Clinical applicability of nursing outcomes in the evolution of orthopedic patients with Impaired Physical Mobility

AIM: to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility METHOD: longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed. RESULTS: The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035). CONCLUSION: the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context.


Introduction
With longer life expectancy and the consequent increase in the number of active and independent elderly people, the surgical replacement of the hip joints are procedures increasingly used in the population with orthopedic problems (1)(2) . The indication of Total Hip Arthroplasty (THA) should be based on the failure of conservative treatment and on the justifiable clinical condition (1)(2) . Total Hip Arthroplasty is a widely used and effective procedure that improves the quality of life of patients by increasing functional capacity, decreasing pain and improving coxofemoral function (1)(2) .
In Brazil, this surgery was one of the most performed in the Brazilian National Health System (SUS) over the previous two years (3) .
Much of the post-operative care, essential to the success of the surgical procedure, is the responsibility of the nurse and is directed toward the correct mobilization and education of the patient (4) . Therefore, these patients require more nursing care time, as they become dependent in the postoperative period, mainly due to mobility limitations and confinement to the bed.
In spite of different interventions being carried out, the measurement of Nursing Outcomes is still new in Brazilian Nursing (5) . In this sense, to obtain desired outcomes it is necessary to establish accurate diagnoses, goals to be achieved and interventions that enable the improvement of the patient (5) .
The Nursing Outcomes Classification (NOC) was developed in order to standardize the nursing language related to the evaluation of outcomes. This classification is structured on three levels of abstraction, including Nursing Outcomes, indicators and Likert scales. The NOC aims to evaluate the progress, stagnation or worsening of the clinical condition of the patient, allowing the verification of the progress, especially as a result of the interventions prescribed and implemented by the Nurse (6) . Its interconnection with classifications used in the Diagnosis (7) and Nursing Interventions (8) improves clinical decision making in patient care and in monitoring the progress.
In patients who underwent THA, the Nursing Diagnosis Impaired Physical Mobility (7) (IPM), has been highlighted as prevalent (9) . However, the clinical progression of the patient with this diagnosis, using a standardized classification, remains unexplored.
In recent years, there has been an increase in the production of studies focused on the NOC. A systematic review identified 312 articles about standardized language, with the majority of studies about the NOC focused on the reliability and validity of its terms (n=12) and the perception of nurses regarding the potential for its use in practice (n=12). However, only six studies used this classification in clinical nursing practice (10) .
The present investigation was outlined from these considerations. The relevance of this study lies in the visibility that it can give to the clinical progression of the patient, through the use of a standardized classification.
It is believed that the changes in mobility achieved by the patient may support the development of more effective care. Thus, the aim of this study was to evaluate the clinical applicability of outcomes, according to the NOC, in the progression of orthopedic patients with impaired physical mobility.

Methods
This longitudinal study was conducted in a large university hospital in southern Brazil, accredited by the Joint Commission International. The institution has 865 beds, distributed over more than 60 specialties.
The Nursing Process, used as a working method, is computerized and has the nursing diagnosis (ND) step based on the terminology of NANDA International (7) and the prescribed care based on the Nursing Interventions Classification (NIC) (8) .  For the selection of the Nursing Outcomes, 44 results were considered, according to the NOC-NANDA-I linkage, including suggested and additional associated outcomes for the IPM diagnosis (6) . These outcomes were evaluated by three nurses with three or more years of clinical experience in the care of orthopedic patients.
Thus, considering the title and the definition of each of the outcomes and indicators, the nurses noted the options recommend or not recommend for the evaluation of the diagnosis studied. Through the consensus, five Nursing Outcomes and 16 indicators were listed for their clinical applicability to be verified. The NOC recommendation regarding the choice of outcomes relevant to the care context in which they will be applied was taken into consideration (6) .
After this step, the data collection instrument was constructed. It contained sociodemographic and clinical variables, the five Nursing Outcomes and the 16 indicators with conceptual and operational definitions developed by the researchers from a literature review. The outcomes evaluated are presented in Figure 1.

Results
The study included 21 patients, who received 68 reviews, with 15 (71.4%) of them evaluated over a fourday monitoring period, and the others over three days, according to the length of hospital stay.
Of the patients monitored, the majority were female with a mean age of 58.8 (±16.7) and 15 of them (71.4%) underwent primary THA. Osteoarthritis was the basal disease in the majority of cases, as shown in Table 1.  Table 2.
Regarding the clinical evolution, the temporal curves show the differences in the scores of the scales of the NOC outcomes for each day evaluated. As can be seen in Figure 2, an increase was verified in virtually all evaluations. In the comparison between the mean scores of the first and last evaluations of the patients, no significant difference was observed in the measurements of the collectors. The mean difference was no more than 0.35 points in any of the parameters analyzed, as shown in Table 3. Knowledge and Behavior domains (6) . It should be noted that the study did not aim to evaluate the validity of the The clinical improvements in the Body Positioning: self-initiated Outcome and the Mobility Outcome, which also presented a significant improvement in the mean scores (p<0.001), were also found the literature, as mobility is a term that has been used to explain a series of functional activities, including transfer from the bed to the chair and walking (13) . The operational definitions of these outcomes included, for example, whether the patient maintained the proper positioning to sit on the bed, or when transferring from the bed to a chair, or vice versa; whether the patient started the first step with the operated limb; whether they kept the leg straight, distributed the weight with crutches or a walking frame; and important nursing care to be evaluated during the movement of these patients (11) . In addition to these evaluations, the degree of impairment of the Nursing Diagnosis under study can be perceived by measuring the Nursing Outcomes, which gradually improved over the days of monitoring.
It was observed that the study sample presented a mean body mass index (BMI) of 23.01 kg/m 2 (±7.09), which indicates normal weight. This data may have influenced the improvement of Mobility, supported by the research findings that showed the BMI to be a predictor for the outcomes of the THA (14) .
The Pain Level Nursing Outcome (p=0.265) showed no statistically significant difference, with the mean scores between the collectors being excellent in the first evaluation and, in the last, the variation was only 0.07 in the Reported Pain indicator scores. In the study setting, pain is evaluated as the fifth vital sign; thus, it is believed that the data can be related to the greater attention given to patients with the possibility of acute pain (15) .
Pain is a subjective phenomenon of extremely complex perception. As a factor related to the IPM diagnosis, patients who will have a hip prosthesis fitted learn to live with pain in their daily activities and not seek help until it becomes unbearable (16) . The algic perception was present in 20 (95.2%) patients prior to the surgery. Accordingly, it can be inferred that the pain was higher in the period leading up to the surgery, when compared to the postoperative period (16) .
Regarding verified inconsistencies in the evaluations of those who did not use them (21) .
Thus, the monitoring of the progress of patients, through a standardized classification, can facilitate evidence-based practice, favoring the quality of care and comprehensiveness of documentation, through the use of internationally recognized nursing language systems, which are valid and applicable in different real clinical settings (22)(23)(24)(25) .

Conclusion
The