earch the GCU Library and find two new health care articles that use quantitative research. Do not use articles from a previous assignment, or articles that appear in the Topic Materials or textbook.
Complete an article analysis for each using the “Article Analysis: Part 2” template.
Refer to the “Patient Preference and Satisfaction in Hospital-at-Home and Usual Hospital Care for COPD Exacerbations: Results of a Randomised Controlled Trial,” in conjunction with the “Article Analysis Example 2,” for an example of an article analysis.RESEARCH PAPER (ORIGINAL)
ARTIGO DE INVESTIGAÇÃO (ORIGINAL)
ISSNe: 2182.2883 | ISSNp: 0874.0283
Available: https://doi.org/10.12707/RIV17075
Dyspnea in palliative care: nursing records and self
assessment of dyspnea
Dispneia em cuidados paliativos: registos de enfermagem e a autoavaliação da dispneia
Disnea en cuidados paliativos: registros de enfermería y autoevaluación de la disnea
Ana Raquel Margarido Vaz Alves*; Paulo Sérgio dos Reis Saraiva Pina**
Abstract
Background: The integration of a quantitative assessment of dyspnea in nursing records (NR) allows adjusting
nursing care delivery to each patient’s needs.
Objectives: To compare NR and the self-assessment of dyspnea intensity using the Numerical Rating Scale (NRS)
in patients with advanced progressive chronic disease and palliative care needs who were admitted to internal medicine wards.
Methodology: A quantitative study was conducted using a cross-sectional, descriptive, and observational approach.
The NRS was applied to assess dyspnea intensity. Seventy-seven NR were selected using a non-random, purposive
sampling technique.
Results: Nurses diagnosed dyspnea at rest and/or functional dyspnea correctly without using a dyspnea assessment
tool. Not all patients diagnosed with dyspnea had nursing care plans. In addition, the specific nursing interventions
do not consider all dimensions of total dyspnea.
Conclusion: Quantitative NR allow for a more accurate identification, monitoring, and management of dyspnea.
A more systematic approach to dyspnea in patients with palliative care needs is required.
Keywords: dyspnea (nursing), dyspnea (classification), nursing records, palliative care, assessment of dyspnea
Resumo
Resumen
Enquadramento: Os registos de enfermagem (RE) que
englobam uma avaliação quantitativa da dispneia permitem adequar a prestação de cuidados de enfermagem
às necessidades do doente.
Objetivos: Comparar os RE e a autoavaliação da intensidade da dispneia realizada com recurso à Escala de
Avaliação Numérica (EAN) por indivíduos com doenças crónicas, progressivas e avançadas, com necessidades
paliativas, internados em serviços de medicina interna.
Metodologia: Realizou-se uma pesquisa quantitativa,
descritiva, transversal e observacional através da aplicação de EAN da intensidade da dispneia. Recolheram-se RE de 77 selecionados de forma intencional e não
aleatória.
Resultados: Os enfermeiros diagnosticam corretamente a dispneia em repouso e/ou dispneia funcional sem
recurso a uma escala de avaliação de dispneia. Não se
observam intervenções autónomas de enfermagem em
todos os indivíduos com o diagnóstico de dispneia, bem
como, as intervenções não abrangem todas as dimensões da dispneia total.
Conclusão: Os RE quantitativos contribuem para
maior rigor na identificação, monitorização e intervenção na dispneia. Considera-se necessária uma abordagem mais sistematizada da dispneia em indivíduos com
necessidades paliativas.
Marco contextual: Los registros de enfermería (RE)
que engloban una evaluación cuantitativa de la disnea
permiten adecuar la prestación de cuidados de enfermería a las necesidades del paciente.
Objetivos: Comparar los RE y la autoevaluación de la
intensidad de la disnea realizada con la Escala de Evaluación Numérica (EEN) por individuos con enfermedades crónicas, progresivas y avanzadas, con necesidades
paliativas, internados en servicios de medicina interna.
Metodología: Se realizó una investigación cuantitativa, descriptiva, transversal y observacional a través de
la aplicación de EEN de la intensidad de la disnea. Se
recopilaron RE de 77 seleccionados de forma intencional y no aleatoria.
Resultados: Los enfermeros diagnostican correctamente la disnea en reposo y/o disnea funcional sin recurrir
a una escala de evaluación de la disnea. No se observan
intervenciones autónomas de enfermería en todos los
individuos con diagnóstico de disnea, y las intervenciones no abarcan todas las dimensiones de la disnea total.
Conclusión: Los RE cuantitativos contribuyen a un
mayor rigor en la identificación, el seguimiento y la intervención en la disnea. Se considera necesario un enfoque más sistemático de la disnea en individuos con
necesidades paliativas.
Palavras-chave: dispneia (enfermagem), dispneia (classificação), registros de enfermagem, cuidados paliativos,
avaliação da dispneia
*MSc., Generalist nurse, Medicine Unit 1, Hospital Garcia de Orta, EPE, 2805-267, Almada, Portugal
[ana.raquel.alves3@hgo.min-saude.pt]. Contribution to the article: literature search, development
of the form applied in the study, data collection, data treatment, analysis, and discussion, article writing and final revision. Address for correspondence: Av. Torrado da Silva, 2805-267, Almada, Portugal.
**MSc., Physician, Casa de Saúde da Idanha, Belas, 2605-077, Sintra, Portugal [preispina@hotmail.
com]. Contribution to the article: development of the form applied in the study, data analysis and
discussion, article writing and final revision.
Revista de Enfermagem Referência
Palabras clave: disnea (enfermeira), disnea (clasificación), registros de enfermería, cuidados paliativos,
evaluación de disnea
Received for publication: 26.09.17
Accepted for publication: 11.12.17
Série IV – n.º 16 – JAN./FEV./MAR. 2018
pp. 53 – 62
Introduction
Background
In palliative care, dyspnea, which is commonly known as breathing difficulty, occurs both
in patients with and without cancer at any
stage of the disease (Coccia, Palkowski, Schweitzer, Motsohi, & Ntusi, 2016).
The prevalence of dyspnea in individuals with
a chronic disease can range from 19% to 50%
(Feio, 2016). In fact, there is no consensual
statistical data because patients with dyspnea
underestimate their breathing difficulty or
health professionals consider patients’ complaints as irrelevant (Banzett & O’Donnell,
2014).
Patients’ self-assessment of dyspnea is a quick
process that does not require patients to decide what is relevant or not to report to the
health professional and allows accurate records (Banzett & O’Donnell, 2014).
This process has many advantages. On the
one hand, the early and regular quantitative
assessment of dyspnea improves its management, relieves the patient’s suffering, and
reduces the possibility of disease worsening
(Baker et al., 2013). On the other hand, it
allows more reliable nursing records (NR)
about patients’ complaints and, therefore,
contributes to the development of nursing
interventions adjusted to each patient’s needs.
