Terms of specialized nursing language for chronic renal patients undergoing conservative treatment.

OBJECTIVES
to validate the terms of the specialized nursing language used in the care of people with chronic kidney disease undergoing conservative treatment identified in the literature by mapping them with terms of the International Classification for Nursing Practice, version 2019, and representing them by means of a mandala.


METHODS
descriptive, documentary and methodological study. The terms were collected in 53 scientific articles, standardized and mapped with the terminology. The validation was performed by six nurses through a focus group. The Content Validity Index was used and terms with a value ≥ 0.80 were validated.


RESULTS
the normalization resulted in 957 relevant terms, of which 499 were constant and 458 not included in the terminology. Terms were validated when Content Validity Index was between 0.86 and 1.0.


CONCLUSIONS
the study allowed the validation of terms that will contribute to unify the professional language of nursing in the care of people with chronic kidney disease.


INTRODUCTION
The World Health Organization reports millions of deaths each year due to chronic noncommunicable diseases, and Chronic Kidney Disease (CKD) stands out among them. It has been considered a public health problem in Brazil and worldwide given its high mortality rates (1)(2)(3)(4) . The lifestyle changes presented by people with CKD are significant, seriously affect physical, emotional, social and spiritual health, and reflect on decreased quality of life (5) .
It is in this context that nurses are inserted, developing preventive and daily maintenance measures for comprehensive and systematic care for people who start conservative treatment of CKD, in order to postpone the progress of the disease.
This systematic care requires nurses' knowledge about a specific theoretical framework that supports their critical and technical intellectual skills, with the aim to identify and document their standards of care through a standardized terminology linking essential elements of professional practice. In this sense, the International Classification for Nursing Practice (ICNP ® ) consists of a standardized terminology of the Nursing language with a structure of terms and definitions that allows the collection, description and systematic documentation of elements of Nursing practice (6) .
The use of ICNP ® contributes to reasoning and clinical decisionmaking, facilitates systematic documentation of professional practice, allows the promotion of communication between nursing professionals and other areas, thus leading to greater visibility for the profession (7) . Nurses describe the evidence of care provided from the description of specific elements that must be registered in a standardized way with the help of a term bank, which allows detecting concepts that help in the construction of diagnoses, results and Nursing interventions (8) .
Thus, the importance of producing knowledge about terms of specialized nursing language terms is seen in the care for people with CKD undergoing conservative treatment. In addition, the search for a term bank promotes the objectivity of the language expressed by the science of Nursing, enabling understanding and intersubjective recognition of its concepts, being applied in the fields of professional practice, which favors clinical decisionmaking, demonstrating the relevance of present research (9) .
In view of the problem presented, the development and importance of this study is justified, since there is a scarcity of studies aimed at chronic renal patients undergoing conservative treatment, since publications on specialized nursing terminologies deal with the following topics: medical clinic and surgical; neonatal and adult intensive care unit; physical-motor rehabilitation; ostomates; people with pressure injuries; leprosy; palliative care; spinal cord injury; elderly women with HIV / AIDS and metabolic syndrome (7)(8)(10)(11)(12)(13)(14)(15)(16)(17)(18) .
As explained above, the following question arose: which terms of the specialized nursing language originating from the literature about the care of people with chronic kidney disease under conservative treatment can be validated in a bank of terms for recording the clinical practice?

OBJECTIVES
To validate for content terms of the specialized nursing language used in the care of people with chronic kidney disease under conservative treatment identified in the literature by mapping these terms with those of the ICNP ® , version 2019, and representing them through a mandala.

Ethical aspects
The study followed the guidelines and regulatory standards for research involving human beings established in Resolution number 466/2012 of the National Health Council and was approved by the Research Ethics Committee at the Federal Fluminense University. In the present study, the Free and Informed Consent Term (ICF) was used and the preservation of the participants' identity was guaranteed at all times of the study.

