Identifying nursing interventions associated with the accuracy used nursing diagnoses for patients with liver cirrhosis 1

ABSTRACT Objective: to identify the nursing interventions associated with the most accurate and frequently used NANDA International, Inc. (NANDA-I) nursing diagnoses for patients with liver cirrhosis. Method: this is a descriptive, quantitative, cross-sectional study. Results: a total of 12 nursing diagnoses were evaluated, seven of which showed high accuracy (IVC ≥ 0.8); 70 interventions were identified and 23 (32.86%) were common to more than one diagnosis. Conclusion: in general, nurses often perform nursing interventions suggested in the NIC for the seven highly accurate nursing diagnoses identified in this study to care patients with liver cirrhosis. Accurate and valid nursing diagnoses guide the selection of appropriate interventions that nurses can perform to enhance patient safety and thus improve patient health outcomes.


Introduction
Cirrhosis is a chronic degenerative disease characterized by replacement of functional liver tissue by fibrosis. The disease is responsible for high rates of morbidity, mortality, consecutive hospitalizations, work absenteeism, and increases in societal costs.
Liver cirrhosis is a public health concern and is the second cause of death amongst gastrointestinal diseases. In Brazil, it is the eighth leading cause of death among men and accounted for almost 9% of hospital admissions in 2010 (1)(2) .
Liver disease affects more people than other types of organ failure. With the progression of the disease, patients can experience associated complications, such as jaundice, portal hypertension, esophageal, gastric and hemorrhoid varices, edema, nutritional deficiency and variceal hemorrhage (3) . Moreover, patients with end-stage liver cirrhosis present calorie and protein malnutrition due to poor intake, absorption, processing and storage of nutrients, resulting in an unfavorable prognosis (4) .
There is no specific cure for cirrhosis. Therefore, the goal of treatment is to minimize the progression of the disease and to prevent complications. In this context, nurses play an important role in the multidisciplinary team because they perform comprehensive and continuous patient care.
To meet comprehensive and complex patient needs in an efficient and safe way, nurses need to have critical thinking skills to accurately diagnose, identify nursingsensitive patient outcomes and select specific nursing interventions to achieve the desired goals. In patients with liver cirrhosis, nursing care goals may include prevention of complications; promotion, maintenance, and restoration of health; facilitating optimal functional ability in the patients' desired roles, maximizing wellbeing, and promoting patient satisfaction (5) .
The use of standardized nursing terminologies in clinical practice contributes to clinical reasoning and decision making to improve healthcare and patient outcomes (6) . The nursing assessment identifies clinical indicators for nursing diagnosis, which represent evidence leading to the identification and implementation of interventions. Accurate and valid nursing diagnoses guide the selection of interventions capable of producing the desired outcomes (7) .

The Nursing Interventions Classification (NIC)
figures among the nursing classification systems widely used by nurses around the world (8) . The interventions provided in the NIC facilitate communication among nurses and other healthcare professionals, provide information to administration to balance the cost of components and quality of care, and facilitate the identification of care for specific populations (9) .
Although the use of a standardized nursing language system, including NANDA-I and NIC taxonomies, is well described in the nursing literature, there is a need for further testing in clinical practice to demonstrate their applicability to patient care and to add to a body of evidence in specific patient populations (8) .
This study addressed patients with liver cirrhosis as a population because the burden of the disease in Brazil has risen steadily, with ever-increasing associated costs and its effect on hospital admissions and mortality rates (10) . To date, previous studies have shown the effectiveness of nursing interventions in the treatment of nursing diagnoses in diverse populations and in different clinical settings (8) . There has been no specific research though that captures the contribution of nursing interventions to improve care to patients with liver cirrhosis.

Purpose
The purpose of this study was to identify the nursing interventions associated with the most accurate and frequently used NANDA-I nursing diagnoses for hospitalized patients with liver cirrhosis.

Methods
In this paper, we present results from a major investigation on nursing diagnosis and interventions in patients with liver cirrhosis (11) . This is a descriptive, quantitative, cross-sectional study, conducted from January 2013 to December 2015.

Settings and Participants
All nurses working at the gastroenterology ward of a Brazilian university hospital were eligible to participate. The exclusion criteria were nurses on vacation during data collection; participants were all Portuguese speakers; they were between 28 and 62 years of age (mean of 39.8 years) and had been working at the gastroenterology ward between one and 27 years (mean of 8.6 years).

Ethical Aspects
The study received approval from the Research  assured that their identity would remain confidential and the written consent form stipulated that they could decline or withdraw from the research at any time with no repercussions in their work.

Procedure
This study was conducted in three phases: (i) evaluating the accuracy of the most frequent used NANDA-I nursing diagnosis for hospitalized patients with liver cirrhosis identified in previous study (11) ; (ii) designing of the data collection tool based on the 5 th edition of NIC (9) ; and (iii) identifying the nursing  reviewed the most frequently used NANDA-I nursing diagnoses identified in a previous study (11) . To evaluate the accuracy of nursing diagnoses, the principal investigator sent the following to the experts: case studies of 20 patients, the Nursing Diagnosis Accuracy Scale (EADE-version 2), adapted to Brazilian culture by Matos and Cruz (12) from Lunney (13) ; a guide for completing the EADE-version 2; and a copy of the 12 most frequently identified nursing diagnoses as stated in a previous study.
The EADE-version 2 allows the nurse to take into consideration the presence, relevance, specificity and coherence of cues to reach a nursing diagnosis.
It also indicates, using ordinal values, the degree of diagnostic accuracy into four categories: zero (0), low (1), moderate (2 / 4.5 and 5.5) and upper (9/10 / 12.5 and 13.5). According to Matos and Cruz (12) cues are determined by the presence or absence of defining characteristics of the nursing diagnosis.

