Predictive factors for the Nursing Diagnoses in people living with Acquired Immune Deficiency Syndrome 1

Abstract Objective: to identify the predictive factors for the nursing diagnoses in people living with Acquired Immune Deficiency Syndrome. Method: a cross-sectional study, undertaken with 113 people living with AIDS. The data were collected using an interview script and physical examination. Logistic regression was used for the data analysis, considering a level of significance of 10%. Results: the predictive factors identified were: for the nursing diagnosis of knowledge deficit-inadequate following of instructions and verbalization of the problem; for the nursing diagnosis of failure to adhere - years of study, behavior indicative of failure to adhere, participation in the treatment and forgetfulness; for the nursing diagnosis of sexual dysfunction - family income, reduced frequency of sexual practice, perceived deficit in sexual desire, perceived limitations imposed by the disease and altered body function. Conclusion: the predictive factors for these nursing diagnoses involved sociodemographic and clinical characteristics, defining characteristics, and related factors, which must be taken into consideration during the assistance provided by the nurse.


Introduction
It is estimated that 35 million people are living with Human Immunodeficiency Virus (HIV). From the beginning of the AIDS epidemic (1980) through to December 2013, approximately 1.5 million deaths were identified which had Acquired Immune Deficiency Syndrome (AIDS) as their basic cause (1) . In this regard, AIDS remains a public health problem, demanding, therefore, attention both from managers and health professionals regarding measures for prevention, treatment, and the rehabilitation of the individuals.
The nurse is inserted in this context as an important facilitator of the care for people living with AIDS, whether this involves undertaking the nursing procedures during inpatient treatment or assessing and providing guidance in relation to their state of health, tests, medications, diet or prevention of the transmission of the virus, among other issues. For this, it is necessary for these actions to be undertaken systematically.
The Systematization of Nursing Care can take place based on the application of the Nursing Process, which is made up of five interrelated, interdependent and recurrent stages: data collection (the patient history), the nursing diagnosis, planning, implementation, and nursing evaluation. Through this, the nurse's practice is based on clinical judgment, greater organization, and quality of care. For this, it is essential for the professional to involve the people living with AIDS and their family members (2) .
In this respect, the identification of the nursing diagnoses and of their predictive factors, which are related to the human responses, facilitates the implementation of the nursing interventions which will be most appropriate for the real necessities of the people living with AIDS -and for their socioeconomic and cultural context.
In order to support and justify the undertaking of this study, an integrative review was undertaken, looking for scientific productions published in the last five years on the issue in question. For this, the following databases provided through the Virtual Health Library with AIDS (2)(3)(4)(5)(6) , with studies being found on the profile and prevalence of the diagnoses, but an absence of investigations on their predictive factors.
Based on the gap in knowledge identified on this issue, in the scientific literature, the question is raised: What are the predictive factors for the nursing diagnoses in people living with Acquired Immune Deficiency Syndrome?
In the light of this, this study's objective was to identify the predictive factors for the nursing diagnoses in people living with Acquired Immune Deficiency Syndrome.

Method
A cross-sectional study, carried out in a public hospital located in the Northeast of Brazil. The study population consisted of 158 people diagnosed with AIDS receiving inpatient treatment in the hospital selected.
For this, one episode of inpatient treatment was counted for each patient. The sample size was calculated based on the formula for finite populations, considering a level of confidence of 95% (Z∞=1.96), sampling error of 5% and the size of the population (7) . The sample was made up of 113 people living with AIDS, selected by convenience, and was of the consecutive type.
The study included people diagnosed with AIDS, who were over 18 years old, and who had been receiving inpatient treatment for at least 12 hours. The study excluded those who did not have the physical or psychic conditions to participate in the study, as well as those who were not aware of the diagnosis of the disease. It is emphasized that people living with AIDS who were receiving inpatient treatment on a subsequent occasion, who had already been interviewed in the present study, were not included again in the sample.
The collection took place in the period March -September 2014, corresponding to the time period necessary to reach the sample calculated. In approaching the subjects, the research proposal was presented, and the Terms of Free and Informed Consent were read. For this, the patients were given the time necessary for taking their decisions. If they wished to contribute to the study, a patient history was taken and the physical examination was undertaken in a separate room, in the above-mentioned hospital, respecting the patient's privacy. Throughout the data collection process, accessible language was used such that there would be no doubts or embarrassments.
The instruments used in collecting the data, for taking the patient history and carrying out the physical examination were adapted (2,(8)(9) , containing open and The NANDA International, 2012-2014 version (9) was used to classify the nursing diagnoses, the defining characteristics, and related factors or risk factors. The process of diagnostic inference was undertaken by two researchers and took place in two stages: analysis (categorization of the data and identification of the gaps) and synthesis (grouping, comparison, identification, and relating of the causative factors).