Design, study location and period
Descriptive, documentary and methodological study guided by the first and second steps of the guidelines for the development of terminological subsets of the ICNP ® (19) with subsequent content validation by nurses from a university hospital in the city of Rio de Janeiro, Southeastern Brazil. The documentary data collection period was between March and July 2019. The content validation occurred in August of the same year.

Population or sample; inclusion and exclusion criteria
The sample of publications consists of articles from journals indexed in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PUBMED); Latin American and Caribbean Health Sciences Information Literature (LILACS); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Nursing Database (BDENF); the Scientific Electronic Library Online (SCIELO); and EMBASE (Elsevier).
The following Descriptors in Health Sciences (DeCS) and Medical Subject Headings (Mesh) were used in the search: "Insuficiência renal crônica" and "Tratamento Conservador" in Portuguese; "Renal Insufficiency, Chronic" and "Conservative Treatment" in English; "Insuficiencia Renal Crónica" and "Tratamiento Conservador" in Spanish.
The following inclusion criteria were used: being a complete article resulting from research; be published in Portuguese, English or Spanish, without time limits; be available in full electronically; and present clinical indicators, that is, clinical evidence of the human responses of the person with chronic kidney disease under conservative treatment. As exclusion criteria, works presented in congresses, dissertations, monographs, theses, editorials, reflection studies, referring to renal replacement therapies and pediatrics.
Regarding the nurses involved in the content validation process, the following criteria were used to include specialists: (I) have at least five years' clinical experience in caring for people with CKD on an outpatient or dialysis level; (II) nurses who use the nursing process and ICNP ® . Thirteen nurses from a kidney disease outpatient clinic in a university hospital were selected and invited, however only 6 accepted to participate in the study.

Terms of specialized nursing language for chronic renal patients undergoing conservative treatment
Menezes HF, Camacho ACLF, Lins SMSB, Campos TS, Lima FR, Jales AKFA, et al.

Study protocol
The following steps were followed to achieve the study objectives: 1) extraction of the terms of publications; 2) standardization of terms; 3) cross-mapping, in which the extracted terms were compared with the terms present in the ICNP ® , version 2019; 4) content validation of terms with nurses and distribution of terms in constant and non-constant according to the seven-axis model of the ICNP ® ; 5) graphical representation with examples of the validated terms in a mandala.
The publications used consisted of 23 in Portuguese, 24 in English and 6 in Spanish, which were subjected to a process of removing sections with low potential for relevant terms, such as titles, authors, information about authors, abstracts, notes footer, methodology, references and thanks. After these extractions, the essential content was grouped into a single file in Word ® format, which was converted to a portable document format (Portable Document Format -PDF); then, the terms were extracted using a computational tool called Poronto, which processes information using large-scale ontologies, being widely used in the health area due to the complexity of its knowledge (20) , resulting in a list of terms organized in order of occurrence, arranged in an Excel ® spreadsheet.
It should be noted that as Poronto is defined as a tool for building ontologies from texts in Portuguese, articles in other languages used for this study were translated by specialized professionals.
Among the extracted terms, nouns, adjectives and verbs were selected based on the frequency of appearance and relevance to the research theme; then, the selected terms were submitted to a normalization process to standardize the inflections of gender, number and degree of nouns and adjectives, as well as verbal inflections, in order to identify and remove repetitions of terms, being constantly checked for reduction of error rate. In this sense, terms related to medical procedures, pathological processes and medications were identified and excluded; later, the standardized terms were subjected to the mapping technique, which made it possible to cross with the terms of ICNP ® , version 2019, using the Microsoft Office Access ® 2010 software to identify constant and non-constant terms in this terminology.
Furthermore, still in the mapping phase, as dictated by the International Organization For Standardization (ISO) 12.300: 2016 (21) standard, the entire mapping process was documented, ensuring the interpretation of the mapped term, within the scenario in which it was mapped, which contributed to the clinical safety of its use. This process was carried out by two of the study authors, since they had knowledge of the terminological resources evaluated, both source and target, in order to identify their similarities and differences.
Afterwards, the content validation of terms identified in the study was performed with use of the Focus Group (FG) technique through three meetings lasting around four hours each and composed of six nurses, who acted as judges. They received an instructional document with all the terms, through which they proceeded with the validation of terms using the Content Validity Index (CVI).
The degree of relevance of each term was assessed using an instrument based on the Theory of Adaptation developed by Callista Roy with the following alternatives and gradations: 5-extremely relevant -when the specialist considered the relationship of the term with the adaptive problems and very important stimuli based on Roy's theoretical model, with evaluation, and also with the elements of care for people with CKD undergoing conservative treatment; 4-relevant -important; 3 -level of relevance similar to that of irrelevance; 2-little relevant -in the expert's assessment, the item was of little importance; 1-irrelevant -the item was not considered important, as there was no relationship between the elements of care with adaptive problems (22) . It is noteworthy that Roy's Theory of Adaptation was used to organize the terms resulting from the present manuscript.
In order to clarify some doubts that may arise in the experts, an instructional guide containing concepts and description of the terms under evaluation was used. As part of the FG dynamics, the following guiding question was elaborated: in his understanding, the terms presented and distributed by the researcher in the model of the seven axes of the ICNP ® are relevant for the development of terminologies and the standardization of the nursing language, in context of care for people with CKD under conservative treatment?

