Clinical usefulness of the definitions for defining characteristics of activity intolerance, excess fluid volume and decreased cardiac output in decompensated heart failure: a descriptive exploratory study.

AIMS AND OBJECTIVES: To assess the clinical usefulness of the operational definitions for the defining characteristics of the NANDA International nursing diagnoses, activity intolerance, decreased cardiac output and excess fluid volume, and the concomitant presence of those diagnoses in patients with decompensated heart failure. BACKGROUND: Content validity of the operational definitions for the defining characteristics of activity intolerance, excess fluid volume and decreased cardiac output have been previously validated by experts. Their clinical usefulness requires clinical validation. DESIGN: This was a descriptive exploratory study. METHODS: Two expert nurses independently assessed 25 patients with decompensated heart failure for the presence or absence of 29 defining characteristics. Interrater reliability was analysed using the Kappa coefficient as a measure of clinical usefulness. The Fisher's exact test was used to test the association of the defining characteristics of activity intolerance and excess fluid volume in the presence of decreased cardiac output, and the correlation between the three diagnoses. RESULTS: Assessments regarding the presence of all defining characteristics reached 100% agreement, except with anxiety. Five defining characteristics of excess fluid volume were significantly associated with the presence of decreased cardiac output. Concomitant presence of the three diagnoses occurred in 80% of the patients. However, there was no significant correlation between the three diagnoses. CONCLUSIONS: The operational definitions for the diagnoses had strong interrater reliability, therefore they were considered clinically useful. Only five defining characteristics were representative of the association between excess fluid volume and decreased cardiac output. Therefore, excess fluid volume is related to decreased cardiac output, although these diagnoses are not necessarily associated with activity intolerance. RELEVANCE TO CLINICAL PRACTICE: The operational definitions may favour early recognition of the sequence of responses to decompensation, guiding the choice of common interventions to improve or resolve excess fluid volume and decreased cardiac output.

Content validation of the operational definitions of the nursing diagnoses of activity intolerance, excess fluid volume, and decreased cardiac output in patients with heart failure.

OBJECTIVES: To consensually validate the operational definitions of the nursing diagnoses activity intolerance, excessive fluid volume, and decreased cardiac output in patients with decompensated heart failure. METHOD: Consensual validation was performed in two stages: analogy by similarity of defining characteristics, and development of operational definitions and validation with experts. RESULTS: A total of 38 defining characteristics were found. Operational definitions were developed and content-validated. One hundred percent of agreement was achieved among the seven experts after five rounds. "Ascites" was added in the nursing diagnosis excessive fluid volume. CONCLUSION: The consensual validation improves interpretation of human response, grounding the selection of nursing interventions and contributing to improved nursing outcomes. IMPLICATIONS FOR PRACTICE: Support the assessment of patients with decompensated heart failure.

Consensual validation of the nursing diagnoses fear and anxiety identified at the immediate preoperative period in patients undergoing elective surgery.

PURPOSE: To identify the most frequent defining characteristics (DCs) for the diagnoses fear and anxiety in Brazilian patients in the immediate preoperative period following elective cardiac surgery; to develop conceptual and operational definitions for the DCs; to develop consensual validation. METHODS: Clinical and observational, descriptive study developed in two phases. FINDINGS: Forty DCs were identified for fear and 19 for anxiety. One expert judged it necessary to include "altered bowel motility" as a DC for fear. There was 100% agreement among the five experts in relation to the DCs. CONCLUSIONS: To add "altered bowel motility" to the DCs for the nursing diagnosis fear. IMPLICATIONS FOR PRACTICE: To enable nurses to more accurately assess patients for these diagnoses.

[Burnout in nursing residents]. / Burnout em residentes de enfermagem.

Nursing residents may experience physical and emotional exhaustion from the daily life of attending the Program. The aim of this study was to determine the Burnout incidence among Nursing Residents. An investigative, descriptive, analytical, longitudinal-prospective study was conducted with 16 Residents over two years. The Maslach Burnout Inventory was used, translated and validated for Brazil, as well as a sociodemographic/occupational data tool. Of all residents, 17.2% showed high rates in Emotional Exhaustion and Depersonalization; 18.8% showed impaired commitment in Personal Accomplishment, 75% of which belonged to specialty areas, such as Emergency Nursing, Adult and Pediatric Intensive Care. Age and specialty area were positively correlated with Personal Accomplishment. One of the Residents was identified with changes in three subscales of the Maslach Burnout Inventory, thus characterized as a Burnout Syndrome patient. Nursing Residents have profiles of disease. Knowing these factors can minimize health risks of these workers.