Results
The majority of people living with AIDS are male

Discussion
The AIDS epidemic, in Brazil, in recent years, has been marked by a change in the epidemiological profile, marked by heterosexualization, povertization and interiorization (that is, its spread from cities into rural areas) (10) .Studies on people living with AIDS have been undertaken predominantly with male patients aged up to 40 years old, resembling that found in this study (4)(5)(6) .
The nursing diagnosis of ineffective protection presented, in general, defining characteristics and related factors linked to the change in immunological status, including the changes of the blood cells. Studies undertaken previously corroborate this finding (2,(4)(5) .
It is known that HIV works by linking itself to Infection by Candida is observed with any level of CD4 T cells, such that the reduction in these cells influences only its frequency and severity (16) .
In the light of the above, the appearance of the The nurse needs to monitor the clinical situation of the people living with AIDS, being attentive to the blood markers and symptomatology, with an aim to identifying the complications caused by the disease. Furthermore, it is important for these people to be aware regarding their current clinical status and prognosis and, above all, regarding how they can contribute to minimizing these.
Regarding the nursing diagnosis of knowledge deficit, it is known that the inadequate following of instructions, and verbalization of the problem, can influence the way that people living with AIDS deal with the disease, as well as their adherence to the treatment and to healthy behaviors (17) .
In this regard, the nurse must encourage people living with AIDS to reports their doubts, sources of distress, and difficulties related to the treatment; principally at the time when they find out about the disease, as it is common to present irritability, guilt or apathy, among other negative feelings, a fact which can negatively influence these peoples' involvement for following the treatment (18) .
It is understood that the more that people living with AIDS are informed, the more capable they are for dealing with the situation, and the better they understand take into account how this information will be passed on, principally to those with a low educational level.
In relation to the predictive factor of years of study, linked to the nursing diagnosis of failure to adhere, studies indicate that the low educational level of people living with AIDS predominates as an aspect which can influence lack of adherence to the treatment of the disease (3)(4)19) . knowledge on their state of health, including aspects related to the disease's development, such as CD4 count and viral load, contribute to the involvement of people living with AIDS in their adherence to the treatment (17) .

Other factors are indicated by some studies as
possibly influencing adherence to the treatment: financial difficulties, nutritional factors, lack of belief in the treatment, drug use, depressive symptoms, the occurrence of adverse reactions during the taking of medications, and the quantity of antiretrovirals ingested per day (16,(20)(21) .
The financial difficulties limit access to appropriate food for minimizing the situation of physical debility, characterized by muscular weakness and low weight, resulting from the action of the virus itself, as well as the adverse reactions to the medications, or symptoms of the opportunistic infections (20)(21)(22) . Lack of belief in the treatment, on the other hand, may be related to an understanding of the inefficacy of the antiretrovirals, due to the fact that this is an incurable disease (18) .
Besides this, adverse events resulting from these medications can also involve anatomical, metabolic or neuropsychiatric changes, as well as gastrointestinal effects of different intensities (12) .Another important aspect relates to the quantity of antiretrovirals ingested per day, which also contributes to people living with AIDS becoming resistant to taking medication or not recording the times that they take the tablets (12,19) .
It is known, however, that the antiretroviral medications have an important role in the control, survival, and improvement of quality of life of people living with AIDS, as they act in viral suppression and maintain the levels of the CD4 cells at a higher level, thus allowing an improvement in the immunological system and a reduction in the occurrence of opportunistic infections (13,15) .
It is important to emphasize that, although in this study there was no statistical significance between the diagnosis of failure to adhere and the variables related to the consumption of alcoholic drinks, tobacco and illicit drugs, it is interesting to note that the factors related to behavior which is indicative of lack of adherence and forgetfulness can result from this lifestyle, which is highly prevalent among the participants in this research.
Studies confirm that unhealthy life behaviors, including the consumption of drugs, can be determined both in contagion with HIV and in relation to adherence to the disease's treatment, as these people commonly -when ingesting alcohol or consuming other drugsreduce their level of cognition and undertake specified behaviors, such as the practice of unsafe sex, multiplicity of partners, the sharing of syringes, and forgetting to take their antiretroviral medications (20)(21)(22)(23) . Furthermore, the drug users, due to their high degree of dependency, prefer to take drugs rather than ingest the medications, bearing in mind that the concomitant use can increase the adverse effects of the antiretrovirals, or even because of the fact that they consider the use of drugs to be mechanisms of escape from life's adversities (12,21) .
In this regard, the nurse must be alert to the this is related to a situation of depression (4) .  The study's limits were related to the nonprobabilistic type of sampling, which does not guarantee the sample's representativity. Another aspect identified consists of the fact that the clinical evaluation is a subjective process; in the light of this, the diagnostic process is subject to uncertainties. It is stressed that the small number of studies addressing the nursing diagnoses in people living with AIDS, and which used inferential statistics, led to a certain difficulty for comparing the findings of the present study.
In this regard, it is suggested that further studies should be undertaken with a view to giving a broader foundation for the nurse's care practice with people living with AIDS, principally in relation to the nursing diagnoses and their predictors.

Conclusion
The study made it possible to identify that the predictive factors of the nursing diagnoses of knowledge deficit, failure to adhere and sexual dysfunction, found in the people living with AIDS and involved sociodemographic and clinical characteristics, defining characteristics, and related factors, which can be used by nurses for identifying the increased risk for the development of specific human responses and complications related to the disease.