Nursing interventions for rehabilitation in Parkinson's disease: cross mapping of terms

ABSTRACT Objective: to perform a cross-term mapping of nursing language in the patient record with the Nursing Interventions Classification system, in rehabilitation patients with Parkinson's disease. Method: a documentary research study to perform cross mapping. A probabilistic, simple random sample composed of 67 records of patients with Parkinson's disease who participated in a rehabilitation program, between March of 2009 and April of 2013. The research was conducted in three stages, in which the nursing terms were mapped to natural language and crossed with the Nursing Interventions Classification. Results: a total of 1,077 standard interventions that, after crossing with the taxonomy and refinement performed by the experts, resulted in 32 interventions equivalent to the Nursing Interventions Classification (NIC) system. The NICs, "Education: The process of the disease.", "Contract with the patient", and "Facilitation of Learning" were present in 100% of the records. For these interventions, 40 activities were described, representing 13 activities by intervention. Conclusion: the cross mapping allowed for the identification of corresponding terms with the nursing interventions used every day in rehabilitation nursing, and compared them to the Nursing Interventions Classification.


Introduction
In recognition of the first descriptions performed by James Parkinson in 1817, Parkinson's disease (PD) was thus entitled years later by Jean-Martin Charcot.
The mean age of onset of symptoms is 60 years of age, and the incidence increases with age and may affect up to 5% of the population over 79 years of age. The mean duration of the disease, from diagnosis through death, is 15 years, and the relationship of mortality in males to females is two to one (1) .
The causal relationships remain as evasive as when described in 1817, however, pathological signs related with genetic and environmental components are strongly discussed (1)(2) . Moreover, radical changes in the conceptualization of the disease, starting with a better understanding of the motor and non-motor pathological manifestations, by means of understanding that the neurodegenerative process can begin even before the onset of motor symptoms, enabled scientific advances in its treatment (2) . Currently, medications and non-pharmacological therapies aim at alleviating the symptoms and improving the quality of life of this population.
In this sense, the nursing care provided to the individual with this disease, permeates through the aspects of this condition related to symptomatology; it is considered to be multisystemic, progressive, and incurable. In the rehabilitation context, the nurse, as a professional member of the multidisciplinary team, has an important role in health promotion, treatment of complications, and adaptation to the limitations imposed by the disease. The nurse directs the plan of care to meet the needs of each patient and family, guiding the search for the patient's independence in relation to his/ her physical, cognitive and behavioral limits through an appreciation of his/her potential (3) .
In this scenario, the adoption of standardized nursing care prevails, based on legal, ethical, scientific and methodological premises. Thus, care grounded in the nursing process enables interactivity, since it is based on mutual relationships of nurses, the multidisciplinary team, the patient and the family (3) .
Beyond the completion of the nursing process steps, based on the use of a language classification system, the universality of information is ensured, which provides the dissemination of concepts and the practical applicability of interventions (4)(5) .
The Nursing Interventions Classification (NIC) is among the various classification systems referring to the interventions to be used with the nursing process.
This taxonomy, of North American origin and worldwide scope, was developed in order to document and communicate nursing care by integration of data in computer systems, and provides a source of data for research (6)(7) . According to this classification system, a nursing intervention is defined as "any treatment, based upon clinical judgment and clinical knowledge, that a nurse performs to enhance patient/client outcomes" (6) . Therefore, the importance of studies that address the nursing interventions in the rehabilitation of patients with PD, structured in an elected classification system, is undeniable. The nursing research that addresses this issue converges on the current global trend to better understand the disease, its symptoms and treatment, contributing to the scientific progress in this area, which will be reflected in improved patient care. However, currently, it is observed that nursing scientific production in this context remains scarce (8)(9)(10)(11) .
Based on the above, this study aimed to perform the nursing language term cross-mapping of the records of rehabilitation patients with Parkinson's disease, with the Nursing Interventions Classification (NIC) system.