Analysis of results and statistics
The terms were distributed among the Action, Client, Focus, Judgment, Location, Means and Time axes, according to the Seven Axis Model of the ICNP ® , version 2019 (23) , taking into account the congruence of the meaning of the term and the definitions of each axis.
The terms not included in the ICNP ® were subjected to a process of analysis as to the similarity and comprehensiveness in relation to the ICNP ® terms according to the following criteria (24) : similar -there is no concordance of the spelling, but its meaning is identical to the existing term in ICNP ® ; more comprehensive -its meaning is broader than that of the existing term in ICNP ® ; more restricted -it has a more specific meaning than the existing term in the ICNP ® ; and does not show agreement -the term is totally different from the existing terms in ICNP ® .
The content validation data was organized in Microsoft Excel 2016, through double insertion, to guarantee the reliability of the inserted data. The Content Validity Index (CVI) was calculated, considering the number of specialists who participated in the study. The acceptable value of the CVI for each item varied between 0.80 and 1.00, with the minimum acceptable score for content validity 0.80.
The results of the validated terms were presented in a table and mandalas, which are diagrams composed of concentric geometric shapes, being considered a representation of the human being and the universe. Thus, the purpose was to present examples of validated terms and their entire universe according to the ICNP ® axes in order to facilitate their visualization.

RESULTS
The extraction of terms for people with CKD under conservative treatment in the 53 selected articles resulted in 19,367 terms. After identifying the terms, they went through a normalization process that resulted in 957 relevant terms, of which 760 nouns, 68 adjectives and 129 verbs.
of Terms of specialized nursing language for chronic renal patients undergoing conservative treatment Menezes HF, Camacho ACLF, Lins SMSB, Campos TS, Lima FR, Jales AKFA, et al.
The mapping between the 957 terms identified in the literature and the terms of the ICNP ® , version 2019, resulted in 387 constant terms and 570 non-constant terms in the ICNP ® , which presented a CVI greater than or equal to 0.80, being considered validated. Of these, 112 were identified as similar, 85 as more comprehensive, 52 classified as more restricted and 321 did not show agreement with the terms of the ICNP ® . Taking Leal into account (12), the similar terms identified in the study should now be considered as constant terms in the ICNP ® , because what changes is the spelling, the meaning being the same. Thus, it resulted in 499 constant terms and 458 non-constant terms in ICNP ® .
However, due to the large number of terms identified and validated in the study, it was decided to discuss those that obtained more frequency after using the tool. Figure 1 presents a mandala with examples of the terms contained in accordance with the ICNP ® axes. Figure 2 shows the non-constant terms according to the similarity in relation to the ICNP ® terms.

