ICNP® nursing diagnoses for clinical practice in spinal cord injury rehabilitation

Clares, Jorge Wilker Bezerra; Moreira, Samara Oliveira; Fernandes, Bruna Karen Cavalcante; Freitas, Maria Célia de

doi:10.1590/0034-7167-2021-0670

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 75 (1) • 2022 • https://doi.org/10.1590/0034-7167-2021-0670 copy

ICNP® nursing diagnoses for clinical practice in spinal cord injury rehabilitation

Diagnósticos de enfermería de la CIPE^® para la práctica clínica de la rehabilitación en lesiones de la médula espinal

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to construct statements of nursing diagnoses for the clinical practice of rehabilitation of people with spinal cord injury using the International Classification for Nursing Practice (ICNP^®) and Orem’s theory of self-care.

Methods:

methodological study developed in four steps: identification of relevant terms to clinical nursing practice in the rehabilitation of people with spinal cord injury; mapping of selected terms with ICNP^® terms; construction of nursing diagnoses statements; mapping of statements constructed with pre-coordinated concepts of the ICNP^®.

Results:

241 statements of nursing diagnoses were constructed and categorized according to the self-care requisites of the theory. The most prevalent statements were those related to universal requisites, followed by developmental requisites and health deviation requisites.

Conclusions:

the constructed nursing diagnoses reflect the complexity of phenomena evidenced in the clinical practice of rehabilitation, allowing a systematic and comprehensive care to the person with spinal cord injury.

Descriptors:
Nursing Diagnosis; Standardized Nursing Terminology; Classification; Rehabilitation Nursing; Spinal Cord Injuries

Universal requisites	Nursing diagnoses
Oxygenation and circulation	Bradycardia (10027274); Heart rate within normal limits (10029229); Effective tissue perfusion (10028593); Impaired peripheral tissue perfusion (10044239); Altered blood pressure (10022954); Blood pressure within normal limits (10027647); Tachycardia (10027288).
Nutrition and hydration	Impaired self feeding (10000973); Low weight (10027316); Impaired swallowing (10001033); Excessive food intake (10000682); Insufficient food intake (10000607); Improved food intake (10047324); Improved fluid intake (10047330); Impaired fluid intake (10029873); Weight within normal limits (10027392); Impaired weight (10013016); Overweight (10027300).
Elimination and excretion	Constipation (10000567); Constipation absent; Improved constipation; Bowel continence (10027741); Urinary continence (10027836); Effective defecation (10028403); Impaired defecation (10022062); Peripheral edema (10027482); No peripheral edema absent (10029020); Increased urinary frequency; Normal urinary frequency; Reduced urinary frequency; Fecal impaction (10021885); Bowel incontinence (10027718); Urinary incontinence (10025686); Stress urinary incontinence (10026797); Urge urinary incontinence (10026811); Functional incontinence of urine (10026778); Overflow incontinence of urine (10026914); Reflex incontinence of urine (10026784); Total urinary incontinence (10026807); Effective urination (10047245); Impaired urination (10021790); Absent urethral resistance; Urethral resistance; Urinary retention (10034654); Risk for constipation (10015053); Risk for urge incontinence of urine (10026848); Risk for urinary retention.
Activity and rest	Effective active range of motion (10052082); Impaired active range of motion (10052095); Impaired ability to transfer (10001005); Able to mobilize (10028461); Able to move in bed (10029240); Able to transfer (10028322); Activity intolerance (10000431); Impaired walking (10001046); Effective wheelchair mobility; Impaired wheelchair mobility (10001363); Effective mobility in bed; Impaired mobility in bed (10001067); Impaired mobility (10001219); Paralysis (10022674); Risk for activity intolerance (10015011); Adequate sleep (10024930); Impaired sleep (10027226); Somnolence (10040141).
Social interaction and loneliness	Effective social support (10045794); Lack of social support (10022753); Social isolation (10001647); Risk for social isolation (10047213).
Prevention of risks to life and wellbeing	Health care associated complication (10042451); No health care associated complication; Aggressive behavior (10002026); No aggressive behavior (10035645); Comfortable (10025574); Confusion (10023633); No confusion (10028847); Pain control (10025831); Inadequate pain control (10039910); Discomfort (10023066); Autonomic dysreflexia (10000496); No autonomic dysreflexia; Acute pain (10000454); Increased pain (10051555); Absent pain (10029008); Chronic pain (10000546); Neurogenic pain (10013125); Reduced pain (10027917); Excoriation (10047060); Spasticity (10018520); increased spasticity; Spasticity absent; Reduced spasticity; Fever (10041539); Suicidal ideation; Infection (10023032); No infection (10028945); Urinary tract infection (10029915); Inflammation (10029927); Effective skin integrity (10028501); Improved skin integrity (10028517); Impaired skin integrity (10001290); Pressure injury (10025798); No pressure injury (10029065); Fall-related injury (10038513); No fall-related injury (10038545); Transfer injury (10030074); No transfer injury (10033659); Friable skin; Dry skin (10047073); Altered perception (10001242); Effective sensory perception (10028173); Fall (10029405); No fall (10034704); Complex medication regime (10022983); Risk for health care associated complications (10041296); Decreased risk for health care associated complications; Reduced risk for plaster cast related complications; Risk for plaster cast related complications; Decreased risk for orthotic device related complications; Risk for orthotic device related complications; Risk for autonomic dysreflexia (10015030); Risk for infection (10015133); Risk for cross infection (10041807); Risk for urinary infection (10051950); Risk for impaired skin integrity (10015237); Risk for pressure injury (10027337); Risk for fall-related injury (10038521); Risk for fall (10015122); Risk for suicide (10015356); Decreased suicide risk (10027938); Risk for impaired thermoregulation (10015244); Risk for deep vein thrombosis (10027509); Risk orf violence (10022487); Body temperature within normal limits (10027652); Effective thermoregulation (10033848); Impaired thermoregulation (10033560); No deep vein thrombosis (10036406); No dizziness (10045681); Dizziness (10045584); No violence (10029168); Improved vision (10047353); Impaired vision (10022748).
Health promotion and maintenance	Impaired ability of caregiver to perform caretaking (10035414); Impaired family ability to manage regime (10000902); Impaired ability to groom (10029632); Ability to perform impaired hygiene (10000987); Impaired ability to perform leisure activity (10040351); Impaired ability to perform oral hygiene (10029645); Impaired ability to perform caretaking (10029621); Ability to manage external continence device (10042548); Impaired ability to participate in care planning (10035134); Improved ability to toilet self (10047266); Impaired ability to dress (10027578); Able to dress and groom (10028207); Effective verbal communication; Impaired verbal communication (10025104); Caregiver able to perform caretaking (10035405); Self-care deficit (10023410).

