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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.51  São Paulo  2017  Epub Mar 27, 2017

https://doi.org/10.1590/s1980-220x2016027203204 

ORIGINAL ARTICLE

Proposal of nursing care plan in people hospitalized with AIDS*

Vinicius Lino de Souza Neto1  * 

Richardson Augusto Rosendo da Silva2 

Cristiane da Costa Silva3 

Rosangela Vidal de Negreiros4 

Cintia Capistrano Teixeira Rocha5 

Maria Miriam Lima da Nóbrega6 

1Universidade Federal do Rio Grande do Norte, Departamento de Enfermagem, Natal, RN, Brazil.

2Universidade Federal de Campina Grande, Campina Grande, PB, Brazil.

3Universidade Federal da Paraíba, Centro de Ciências da Saúde, João Pessoa, PB, Brazil.


Abstract

OBJECTIVE

to elaborate and validate a proposal for a nursing care plan in people hospitalized with AIDS, in an infectious disease unit, using ICNP® version 2015.

METHODS

A cross-sectional study, followed by validation of content, performed with 20 nurses and 120 people, living with AIDS in an infectious disease unit of a hospital of infectious diseases in Northeast Brazil. The methodological trajectory was carried out in the following stages: elaboration of the diagnosis, nursing outcomes; Initial proposal of nursing interventions; Preparation of a care plan; And validation of the plan by field experts.

RESULTS

42 diagnoses were elaborated and validated, 33 presented CVI > 0.80 (55.42%) among field experts. From this quantitative, 228 interventions were elaborated and 41 obtained a CVI > 0.80 (44.78%), considered validated.

CONCLUSION

The study allowed us to identify and validate nursing diagnoses, outcomes and interventions for the use in clinical practice, aiming to subsidize the process of care for people with AIDS.

Descriptors Acquired Immunodeficiency Syndrome; Nursing Process; Nursing Diagnosis; Classification

Resumo

OBJETIVO

Elaborar e validar uma proposta de plano de cuidados de enfermagem para pessoas internadas com Aids, em unidade de infectologia, utilizando a CIPE® versão 2015.

MÉTODO

Estudo transversal, seguido de validação de conteúdo, realizado com 20 enfermeiros e 120 pessoas, vivendo com Aids em uma unidade de infectologia de um hospital de doenças infectocontagiosas no Nordeste do Brasil. A trajetória metodológica foi realizada nas seguintes etapas: elaboração dos diagnósticos, resultados de enfermagem; proposta inicial das intervenções de enfermagem; elaboração de um plano de cuidados; e validação do plano por especialistas.

RESULTADOS

Foram elaborados 42 diagnósticos; resultados e validados, 33, os quais apresentaram IVC > 0,80 (55,42%) entre os especialistas. A partir desse quantitativo, elaboraram-se 228 intervenções e 41 obtiveram um IVC > 0,80 (44,78%), consideradas validadas.

CONCLUSÃO

O estudo permitiu identificar e validar diagnósticos, resultados e intervenções de enfermagem para aplicação na prática clínica, com vistas a subsidiar o processo de cuidado às pessoas com Aids.

Descritores Síndrome da Imunodeficiência Adquirida; Processos de Enfermagem; Diagnóstico de Enfermagem; Classificação

Resumen

OBJETIVO

Elaborar y validar una propuesta de plan de cuidados de enfermería para personas internadas con SIDA en una unidad de infectología, utilizando el CIPE® versión 2015.

MÉTODO

Estudio transversal con validación de contenido posterior, realizado con 20 enfermeros y 120 personas viviendo con SIDA en una unidad de infectología de un hospital de enfermedades infecto-contagiosas en el nordeste de Brasil. La trayectoria metodológica fue realizada con las siguientes etapas: elaboración de los diagnósticos, resultados de enfermería, propuesta inicial de intervenciones de enfermería y validación de este plan por especialistas.