DISCUSSION
After the analysis with ICNP ® , version 2019, the number of non-constant terms computed was 458, of which 326 are only on the Focus axis, which can portray a contribution to language and the development of specific knowledge and the standardization of professional records which will determine the forwarding of priority orders from a conservative treatment clinic, where it is necessary to recognize the main nursing phenomena to assist, manage, teach and research more effective professional care.
In general, chronic diseases such as CKD are not defined by their apparent or real severity, but by the fact of having no cure and affecting a prolonged course that leads to death. Therefore, the action of health professionals in these diseases is decisive in a treatment that affects people's daily lives regardless of their age group (25) .
Thus, a study points out that the relationship between the stages of kidney disease and the outcome of the prognosis is narrow. Thus, treatment consists of clinical measures to delay the worsening of renal function, which makes it possible to reduce symptoms and prevent complications, whether in stages one to three, pre-dialysis, four and five, non-dialysis, terminal stage and in renal replacement therapy in stage five, dialysis. Therefore, the earlier the conservative treatment begins, the greater the chances of preserving kidney function for a longer time and thus directing interventions that address changes in the standard of living of people with chronic kidney disease (26) .
From a clinical point of view, the terms 'Edema' , 'Fatigue' , 'Glycemia' , 'Systemic arterial hypertension' and 'Obesity' , allocated to the ICNP ® Focus axis had relevant frequency. These indicator terms demonstrate the need for management, which can have an important influence in delaying the evolution of the disease. A study of 100 elderly people with chronic kidney disease mentioned arterial hypertension, diabetes and obesity as the main risk factors for this disease, since they are directly linked to progressive renal dysfunction (27) .
These factors cause renal vasodilation and glomerular hyperfiltration, which act as compensatory mechanisms to maintain sodium balance. These compensations together with increased blood pressure and metabolic imbalances can lead to glomerular lesions. Furthermore, inflammation, oxidative stress and lipotoxicity mediated by these factors, for example, can also contribute to renal worsening (28) . In this context, the professional support given in the nursing consultation, in the conservative treatment phase, can serve as a subsidy for professionals to improve the outpatient follow-up of these individuals, with effective adherence to treatment, leading to considerable clinical results and, consequently, to quality of life (29) .
Still from a clinical point of view, terms such as "Urea", "Creatinine" and "Anemia" were identified as prevalent in the literature found. The determination of the concentration of urea and creatinine is  an important parameter to diagnose several kidney problems. Creatinine assesses the glomerular filtration rate, increases its concentration in the blood as it reduces the rate of renal filtration. The measurement of urea, another type of laboratory test performed, synthesized in the liver from CO2 and ammonia, is the main product of protein metabolism, circulating in the blood, being filtered in the kidneys and most of it excreted in the urine. It is not as specific for assessing kidney function as creatinine. Even though the urea dosage does not have the good specificity to diagnose changes in general renal function, it is more sensitive to primary changes in renal conditions, so it is a biomarker that is highly important in cases involving this condition (30) . These changes affect the hydroelectrolytic balance, more specifically the levels of sodium and potassium and changes in the pH of the blood. Anemia is another important condition that can occur at any stage of CKD, and its prevalence and incidence increase as the glomerular filtration rate decreases. This condition causes fatigue, reduced libido and cognitive function, lethargy, anorexia, sleep disorders, and increases cardiac overload due to the decrease in hemoglobin concentration, which leads to a decrease in tissue oxygenation (31) . In view of these complications, the nurse needs scientific knowledge about renal pathophysiology, with a view to prescribing a unique therapeutic project shared with the team professionals, since this assessment needs to be joint and judged according to the characteristics of each person.
Terms like "Skin" and "Abdomen" are linked to people with chronic kidney disease, because these are locations where they show physical changes, which requires attention from the health team must during clinical assessment. For example, the occurrence of pruritus in the skin can be a consequence of the accumulation of uremic substances, elevated serum levels of calcium and phosphorus and secondary hyperparathyroidism (32) . The abdomen, on the other hand, may be a location that shows signs and symptoms of changes in the disease originated, for example, by nutritional intake. A common alteration is intestinal constipation, since its etiology may be related to a diet low in dietary fiber, restricted in liquids, due to pathological, emotional and medication factors, such as the use of phosphorus chelator (33) .
Thus, due to these common changes, the nurse can contribute by guiding this individual about their diet and skin care, emphasizing in their record the possible interventions indicated and the possibility of referrals to team professionals and thus monitoring the evolution with the suggested indications.
The constant term "Frailty" appeared frequently in the articles, demonstrating that studies are concerned with the characterization of this concept and the promotion of accurate assessments. The clinical and multidimensional nature of frailty is characterized by higher vulnerability to stressors, decreased strength, resistance and physiological function, with a consequent risk of adverse health events, such as dependency, hospitalization, institutionalization and mortality (34) . Studies have shown that the recognition of frailty must lead to a holistic assessment of the individual to address the risk factors that can exacerbate their progression and ensure appropriate psychological and social support. Thus, the recognition of frailty should lead to discussions that explore future desires to care for these vulnerable people (35)(36) .
However, terms of virtue indicators such as "Spirituality", "Empathy" and "Faith" were found and reflect the concern that these themes have on the person, which resumes the importance of developing nursing diagnoses and interventions based on these terms, once that the nurse seeks to find options that contribute to better control and a harmonious coexistence with the disease, since the negative physical, social and economic impacts perceived in the disease also cause consequences in the sense of life. In studies, the scenario of low frequency of psycho-emotional diagnoses in medical records has shown that care provided by nurses is still very much focused on a medical-centered model (37) .
Therefore, it is necessary that nursing actions, based on their care instrument, give value to the issues surrounding the psychosocial experiences of individuals with chronic kidney disease and their approximation in their social support network, whether family or community. Furthermore, the relationships established are valid when it is observed that when a close person can understand and explain the changes that may be imposed on the individual by diagnosis or treatment, with a more specific language, coping becomes better managed (38) .
Concomitant to this aspect, terms of the Customer axis such as "Family", "Group" and "Ent" can contribute to the construction of statements of nursing interventions with regard to social support and the perspective for coping and adapting the disease arising of this support, which suggests the inclusion of the evaluation of this support in the assistance planning. The assessment of this support may contribute to the detection of those individuals who will have greater difficulties in rehabilitating themselves, since little or no help may reflect feelings of inability to change and maintain health-friendly behaviors (39) .
The verbs found and classified as not included in the ICNP ® , for example, "Approach", "Adopt", "Understand", "Cooperate" and "Reference", touch subsidized activities for possible nursing actions. Such actions take the benchmark in favor of the management of individualized clinical care, insofar as it aims to promote health results that focus on comprehensiveness, longitudinality and, mainly, on improving the quality of health care for individuals (40) . In this way, the nurses' performance expresses relevant merit when they (re) think about their practice and commit their efforts in the search for the development of their reasoning in order to propose productive and resolving actions.
In the Judgment and Time axes, few new terms were inserted, for example, "Abandoned" and "Internship", respectively, however they indicate and reinforce the determination of a clinical opinion or a period related to a focus of nursing practice. Therefore, these terms can contribute to the composition of a diagnosis and, consequently, a nursing decision making in this specific context, which is nephrology.
As a highlight, in the Means axis, terms such as "Glomerular Filtration Rate", "Conservative Treatment" and "Nursing Consultation" stood out in their frequencies and are characterized as a possible way in the performance of an intervention. The glomerular filtration rate determines the stage of chronic kidney disease and its control affects the course of treatment, since it aims to assess renal function from the clearance of substances that are freely filtered by the glomerulus and do not undergo reabsorption or secretion tubular. Thus, it is shown as an important indicator in conservative treatment and needs to be determined by a specialized health professional who directs the best strategies (41) .