However, although there are several scales to
measure dyspnea intensity, it is known that
the application of dyspnea assessment tools is
not a common practice in nursing care delivery. In view of the above, it is important to assess the whole process, from the identification
to the implementation of nursing interventions in cases of dyspnea using the Numerical
Rating Scale (NRS).
To better understand the phenomenon under
analysis, the sampled subjects’ self-assessment
of dyspnea using the NRS included in forms
was analyzed and then compared with the NR.
Therefore, this study aimed: to compare the
NR with patients’ dyspnea self-assessment; to
identify the intensity of functional dyspnea;
to identify the nursing care plans recorded by nurses; to determine the prevalence
of nursing care plans; to achieve an optimal
treatment for dyspnea; and to determine if
patients’ dyspnea self-assessment is biased by
nursing shifts.
Dyspnea is a subjective experience of breathing discomfort that consists of distinct qualitatively sensations that vary in intensity
(American Thoracic Society, 2012). The experience derives from interactions among
multiple physiological, psychological, social,
and environmental factors, and may induce
secondary behavioral and physiological responses (Coccia et al., 2016).
Due to its subjective nature, only the person
with dyspnea is in a position to determine
its severity (Hayen, Herigstad, & Pattinson,
2013). Thus, whenever possible, dyspnea intensity should be self-reported.
There are multiple scales available for the
self-assessment of dyspnea intensity (Berliner, Schneider, Welte, & Bauersachs, 2016),
among which the NRS stands out due to its
objectivity and easy interpretation and application (Johnson et al., 2016). In addition,
according to Bailey et al. (2013), the NRS
allows nurses to identify the presence of dyspnea, as well as to explain and assess the effectiveness of their interventions.
The NRS consists of a ruler divided into 11
equal sections, each numbered 0 to 10 (Wysham et al., 2015). In this scale, individuals are
expected to rate their dyspnea intensity using
a numerical rating, in which 0 corresponds
to not breathless at all and 10 corresponds to
breathlessness as bad as you can imagine (Wade
et al., 2017).
Despite the recommendations to implement
the NRS in nursing care delivery and, therefore, in NR (American Nurses Association,
2010), the state-of-the-art on this topic, both
at national and international levels, is still
very tenuous.
Yet, a pilot study by Baker et al. (2013) should
be highlighted. In this study, the authors tested the feasibility of nurses measuring dyspnea in inpatient units using an assessment
tool derived from three scales, including the
NRS. At the end of the study, 92% of the
nurses reported that it was important to assess
dyspnea using an assessment tool. According
to the authors, the integration of dyspnea assessment into care delivery did not increase
the nursing team’s workload. More recently,
Johnson et al. (2016) recommended the use
Dyspnea in palliative care: nursing records and patient self
assessment of dyspnea
Revista de Enfermagem Referência – IV – n.º 16 -2018
54
of NRS in detriment of the modified Borg
scale for the assessment of dyspnea intensity
at various moments and in certain situations,
such as at rest and during exertion. Finally,
according to Wade et al. (2017), although the
NRS is highly recommended for the assessment of dyspnea intensity, it requires accurate
statements.
Therefore, an appropriate dyspnea assessment
allows monitoring the intensity of dyspnea
during hospitalization facilitates the assessment of the nursing interventions for relieving dyspnea, thus contributing to the visibility of nursing care and the combination
of multidisciplinary care (Registered Nurses’
Association of Ontario, 2012).
NR are defined as the information written
down by nurses during their clinical practice,
which includes information related to patients’ nursing care needs (Ordem dos Enfermeiros, 2005). Nursing information systems
(NIS) were created to enable the standardization and automation of this process. The
NIS in use in the units under analysis is the
Nursing Practice Support System (Sistema de
Apoio à Prática de Enfermagem, SAPE®). The
SAPE® allows diagnosing dyspnea at rest and/
or functional dyspnea and, based on clinical
judgement, identifying, recording, and monitoring the patient’s needs. However, and contrary to what is recommended by the abovementions scientific evidence, the SAPE® does
not include a dyspnea assessment scale.
population is composed of consecutive patients admitted to the medicine units I and
II of the HGO between 13 May 2016 and 13
June 2016.
The inclusion criteria were: subjects aged over
18 years, diagnosed with advanced progressive chronic disease, who signed informed
consent form, were capable of self-reporting
the intensity of their dyspnea on a NRS, and
had complete NR available.
Taking into account the guidelines of the Portuguese National Plan for Palliative Care (Direção-Geral da Saúde, 2005) and of the European Association for Palliative Care (2009),
an advanced progressive disease is defined as a
chronic disease that causes patients to require
palliative care and is expected to result in the
death of the patient within a period of 1 to
2 years.
The final sample was selected using a
non-random purposive sampling technique.
It was composed of all individuals who met
the above-mentioned criteria and had less
than four incorrect answers in the potuguese
version of the Short Portable Mental Status
Questionnaire (SPMSQ). A form, which
included sociodemographic questions, the
SPMSQ, and two NRSs for self-assessment
of dyspnea at rest and functional dyspnea in
light of the studies by Baker et al. (2013) and
Johnson et al. (2016), was applied to the sampled subjects.
The first NRS asks the respondent to assess
the intensity of dyspnea at rest: “How would
you rate your shortness of breath and breathing difficulty when you are resting?”. The
second NRS asks “How would you rate your
shortness of breath and breathing difficulty
when you are performing an activity of daily
living, such as eating or bathing?”.
Data were also collected from the NR available in the SAPE® and gathered in a document created for this purpose.
Prior to the application of the final version
of the form, a pre-test was applied to five
subjects. It was concluded that the subjects’
answers should be written down by the interviewer.
Finally, data were entered and processed in
IBM SPSS Statistics, version 23.0, and a
statistical and descriptive analysis was performed.
Research question
What is the association between NR and
dyspnea self-assessment (using the NRS) performed by adult individuals with advanced
progressive chronic disease?
Methodology
This study was approved by the Ethics Committee, and the Board of Directors of the
Hospital Garcia de Orta, EPE (HGO), and
the by Ethics Committee of the Lisbon Academic Medical Center.
This is a quantitative, descriptive, cross-sectional, and observational study. The target
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
55
Results
than 71 years (65%), with primary education.
In addition, circulatory system diseases were the
main cause of hospitalization, with stroke and
heart failure (HF) representing almost 40% of
health problems. More than half of the subjects
had three or more health antecedents. Table 1
describes the characteristics of the sample.
Ninety-two forms were applied, of which 15
were excluded because subjects did not meet the
inclusion criterion related to the SPMSQ. Thus,
the final sample consisted of 77 individuals. The
sample was mostly composed of men, older
Table 1
Sample sociodemographic characterization
Sociodemographic characteristics of the sample
Age
Years
Mean
73
Median
74
Minimum-Maximum
28-90
Age, age groups
% of subjects
Under 70 years
35.1
71 to 80 years
29.8
Over 81 years
35.1
Gender
Male
53.2
Female
46.8
Education level
None
16.9
Primary education
68.8
Secondary education
10.4
Higher education
3.9
Table 2 shows that 16.9% of the patients reported dyspnea at rest. However, according to the
NR, only 11.7% had dyspnea at rest.