RESULTADOS

fueron elaborados 42 diagnósticos; resultados y validados, 33, los que presentaron IVC>0,80 (55,42%) entre los especialistas. A partir de esta cantidad se elaboraron 229 intervenciones y 41 de ellas obtuvieron un IVC> 0,80 (44,78%) siendo consideradas validadas.

CONCLUSIÓN

El estudio permitió identificar y validar diagnósticos, resultados e intervenciones de enfermería para aplicación en la practica clínica, con el fin de mejorar el proceso de cuidado a las personas con SIDA.

Descriptores Sindrome de Inmunodificiencia Adquirida; Procesos de Enfermería; Diagnóstico de Enfermería; Classificación

Introduction

The Acquired Immunodeficiency Syndrome (AIDS) is still considered one of the most serious public health problems, representing a dynamic and unstable global phenomenon. In addition, the condition prompts concern that affects the whole world, facing the large responsibilities of attention and specific care, which require those involved with care to reinforce actions that positively influence the lives of people infected by the aforementioned virus1-2.

Thus, it is up to the nurse, as a member of the health team, to improve the care, through the restructuring of their practices, in order to use specific Nursing instruments that will increase the care in people with AIDS, increasing their visibility and their professional recognition. In this sense, the Systematization of Nursing Care (SNC) emerges as an instrument that assists in the provision of nursing care, reducing complications during treatment and/or facilitating client adaptation and recovery, as well as identifying priority needs and the elaboration of an individualized, humanized and integrality of care3.

To this end, the International Classification for Nursing Practice (ICNP®) emerges as a unifying framework for the different classification systems of the professional practice elements - nursing diagnoses, outcomes and interventions -, collaborating for critical thinking, scientific and resoluteness of the nurse4. Such a classification system has its structure developed based on the Seven Axes Model, being these: Focus, Judgment, Means, Action, Time, Location and Client4-5.

In addition, the ICNP® complements any systematic activity that may be developed by the nurse, among them the care plan, which is characterized as a tool of the professional’s daily practice and that allows care in the organization of the work of the nursing team. In addition to optimizing the practice, the care plan must work towards the basic human needs, characterized by the aspects related to food, water, safety, love, necessary for survival and health. Thus, the implementation of the care plan, based on a theoretical framework, guides and enhances the practice, directing the observation of the phenomena, the nursing intervention and the outcomes to be expected5.

Therefore, the rationale for the development of the study is based primarily on the search for scientific productions published during the last 5 years on the subject, in the following databases: Latin American and Caribbean Literature (Lilacs), PUBMED, SCOPUS, Web of Science and CINAHL, through the descriptors: Nursing Processes; Nursing; Nursing Diagnosis and Acquired Immunodeficiency Syndrome. There was scarcity of scientific productions that addressed the applicability of SNC to people living with AIDS, especially regarding the use of ICNP® for these clients6-7.

In addition to this scientific production problem, the study provides a greater dimension and broadening of knowledge about care for people living with AIDS, as well as emphasizes the importance of systematic practices in the field of infectology and the implementation of new nursing technologies, the ICNP® is an example. The study also intends to carry out these practices with the clients cited in these databases in the future. In view of this, the question is: What are the care needs identified in people living with AIDS? Consistent with this research-question, the study aims to elaborate and validate a proposal for a care plan for people living with AIDS, using the ICNP® version 2015.

Method

Cross-sectional, quantitative approach study, followed by content validation conducted by field experts, carried out with people living with AIDS and nurses from a hospital of infectious diseases in Northeast Brazil. The methodological trajectory was carried out in four stages: a) elaboration of the diagnoses; b) nursing outcomes; c) initial proposal of nursing interventions; d) elaboration of a care plan and content validation of the care plan by nurses who provide care to people with AIDS.

In the first step, the sample was calculated from the arithmetic mean of the number of people living with AIDS who were cared for between 2010 and 2014, reaching 300.2 patients per year. Thus, the formula for finite populations was adopted, which takes into account the 95% confidence level, the 5% sampling error and the population size8.