The concordance index (IVC) among experts
in the degree of accuracy of nursing diagnoses was calculated as follows: the number of experts who rated the nursing diagnoses as "High Accuracy" was divided by the total number of experts. Researchers considered an IVC equal to or greater than 0.80 as high accuracy (14) .

Second phase: designing of the data collection tool
The identification of nursing interventions in the NIC was performed only for the nursing diagnoses classified as high accuracy. A data collection tool was developed based on the 5 th edition of NIC (9) , as no other instrument was found suitable for this study. The development of this tool occurred in two steps.
In the first step, the principal investigator identified the NIC interventions linked to NANDA-I diagnoses. For each high accuracy diagnosis, researchers identified the list of suggested interventions for resolving the seven identified diagnoses. Then, the principal investigator developed a data collection tool containing three parts.
The first part was composed of demographic data of the nurses working in the gastroenterology ward.
The second part contained the NANDA-I/NIC linkage, definitions of each nursing intervention chosen from the NIC suggested list (9) , and the assessment scores based

Discussion
The purpose of this study was to identify the nursing interventions associated with the most frequent and accurately used NANDA-I nursing diagnoses for hospitalized patients with liver cirrhosis.
The prognosis of patients with advanced cirrhosis is poor because only less than 10% of patients live more than five years. People with decompensated liver cirrhosis integrate a large number of hospitalizations, representing a significant burden for healthcare services (16) . In this context, adequate evaluation and constant monitoring by nurses are strategies that can contribute to the prevention of complications.
In this research, a total of 12 nursing diagnoses were evaluated and seven had high accuracy (IVC ≥ 0.8).
It highlights the importance of evaluating and obtaining nursing diagnosis to establish how accurately the information obtained represents the phenomenon and the adequacy of the clinical reasoning process, thus strengthening evidence-based practice (17) . Additionally, there is concern in the scientific literature regarding nutritional management and the provision of nutritional support that is culturally acceptable, as evidenced in a study conducted in three Czech regions, which determined the frequency of the NIC in terminal patients (19) .
Nurses also suggested other interventions, not described in NANDA-I/NIC linkage, as useful measures in clinical practice to assist patients with liver cirrhosis.

These interventions included: VAD Maintenance
From five interventions selected for the diagnosis Self-Care Deficit: Dressing (00109), all were carried out occasionally or very often by nurses to treat patients with liver cirrhosis. According to Figure 1, the following interventions obtained scores superior to 0.90:

NANDA-I/NIC linkage Score
Infection, Risk for (00004) Bathing (1610)  Nurses also showed concern with the patients' skin integrity of patients. This organ is the main barrier against infection. Thus, the implementation of specific interventions may decrease the risk of skin breakdown and prevent infection. One possible intervention is to maintain skin integrity by promoting hydration (20) .
When performing the nursing process, nurses have a remarkable concern with the diagnoses Infection, Risk and Impaired Skin Integrity, Risk for, and the intervention Skin Care: Topical Treatments (3584); both can be utilized effectively (21) .
In relation to the nursing diagnosis Self-Care Deficit: Bathing, one nurse suggested "Privacy" as a desirable intervention, although it is not described in ethical conduct (22) . in which it may be necessary for patient protection and safety (25) .
Physical restraint is constantly used in order to reduce falls. The use of this intervention should be assessed by nurses, according to clinical criteria and patient assessment (26) . An alternative approach could be to positively modify the hospital environment to be less hostile and employ better therapeutic restraint management tools; this is a humanizing care task that nurses can foster and advocate within the wider multidisciplinary team (23) .
The researchers concluded that, in general, nurses on one gastroenterology unit characteristically perform nursing interventions that figure among the suggested interventions for the seven most accurate and frequently identified nursing diagnosis in this study to care for patients with liver cirrhosis. Accurate and valid nursing diagnoses guide the selection of appropriate interventions that nurses can perform to enhance patient safety, and thus improve patient health outcomes.
The limitation of this study is that the number of nurses who participated in the third phase of the study was small and limited to one specialty unit in one hospital. It is suggested that the study be conducted with larger samples of nurses, so that interventions that are never performed on patients are identified.
Future studies may also identify the reasons why nurses perform some interventions occasionally.

Conclusion
People with liver cirrhosis are subject to invasive procedures for diagnosis and treatment during hospitalization. It is necessary for nurses to develop skills and competencies in recognizing accurate nursing diagnoses and identifying appropriate nursing interventions in order to provide the best care possible.
Accurate and valid nursing diagnoses guide the selection of interventions that improve patient outcomes, thus avoiding rehospitalization due to inadequate nursing care management.