Clinical Indicators for Evaluation of Outcomes of Impaired Tissue Integrity in Orthopedic Patients: Consensus Study

Abstract

Support to the definition the priority interventions in nursing process documentation.

Evaluation of Surgical Wound Healing in Orthopedic Patients with Impaired Tissue Integrity According to Nursing Outcomes Classification

“…The data collection instrument was constructed through consensus between nurses with orthopedics clinical expertise and research experience using the NOC (Silva et al., ). The content consensus defined the clinical indicators of Wound healing: Primary Intention NO that could better lead the SW healing, and its conceptual and operational definitions (Silva et al., ).…”

“…(110202) Purulent drainage, (110203) Serous drainage, (110204) Sanguineous drainage, (110205) Serosanguineous drainage, (110208) Surrounding skin erythema, (110209) Periwound edema, (110210) Increased skin temperature, and (110211) Foul wound odor, were evaluate using the NOC scale Extensive to None (Moorhead et al., ). In order to refine the selected clinical indicators evaluation derived from the consensus, the grouping of some indicators was performed with the objective of to reduce clinical assessment subjectivity, considering the magnitude of these NO scales (Moorhead et al., ; Silva et al., ).…”

“…The magnitude of the definition on the Likert scale stayed: (1) presence of flushing, heat, edema, pain, and serosanguineous secretion; (2) presence of at least one of the following characteristics: flushing, heat, edema, pain. Absence or little serosanguineous or serous secretion; (3) progressing red area for rose; (4) scar presence, pale pink tissue; (5) scar presence, gray or slightly elastic tissue (Moorhead et al., ; Silva et al., ).…”

“…The distance between wound edges, the presence of serous and bloody secretion were evaluate by means of the indicator (110201) Skin Approximation . According to the scale None to Extensive, from NOC, the magnitude were defined as: (1) wound dehiscence; (2) start of dehiscence with sanguineous or serosanguineous secretion; (3) suture with juxtaposed edges, with serosanguineous or sanguineous drainage; (4) suture with juxtaposed edges, with minimal serous drainage; (5) suture with juxtaposed edges, with no secretion presence (Moorhead et al., ; Silva et al., ).…”

“…The indicators related to Drainage were assembled into one single indicator, observating of amount and type of drainage from wound exudates, following magnitude for the operational definition: (1) abundant and purulent or piohematic drainage; (2) drainage in average quantity piohematic; (3) drainage in little or medium quantity, with presence of serosanguineous or sanguineous secretion; (4) low drainage, serous secretion; (5) no exudates presence (Moorhead et al., ; Silva et al., ).…”