After applying the formula, we found the study sample: 120 people living with AIDS. The selection was for convenience, consecutively, adopting the following inclusion criteria: having been clinically diagnosed with AIDS, being over 18 years old and hospitalized at the time of data collection. As exclusion criteria: those people who were unaware of their diagnosis and who did not have preserved cognitive functions, evaluated through the Mini Mental State Examination9.

The data collection was performed through an interview script and physical examination for people living with AIDS, based on Wanda de Aguiar Horta's basic human needs theory. This instrument included: sociodemographic aspects, clinical data (transmission form, time of diagnosis, presence of infections, adherence to antiretrovirals, drugs and laboratory tests) and empirical indicators of basic psychobiological, social and spiritual human needs.

To validate content, appearance, clarity and applicability of the instrument, expert nurses were searched in the Lattes platform (a national curriculum database created, above all, to follow up researchers’ work in Brazil) of the National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq). These are research experts in the following fields: Nursing; Subareas: Nursing of contagious diseases; Systematization of nursing care; International Classification for Nursing Practice (ICNP®). The sample adopted by the research was based on Fehring's framework, which deduces that the minimum number of experts should be 25 and the ideal number, 50 participants10. Thus, the experts were intentionally selected and the author’s eligibility criteria were adopted, as shown in Quadro 1. In this sense, 45 experts were selected, who scored above five points, but only 27 responded the script.

For the analysis of the expert nurses, we sent them the script in Microsoft Word version 2010, which contained, for each variable, an agreement column and a disagreement column. If they did not agree with the variable, we suggested they should suggest improvements in the suggestion column, which would later be analyzed by the researchers and returned to the experts, aiming at a new appreciation.

The suggestions pointed out by the experts are directed to each variable, such as laboratory tests, viral load, infection time and aspects of morbidities, since they refer to the object of the study. Thus, the modifications were contemplated in the study and adapted according to reality. The instrument was then returned for evaluation of this group with no further suggestion pointed out. For greater reliability, a pre-test was also performed with 10% of the sample of people living with AIDS, so that possible gaps were identified, and there was no need for modifications.

Chart 1 Criteria for selection of experts proposed by Fehring - Natal, RN, Brazil, 2016. 

Once the script was elaborated, the data collection took place from August to September 2015. The elaboration of the diagnoses was procedural, that is, after the data collection performed through the validated instrument, two of the researchers of the present study, one with a master’s degree and one with a PhD, identified the priority nursing centers, so that the diagnoses and nursing results using ICNP® version 2015 could be elaborated.

In this process of elaboration of nursing diagnosis statements, Gordon’s diagnostic reasoning was adopted, which uses the hypothetical-deductive model, considering the predictive testing of the hypothesis as the key of the diagnostic process, defining that the diagnostic process involves four perceptual and cognitive activities11. For the structuring of the diagnoses, nursing results by ICNP®, the statements should be composed of a term from the axis focus and judgment12.

A database was built, using Microsoft Excel 2009, with the respective diagnoses and nursing outcomes for people with AIDS. For each diagnosis, the two researchers prepared an initial proposal for the respective nursing interventions based on ICNP®, which should contain a term of the axis action and client, in accordance with ISO resolution 18.10412.

Finally, a proposal of a care plan with the respective diagnoses, outcomes and nursing interventions was structured. For the clinical validation of the plan, there were 20 nurses from the practice of care, who met basic requirements, such as: having at least 5 years of experience in the practice of care for people living with AIDS; and being Graduate and/or having residency in the area of ​​infectology. The expert nurses were responsible for assessing whether the proposed statements were applicable to the clients. However, before sending the plan electronically, a course for nurses was held, in October 2015, with a 40-hour workload, in the auditorium of the hospital unit, given by the researchers of the present study.

The objective of the training was to qualify nurses on the clinical and epidemiological aspects of AIDS; nursing care to these clients, highlighting nursing technologies such as SAE, PE, Nursing Diagnostics and ICNP®, with emphasis on clinical reasoning and practice of nursing diagnosis. During the presentation of these topics, constant elements were discussed in the instrument of data collection. In addition, a practical activity was organized, proposed by the researchers, through fictitious clinical cases, with the objective of analyzing the diagnostic inferences of the expert nurses.

