Indicators of Nursing Outcomes Classification for evaluation of patients with pressure injury: expert consensus

Santos, Cássia Teixeira dos; Barbosa, Franciele Moreira; Almeida, Thayná de; Einhardt, Raquel Silveira; Eilert, Ana Carolina; Lucena, Amália de Fátima

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RESEARCH • Esc. Anna. Nery 25 (1) • 2021 • https://doi.org/10.1590/2177-9465-EAN-2020-0155 copy

Indicators of Nursing Outcomes Classification for evaluation of patients with pressure injury: expert consensus^a a Article extracted from the doctoral thesis under development with the title Evidence of clinical validity of the nursing diagnosis Pressure Injury and the Results of Nursing Outcomes Classification/NOC in patients with pressure injury, by Cássia Teixeira dos Santos, under the supervision of Professor Amália de Fátima Lucena. Nursing Graduate Program of the Universidade Federal do Rio Grande do Sul. 2020.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

to select the nursing outcome indicators Tissue integrity: skin and mucous membranes (1101) and Wound healing: second intention (1103) of the Nursing Outcomes Classification, and to construct their conceptual and operational definitions for the evaluation of patients with pressure injuries.

Methods

expert consensus study conducted at a university hospital in September 2018. Ten nurses with experience in using the Nursing Outcomes Classification and in caring for patients with pressure injuries participated in the study. Data collection took place through face-to-face meetings with the specialists.

Results

Seventeen indicators from the Nursing Outcomes Classification were selected for the evaluation of patients with pressure injuries, with 100% agreement among the specialists. That's them: Blanching, Erythema, Sensation, Tissue perfusion, Hydration, Thickness, Necrosis, Foul wound odor, Blistered skin, Macerated skin, Undermining, Wound inflammation, Exudate/drainage, Granulation, Tunneling, Scar formation, Decreased wound size.

Conclusion and implications for practice

the selected indicators allowed the elaboration of an instrument that will assist in the evaluation of patients with pressure injuries in an accurate way. This instrument will assist the nurses in the diagnostic and therapeutic decision making of the pressure injuries.

Keywords:
Pressure Injury; Nursing Process; Standardized Nursing Terminology; Outcome Assessment; Health Care, Wound Healing

Tissue integrity: skin and mucous membranes (1101)
Definition: Structural intactness and normal physiological function of skin and mucous membranes ^¹⁴14 Moorhead S, Johnson M, Maas ML, Swanson E. Classificação dos Resultados de Enfermagem: mensuração dos resultados em saúde. 6. ed. St. Louis, Missouri: Elsevier; 2018.
Indicator/ code numeric	Conceptual definition	Operational definition according to its magnitude
Blanching (110122)	Skin with partial or total whitish pigmentation in the area of the lesion.	Serious (1): Whitish Pigmentation (WP) in 100% of the PI area
		Substantial (2): WP in 75%-50% of the PI area
		Moderate (3): WP in 25%-50% of PI area
		Light (4): WP in 1%-25% of PI area
		None (5): No bleaching on the skin
Erythema (110121)	State in which the skin is reddened due to vascular dilation.	Serious (1): Erythema in 75-100% of PI area
		Substantial (2): Erythema in 50%-75% of PI
		Moderate (3): Erythema in 25%-50% of PI
		Light (4): Erythema from 0-25% PI
		None (5): Absence of erythema
Sensation (110102)	The body's ability to react to external or internal stimuli.	Severely compromised (a) (1): Does not react to pain, even with deep stimulus
		Very compromised (a) (2): Limited ability to react to pain, sensitivity to deep stimulus
		Moderately compromised (a) (3): Limited ability to react to pain, with sensitivity to surface stimulus
		Slightly compromised (a) (4): Ability to react to pain, with sensitivity in the extremities
		Not compromised (5): Ability to react to pain, no change in sensitivity
Tissue perfusion (1101111)	It is the level of capillary oxygenation, that is, the time of vascular filling.	Severely compromised (a) (1): Pallor in the skin and mucous membranes (PSM) with capillary filling time >10 seconds (s).
		Very compromised (a) (2): PSM with capillary filling time >3 and <10 s
		Moderately compromised (a) (3): PSM with 3 s capillary filling time
		Lightly compromised (a) (4): Light PSM with capillary filling time < 3 s
		None (5): There´s no bleaching on the skin
Hydration (110104)	Property of the natural skin barrier, moisture. In the expected state, the skin is with the water content normally humid, suitable to keep it looking healthy (with vigor and integrity).	Severely compromised (a) (1): Xerosis with burning, itching and cracks or with white spots, loose tissues and scaly skin
		Very compromised (a) (2): Rough/dry skin with cracks; or with white spots and loose tissues
		Moderately compromised (a) (3): Dry skin with furfur peeling (appearance of flour) or with white spots
		Gently compromised (a) (4): Skin dry or without flaking or swollen (swollen)
		Uncompromised (5): Full skin with healthy skin
Thickness (110109)	Depth affected by the lesion, with layers and structures of the skin altered by the loss of tissue integrity.	Severely compromised (a) (1):
		Commitment from dermis to bones
		Very compromised (a) (2):
		Commitment of dermis, subcutaneous tissue and muscles
		Moderately compromised (a) (3):
		Dermis and subcutaneous tissue commitment
		Slightly compromised (a) (4):
		Dermis only commitment
		Uncompromised (a) (5): Epidermis Integral
Necrosis (110123)	Destruction of a cell or tissue, due to lack of nutrients, with black, brown or brown coloration.	Serious (1): Necrosis in 75%- 100% of PI
		Substantial (2): Necrosis in 50%-75% of PI
		Moderate (3): Necrosis in 25%-50% of PI
		Light (4): Necrosis at 0-25% of PI
		None (5): Absence of necrosis

