Nursing diagnoses related to skin : operational definitions

Objective: to validate the operational definitions of the defining characteristics and risk factors of the three NANDA International (NANDA-I) nursing diagnoses and to revise these diagnoses’ definitions. Method: content validation of nursing diagnosis. 146 defining characteristics and risk factors were identified in the literature in Brazilian and international databases. This was followed by content validation of the definitions of these diagnoses (presented by NANDA-I) and of the operational definitions (developed by the researchers) of the defining characteristics and risk factors, carried out by six expert nurses, regarding relevance, clarity and comprehensiveness. Result: of the 146 defining characteristics and risk factors, 22 were considered redundant and were excluded. The experts proposed changing the definitions of the diagnoses of Impaired Tissue Integrity and Risk for Impaired Skin Integrity. It was possible to identify various defining characteristics and risk factors which are not present in the NANDA-I taxonomy but which are indicated in the literature. Conclusion: the process attained its objective of producing valid operational definitions for defining characteristics and risk factors, which will permit the undertaking of validation studies for these diagnoses. The study’s contribution to advancing scientific knowledge consists in its presenting clearer operational definitions for these diagnoses and a higher number of defining characteristics and risk factors, which will assist the nurses in the identification and use of the same with greater accuracy in clinical practice.


Introduction
Research in the area of nursing has grown significantly in recent decades, including on Nursing Diagnoses (ND).Validation of nursing diagnoses comprises the degree to which a group of defining characteristics describes a reality which may be observed in the client-environment interaction (1) .
Various validation methods exist, among which are three models set out by Fehring (2)  These methods are still the most used.
in the 1990's, due to greater concern about improving and legitimating the diagnoses described in the NANDA-International Taxonomy (NANDA-I) (3) .
The NANDA-I (4) describes three nursing diagnoses related to the skin: Impaired Skin Integrity and Risk for Impaired Skin Integrity, approved in 1975, and Impaired Tissue Integrity, approved in 1986.These were last updated in 1998.
The principle international studies on the validation of these diagnoses occurred in the 1990s.In Brazil, there are several publications describing and discussing the presence, incidence and prevalence of these diagnoses, their defining characteristics (DCs), risk factors (RFs) and related factors, but until recently there were no validation studies.
Bear in mind that defining characteristics are observable indications/inferences which may be grouped as manifestations of an actual ND or of wellbeing, and that risk factors are environmental factors and physiological, psychological, genetic or chemical elements which increase the vulnerability of an individual, family or community to an unhealthy event (4) .
In 2010 and 2011, two master's degree dissertations were published on diagnoses of Impaired Tissue Integrity and Impaired Skin Integrity.One was about validation, and the objective of the other was to verify the occurrence of these diagnoses in patients with vasculogenic ulcers (5)(6) .
No studies were found addressing the validation of the three diagnoses together, with discussion about each's definition and scope.In addition, the two most recent studies explored -in a way which would describe these diagnoses better -few defining characteristics and risk factors reported in the literature other than those described in the NANDA-I taxonomy.Accordingly, if nurses are to be offered scientific support to facilitate the use of these diagnoses in their clinical practice, it is necessary to develop studies addressing this issue.
Before carrying out any study on validation, a literature review is recommended, to provide theoretical support, both for the diagnoses and the DCs/ RFs, benefitting the development of the operational definitions (2) .
Based on these considerations, the authors' proposal was to validate the operational definitions of the DCs and RFs of the skin-related nursing diagnoses in NANDA-I described in the literature and to revise these diagnoses' definitions, that is, to ascertain if these diagnoses are appropriate and, if necessary, to propose new definitions.the Brazilian Association of Nursing (ABEn).Two books on nursing diagnoses, both considered classics, were also used (4,7) .

Method
The survey was undertaken with the following descriptors, using the Boolean operator AND: diagnóstico de enfermagem/nursing diagnosis AND estudos de validação/validation studies, as recommended in the list of Descriptors in Health Sciences (DeCS) of the Regional Library of Medicine (Bireme) and in the list of Medical Subject Headings (MeSH) of the National Library of Medicine (NLM).
In addition to these descriptors, the following terms   The definitions of the diagnoses proposed by NANDA-I and the operational definitions elaborated by the researchers were evaluated for relevance, clarity and comprehensiveness, according to the model used in a previous study (8) .
The relevance indicated that the OD elaborated was in line with the DC/RF of the diagnosis studied.Each item was evaluated as: (-1) not relevant; (0) not possible to evaluate/don't know; and (+1) relevant.
The clarity referred to the fact of the OD being clear and easy to understand, principally by nurses who are not specialists on the subject.Thus, the operational definitions were evaluated as: (-1) not clear; (0) not possible to evaluate/don't know and (+1) clear.
The comprehensiveness referred to the OD being sufficiently broad and comprehensive for the DC/ RF studied.For the evaluation of comprehensiveness, each item was evaluated as: (-1) not comprehensive; (0) not possible to evaluate/don't know, and (+1) comprehensive.In addition to this, the judges were requested to ascertain if there was any redundancy between DCs/RFs, or if there was any need for additions.
Excel (version 2007 Microsoft Ò ), was used for tabulation and analysis of the data.The percentage agreement was used for calculating the content validity, a method used for calculating agreement between the judges.This is calculated based on the number of participants who agree, divided by the total number of participants and multiplied by 100 (9) .A percentage agreement equal to or greater than 80% is considered adequate, that is, five of the six judges would have to agree on the definition presented, as recommended in the literature (10) .