Finally, a spreadsheet was sent to the nurses, containing the respective diagnoses, outcomes and nursing interventions and, for each statement, a column of agreement, disagreement and suggestions was elaborated. The validation phase occurred between November and December 2015. In case of disagreement of the claims, it was requested that the suggestions should be presented for adequacy to the reality of the nursing practice.

In order to perform the analysis of the agreement of the experts, the method called Content Validity Index (CVI) was adopted, which measures the proportion of experts who agree on certain aspects of the instrument and its items, represented by the diagnostic/outcomes statements and nursing interventions, which were evaluated for their use in the practice of care for people with AIDS. The items that obtained an agreement of at least CVI ≥ 0.80, which is considered optimal, were considered validated.

The study also met the ethical precepts of research involving human subjects, with favorable evaluation by the Research Ethics Committee of the Universidade Federal do Rio Grande do Norte (UFRN), according to the protocol number 1.117.410 and Certificate of Presentation for Assessment Ethics n° 47380915.2.0000.5537.

Results

The study included 120 people living with AIDS, with a minimum age of 35 years and a maximum of 45 years (67.75%), average of 40.27 years. The majority were female (57.78%), married (63.85%), self-employed (41.33%), white (54.21%) and Catholic (85.74%). Regarding the characterization of the expert nurses, 18 (64.28%) had more than 16 years of professional experience in the field of infectious diseases, they had either a Certificate of specialist (58.64%) or a masters’ degree (41.36%). In the identification of the data, the focus of the nursing practice was obtained, which were the empirical indicators for diagnosis, nursing results. Chart 2 shows the focuses of nursing practice, grouped by their respective basic human needs.

Chart 2 Distribution of the elements of nursing practice on people living with AIDS - Natal, RN, Brazil, 2016. 

From the elements of nursing practice, 42 diagnoses were produced, but 33 were validated, which presented a CVI > 0.80 (55.42%) among expert nurses, categorized according to basic human needs, as shown by the Table 1.

Table 1 Basic Human Needs changed in people living with AIDS from ICNP® 2015 - Natal, RN, Brazil, 2016. 

BASIC HUMAN NEEDS
Psychobiological needs
Nursing diagnosis statements
Oxygenation and vascular regulation f(%) CVI > 0.80
Dyspnea 94 1.0
Increased heart rate 90 1.0
Bleeding 79 0.70
Expectoration 70 0.50
Hydration and electrolytic regulation
Impaired swallowing 82 0.90
Dehydration 80 0.80
Hyperthermia 80 0.80
Nutrition and excretion
Cachexia 78 0.70
Impaired Defecation 74 0.62
Committed spontaneous bladder elimination 74 0.60
Excessive intestinal elimination 71 0.50
Vomit 70 0.50
Sleep and rest
Insomnia 68 0.42
Thermal regulation, body care and cutaneomucous integrity
Impaired skin integrity 68 0.40
Impaired oral cavity hygiene 65 0.40
Impaired scalp hygiene pattern 61 0.35
Physical security of the environment, immunological regulation, therapeutics
Exposure to contamination 60 0.35
Tobacco abuse 60 0.30
Drug abuse 59 0.30
Alcohol and tobacco abuse 55 0.30
Psychosocial needs
Communication / Learning (health education) / Sociability / Recreation and leisure
Acceptance of the impaired therapeutic regimen 81 1.0
Loneliness 80 1.0
Fear 79 0.80
Communication impaired 75 0.70
Altered state of consciousness 70 0.70
Social isolation 69 0.65
Low health knowledge 65 0.60
Self-realization, Self-esteem and Self-image
Acceptance 61 0.50
Body Modification 60 0.50
Socialization 50 0.40
Will to Live 47 0.40
Spiritual needs
Religious / Spirituality
Spiritual Anguish 47 0.40

In this sense, from the diagnoses, 228 interventions were elaborated and evaluated by the experts, and only 41 interventions obtained a CVI > 0.80 (44.78%), and were therefore validated. Chart 3 shows the diagnoses/outcomes and interventions, according to ICNP® 2015.