Method
This was a descriptive, quantitative study, developed in accordance with the technical procedure of documentary research, using records as a primary source of data collection. The methodological framework uses concepts and principles of cross-mapping. This method was chosen because it allows the linguistic comparison and semantics between non-standardized terminologies with the chosen classification system (4,7,12) . to the diagnosis of PD, had a medical diagnosis that characterized other parkinsonian syndromes, such as secondary Parkinsonism, for example, were excluded.
Thus, 148 records were obtained. From this total, the calculation for a probability sample of the simple random type was calculated using the formula (13) : In this case: N = 148 records (population size), E = 9% (tolerable sampling error), n0 = 123 records (first approximation of the sample size) and n = 67 records (sample size).
Thus, the sample consisted of 67 patient charts, which represented 45% of the total population, and 9% of sampling error. Of these, the last five nursing assessments were considered for this study, totaling 335 analyzed nursing assessments..
The study limitation is the adoption of a 9% error, instead of 5% that is usually used as maximum error. However, this limitation was considered by the multiplicity of nursing records obtained in each medical chart, which provided significant data collection for the researchers.
After conducting three pilot tests, for training and improvement of three researchers on the method, the cross-mapping was completed, simultaneously, cross-mapping of the terms identified in the previous step, with the NIC taxonomy. The following rules of crossmapping were considered: 1-mapping the "meaning" of the words, not just the words, 2-using the "keyword" in the intervention to map to the NIC intervention, 3-using verbs as "keywords" in the intervention, 4-mapping the intervention from the NIC intervention label for the activity, 5-maintaining consistency between the intervention being mapped and the NIC definition of the intervention, 6-using the more specific NIC intervention label and 7-mapping interventions that have two or more verbs for the two or more corresponding NIC interventions (12) .
The nursing terms in natural language were compared with the NIC interventions. The categorization of the nursing terms was performed with a combination of analyses, where: when the term found, was matched with the classification system term, it was categorized as an exact match, and when that term had similar concepts, synonyms and related terms, it was categorized as a partial match. For presentation of the results, the exact and partial matches were considered to have the same value.
In the examples previously cited, the term "bladder reeducation", extracted after the fragmentation of parts of the nursing record, and assumed to be a nursing intervention, was considered to be an exact match with NIC. However, the terms "oriented", " home adaptation "and "safety" were considered to be partial matches, and were correlated to the standardized NIC intervention,

Results
The characteristic profile of the 67 patients of the sample was: 63% male, mean age of 69.3 (± 10). The progression of PD ranged from one to 24 years, with a higher representation of those who had one to eight years of disease progression (75%).
In the case of nursing interventions, there  approach. However, guided by clinical reasoning many patients were included by nurses for both approaches,. In other words, for those patients who had not achieved the expected outcomes, these were also individually addressed after group intervention, and vice versa.
The data shown in Table 2 demonstrate that nine nursing interventions equivalent to the NIC classification system, were prescribed concurrently at individual (19%) and group (54%) levels, representing 73% of the total number of interventions.  11 16 In addition, the standardization of the approaches with patient groups was identified, represented by (NIC code 5602) Teaching: Disease Process "Definition: Assisting the patient to understand information related to a specific disease process" (6)

1.
Appraise the patient´s current level of knowledge related to specific disease process 2.
Explain the pathophysiology of the disease and how it relates to anatomy and physiology 3.
Review patient´s knowledge about condition 4.
Acknowledge patient´s knowledge about condition 5.
Describe common signs and symptoms of the disease 6.
Explore with the patient what she/he has already done to manage the symptoms 7.
Provide information to the patient about condition 8.
Provide the family with information about the patient´s progress 9.
Discuss lifestyle changes that may be required to prevent future complications or control the disease process 10. Discuss therapy/treatment options 11. Describe rationale behind management/therapy/treatment recommendations 12. Describe possible chronic complications 13. Instruct the patient on measures to control/minimize symptoms 14. Reinforce information provided by other health care tam member (NIC code 4420) Patient Contracting "Definition: Negotiating an agreement with an individual that reinforces a specific behavior change" (6)

1.
Determine the individual's mental e cognitive ability to enter into a contract 2.
Encourage the individual to identify own strengths and abilities 3.
Asist the individual in identifying the health practices se/she wishes to change 4.
Identify with individual goals of care 5.
Avoid focusing on diagnosis or disease process alone when assisting the individual in identifying goals 6.
Assist the individual in identifying appropriate short term and long term goals 7.
Assist the individual in breaking down complex goals into small manageable steps 8.
Clarify with the individual roles of the health care provider and individual 9.
Assist the individual in examining available resources to meet the goals 10. Facilitate involvement of significant others in the contracting process if desirable 11. Assist the patient in identifying even small success (continue...)  Figure 1 continue in the next page...) Rev. Latino-Am. Enfermagem 2016;24:e2728.
(NIC code 5520) Learning Facilitation "Definition: Promoting the ability to process and comprehend information" (6)