Table 2
Dyspnea at rest
Self-assessment
% of subjects
Nursing records
% of subjects
Yes
16.9
11.7
No
83.1
88.3
Dyspnea at rest
Dyspnea at rest (yes)
Mean
3.8
–
Median
4
–
Mode
5
–
Minimum-maximum
1-7
–
Standard deviation
1.9
–
Coefficient of variation
0.5
–
Dyspnea in palliative care: nursing records and patient self
assessment of dyspnea
Revista de Enfermagem Referência – IV – n.º 16 -2018
56
With regard to the assessment of functional dyspnea, 31.2% of patients reported dyspnea when
performing an activity of daily living (ADL). As
Table 3 shows, patients’ self-assessment of func-
tional dyspnea intensity is very heterogeneous,
with some of them experiencing a very intense
sensation of dyspnea. According to the NR,
28.6% of the patients had functional dyspnea.
Table 3
Functional dyspnea
Self-assessment
% of subjects
Nursing records
% of subjects
Yes
31.2
28.6
No
68.8
71.4
5.3
–
Median
5
–
Mode
5
–
2-10
–
Standard deviation
2.5
–
Coefficient of variation
0.47
–
Functional dyspnea
Functional dyspnea (yes)
Mean
Minimum-maximum
After reencoding the data for functional dyspnea
in Table 3 into mild (NRS 1-3), moderate (NRS
4-6), and severe (NRS 7-10) functional dyspnea,
it can be concluded that 7.8% of individuals had
mild functional dyspnea, 14.3% had moderate
functional dyspnea, and the remaining 9.1%
had severe functional dyspnea. Equal percentages were obtained in the NR.
sessment was inconsistent with the NR – inconsistent group.
For reasons of simplicity and organization, the
filter was applied in two phases: the first phase
focused on dyspnea at rest, and the second phase
on functional dyspnea. Absolute frequencies
were calculated after the eligibility filter was applied.
The first phase of filter application resulted in
60 consistent and 17 inconsistent cases. In 10
of the 17 inconsistent cases, the patient reported
dyspnea at rest but it was not documented in the
NR; in the remaining 7 cases, the patient did not
report dyspnea at rest, but it was documented in
the NR.
Later, the second phase of filter application resulted in 26 inconsistent cases. Table 4 shows a
cross-comparison between the self-assessment of
the subjects included in the inconsistent group
and the NR, based on dyspnea intensity.
Association between patient self-assessment
and NR
In order to ensure data consistency between the
NRS and the NR, an eligibility filter was applied
in the database of the IBM SPSS Statistics software, thus dividing the sample into two large
groups. The first group was composed of the
sampled individuals whose dyspnea self-assessment was consistent with the NR – consistent
group; and the second group was composed of
the sampled individuals whose dyspnea self-as-
Table 4
Cross-comparison between patient self-assessment and the NR, based on the intensity of dyspnea
No functional
dyspnea
Mild functional
dyspnea
Moderate
functional
dyspnea
Severe
functional
dyspnea
No functional dyspnea
–
2
7
3
Mild functional dyspnea
6
–
0
1
NR/NRS
(n)
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
57
Moderate functional dyspnea
4
1
–
1
Severe functional dyspnea
0
1
0
–
Nota. NR = Nursing records; NRS = Numerical Rating Scale; n = Number of subjects.
the afternoon shift, and one during the night
shift.
Association between nursing shifts and response bias
The obtained results do not allow concluding
on whether patients’ answers were biased by
the shift during which the form. Of the 77 eligible forms, 32 (41.5%) were collected during
the morning shift (8:00 a.m. to 4:30 p.m.), 35
(45.5%) during the afternoon shift (4:31 p.m. to
10:30 p.m.), and 10 (13.0%) during the night
shift (10:31 p.m. to 7:59 a.m.).
In the inconsistent group, which was obtained in the first phase of eligibility filter application, seven forms were collected during
the morning shift, six during the afternoon
shift, and three during the night shift. In the
second phase, 14 inconsistent cases were obtained during the morning shift, 11 during
Autonomous nursing interventions
Nursing interventions can only be designed
based on a diagnosis. In this study, only 38%
of the sampled individuals were diagnosed with
dyspnea at rest and/or functional dyspnea. Thus,
Table 5 shows the autonomous nursing interventions identified within the sample under
analysis and the percentage of subjects to whom
they were provided. These data were collected
by analyzing only the interventions that were
designed using the SAPE®. Based on the NR,
not all individuals diagnosed with dyspnea at
rest and/or functional dyspnea receive targeted
interventions (Table 5).
Table 5
Autonomous nursing interventions
Autonomous nursing interventions
% of subjects
Praising the learning of new skills
7%
Performing respiratory kinesiotherapy
28%
Optimizing ventilation through positioning techniques
62%
Optimizing inhalation therapy
10%
Monitoring breathing
90%
Discussion
symptoms before completing the form, either
in the emergency department or in the internal medicine ward. In addition, the heterogeneity of the sample in terms of diagnosis and
comorbidities can influence the presence of
dyspnea.
Based on the self-assessment of individuals who reported dyspnea at rest/functional
dyspnea, its intensity, calculated through the
NRS, was very heterogeneous. Some individuals experienced maximum intensity (NRS10) while performing an ADL.
The results obtained from the NR reveal that
the majority of the subjects did not have
dyspnea at rest and/or functional dyspnea.
Moreover, the eligibility test showed consistency between the NR and patients’ dyspnea
self-assessment.
The sample was composed of 77 subjects,
mostly men. It was very heterogeneous regarding personal health history and diagnosis,
among which HF was the most prevalent. It
is well known that dyspnea is one of the most
common clinical manifestations of HF (Arrigo, Parissis, Akiyama, & Mebazaa, 2016).
The results show that more than half of the
sampled subjects did not report dyspnea at
rest and/or functional dyspnea. Indeed, it
should be noted that the forms and, consequently, the NRSs for assessment of dyspnea
intensity, were applied at any moment during
the patient’s hospitalization at the internal
medicine ward. It is likely that the patient
had already received dyspnea care to manage
Dyspnea in palliative care: nursing records and patient self
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Revista de Enfermagem Referência – IV – n.º 16 -2018
58
Therefore, given that the SAPE® does not include a dyspnea assessment scale to be used
by nurses, it can be concluded that nurses
tend to diagnose dyspnea at rest and functional dyspnea correctly, even without a specific assessment tool.