Chart 3 Proposal of the care plan for people living with AIDS from the nursing diagnoses of CIPE® version 2015 - Natal, RN, Brazil, 2016. 

Discussion

The purpose of systematic practices is to identify the priority needs of nursing care, providing a homogeneous language among the members of the team, thus performing a less intuitive and more scientific kind of care. In this sense, the elaboration and use of care plans implies the representation of guiding instruments for the management of nursing care, as it favors the decision-making process, assisting patients in all their complexity13.

It is worth mentioning that the results are directed to hospitalized patients and do not apply to patients seen at the outpatient clinic. Among the psychobiological needs, the diagnoses, nursing outcomes: hyperthermia, dehydration, increased heart rate, dyspnea and impaired swallowing were elaborated and validated.

According to ICNP®, hyperthermia is defined as a decrease in the ability to regulate the internal thermostat14. In people living with AIDS, the cause is related to the immune depletion that HIV causes, making them susceptible to infections. Hyperthermia is characterized by the exacerbation of heat caused by the action of toxins that affects the thalamic system, leading to an increase in body temperature. Thus, it can lead to protein denaturation, loss of large amounts of water and, consequently, exacerbate the clinical situation. Therefore, the nurse should guide the patient to recognize the warning signs of hyperthermia; avoid an environment free of air chain and ingestion of ice-cold liquids; reinforce the importance of hydration; in addition to monitoring body temperature, level of consciousness, ingestion and excretion of liquids and signs of electrolyte imbalance15-16.

In hyperthermia, people living with AIDS lose water and electrolytes, essential in the homeostatic stability and dynamics of the body, developing dehydration, which is considered by ICNP® as the reduction of the balance of ingestion and elimination of liquids and electrolytes14.

Dehydration in people living with AIDS does not only arise from hyperthermia, but also from complications related to episodes of vomiting, diarrhea, increased urinary frequency, dysphagia and lesions in the oral and esophageal mucosa, which compromise water intake. With this, the nursing care plan has, as its goal, the volume replacement, being an intervention that tries to attenuate the dehydration and the case of hyperthermia together with antipyretics16.

It is common to identify, in people living with AIDS, the development of cardiological symptoms, such as increased heart rate due to pathological factors related to heart disease, complications of dehydration and other morbidities, psychological factors such as anxiety and fear, in addition to the relation of the symptomatology as an adverse drug event17.

Thus, the nursing diagnosis increased heart rate is characterized by any type of organic dysfunction of pathological origin that affects cardiac contractility14. Factors contributing to rhythm mismatch, known as arrhythmia, are linked to heart disease and drug use, such as antiretroviral drugs of the protein inhibition class17.

In view of this diagnosis, it is important to carry out the control of liquids and electrolytes; maintain a balanced diet; monitor vital signs; as well as develop strategies to keep the patient calm18.

The use of the accessory musculature was observed in the majority of patients examined, in the process of inspiration and expiration and respiratory discomfort. The diagnosis of dyspnea, according to ICNP®, is conceptualized by respiratory discomforts that present qualitatively different sensations in their intensity. The cause in people living with AIDS may be linked to infections from fungi and bacteria14.

Thus, among the various nursing interventions, in view of dyspnea, oxygen therapy administration ; aspiration of secretions; pulmonary auscultation; evaluation of peripheral perfusion; bed head elevation; monitoring of vital signs; and orientation in bed rest are recommended actions to be taken19.

The nursing diagnosis of impaired swallowing is characterized by difficulty in passing fluids and foods from the mouth to the stomach14. The factors that lead to the appearance of symptoms in people living with AIDS include lack of oral hygiene, candidiasis, herpes simplex, atypical oral ulceration, parotid hypertrophy and lymphadenitis of the head and neck region presenting odynophagia and dysphagia20.

