Nursing Intervention Classifications (NIC) validated for patients at risk of pressure ulcers

Abstract

Objective: to validate the Nursing Intervention Classifications (NIC) for the diagnosis 'Risk of Impaired Skin Integrity' in patients at risk of pressure ulcers (PU). Method: the sample comprised 16 expert nurses. The data was collected with an instrument about the interventions and their definitions were scored on a Likert scale by the experts. The data was analyzed statistically, using the calculation of weighted averages (WA).

Mapping the nursing care with the NIC for patients in risk for pressure ulcer

“…Within the NDs of NANDA-I (19) , it is understood that the Risk for impaired skin integrity is the one that better describes the patients' condition at PU risk, subsidizing the better lesion preventive care planning although it is not the more specific for this type of worsening (12) . For its better accuracy, the Braden Scale risk assessment instrument can be used (12)(13)(14)19,23) .…”

“…For its better accuracy, the Braden Scale risk assessment instrument can be used (12)(13)(14)19,23) . The prescribed cares to patients with this ND were majorly related to the PU prevention, for example to protect skin to avoid rupture, to moisturize skin, to inspect skin searching for hyperemic or ischemic points.…”

“…This requires the patients' evaluation with risks identification for this type of lesion and, consequently, to implement nursing interventions (8,12) to prevent complications that can compromise their health status and quality of life. The identification of patients at PU risk is essential to implement preventive actions since the initial hospitalization moment until the discharge (12) . One of the most broadly used instruments by nurses to predict the PU risk is the Braden Scale (11,13) .…”

“…However, although the literature points nursing interventions as indicated to those patients (12,15) , it is observed a lack of studies that describes in the clinical practice the types of prescribed care in accordance with the ND designed to the patients with PU risk. Adding to that, most of the times nursing care is described without a standardized language as the Nursing Interventions Classification (NIC) (15)(16) .…”

At risk of pressure ulcers - a nursing diagnosis

“…Systematic reviews of some predictive scales with various lists of risk factors can be found in Bóriková (2006) and Fúrová (2006). The foreign literature refers to substantially more scales for prediction of pressure ulcers; some authors have attempted to modify the existing scales (Lepistӧ et al, 2006;Pancorbo-Hidalgo et al, 2006;Bavaresco, Lucena, 2012;Hyun et al, 2014;Demarre et al, 2015;Kumari et al, 2015). The nursing diagnosis of at Risk of Pressure Ulcers 00249 was included in the international classification of nursing diagnoses, NANDA International for 2015-2017, as a potentially new nursing diagnosis in Domain 11 Safety/Protection -a Class 2 Physical Injury (NANDA International, 2014).…”