Burnout em residentes de enfermagem / Burnout in nursing residents / Burnout en residentes de enfermería

Enfermeiros Residentes podem experimentar desgaste físico e emocional decorrentes do cotidiano da Residência de Enfermagem. O objetivo deste estudo foi determinar a incidência do Burnout em Residentes de Enfermagem. Realizou-se um estudo exploratório, descritivo, analítico e longitudinal-prospectivo com 16 Residentes, no período de dois anos. Utilizou-se o Maslach Burnout Inventory traduzido e validado para o Brasil e um instrumento de dados sociodemográficos/ocupacionais. Dos Residentes, 17.2 por cento mostraram valores elevados em Exaustão Emocional e Despersonalização; 18.8 por cento comprometimento em Incompetência/falta de Realização Profissional, dos quais 75 por cento pertenciam às especialidades de Pronto Socorro, Unidade de Terapia Intensiva Adulto e Pediátrica. Idade e especialidade correlacionaram-se positivamente com a Incompetência/falta de Realização Profissional. Identificou-se um Residente de Enfermagem com alteração nas três subescalas do Maslach Burnout Inventory, sendo caracterizado como portador da Síndrome de Burnout. Os Residentes de enfermagem possuem perfis de adoecimento. Conhecer esses fatores pode minimizar os agravos à saúde desse trabalhador.

Nursing residents may experience physical and emotional exhaustion from the daily life of attending the Program. The aim of this study was to determine the Burnout incidence among Nursing Residents. An investigative, descriptive, analytical, longitudinal-prospective study was conducted with 16 Residents over two years. The Maslach Burnout Inventory was used, translated and validated for Brazil, as well as a sociodemographic/occupational data tool. Of all residents, 17.2 percent showed high rates in Emotional Exhaustion and Depersonalization; 18.8 percent showed impaired commitment in Personal Accomplishment, 75 percent of which belonged to specialty areas, such as Emergency Nursing, Adult and Pediatric Intensive Care. Age and specialty area were positively correlated with Personal Accomplishment. One of the Residents was identified with changes in three subscales of the Maslach Burnout Inventory, thus characterized as a Burnout Syndrome patient. Nursing Residents have profiles of disease. Knowing these factors can minimize health risks of these workers.

Los Enfermeros Residentes pueden experimentar desgaste físico y emocional derivado del trabajo cotidiano de la Residencia de Enfermería. El objetivo de este estudio fue determinar la incidencia del Burnout en residentes de enfermería. Se realizó un estudio exploratorio, descriptivo, analítico y longitudinal-prospectivo con 16 Residentes, en el período de dos años. Se utilizó el Maslach Burnout Inventory traducido y validado para Brasil y un instrumento de datos socio-demográficos/ocupacionales. 17,2 por ciento de los Residentes mostraron valores elevados en Agotamiento Emocional y Despersonalización, respectivamente; 18,8 por ciento compromiso en Incompetencia/falta de Realización Profesional, entre estos, 75 por ciento pertenecían a las especialidades de Emergencias, Unidad de Terapia Intensiva de Adultos y Pediátrica. Edad y especialidad se correlacionaron positivamente con Incompetencia/falta de Realización Profesional. Se identificó a un Residente de Enfermería con alteración en las tres sub-escalas del Maslach Burnout Inventory, caracterizándoselo como portador de Síndrome de Burnout. Los Residentes de Enfermería poseen perfiles de sufrimiento. Conocer tales factores puede minimizar los transtornos de salud de dichos trabajadores.

Débito cardíaco diminuído: revisão sistemática das características definidoras / Decreased cardiac output: a systematic review of the defining characteristics / Débito cardíaco disminuído: revisión sistemática de las características definidoras

OBJETIVOS: Caracterizar os artrigos científicos relacionados ao diagnóstico de enfermagem débito cardíaco diminuído. Verificar os artigos que descrevem o comportamento das características definidoras deste diagnóstico, identificando aquelas que ocorrem com maior frequência. MÉTODOS: Trata-se de uma revisão sistemática realizada nas bases de dados: Lilacs, SciELO, Embase, Medline, Pubmed e Cochrane, no período de 1985 a 2008. RESULTADOS: Foram selecionados 13 artigos, identificando 50 características definidoras, sendo dez com maior frequência: alteração da frequência/ritmo cardíaco, dispneia, labilidade da pressão arterial, estertores, oligúria/ anúria, edema, pele fria, fadiga/fraqueza, diminuição dos pulsos periféricos e diminuição da perfusão periférica. CONCLUSÃO: A temática vem sendo pouco explorada. Constatou-se a importância do exame físico, a utilização de técnicas menos invasivas e a necessidade de rever as características definidoras propostas a fim de proporcionar clareza e objetividade na identificação desse diagnóstico de enfermagem.