According to Baker et al. (2013), only a small
percentage of the nurses recognized the importance of implementing a dyspnea assessment tool in NISs. Indeed, based on the
obtained results, the lack of a standardized
scale in NR does not bias nurses’ judgment
at the time of diagnosis of dyspnea. However, according to the recommendations of the
American Nurses Association (2010) and the
Registered Nurses’ Association of Ontario
(2012), the implementation of a dyspnea assessment tool provides objective and accurate
NR that facilitate the multidisciplinary team’s
understanding of how dyspnea intensity will
evolve throughout hospitalization.
The NR were analyzed based on these results.
At the time of data collection, there was no
differentiated therapeutic plan for the symptomatic management of different intensities
of dyspnea. Only the autonomous nursing
interventions targeting dyspnea from the
SAPE® were considered. These interventions
were not observed in all individuals diagnosed with dyspnea, possibly due to a documentation error or the lack of symptom management measures.
The most prevalent intervention was monitoring breathing, followed by optimizing
ventilation through positioning techniques.
According to Bailey et al. (2013), dyspnea can
be reduced through positioning, however, in a
study conducted by Costa (2016), nurses recognized the importance of an adequate positioning to relief dyspnea, but not all of them
had enough knowledge about appropriate positioning techniques.
More specific and accurate NR, Based on interprofissional reflective practice, would certainly provide greater visibility to the profession, enable the monitoring of interventions,
and promote care quality and development of
indicators (Registered Nurses’ Association of
Ontario, 2012).
As previously stated, dyspnea is a subjective
experience with physiological, psychological,
social, and environmental factors (American
Thoracic Society, 2012). No nursing interventions were found that covered the social
and environmental dimension. The psychological dimension is represented by praising
the learning of new skills.
No NR were found on the effectiveness of the
above-mentioned autonomous nursing interventions.
Finally, assuming that dyspnea intensity varies throughout the day (Mercadante et al.,
2016) and that the most severe episodes of
dyspnea occur more frequently during the
day than at night (Weingärtner et al., 2015),
the potential influence of the nursing shift in
dyspnea assessment was also analyzed. Thus,
the forms were applied during three different
shifts (morning, afternoon, and night) and it
was concluded that the shift during which the
form was applied did not influence dyspnea
self-assessment.
This study had some limitations, namely the
use of a non-random purposive sample, the
sample heterogeneity in terms of personal
health history and diagnosis, regardless of any
inclusion criteria, the institution’s organizational aspects, and the lack of a protocol that
defined the criteria for form application.
In view of the above, these findings can only
be used to describe the context under analysis
and cannot be generalized to other populations or situations. However, the importance
of the findings and the innovative nature of
the study should not be underestimated.
Conclusion
Dyspnea is a subjective experience, which is
often described as a feeling of breathlessness or
breathing difficulty resulting from the interaction of multiple physiological, psychological,
social, and environmental factors.
This study compared NR and patient self-assessment of dyspnea using a NRS. Although
nurses lack dyspnea assessment tools, the obtained results show little discrepancy between
nurses’ and patients’ assessment of dyspnea.
The NR available in the SAPE® are structured
based on the nursing process, thus each diagnosis of dyspnea at rest and/or functional
dyspnea must have associated interventions.
The analysis of the NR revealed the lack of a
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
59
differentiated therapeutic plan for managing
dyspnea symptoms of different intensities.
Similarly, it also revealed that autonomous
nursing interventions did not cover all the
dimensions of dyspnea. Due to documentation errors or lack of dyspnea management
measures, no autonomous nursing interventions were associated with some diagnoses of
dyspnea.
In addition, the effectiveness of the autonomous nursing interventions performed on
patients was not assessed.
Therefore, according to the NR, and particularly in what concerns dyspnea, nurses
diagnose dyspnea at rest and/or functional
dyspnea without using standardized criteria,
document non-differentiated autonomous
nursing interventions that do not target the
patient’s needs, and, finally, do not reassess
the effectiveness of their interventions.
Lastly, it can be concluded that the research
question was answered and the study objectives were reached.
However, some aspects should be considered.
The correct identification and monitoring of
dyspnea is essential to ensure the quality of
life of the patient with dyspnea. This procedure should be performed at the beginning
of hospitalization and be regularly performed
throughout it using a single assessment tool.
The NRS is recommended for the assessment
of dyspnea intensity because it enables the
self-report of subjective conditions and the
assessment of dyspnea at rest and functional
dyspnea.
Furthermore, it would be interesting to conduct a study on nurses’ perceptions about the
use of dyspnea assessment tools for measuring and monitoring dyspnea. It is important
to understand if the nursing team becomes
more aware of dyspnea in nursing care delivery after using dyspnea assessment tools.
It would also be important to study whether
nurses’ greater awareness would translate into
the development of a differentiated therapeutic plan for managing dyspnea symptoms of
different intensities.
Finally, it is urgent to conduct a study on
nursing interventions targeted at individuals
diagnosed with dyspnea and their expected
outcomes.
In summary, despite the limitations and diffi-
culties experienced throughout this study, the
research question was answered and the proposed objectives were achieved through the
scientific method. This study contributed to
the production of knowledge about this topic
and opened the way to future studies. A more
systematic approach to dyspnea is required in
case of individuals with advanced progressive
chronic disease and palliative care needs.
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Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
61
ARTIGO DE INVESTIGAÇÃO (ORIGINAL)
RESEARCH PAPER (ORIGINAL)
ISSNe: 2182.2883 | ISSNp: 0874.0283
Disponível em: https://doi.org/10.12707/RIV17075
Dispneia em cuidados paliativos: registos de enfermagem
e a autoavaliação da dispneia
Dyspnea in palliative care: nursing records and self-assessment of dyspnea
Disnea en cuidados paliativos: registros de enfermería y autoevaluación de la disnea
Ana Raquel Margarido Vaz Alves*; Paulo Sérgio dos Reis Saraiva Pina**
Resumo
Enquadramento: Os registos de enfermagem (RE) que englobam uma avaliação quantitativa da dispneia permitem
adequar a prestação de cuidados de enfermagem às necessidades do doente.
Objetivos: Comparar os RE e a autoavaliação da intensidade da dispneia realizada com recurso à Escala de Avaliação Numérica (EAN) por indivíduos com doenças crónicas, progressivas e avançadas, com necessidades paliativas,
internados em serviços de medicina interna.
Metodologia: Realizou-se uma pesquisa quantitativa, descritiva, transversal e observacional através da aplicação de
EAN da intensidade da dispneia. Recolheram-se RE de 77 selecionados de forma intencional e não aleatória.
Resultados: Os enfermeiros diagnosticam corretamente a dispneia em repouso e/ou dispneia funcional sem recurso
a uma escala de avaliação de dispneia. Não se observam intervenções autónomas de enfermagem em todos os indivíduos com o diagnóstico de dispneia, bem como, as intervenções não abrangem todas as dimensões da dispneia total.
Conclusão: Os RE quantitativos contribuem para maior rigor na identificação, monitorização e intervenção na
dispneia. Considera-se necessária uma abordagem mais sistematizada da dispneia em indivíduos com necessidades
paliativas.