Wound healing: secondary intention (1103)
Definition: Extent of regeneration of cells and tissues in an open wound ^¹⁴14 Moorhead S, Johnson M, Maas ML, Swanson E. Classificação dos Resultados de Enfermagem: mensuração dos resultados em saúde. 6. ed. St. Louis, Missouri: Elsevier; 2018.
Indicator / numerical code	Conceptual definition	Operational definition according to its magnitude
Foul wound odor (110317)	Presence of unpleasant odor that exhales from the injury.	Extensive (1): Extremely stinking wound, with perceptible smell when entering the room
		Substantial (2): Very stinking wound with perceptible odor on removal of secondary cover
		Moderate (3): Foul-smelling wound, perceptible odor at removal of primary cover
		Limited (4): Slightly stinking wound, odor only perceptible when cleaning
		None (5): Odorless wound
Blistered skin (110310)	Superficial elevations, over 1 cm, formed by liquids in a cavity inside the skin.	Extensive (1): Skin with several blisters covering the entire length of the bed and the edges of the lesion
		Substantial (2): Skin with several blisters covering part of the bed and the edges of the lesion
		Moderate (3): Skin with one or more blisters covering only the edges of the lesion
		Limited (4): Skin with a blister on the injury bed
		None (5): Blister-free skin
Macerated skin (110311)	Whitish tissue, softened or ruptured skin due to excessive hydration.	Extensive (1): Extensive tissue maceration around the lesion 100% -75%
		Substantial (2): Great maceration 75-50%.
		Moderate (3): Average maceration 50%-25%
		Limited (4): Small maceration 25%- 0%
		None (5): Unstained Skin
Undermining (110315)	Condition of separation or distance of the tissue (s) from the bed under the edges of the lesion.	Extensive (1): Extensive detachment area under the edges of the lesion 100% -75%
		Substantial (2): Large area of detachment under the edges of the lesion 75%-50%.
		Moderate (3): Average detachment area under the edges of the lesion 50%-25%
		Limited (4): Small detachment area under the edges of the lesion 25% -0%
		None (5): Tissue without detachment
Wound inflammation (110322)	Healing phase with infiltration of neutrophils, macrophages and lymphocytes.	Extensive (1): Extensive area of inflammation (redness, heat, pain) in the lesion 100% -75%
		Substantial (2): Large area of inflammation 75%-50%.
		Moderate (3): Average area of inflammation 50%-25%
		Limited (4): Small area of ignition 25% - 0%
		None (5): Injury without inflammation
^* * According to NOC the indicators of Purulent, Sanguineous, Serosanguineous and Serous drainage are independent. In this study, they were grouped into a single indicator called Exsudate/Drainage, in order to facilitate its clinical application, according to the consensus of experts. Exudate/drainage	Aqueous content from the lesion composed of cells, protein content and dead microorganisms.	Extensive (1): Purulent exudate (green or brown aqueous)
(110303-304-305-306)		Substantial (2): Bloody exudate (aqueous)
		Moderate (3): Serum exudate (aqueous or yellowish-pink colored liquid)
		Limited (4): Serous exudate (yellowish aspect) None (5): Absence of exudate
Granulation (110301)	Vivid red tissue with shiny appearance due to the circulation of red blood cells.	None (1): No granulation tissue
		Limited (2): 0-25% PI granulation area
		Moderate (3): Granulation area of 25-50% PI
		Substantial (4): Granulation area of 50-75% of PI
		Extensive (5): 75-100% PI granulation area
Tunneling (110314)	Creation of an artificial conduit within the lesion.	Extensive (1): tunnel >10cm in lesion
		Substantial (2): tunnel between 9 > 7cm in the lesion
		Moderate (3): tunnel between 6 > 4cm in lesion
		Limited (4): tunnel between 3 > 1cm in lesion
		None (5): No tunnel
Scar formation (110320)	Wound covered with epithelial tissue in a pinkish color that develops from the edge.	None (1): Absence of epithelial tissue
		Limited (2): Area of epithelial tissue of 0-25%.
		Moderate (3): Area of epithelial tissue 25-50%.
		Substantial (4): Area of epithelial tissue 50-75%.
		Extensive (5): Area of epithelial tissue from 75-100%.
Decreased wound size (110321)	Wound area: greatest length versus greatest width (cm2)	None (1): No reduction in the size of the injury
		Limited (2): Small 0%-25% reduction
		Moderate (3): Average reduction of 25%-50%
		Substantial (4): Large reduction of 50%-75%
		Extensive (5): Virtually closed lesion 75%-100%

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[1] Corresponding author:Cássia Teixeira dos Santos E-mail: cassia.teixeira87@hotmail.com