OBJECTIVES: To characterize the scientific articles related to the NANDA-I nursing diagnosis, decreased cardiac output. Verify those articles that describe the behavior of the defining characteristics of this diagnosis, identifying those that occur with the highest frequency. METHODS: A systematic review of literature published between the years 1985 - 2008 was conducted, using the following databases: Lilacs, SciELO, EMBASE, Medline, Pubmed and Cochrane. RESULTS: The sample included 13 articles which identified 50 defining characteristics. Ten characteristics were noted to occur with high frequency: altered heart rate/rhythm, dyspnea, labile blood pressure, rales, oliguria / anuria, edema, cold skin, fatigue / weakness, decreased peripheral pulses and decreased peripheral perfusion. CONCLUSION: This subject has not been explored in depth in the literature. The importance of physical examination, the use of less invasive techniques, and the need to review the proposed defining characteristics to provide clarity and objectivity in the identification of this nursing diagnosis was identified.

OBJETIVOS: Caracterizar los artículos científicos relacionados al diagnóstico de enfermería débito cardíaco disminuído. Verificar los artículos que describen el comportamiento de las características definidoras de este diagnóstico, identificando aquellas que ocurren con mayor frecuencia. MÉTODOS: Se trata de una revisión sistemática realizada en las bases de datos: Lilacs, SciELO, Embase, Medline, Pubmed y Cochrane, en el período de 1985 al 2008. RESULTADOS: Fueron seleccionados 13 artículos, identificando 50 características definidoras, siendo diez con mayor frecuencia: alteración de la frecuencia/ritmo cardíaco, disnea, labilidad de la presión arterial, estertores, oliguria/ anuria, edema, piel fría, fatiga/debilidad, disminución de los pulsos periféricos y disminución de la perfusión periférica. CONCLUSIÓN: La temática viene siendo poco explorada. Se constató la importancia del examen físico, la utilización de técnicas menos invasivas y la necesidad de revisar las características definidoras propuestas a fin de proporcionar claridad y objetividad en la identificación de ese diagnóstico de enfermería.

Alterações do nível pressórico e fatores de risco em graduandos de enfermagem / Alteraciones del nível de la presión y factores de riesgo en profesionales graduandos en enfermería / Risk factors and alterations in blood pressure levels in undergraduate nursing students

Objetivos: Identificar possíveis alterações do nível presóricoem graduandos de Enfermagem da Universidade Federal de São Paulo; Identificar fatores de risco para hipertensão arterial sistêmica; Verificar a associação entre os níveis pressóricos e os fatores de risco para hipertensão arterial sistêmica. Métodos: Estudo de corte transversal, desenvolvido entre novembro de 2006 a maio de 2007. A amostra foi composta por 120 graduandos de enfermagem da Universidade Federal de São Paulo. Foi aplicado um questionário específico sobre fatores de risco para hipertensão arterial e aferição da pressão arterial. O Teste de Fischer foi usado para determinar possíveis associações. Resultados: Dos graduandos, 92,5 por cento apresentaram níveis pressóricos normais, 4,2 por cento eram hipertensos e 3,3 por cento com pressão limítrofe. Notou-se o aparecimento de alguns fatores de risco para hipertensão arterial e doença cardiovascular. Conclusão: De acordo com os resultados, deve-se atentar para mudanças de hábito e estilo de vida mais saudável desses futuros enfermeiros.