Palavras-chave: dispneia (enfermagem), dispneia (classificação), registros de enfermagem, cuidados paliativos, avaliação da dispneia
Abstract
Resumen
Background: The integration of a quantitative assessment of dyspnea in nursing records (NR) allows adjusting nursing care delivery to each patient’s needs.
Objectives: To compare NR and the self-assessment
of dyspnea intensity using the Numerical Rating Scale
(NRS) in patients with advanced progressive chronic
disease and palliative care needs who were admitted to
internal medicine wards.
Methodology: A quantitative study was conducted
using a cross-sectional, descriptive, and observational approach. The NRS was applied to assess dyspnea
intensity. Seventy-seven NR were selected using a
non-random, purposive sampling technique.
Results: Nurses diagnosed dyspnea at rest and/or functional dyspnea correctly without using a dyspnea assessment tool. Not all patients diagnosed with dyspnea
had nursing care plans. In addition, the specific nursing
interventions do not consider all dimensions of total
dyspnea.
Conclusion: Quantitative NR allow for a more accurate identification, monitoring, and management of
dyspnea. A more systematic approach to dyspnea in patients with palliative care needs is required.
Marco contextual: Los registros de enfermería (RE)
que engloban una evaluación cuantitativa de la disnea
permiten adecuar la prestación de cuidados de enfermería a las necesidades del paciente.
Objetivos: Comparar los RE y la autoevaluación de la
intensidad de la disnea realizada con la Escala de Evaluación Numérica (EEN) por individuos con enfermedades crónicas, progresivas y avanzadas, con necesidades
paliativas, internados en servicios de medicina interna.
Metodología: Se realizó una investigación cuantitativa, descriptiva, transversal y observacional a través de
la aplicación de EEN de la intensidad de la disnea. Se
recopilaron RE de 77 seleccionados de forma intencional y no aleatoria.
Resultados: Los enfermeros diagnostican correctamente la disnea en reposo y/o disnea funcional sin recurrir
a una escala de evaluación de la disnea. No se observan
intervenciones autónomas de enfermería en todos los
individuos con diagnóstico de disnea, y las intervenciones no abarcan todas las dimensiones de la disnea total.
Conclusión: Los RE cuantitativos contribuyen a un
mayor rigor en la identificación, el seguimiento y la intervención en la disnea. Se considera necesario un enfoque más sistemático de la disnea en individuos con
necesidades paliativas.
Keywords: dyspnea (nursing), dyspnea (classification),
nursing records, palliative care, assessment of dyspnea
*MsC., Enfermeira de cuidados gerais, Serviço de Medicina 1, Hospital Garcia de Orta, EPE, 2805267, Almada, Portugal [ana.raquel.alves3@hgo.min-saude.pt]. Contribuição no artigo: pesquisa
bibliográfica, desenvolvimento do formulário aplicado no estudo, colheita de dados, tratamento,
análise e discussão de dados, redação e revisão final do artigo. Morada para correspondência: Av.
Torrado da Silva, 2805-267, Almada, Portugal.
**MsC., Médico, Casa de Saúde da Idanha, Belas, 2605-077, Sintra, Portugal [preispina@hotmail.
com]. Contribuição no artigo: desenvolvimento do formulário aplicado no estudo, análise e discussão de dados, redação e revisão final do artigo.
Revista de Enfermagem Referência
Palabras clave: disnea (enfermeira), disnea (clasificación), registros de enfermería, cuidados paliativos,
evaluación de disnea
Recebido para publicação: 26.09.17
Aceite para publicação: 11.12.17
Série IV – n.º 16 – JAN./FEV./MAR. 2018
pp. 53 – 62
Introdução
identificar as intervenções autónomas de enfermagem registadas pelos enfermeiros que
visem o cuidar, determinar a prevalência das
intervenções autónomas de enfermagem, alcançar um tratamento ótimo para a dispneia e
determinar se o turno de enfermagem enviesa
a autoavaliação da dispneia.
Em cuidados paliativos, a dispneia, comummente conhecida por dificuldade
respiratória, ocorre quer em doentes com
cancro, quer em não oncológicos e pode
surgir em qualquer fase da doença (Coccia,
Palkowski, Schweitzer, Motsohi, & Ntusi,
2016).
A prevalência da dispneia em pessoas portadoras de doenças crónicas pode variar entre 19% a 50% (Feio, 2016). Efetivamente,
não existem dados estatísticos consensuais,
ora porque as pessoas com dispneia negligenciassem a dificuldade respiratória sentida, ora porque os profissionais de saúde
considerassem irrelevantes as queixas da
pessoa (Banzett & O’Donnell, 2014).
A autoavaliação da dispneia pelo doente é
um processo rápido, não exige que o indivíduo decida se é relevante ou não transmitir
ao profissional de saúde e permite registos
objetivos (Banzett & O’Donnell, 2014).
As vantagens deste processo são várias. Por
um lado, uma avaliação quantitativa precoce
e frequente da dispneia permite um melhor
controlo da mesma, alívio do sofrimento e
diminuição da possibilidade de agravamento da doença (Baker et al., 2013). Por outro
lado, permite registos de enfermagem (RE)
mais fidedignos e relacionados com as queixas do doente e, por conseguinte, possibilita
intervenções de enfermagem mais adequadas às necessidades da pessoa.
Todavia, apesar de existirem várias escalas
para classificar a intensidade da dispneia,
sabe-se que a aplicação de instrumentos
de avaliação da dispneia não é uma prática
frequente na prestação de cuidados de enfermagem. Nesta linha de raciocínio, surge
a inquietação de aferir todo o processo desde a identificação à intervenção de enfermagem na dispneia com recurso a Escala de
Avaliação Numérica (EAN).
Para a compreensão do fenómeno em estudo optou-se por indagar a autoavaliação da
dispneia dos sujeitos da amostra através de
EAN presentes em formulários e seguidamente confrontá-los com os RE.
Deste modo, é possível comparar os RE e a
autoavaliação da dispneia, conhecer a intensidade da dispneia funcional do doente,
Enquadramento
A dispneia é uma experiência subjetiva de
desconforto respiratório que consiste em
sensações qualitativamente distintas, variáveis na sua intensidade (American Thoracic
Society, 2012). A experiência deriva de interações entre múltiplos fatores fisiológicos,
psicológicos, sociais e ambientais, podendo
induzir respostas comportamentais e fisiológicas secundárias (Coccia et al., 2016).
Por ser uma experiência subjetiva, apenas
a pessoa com dispneia está em posição de
determinar a sua gravidade (Hayen, Herigstad, & Pattinson, 2013). Assim, sempre que
possível, a autoavaliação da intensidade da
dispneia deve ser o método de avaliação a
utilizar.