1.
Set mutual, realistic learning goals with the patient 2.
Identify learning objectives clearly and in measurable terms 3.
Adjust the instruction to the patient´s level of knowledge and understanding 4.
Tailor the content to the patient´s cognitive, psychomotor and affective abilities 5.
Provide information appropriate to developmental level 6.
Provide an environment conducive to learning 7.
Arrange the information in a logical sequence 8.
Adapt the information to comply with the patient's lifestyle and routines 9.
Provide information that is compatible with the patient´s locus of control 10. Ensure that the material is current and up to date 11. Provide educational materials to illustrate important and complex information 12. Use multiple teaching modalities 13. Present the information in a stimulant manner 14. Encourage the patient´s active participation 15. Correct information, misinterpretation

Discussion
In terms of characteristics of the sample of this research, the findings converge with studies showing that PD tends to occur more frequently in men, especially in the age group over 60 years (1) .
Regarding the progression of the disease, the results of this study have representativeness, showing that the neurodegenerative process of PD is nonlinear, but it is concerned with individual aspects (14) . However, the decompensation rate is much faster in the early stage of the disease, leading to functional impairment of the patient that should be evaluated in order to consider his/her personal characteristics (14) . In addition, patients in the early stages of the disease can demonstrate more doubts and anxieties about this disease. This requires that the rehabilitation nurse takes a more careful look at the educational aspects, giving information about current symptoms to these patients, considering those of a prognostic nature (3) . Therefore, nurses who provide care to patients with PD should consider the magnitude of aspects, and their interventions should respect the peculiarities inherent to the individual process of the disease progression.
With regard to nursing interventions, the results demonstrate effectiveness of the methodological tools used in this study, which enabled the achievement of objectives. The cross-mapping identified nursing language terms prescribed by nurses in the records of patients with PD who participated in the rehabilitation program, and compared them to the standardized NIC language, which is globally recognized. This method is a viable tool in the standard language implementation process in health services, as it allows the nurses to compare data consistently and generalizable (7,12) .
Furthermore, nursing interventions, as part of the nursing process, are recognized in the care plan, which is developed in order to eliminate or minimize a nursing diagnosis, seeking to achieve the goal or pre-established outcome (4) .
Thus, the interventions mapped and described in this study are highlighted, which were directly linked to educational practice, and used by nurses as the main tool for health promotion. Health promotion, as a change strategy in technical healthcare models, has been used for decades as an alternative for expanding the quality of health and life of the population, by intervention with individuals and the understanding of the health/disease process, such as social production (15) .
In the context of neurological rehabilitation, the actions for health promotion are aimed toward recovery, but, mainly, for the adaptation to limitations imposed by the disability, according the needs of each patient/ family. These actions are primarily guided by functional, motor, psychosocial and spiritual aspects (15) . Nurses must establish a bond with the patient/family and guarantee guidance for the health/disease process, providing the necessary resources for facilitation and implementation of this learning. The autonomy of the individual is important within this relationship, asserting the principles of citizenship and democracy, socially committed to improving health status in accordance with the principles of neurorehabilitation (15) . neurodegeneration (16) . In this scenario, nurses action aim to intervene to restore bowel function of patients with non-pharmacological measures that minimize neurological damage, due to the degenerative process.
However, these measures depend on change in the patient's lifestyle. The nurses use references beyond the biological in their work methodology, and recognize that the actions required for adherence to long-term treatment and care are deeply interrelated with the culture, i.e., with the lifestyle, habits, routines and rituals in the lives of patients, converging with contemporary scientific references (17) . The concepts described seek complicity with the patient/family for active participation in the process of change and adaptation to achieve provided the nursing care to the individual / family, in order to consider their singularities, and in an extended mode, converge with professional recommendations widely discussed in the nursing literature (18) .
During the analysis of records, the recognition of the nurses about their role in the rehabilitation process with the patient who progresses with a neurodegenerative, multisystem and still incurable disease was clear.. Their full involvement in this process allowed for prescribing interventions, mostly permeated with the principles of health promotion. Thus, rehabilitation was based on the search for patient potential, aimed at his/her restoration through reciprocal and realistic goals. These actions may lead to the opportunity for a life with better quality, reemergence of self-esteem, independence and family involvement, which confirms the principles of neurorehabilitation, as discussed in the scientific community area (16) .

Conclusion
The