The project was approved by the Research Ethics
Committee of the Dr. Mário Gatti hospital under protocol number 029/2010.

Results
As may be observed in Figure 2 The most commonly used methods (60% or 3/5) were content validation and clinical validation (2) and the nurses who participated in the studies, as experts, were those with professional registration.Only one study adopted as a criteria being an intensive care nurse, a member of the American Association of Critical Care Nurses.The other two were clinical, with data collected from medical records and retrospective validation of the diagnosis (11) .
Practically all the studies selected presented other DCs and RFs, in addition to those described by NANDA-I -such as, for example, hyperemia, pain, cellulitis and blisters.Only one presented the ODs used, but without informing whether they were validated or not.
Regarding the result of the validation of the definitions of the diagnoses by the six judges, the definition of the diagnosis of Impaired Skin Integrity obtained a percentage agreement of 83%, and the judges made no suggestions for modifying it.
Although the diagnosis of Risk for Impairment of Skin Integrity also received a percentage agreement of 83%, the judges suggested that its definition be modified from "at risk for skin being adversely altered" to "Risk of loss of skin integrity".

The definition of the diagnosis "Impaired Tissue
Integrity" presented a percentage agreement of 83%, and the judges suggested modifying it.Thus, the original definition of "damage to mucous membrane, corneal, integumentary, or subcutaneous tissues" was modified by the researchers to: "damage to the mucous membranes (oral, nasal, ocular, anal, urethral or vaginal), ocular cornea, skin, subcutaneous tissue (hypodermis), muscular fascia, muscle, tendons and bone".
After further evaluation by the judges, one suggested removing the word "skin", and the definition became: "damage to the mucous membranes (oral, nasal, ocular, anal, urethral or vaginal), ocular cornea, subcutaneous tissue (hypodermis), muscular fascia, muscle, tendons and bone".
As the skin is also involved when Tissue Integrity is impaired, the researchers decided to keep the two definitions, in addition to the original proposed by NANDA-I, so that they might be validated by future studies.
Regarding the operational definitions of the defining

Conclusion
It was possible to identify various defining characteristics and risk factors which are not present in the NANDA-I taxonomy but which were indicated by the literature.
The use of a rigorous methodology for evaluating and refining allowed the construction of operational definitions for DCs/RFs which were relevant, clear and comprehensive, as well as the proposing of new definitions for two diagnoses, Impaired Tissue Integrity and Risk for Impaired Skin Integrity, which will be evaluated in future studies.
By presenting clearer definitions for these diagnoses, and a higher number of DCs/RFs, the hope is to assist nurses in identifying them with greater accuracy in clinical practice.This study's contribution consists of presenting clearer operational definitions and a higher number of DCs/RFs, which may assist nurses in the identification and use of the same with greater accuracy in clinical practice.
This was methodological research, on the content validation of DCs/RFs of the diagnoses of Impaired Skin Integrity, Risk for Impaired Skin Integrity and Impaired Tissue Integrity.The period researched included the publications on the issue from 1975 until March 2009, as it was in 1975 that the diagnoses of Impaired Skin Integrity and Risk of Impaired Integrity were approved by NANDA-I.To identify what the DCs/RFs of these diagnoses were, a bibliographic survey was undertaken in Brazilian and international health databases, namely: the Latin American and Caribbean Center on Health Sciences Information (LILACS), Brazilian Nursing databank (BDENF), Medical Literature Analysis and Retrieval System Online (Medline), the State University of São Paulo's bibliographic database (Dedalus), the National Library of Medicine and the National Institute of Health (Pubmed), the Cumulative Index to Nursing Allied Health Literature (Cinahl) and also the library system of the University of Campinas (SBU).The NANDA-I periodical, currently termed the International Journal of Nursing Knowledge, but formerly known as Nursing Diagnoses, was also consulted.Further, research was carried out manually by reading the titles and abstracts in the proceedings of the NANDA-I conferences held in Brazil, and in the Annals of the National Symposiums on Nursing Diagnoses (Sinadens) which were arranged and made available by