Terms of specialized nursing language for chronic renal patients undergoing conservative treatment
Menezes HF, Camacho ACLF, Lins SMSB, Campos TS, Lima FR, Jales AKFA, et al.
The frequency of the term "Nursing Consultation" reveals this activity as a possibility for care technology and as an essential element for improving the quality of care, making it more humanized and focused on the person and his environment. For this, consultation is a method of executing an intervention, as it is guided by a systematic practice, which provides communication, promotion, protection and maintenance of life (42) .
Therefore, the survey of terms, hitherto described, brings a significant contribution to nephrology nursing, especially for conservative treatment, in order to launch a set of phenomena originating from academic literature and its adequacy and validity in professional practice. In this way, the cross-mapping with the terms of the current ICNP ® , version 2019, brings together the development of standardized words and reveals the eternal cycle that does not end, but which is elaborated in depth. In this context, the way that nurses register denotes representation of their practice and, for that, they must appropriate the meanings instituted of these terms, determining their care context and thus reflecting on a standardized and safe documentation (43)(44) .
The development of a bank of nursing terms brings recognition of its own language of professional practice, as well as of its standardization. In this sense, this data set will allow the composition of the statements of diagnoses, results and nursing interventions, reaffirming the presence of nursing as an adjunct in the areas of specialties, thus pointing out parameters of its precise and comprehensive evaluation (11)(12) .
Finally, the mandala of terms reflects on the feasibility and understanding of evidencing the adaptive problems, behaviors and needs of individuals through the cyclical understanding that the figure proposes, that is, the terms demonstrate specificities and are capable of directing nurses' perception towards reasoning determinant characteristics for the required care. Finally, the graphic representation of the terms in a mandala is presented as a proposal for a technological tool that facilitates teaching and assistance using the ICNP ® , since it allows greater opportunity to visualize and recognize the terms and their respective axes