Atualmente existem várias escalas aptas para
a autoavaliação da intensidade da dispneia
(Berliner, Schneider, Welte, & Bauersachs,
2016). Destas, devido à sua objetividade e
facilidade de compreensão e de aplicação,
destaca-se a EAN (Johnson et al., 2016). Em
consonância, Bailey et al. (2013) acrescenta
que a EAN permite aos enfermeiros identificar a presença de dispneia, fundamentar e
avaliar a eficiência das suas intervenções.
A EAN consiste numa régua dividida em 11
partes iguais, numeradas sucessivamente de
0 a 10 (Wysham et al., 2015). Ao aplicar esta
escala pretende-se que a pessoa faça a equivalência entre a intensidade da sua dispneia
e uma classificação numérica, sendo que a
0 corresponde sem dispneia e a 10 a classificação de dispneia insuportável (Wade et al.,
2017).
Independentemente das recomendações para
a implementação de EAN na prestação de
cuidados de enfermagem e por conseguinte
nos RE (American Nurses Association, 2010)
até ao momento da redação do presente artigo o estado de arte nacional e internacional
Dispneia em cuidados paliativos: registos de enfermagem e a
autoavaliação da dispneia
Revista de Enfermagem Referência – IV – n.º 16 -2018
54
sobre esta realidade é bastante ténue.
Ainda assim, salienta-se um estudo piloto
de Baker et al. (2013) que testou a viabilidade da equipa de enfermagem monitorizar
a dispneia das pessoas internadas através de
um instrumento de avaliação composto por
três escalas, sendo uma delas uma EAN. No
fim do estudo, 92% dos enfermeiros assumiram ser importante avaliar a dispneia
através de um instrumento de avaliação. Os
autores consideraram que a implementação da avaliação da dispneia na prestação
de cuidados não acresce a carga de trabalho
da equipa de enfermagem. Recentemente,
Johnson et al. (2016) recomenda o uso da
EAN em detrimento da Escala Modificada de Borg para avaliação da intensidade
da dispneia em vários momentos e em determinadas situações, como por exemplo,
em repouso e em esforço. Finalmente para
Wade et al. (2017) a EAN é altamente recomendável para a avaliação da intensidade
da dispneia, porém, salienta para a necessidade de enunciados rigorosos.
Por conseguinte, o facto de o registo da
avaliação da intensidade da dispneia em
suporte apropriado permitir monitorizar a
intensidade da dispneia ao longo do internamento, facilita a avaliação das intervenções de enfermagem no alívio da dispneia,
contribuindo para a visibilidade dos cuidados de enfermagem e articulação de cuidados multidisciplinares (Registered Nurses’
Association of Ontario, 2012).
Por RE entende-se o conjunto de informações escritas, produzidas pelo enfermeiro
na prática clínica, nas quais são compiladas
as informações resultantes das necessidades
de cuidados de enfermagem (Ordem dos
Enfermeiros, 2005). Para a uniformização e informatização de todo este processo
criou-se o Sistema de Informação em Enfermagem (SIE) representado pelo Sistema
de Apoio à Prática de Enfermagem (SAPE®)
na realidade em estudo. Através do SAPE®
é possível traçar os diagnósticos de dispneia
em repouso e/ou funcional, que mediante
um juízo clínico identifica, documenta e
monitoriza as necessidades do doente. Todavia, sabe-se que o SAPE® não inclui uma
escala de avaliação da dispneia indo, assim,
em sentido divergente ao recomendado
pela evidência científica apresentada anteriormente.
Questão de investigação
Qual a relação entre os RE e a auto-avaliação da dispneia (com recurso às EAN) feita
por indivíduos adultos com doença avançada, progressiva e incurável?
Metodologia
A realização do presente estudo foi autorizada pela Comissão de Ética e Conselho de
Administração do Hospital Garcia de Orta,
EPE (HGO) e pela Comissão de Ética do
Centro Académico de Medicina de Lisboa.
Trata-se de um estudo quantitativo, descritivo, transversal e observacional. A população alvo é constituída por todos os doentes
consecutivos internados nos Serviços de
Medicina I e II do HGO no período de 13
de maio de 2016 a 13 de junho de 2016.
Os critérios de inclusão foram: sujeitos
com idade superior a 18 anos; portadores
de doença incurável, avançada e progressiva; com consentimento esclarecido e informado assinado; com capacidade para
autoavaliar a intensidade da sua dispneia
numa EAN; RE do doente, disponíveis e
completos.
Tendo em consideração as diretivas do Programa Nacional de Cuidados Paliativos
(Direção-Geral da Saúde, 2005) e da European Association for Palliative Care (2009),
considera-se doença avançada e progressiva
uma doença incurável com necessidade de
cuidados paliativos e onde se prevê o fim da
vida num período de 1 a 2 anos.
A amostra final do estudo foi composta
por todos os indivíduos que cumpriram os
critérios supramencionados e com menos
de quatro erros na versão portuguesa do
Short Portable Mental Status Questionnaire
(SPMSQ). Assim, obteve-se uma amostra
não aleatória e intencional à qual se aplicou um formulário. Este é constituído por
questões de caracterização sócio demográfica, pelo SPMSQ e por duas EANs para autoavaliação da dispneia em repouso e funcional
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
55
à luz dos estudos de Baker et al. (2013) e de
Johnson et al. (2016).
O enunciado da primeira EAN pede ao entrevistado que avalie a intensidade de dispneia em
repouso através da seguinte questão: “Quando
se encontra em repouso como classifica a sua
sensação de falta de ar e dificuldade respiratória?”. O enunciado da segunda EAN refere-se à
dispneia funcional “Quando realiza uma atividade de vida diária, como por exemplo comer
ou tomar banho, como classifica a sua sensação
de falta de ar e dificuldade respiratória?”.
Foram igualmente recolhidos dados dos RE
do SAPE® e agrupados em documento criado
para o efeito.
Previamente à aplicação da versão definitiva
do formulário foi aplicado um pré-teste a um
grupo de cinco indivíduos. No final desta
aplicação concluiu-se que deveria ser o entrevistador a redigir as respostas de todos os
indivíduos inquiridos.
Finalmente os dados foram introduzidos e
processados no software IBM SPSS Statistics,
versão 23.0 procedendo à análise estatística e
descritiva dos mesmos.
Resultados
Foram aplicados 92 formulários, 15 foram
excluídos por não cumprirem com o critério de eleição segundo o SPMSQ. Assim,
obteve-se uma amostra constituída por 77
indivíduos. A amostra é representada sobretudo por homens, cerca de 65% tem mais
de 71 anos de idade, possuindo um nível
de escolaridade básico. Igualmente, sabese que as doenças do aparelho circulatório
são o principal motivo de internamento dos
sujeitos da amostra, sendo que o acidente
vascular cerebral e a insuficiência cardíaca
(IC) representam quase 40% dos problemas
de saúde. Mais de metade dos sujeitos da
amostra tem três ou mais antecedentes de
saúde. A Tabela 1 reúne os dados que caracterizam a amostra.
