analyzed by domains and classes, selecting those in which, for the identification of risk factors, related factors or defining characteristics, it is necessary to use anthropometric techniques. Likewise, the interventions and activities of the NIC classification related to the application of anthropometric techniques were reviewed.

Study protocol
The procedure to select the anthropometric techniques related to the nursing diagnoses and interventions was carried out in several phases: • Identification by all members of the work team of the anthropometric techniques used in the provision of nursing care. The techniques required were not the same for nursing diagnoses as for interventions and activities. This was done using a nominal group technique (10)(11) . Raising the initial question (what anthropometric techniques are required for nursing care?) each member of the research group (authors of Application of anthropometric methods in the nursing process of nursing research Fernández SD, León SG, Bazán MJA, Cerro JLP, Marques-Vieira CMA, Rivas FJP. of the article) wrote their proposal individually. The following step was compiled the proposals and displayed to the entire group. The various proposals were clarified and discussed by all the panelists. Finally, the consensus of the anthropometric techniques was established when at least 75 % of the panelists expressed their agreement with the proposal. • Comprehensive and independent review of the NANDA-I and NIC taxonomies by two members of the research team, establishing relationships with anthropometric techniques. • A third member reviewed the existing discrepancies, making an integrative proposal that was accepted by the entire team.

Analysis of results and statistics
The data collected were organized into spreadsheet using Microsoft Office Excel 2010. In-depth analysis of the NANDA-I nursing diagnosis classifications and NIC classification to identify those that require different anthropometric measurements. Descriptive statistics was used to describe and summarize the results found.

RESULTS
After an in-depth analysis of the NANDA-I nursing diagnosis classifications, a total of 24 nursing diagnoses (10.2%) (Chart 1) that require different anthropometric measurements were identified, either for the identification of related factors or risk factors or for the validation of the defining characteristics. Between two and seven anthropometric measurements are used per nursing diagnosis. The nursing diagnoses susceptible to the use of more anthropometric techniques were those related to mobility (Chart 1).
The anthropometric measurements that are required in the nursing diagnostic stage are weight, BMI, mid-upper arm circumference/arm circumference (MUAC/AC), body fat percentage, height-weight curves, height, waist circumference and muscle mass.
In relation to the nursing interventions of the NIC classification, a total of 20 nursing interventions (3.6%) were identified (Chart 2) in which different anthropometric measurements are required for its realization. In these interventions, between two and three measurements are used per intervention. The interventions requiring more anthropometric techniques were weight management and nutrition therapy, which both need three anthropometric measurements (Chart 2).
The anthropometric measurements that are required for performing the different nursing interventions are weight, ideal weight, body fat percentage, BMI, waist circumference and triceps skin fold thickness/MUAC.
A total of 71 nursing activities also require an anthropometric technique or measurement (Chart 3). 1. Encourage the patient to maintain caloric intake at a level that allows achieving the desired weight.
2. Focus the assistance and therapeutic objectives to allow the patient to continue controlling their weight, not smoking and to be as active as possible.

DISCUSSION
There are no previous studies that describe the application of anthropometric methods in the clinical practice of nursing. While we have identified several studies that relate methods of anthropometry and nutrition (12)(13)(14)(15)(16) there is no evidence on the existence of studies in anthropometry and nursing care.
The standards of a professional nursing practice, developed by scientific associations and international regulatory bodies, include the different stages of the nursing process as requirements set in their nursing practice standards (17)(18) . Likewise, in legislation both in Spain (19) and at the international level (20) , the nursing process is included as the main topic; in Spain, all the stages of the nursing process should be part of the minimum data included in the nursing care report.
To correctly apply the different stages of the nursing process, it is necessary to use various techniques and anthropometric measurements. If during the training process of nursing students the theoretical knowledge, skills and abilities related to anthropometry have not been acquired, errors can be made in the identification of the nursing diagnoses, interventions and activities to be developed, which would ultimately lead to providing inadequate care.
In the context of primary care, there is also agreement that many of the nursing diagnoses that nurses consider relevant require anthropometric measurements to identify the related factors or defining characteristics. In a study by Brito (21) , 10 of the 28 nursing diagnoses prioritized by a group of nurses in Spain required anthropometric techniques for their development: obesity (00232), overweight (00233), impaired skin integrity (00046), risk for falls (00155), impaired walking (00088), impaired physical mobility (00085), risk for injury (00035), sedentary lifestyle (00168), risk for overweight (00234) and fatigue (00093). Similarly, in a study by Besora et al. (22) , among the 36 nursing diagnoses prioritized by their frequency of use and relevance, there were seven that required anthropometric measurements. Additionally, in a study by Pérez et al. (4) , among the 10 most frequent nursing diagnoses in a health area, four required anthropometric measurements: impaired skin integrity (00046), imbalanced nutrition more than body requirements (00001), impaired tissue integrity (00044) and impaired physical mobility (00085).
Additionally, in the hospital environment, many authors have highlighted the need to use anthropometric measurements to identify various nursing diagnoses: imbalanced nutrition in patients with depression (23) ; impaired physical mobility, risk for impaired skin integrity or imbalanced nutrition (less than body requirements) in institutionalized elderly patients (24) ; imbalanced nutrition (less than body requirements), impaired skin integrity and impaired physical mobility in patients with chronic renal pathology (13,25) .
In relation to the anthropometric techniques and measurements required to perform nursing interventions, numerous studies have been identified, in both primary care and hospital care, where the need to use various anthropometric measurements to perform very common interventions in certain contexts were identified. In a study by Lucena et al. (26) , among the interventions that are commonly used in intensive care units, several are related, such as "exercise therapy: ambulation" or "pressure ulcer care" that require anthropometric measurements for their execution. Likewise, in the article by Scherb et al. (27) on interventions in patients with heart failure, several interventions requiring anthropometric techniques were found ("fluid management", "nutrition management", among others). Finally, a study by Aguilar and Pancorbo-Hidalgo (28) carried out in an elderly population also highlighted the use of many of the interventions that we have identified in our study: "self-care assistance: feeding", "exercise therapy: muscle control", "nutrition management" and "pressure ulcer care".

Study limitations
The comprehensive and independent review of the NANDA-I and NIC taxonomies should have been done by all members of the research except one member for review the possible existing discrepancies.

Contributions to the fields of Nursing, Health or Public Policy
These studies show that nursing diagnoses and interventions that require anthropometric techniques or measurements are commonly used. Therefore, to contribute to improving the diagnostic accuracy and correct execution of the care plans that include these interventions, it is necessary to ensure the correct education and training, both of the nursing students and the already graduated professionals, for the anthropometric techniques identified in our study. As we mentioned earlier, there are no previous studies that describe the application of anthropometric methods in the clinical practice of nursing.

CONCLUSIONS
This study identifies the main anthropometric techniques and measurements related to nursing diagnoses and interventions, included in the NANDA-I and NIC classifications, respectively.
Determining the necessary anthropometric techniques and measurements to be able to define a nursing diagnosis or execute nursing interventions in an appropriate manner can be very useful for their systematization.
In addition, it is necessary that nurses use these anthropometric techniques appropriately, to maintain the quality of the Chart 3 (concluded)