Self-care requisites

Nursing diagnoses

Developmental requisites

Spiritual distress (10001652); Decreased spiritual distress (10027149); Anxiety (10000477); Reduced anxiety (10027858); Positive self-esteem (10025751); Negative self-image (10022724); Positive self-image (10027108); Low self-esteem (10029507); Chronic low self-esteem (10000533); Situational low self-esteem (10000844); Adequate knowledge (10027112); Knowledge of skin care; Knowledge of care with plaster casts; Knowledge of orthotic device care; Knowledge of wound care (10033784); Knowledge of disease (10023826); Knowledge of spinal cord injury; Knowledge of pain management (control) (10033750); Knowledge of medication (10025968); Knowledge of safety measures (10028643); Knowledge of rehabilitation regime; Knowledge of medication regime (10023819); Knowledge of fall prevention (10040276); Knowledge of treatment regime (10025733); Helplessness (10039952); Impaired sexual functioning (10001288); Difficulty coping (10001120); Readiness for effective coping (10001469); Effective caregiver coping (10034838); Impaired coping of the caregiver; Effective coping (10022378); Effective family coping (10034770); Impaired family coping (10034789); Lack of knowledge (10000837); Lack of knowledge about skin care; Lack of knowledge of plaster cast care; Lack of knowledge of orthotic device care; Lack of knowledge of wound care; Lack of knowledge of disease (10021994); Lack of knowledge of pain management (10040016); Lack of knowledge of medication (10025975); Lack of knowledge of safety measure (10022015); Lack of knowledge of medication regime (10021941); Lack of knowledge of rehabilitation regime; Lack of knowledge of fall prevention (10040230); Lack of knowledge of treatment regime (10021925); Lack of knowledge of spinal cord injury; Depressed mood (10022402); Improved Mood (10050027); Fear about death (10037834); Reduced fear (10027889); Risk for situational low self-esteem (10015180).

Health deviation requisites

Effective adaptation; Impaired adaptation (10022027); Adherence to rehabilitation regime (10033671); Adherence to dietary regime (10030159); Adherence to medication regime (10030192); Adherence to therapeutic regime (10030205); Health-seeking behavior (10000735); Impaired health-seeking behavior (10022920); Effective Continuity of Care (10035507); Effective role performance (10027940); Impaired role performance (10000941); Impaired health maintenance (10000918); Non-adherence to rehabilitation regime; Non-adherence to dietary regime (10022117); Non-adherence to medication regime (10021682); Non-adherence to therapeutic regime (10022155); Denial (10000624); No denial (10044260); Inadequate income (10022563).

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[1] Corresponding author: Jorge Wilker Bezerra Clares E-mail: jorgewilker_clares@yahoo.com.br

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ICNP® nursing diagnoses for clinical practice in spinal cord injury rehabilitation

Diagnósticos de enfermería de la CIPE® para la práctica clínica de la rehabilitación en lesiones de la médula espinal

ABSTRACT

Objectives:

Methods:

Results:

Conclusions:

Diagnósticos de enfermería de la CIPE^® para la práctica clínica de la rehabilitación en lesiones de la médula espinal