Tabela 1
Caracterização sociodemográfica da amostra
Características sociodemográficas da amostra
Idade
Anos
Média
73
Mediana
74
Mínimo-Máximo
28-90
Idade, grupos etários
% de sujeitos
Até 70 anos
35,1
De 71 a 80 anos
29,8
Mais de 81 anos
35,1
Género
Masculino
53,2
Feminino
46,8
Nível de escolaridade
Nenhum
16,9
Ensino Básico
68,8
Ensino Secundário
10,4
Ensino Superior
3,9
Dispneia em cuidados paliativos: registos de enfermagem e a
autoavaliação da dispneia
Revista de Enfermagem Referência – IV – n.º 16 -2018
56
Através da Tabela 2 é possível concluir que
16,9% dos doentes relata dispneia em repou-
so, porém segundo os RE somente 11,7% dos
sujeitos da amostra tem dispneia em repouso.
Tabela 2
Dispneia em repouso
Autoavaliação
% de sujeitos
Registos de enfermagem
% de sujeitos
Presente
16,9
11,7
Ausente
83,1
88,3
3,8
–
Mediana
4
–
Moda
5
–
Mínimo-máximo
1-7
–
Desvio padrão
1,9
–
Coeficiente variação
0,5
–
Dispneia em repouso
Dispneia em repouso presente
Média
Relativamente à avaliação da dispneia funcional, 31,2% dos doentes assume a presença de
dispneia aquando da realização de uma atividade de vida diária (AVD). A intensidade da
dispneia funcional, segundo a autoavaliação
dos indivíduos, é bastante heterogénea existindo sujeitos a experienciar uma sensação de
dispneia muito intensa como se pode observar
na Tabela 3. À luz dos RE, 28,6% dos indivíduos da amostra apresenta dispneia funcional.
Tabela 3
Dispneia funcional
Autoavaliação
% de sujeitos
Registos de enfermagem
% de sujeitos
Presente
31,2
28,6
Ausente
68,8
71,4
Dispneia funcional
Dispneia funcional presente
Média
5,3
–
Mediana
5
–
Moda
5
–
Mínimo-máximo
2-10
–
Desvio padrão
2,5
–
Coeficiente variação
0,47
–
Recodificando os dados da Tabela 3 para dispneia funcional em grau reduzido (EAN 1-3),
grau moderado (EAN 4-6) e grau elevado
(EAN 7-10), sabe-se que 7,8% dos indivíduos
inclui-se em dispneia funcional de grau reduzido, 14,3% de grau moderado e os restantes
9,1% em dispneia funcional em grau elevado.
As mesmas percentagens são obtidas nos RE.
Relação da autoavaliação do paciente com
os RE
No sentido de salvaguardar que os dados obti-
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
57
dos através das EANs e dos RE eram concordantes e coincidentes aplicou-se um filtro de
elegibilidade na base de dados do IBM SPSS
Statistics software. Através deste, foi possível
separar a amostra em dois grandes grupos. O
primeiro grupo, intitulado de congruentes,
constituído pelos indivíduos da amostra em
que a autoavaliação da dispneia está de acordo
com os RE – grupo consistente; e o segundo
grupo, designado de incongruentes, composto pelos casos em que a autoavaliação da dispneia é incongruente com os RE.
Por motivos de simplicidade e organização
aplicou-se o filtro em duas fases, sendo a primeira fase dedicada à dispneia em repouso e
a segunda direcionada para o estudo da disp-
neia funcional. Após a aplicação do filtro de
elegibilidade procedeu-se ao cálculo das frequências absolutas.
Neste sentido, na primeira fase de aplicação
do filtro obtiveram-se 60 casos congruentes
e 17 incongruentes. Em 10 casos dos 17 incongruentes o sujeito assumiu dispneia em
repouso, mas esta não constava dos RE; nos
restantes 7 casos os sujeitos negaram dispneia
em repouso, mas esta constava dos RE.
Posteriormente na segunda fase de aplicação
do filtro verificaram-se 26 casos incongruentes. A Tabela 4 apresenta uma comparação
cruzada entre as avaliações dos sujeitos incluídos no grupo incongruentes e dos RE, conforme a intensidade da dispneia.
Tabela 4
Comparação cruzada entre as avaliações dos sujeitos e dos RE, conforme a intensidade da dispneia
Sem dispneia
funcional
Dispneia funcional
em grau reduzido
Dispneia
funcional em grau
moderado
Dispneia funcional
em grau elevado
Sem dispneia
funcional
–
2
7
3
Dispneia funcional
em grau reduzido
6
–
0
1
Dispneia funcional
em grau moderado
4
1
–
1
Dispneia funcional
em grau elevado
0
1
0
–
RE/EAN
(n)
Nota. RE = Registos de enfermagem; EAN = Escala de Avaliação Numérica; n = Número de sujeitos.
Relação dos turnos de enfermagem com o
enviesamento de resposta
Ao refletir sobre os resultados urge a incerteza
se o turno no qual foi aplicado o formulário é
motivo de enviesamento de resposta. Dos 77
formulários elegíveis para o presente estudo,
32 (41,5%) foram colhidos durante o turno da
manhã (08h00 às 16h30), 35 (45,5%) no turno da tarde (16h31 às 22h30) e 10 (13,0%) no
turno da noite (22h31 às 07h59).
Dos casos incongruentes obtidos na primeira fase de aplicação do filtro de elegibilidade:
sete formulários foram colhidos no turno da
manhã, seis no turno da tarde e três no turno
da noite. Consequentemente na segunda fase
de aplicação do mencionado filtro: 14 casos incongruentes foram obtidos no turno da manhã,
11 no turno da tarde e um no turno da noite.
Intervenções autónomas de enfermagem
As intervenções de enfermagem só podem
ser delineadas perante um diagnóstico. Neste estudo, somente 38% da amostra apresentou diagnóstico de dispneia em repouso e/ou dispneia funcional. Neste sentido,
assumindo este universo, a Tabela 5 exibe
as intervenções autónomas de enfermagem
identificadas e a percentagem de sujeitos a
quem estas foram prestadas. Para o levantamento dos dados expostos analisaram-se
somente as intervenções parametrizadas
por SAPE®. Analisando a Tabela 5 pode-se
concluir que, à luz dos RE, nem todos os
indivíduos com diagnóstico de dispneia em
repouso e/ou dispneia funcional são alvo de
intervenções dirigidas a esta situação.
Dispneia em cuidados paliativos: registos de enfermagem e a
autoavaliação da dispneia
Revista de Enfermagem Referência – IV – n.º 16 -2018
58
Tabela 5
Intervenções autónomas de enfermagem
Intervenções autónomas de Enfermagem
% de sujeitos
Elogiar a aprendizagem de habilidades
7%
Executar cinesioterapia respiratória
28%
Otimizar a ventilação através de técnicas de posicionamento
62%
Otimizar inaloterapia
10%
Vigiar a respiração
90%
Discussão
pode afirmar-se que os enfermeiros diagnosticam corretamente a dispneia em repouso e
a dispneia funcional, mesmo sem recurso a
uma escala de avaliação específica.