Study limitations
The limitations considered in the review proposed by the method were the restriction of databases and inclusion of articles available only in English, Portuguese and Spanish. Such facts may have hidden studies available on less usual databases.

Contributions to the Nursing area
In the context of people with chronic kidney disease undergoing conservative treatment, the identification and use of these well-defined and standardized terms enables the unification of professional language, implementation of the systematization of nursing care at the level of outpatient care, evaluation of actions and generation of scientific knowledge. In addition, the terms identified in the present study can be used to compose nursing diagnoses, results and interventions for this population and, thus, help to ensure that nurses have the necessary information tools to meet changes in health needs and assistance from citizens.

CONCLUSIONS
The extraction of terms in the 53 articles selected by means of a review resulted in 957 terms about the conservative treatment of chronic kidney disease, of which 499 are constant in the ICNP ® , version 2019, and 458 are not included. There was a prevalence of terms on the "Focus" axis and less frequency in the "Client" axis.
The "Focus" axis reflects the essential elements for the treatment of people with CKD undergoing conservative treatment; then, the "Action" axis showed terms capable of building nursing interventions to minimize complications and delay the start of dialysis. The "Means" axis grouped terms that signaled methods on how to carry out nursing interventions for this clientele. The "Location" axis concentrated terms related to the anatomical structures of people with CKD. The "Judgment" axis demonstrated the clinical opinion or determination related to the focus of nursing practice during care for this population. The "Time" axis presented terms related to the time period of nursing actions. The "Customer" axis showed the people who will receive care.
As future perspectives, the term bank proposed in this study can be used as a starting point for the elaboration of a complete terminological subset based on nursing diagnoses, results and interventions, in which content and clinical validation aimed at the person with chronic kidney disease under conservative treatment.