Objectives: To identify risk factors and alterations in blood pressure levels in undergraduate nursing students and to examine the associations between the risk factors and blood pressure levels. Methods: A cross-sectional descriptive study was conducted between November 2006 and May 2007. The sample consisted of 120 undergraduate nursing students from the Federal University of São Paulo. A specific questionnaire on risk factors for high blood pressure was used. Blood pressure measures were taken and recorded. Fisher's exact test was used to determine associations between risk factors and high blood pressure. Results: The majority of participants (92.5 percent) had normal blood pressure levels. A few students had high (4.2 percent) or borderline (3.3 percent) blood pressure levels. Students had some of the risk factors for high blood pressure and cardiovascular diseases. Conclusion: There is a need to emphasize lifestyle changes among those future nurses.

Objetivos: Medir la presión arterial para identificar posibles alteraciones en profesionales graduandos en Enfermería; identificar factores de riesgo para hipertensión arterial; verificar la asociación entre los niveles de presión y los factores de riesgo para hipertensión arterial. Métodos: Estudio de corte transversal, desarrollado entre noviembre de 2006 y mayo de 2007. La muestra fue compuesta por 120 graduandos de enfermería de la Universidad Federal de Sao Paulo. Fue aplicado un cuestionario específico sobre factores de riesgo para hipertensión arterial y para evaluar la presión arterial. La Prueba de Fischer fue usada para determinar posibles asociaciones. Resultados: 92,5 por ciento de los graduandos presentaron niveles de presión normal, 4,2 por ciento eran hipertensos y 3,3 por ciento tenían presión limítrofe. Se notó el aparecimiento de algunos factores de riesgo para hipertensión arterial y enfermedad cardiovascular. Conclusión: De acuerdo con los resultados, se deben cambiar hábitos y estilo de vida de modo que sean más saludables para los futuros enfermeros.

Clinical validation of the signs and symptoms and the nature of the respiratory nursing diagnoses in patients under invasive mechanical ventilation.

AIMS: The aims of this study were to validate the signs and symptoms of the respiratory nursing diagnoses impaired gas exchange, ineffective airway clearance and ineffective breathing pattern in patients under mechanical ventilation; to verify whether intubation time and ventilatory modalities were related factors for respiratory nursing diagnoses; to verify the occurrence of shared signs and symptoms in the diagnoses and compare them with North American Nursing Diagnosis Association's proposition and to ascertain whether respiratory nursing diagnoses occur in isolated or associated patterns. BACKGROUND: The need for mechanical ventilation is common in several patients admitted to intensive care units. Therefore, critical care nurses should identify the respiratory nursing diagnoses of high incidence. DESIGN AND METHODS: Descriptive observational study, with 177 evaluations of surgical and medical critically ill adult patients undergoing invasive mechanical ventilation. The study adopted Fehring's Modified Clinical Diagnostic Validity Model, with a suggested alteration. RESULTS: The critical signs and symptoms were the same as proposed by North American Nursing Diagnosis Association, when the diagnoses were separately identified, although no particular sign and symptom was found for ineffective breathing pattern. Impaired gas exchange and ineffective airway clearance were identified as having 88 (49.7%) evaluations sharing the critical signs and symptoms. Intubation time and ventilation modality were related factors for the development of ineffective airway clearance and ineffective breathing pattern. CONCLUSION: The critical signs and symptoms of impaired gas exchange were abnormal blood gases and hypoxemia. For ineffective airway clearance, they were rhonchi and decreased breath sounds. No highlights were found for ineffective breathing pattern signs and symptoms. Validation by experts has confirmed these findings. The interface between ineffective airway clearance and impaired gas exchange was confirmed by the presence of the shared critical signs and symptoms. RELEVANCE TO CLINICAL PRACTICE: Studies like this are relevant to clinical practice because they evaluate the adequacy of Taxonomy II for patients under mechanical ventilation in clinical practice, thus allowing for the intensive care nurses to go from one mechanical and routine practice to a critical, reflexive practice, committed to professional progress.

Validação clínica dos sinais e sintomas e comportamento dos diagnósticos de enfermagem respiratórios em pacientes sob ventilação mecânica invasiva / Clinical validation of the signs and symptoms and behavior of the respiratory nursing diagnoses in patients under invasive mechanical ventilation