In view of this diagnosis, it is up to the nurse to investigate the conditions that affect the development of impaired swallowing, as well as to promote assistance strategies to minimize the risk of malnutrition or weight loss, including the implementation of a high protein diet, since AIDS over-catabolizes protein reserves21.

In the axis of basic human psychosocial needs, the validated nursing diagnoses were acceptance of the therapeutic plan, loneliness and fear. The diagnosis of nursing loneliness is defined as a state of isolation, melancholy and low self-esteem14. It is linked not only to the health condition, but also to the difficulty of social interaction, psychological trauma caused by the diagnosis of AIDS, stigma and fear of death2. However, isolation is a strong indication of psychological change and is directly related to depression, indicating the need for emotional therapeutic care22-23.

In this sense, nursing interventions are focused on the promotion of therapeutic mechanisms that facilitate the process of interlocution between the subjects, that is, people living with AIDS - professionals - society . Therefore, the development of strategies for social reintegration of people living with AIDS are necessary through care behaviors aimed at collective practice and group therapy22-24.

A study carried out in Portugal clarifies the nursing intervention model that consists of the decision tree, which allows nurses to decide, according to the needs of the patient, the best psychotherapeutic behavior to be adopted. The conducts have two intervention options: based on Psychodynamic Psychotherapy, focused on the unconscious mental processes, and based on Cognitive-Behavioral Therapy, if the problem of the person resides in the emotions, behaviors and dysfunctionalities of the thoughts24.

The nursing diagnosis fear is characterized by a feeling of anxiety attached to the emotion of a real cause and has the defense function as it generates a reaction in the body to imminent danger14. However, fear triggers physiological reactions of escape to challenging situations, in this way, the presented feeling directly influences the acceptance of the therapeutic regimen, which is impaired, and non-adherence to the drug treatment. Thus, it is important to reassure the patient about the present feeling; stimulate coping with fear; as well as promoting individual and group activities of tolerance to fear and better quality of life25.

Acceptance of the impaired therapeutic regimen, characterized by poor adherence or non-adherence of pharmacological treatment14, is associated to adverse effects of drugs, the lack of knowledge about the disease, the factor of having to hide the illness from the family and friends, the use of alcohol and drugs and the forgetfulness of the medication intake26.

From this perspective, educational actions can be developed to promote the adherence of people living with AIDS to treatment, to identify the factors that compromise drug adherence; to make the caregiver and/or family members aware of the importance of participation in adherence to the patient’s therapeutic plan27. Thus, the nurse is a privileged ally in the support to families with care needs for people living with AIDS and coping with the adversities of the disease28.

Conclusion

From the data presented, it was possible to elaborate and validate a care plan with the use of ICNP® version 2015, composed of eight diagnoses, outcomes and 41 nursing interventions. The proposal of a care plan for people living with AIDS opens the design for a scientific nursing practice, optimizing, prioritizing and improving the actions and care interventions to these clients.

The use of Horta’s theoretical framework provided the identification of priority needs, so that specific strategies can be articulated and timely outcomes can be quickly obtained, thus reflecting the quality of life of clients. In addition, the use of ICNP® terminology favored the elaboration of the care plan for people living with AIDS, contributing to the improvement of the nursing practice. The limits of the study were related to the type of non-probabilistic sampling, which does not guarantee the representativeness of the sample.

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*Extracted from the masters’ dissertation “Diagnósticos, resultados e intervenções de enfermagem da CIPE para pessoas vivendo com Aids”, Universidade Federal do Rio Grande do Norte, 2016.

Received: July 16, 2016; Accepted: December 20, 2016

Corresponding author: Vinicius Lino de Souza Neto. Universidade Federal do Rio Grande do Norte, Centro de Ciências da Saúde - Departamento de Enfermagem, Campus Central, s/n, Lagoa Nova, CEP 59078-970 - Natal, RN, Brazil. vinolino@hotmail.com

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