Figure 1 ,
Figure1, after reading the texts in their entirety, 36 articles were selected.
Classification of nursing diagnoses: proceedings of the eighth conference held in St. Louis,MO, March, 1988.1989.p. 345-8.Impaired Skin Integrity (DC/RF) 5 -Schue RM, Langemo DK.Pressure ulcer prevalence and incidence and a modification of the Braden Scale for a rehabilitation unit.J Wound Ostomy Continence Nurs.1998; 25(1): 36-43.Impaired Skin Integrity (RF) 6 -Hardy MA.A pilot study of the diagnosis and treatment of impaired skin integrity: dry skin in older persons.Nursing Diagnosis.1990;1(2):57-63.Impaired Skin Integrity (DC) 7 -Anderson J, Thomson A. Impaired skin integrity: clinical validation of the defining characteristics.In: Carroll-Johnson RM; J.B. Lippincott.Classification of nursing diagnoses: proceedings of the ninth conference held in Orlando, FL, 1990.Orlando.1991 p.126-32.14 -Pasini D, Alvim I, Kanda L, Mendes RSP, Cruz, DALM.Diagnósticos de enfermagem de pacientes em unidades de terapia intensiva.Rev. esc.enferm.USP.1996; 30(32):501-18.Impaired Skin Integrity (DC) 30 -Bassoli, SRB, Guimarães HCQC, Virmond MCL.Identificação dos diagnósticos de enfermagem em uma clínica dermatológica.In Elizalva FO; Maria Mirian LN; Maria Julia GOS, organizers.Trilhando caminhos na construção de uma terminologia brasileira de enfermagem.8th National Symposium of Nursing Diagnoses (Sinaden); 23-26th May 2006; João Pessoa, Paraíba.João Pessoa: UFPB; 2006.CD ROM.Impaired Skin Integrity (DC/RF) 31 -Baldissera VDA, Nogueira AMA, Fernandes FO, Araújo RD.Diagnósticos de enfermagem relacionados a complicação periostomal segundo NANDA: análise crítica das habilidades necessárias ao enfermeiro.Arq.Ciênc.Saúde Unipar.2007; 11(1): 63-0.Impaired Skin Integrity (DC) 32 -Schindler CA, Mikhailov TA, Fischer K, Lukasiewicz G, Kuhn EM, Duncan L. Skin integrity in critically ill and injured children.American journal of critical care.2007; 16(6):568-74.Impaired Skin Integrity (RF) 33 -Collen TB Pediatric Skin Care: Guidelines for Assessment, Prevention, and Treatment.Dermatology Nursing.2007:19(5):471-85.Impaired Skin Integrity (RF) 34 -Galiza FT, Bastos NP, Teixeira SC, Freitas MC, Gudes, MVC, Gomes LDP.Risco de integridade da pele prejudicado no idoso: Cuidado clínico de enfermagem.Contribuição Brasileira para o desenvolvimento das Classificações de Enfermagem.9th National Symposium of Nursing Diagnoses (Sinaden); 26-29th May 2008; Porto Alegre, Rio Grande do Sul: HC Porto Alegre; 2008.nº 42.CD ROM.After closing the article search, the DCs and RFs were identified and organized into a list.At this point, each one's operational definition (OD) was constructed, using literature relevant to the issue.After this, the content validation was carried out.Six nurses with known expertise in the areas of dermatology and stomal therapy were intentionally invited to be the judges in validating the ODs.All were female, with an average age of 46 years (38 to 49 years) and an average professional experience of 22.8 years (13 to 26 years).The judges stated that: they were experienced with www.eerp.usp.br/rlae Regarding the presence of redundant DCs/RFs, the judges identified 13 DCs for the diagnosis of Impaired Skin Integrity and 9 RFs for the diagnosis of Risk for Impaired Skin Integrity.Of the 146 defining characteristics/risk factors, 22 were considered redundant and excluded.Thus, 35 DCs for the diagnosis of Impaired Skin Integrity, 68 RFs for the diagnosis of Risk for Impaired Skin Integrity, and 21 DCs for the diagnosis of Impaired Tissue Integrity remained, as may be seen in Figures 3, 4 and 5.Ribeiro MAS, Lages JSS, Lopes MHBM.definitions, prior to submitting them to a second evaluation by the judges.This is perfectly acceptable in this type of study, as it is very difficult to achieve consensus among all the judges in the first round.The modifications made improved the qualification of the operational definitions, assisting the validation process.One very important aspect in this process of the validation of the ODs was the suggestion made by the judges to modify the definitions of the diagnoses of Risk for Impaired Skin Integrity and Impaired Tissue Integrity, as, if the process of change really should be carried through after other studies, this will be reflected directly in nurses' clinical practice, because more precise definition of these diagnoses would permit them to distinguished from the others.Further, a higher number of DCs/RFs representing these diagnoses will probably allow them to be identified more accurately, although caution is necessary here because when DCs/RFs are shared by more than one diagnosis, the fact may create doubts; in addition to this, an excessively high number of DCs/RFs may lead to a less accurate diagnosis, when in a specified clinical situation, only secondary DCs or RFs are identified.