Estudo descritivo observacional com 177 avaliações em pacientes criticamente doentes, intubados e sob ventilação mecânica invasiva, internados nas UTI Geral e de Pneumologia de um Hospital Escola da rede pública de São Paulo, com os objetivos de: validar os sinais e sintomas dos diagnósticos de enfermagem respiratórios (DER) troca de gases prejudicada (TGP), desobstrução ineficaz de vias aéreas (DIVA) e padrão respiratório ineficaz (PRI); verificar se o tempo de canulação e o modo de ventilação mecânica são fatores etiológicos dos DER; verificar a ocorrência de SS compartilhados nos três DER e compará-los com a relação proposta na Taxonomia II da NANDA; verificar se a presença dos três DER ocorre de forma isolada ou em conjunto. Na primeira etapa metodológica foram selecionados, a partir do elenco de SS propostos pela NANDA para os DER, aqueles que, seriam passíveis de identificação no tipo de pacientes que fariam parte do estudo. A seguir foram elaboradas as de definições conceituais e operacionais de cada SS para submissão à validação consensual entre especialistas. Na segunda etapa metodológica foram elaborados o instrumento de coleta de dados, realizado o teste piloto e iniciada a coleta de dados, por meio do exame físico. Na terceira etapa, as avaliações realizadas foram submetidas a duas especialistas para validar os diagnósticos identificados pela pesquisadora. Dados adicionais foram analisados como a escala de Glasgow (para pacientes em coma) e Ramsay (para pacientes sedados) e análise do Raio-X de tórax (para enriquecer as informações acerca dos SS apresentados pelos pacientes). A análise estatística descritiva utilizou os seguintes testes: Mann-VVhitney, Quiquadrado ou exato de Fisher, quando prudente, análise do resíduo padronizado e Kappa. Os resultados mostraram que quanto maior o tempo de canulação, maior a possibilidade do paciente desenvolver DIVA e PRI. Quanto ao modo de ventilação mecânica, houve associação significativa apenas de ventilação com pressão suporte com a presença de PRI (p<0,001). Os pacientes estavam em coma (Glasgow 7,32 ± 0,41 EMP) ou adequadamente sedados (Ramsay 4,400,12 EMP). Quanto aos DER, das 117 avaliações, TGP foi identificado em 10 (5,6 por cento), DIVA em 21 (11,9 por cento), TGP e DIVA em 88 (49,7 por cento), DIVA e PRI em 1 (0,6 por cento) e TGP, DIVA e PRI em 57 (32,2 por cento)...

A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system.

The objective of this study was to verify the incidence of nosocomial pneumonia in intubated and extended mechanically ventilated patients having endotracheal suctioning by an open vs. closed suction method aiming to decrease nosocomial pneumonia. Twenty-four (51.1%) patients received open-tracheal suction and 23 (48.9%) received closed-tracheal suction. The inclusion criteria were: surgical and medical patients older than 13 years, undergoing mechanical ventilation for more than 48 hours. Additional data were gathered using the Acute Physiology and Chronic Health Evaluation II, and details on smoking, alcoholism, diabetes mellitus, renal failure, previous lung disease, and previous use of antibiotics, steroids, H2 antagonists and antacids. Among the 24 patients having open-tracheal suction, 11 developed nosocomial pneumonia while of the 23 patients undergoing closed-tracheal suction, seven developed infection (P = 0.278). Risk factors for nosocomial pneumonia were not significantly different between the two groups. In the final logistical regression model the following variables remained: groups (open and closed) [odds ratio (OR) = 0.014; confidence interval (CI) = 0.001-0.416; P = 0.014] and use of prior antibiotics (OR = 2.297; CI = 1.244-4.242; P = 0.008). Use of a closed suction system did not decrease the incidence of nosocomial pneumonia when compared with the open system. The exogenous risk factors were the most important for acquiring this infection.

Incidência de pneumonia associada à ventilação mecânica em pacientes submetidos à aspiração endotraqueal pelos sistemas aberto e fechado: estudo prospectivo - dados preliminares / Incidence of ventilator-associated pneumonia in patients using open-suction systems and closed-suction systems: a prospective study - preliminary data

Ensaio clínico, randomizado, com amostra de 20 pacientes, sendo 12 submetidos à aspiração endotraqueal pelo sistema aberto e 8 a aspiração endotraqueal pelo sistema fechado, com o objetivo de verificar a incidência de pneumonia associada à ventilação mecânica (PAV) entre os dois grupos. A incidência de PAV entre os mesmos não foi significante (p = 0.39). Diferenças como Acute Physiology and Chronic Health Evaluation II, tempo de entubação e uso de esteróides foram todas não significantes. Todos os pacientes da amostra usaram bloqueador H2 e sonda nasogástrica. O prosseguimento deste estudo implicará em aumento da amostra com possíveis alterações dos resultados.