Segundo o estudo de Baker et al. (2013) apenas uma minoria dos enfermeiros envolvidos
no estudo reconhece a importância de implementar uma escala de avaliação da dispneia
nos SIEs. Efetivamente, à luz dos resultados
obtidos a carência de uma escala protocolada nos RE não enviesa o juízo do enfermeiro
no momento do diagnóstico de dispneia. No
entanto, contrapondo com as recomendações
da American Nurses Association (2010) e
Registered Nurses’ Association of Ontario
(2012), a implementação de uma escala de
avaliação da dispneia permite RE objetivos e
rigorosos que facilitam a compreensão da evolução da intensidade da dispneia ao longo do
internamento pela equipa multidisciplinar.
Em consonância com estes resultados analisaram-se os RE. Aquando da colheita de dados
observou-se a inexistência de um plano terapêutico diferenciado para o controlo sintomático das diferentes intensidades da dispneia.
Somente se fez um levantamento das intervenções de enfermagem autónomas dirigidas
à dispneia, parametrizadas em SAPE®. Estas
intervenções não foram observadas em todos
os indivíduos com o diagnóstico de dispneia,
assumindo-se uma falha de registo ou uma
ausência de medidas de controlo do sintoma.
Salienta-se vigiar a respiração como a intervenção mais prevalente seguida de otimizar
a ventilação através de técnicas de posicionamento. Bailey et al. (2013) refere que se
pode diminuir a dispneia através do posicionamento, porém, num estudo realizado por
Costa (2016) verifica-se que os enfermeiros
reconhecem a importância de um adequado
posicionamento no alívio da dispneia, mas
nem todos têm conhecimentos sobre o posicionamento a adotar.
A existência de RE mais específicos e rigorosos, com a utilização do método de pensa-
Obteve-se uma amostra constituída por 77
sujeitos, maioritariamente do género masculino, bastante heterogénea respetivamente a antecedentes de saúde e diagnósticos de saúde.
Destes diagnósticos a insuficiência cardíaca
foi dos mais prevalentes e sabe-se que a dispneia é das manifestações clínicas mais comuns
nesta patologia (Arrigo, Parissis, Akiyama, &
Mebazaa, 2016).
De acordo com os resultados obtidos pode-se
concluir que mais de metade dos sujeitos da
amostra nega a presença de dispneia em repouso e/ou dispneia funcional. Com efeito, é
de salientar que a aplicação dos formulários,
por conseguinte das EANs para avaliação da
intensidade da dispneia, foi realizada a qualquer momento no período de internamento
numa enfermaria de medicina interna. Possivelmente antes de responder ao formulário o
doente já recebera cuidados dirigidos à dispneia ora no serviço de urgência, ora no serviço
de medicina interna, garantindo-se o controlo da sintomatologia. Além do mencionado,
a heterogeneidade da amostra, em termos de
diagnóstico e comorbilidades, pode influenciar a presença de dispneia.
De acordo com as autoavaliações dos indivíduos que assumiram dispneia em repouso/
funcional, a intensidade da mesma, calculada
pela utilização da EAN, é bastante heterogénea existindo sujeitos a experienciar uma intensidade máxima (EAN 10) durante a realização de uma AVD.
Do mesmo modo, segundo os RE, a maioria
dos sujeitos da amostra não apresenta dispneia em repouso e/ou dispneia funcional;
ademais, pelo teste de elegibilidade, sabe-se
que há concordância entre os RE e a autoavalição da dispneia.
Assim, sabendo que os enfermeiros não dispõem de escalas de avaliação da dispneia no
SAPE®, nem recorrem às mesmas para a avaliação da intensidade da dispneia do doente,
Revista de Enfermagem Referência – IV – n.º 16 -2018
ANA RAQUEL MARGARIDO VAZ ALVES et al.
59
mento em enfermagem, compreenderia, com
certeza, uma maior visibilidade da profissão,
possibilitando a monitorização dos cuidados,
a promoção da qualidade e o desenvolvimento de indicadores (Registered Nurses’ Association of Ontario, 2012).
Tal como dito anteriormente, sendo a dispneia uma experiência subjetiva com fatores
fisiológicos, psicológicos, sociais e ambientais
(American Thoracic Society, 2012) não se
verificaram intervenções de enfermagem que
englobassem a dimensão social e ambiental. A
dimensão psicológica é representada por elogiar a aprendizagem de habilidades.
Não se encontraram RE sobre a eficácia das intervenções autónomas de enfermagem prestadas.
Por fim, assumindo que existem variações
na intensidade da dispneia ao longo do dia
(Mercadante et al., 2016) e sabendo que os
episódios de dispneia de intensidade elevada
são mais frequentes durante o dia do que de
noite (Weingärtner et al., 2015), testou-se a
possibilidade do turno de enfermagem poder
influenciar a avaliação da dispneia. Assim, recolheram-se formulários nos três turnos que
compõem um dia e concluiu-se que o turno
no qual foi aplicado o formulário não enviesou a autoavaliação da dispneia.
Ao longo do estudo surgiram algumas limitações. Destas destacam-se a amostra não aleatória, a amostra heterogénea em termos de
diagnóstico e antecedentes de saúde independentemente de existirem critérios de inclusão,
as circunstâncias organizativas da instituição;
e a ausência de um protocolo com critérios de
aplicação do formulário.
Perante o mencionando, não é possível extrapolar estes factos a outras populações ou situações, servindo apenas para descrever o caso
presente. Muito embora o referido, não se pode
invalidar a importância dos resultados obtidos
e apequenar o caráter inovador do estudo.
ótica do enfermeiro e na ótica do doente.
Os RE disponibilizados na aplicação SAPE®
seguem a estrutura do processo de enfermagem, logo, para cada diagnóstico de dispneia
em repouso e/ou dispneia funcional devem
existir intervenções associadas.
A análise dos RE permitiu constatar a inexistência de um plano terapêutico diferenciado para o controlo sintomático de distintas
intensidades da dispneia. De igual modo,
verificou-se que as intervenções autónomas
de enfermagem não abrangeram todas as dimensões da dispneia. Por falha de registo ou
inexistência de medidas de controlo da dispneia, existiam diagnósticos de dispneia sem
intervenções autónomas de enfermagem associadas.
Igualmente, aferiu-se a ausência de avaliação
da eficácia das intervenções autónomas de enfermagem prestadas.
Deste modo, segundo os RE e na ótica de
auditor de RE sobre a dispneia, pode-se concluir que os enfermeiros diagnosticam dispneia em repouso e/ou dispneia funcional sem
critérios formalizados, registam intervenções
autónomas de enfermagem não diferenciadas
e não direcionadas às necessidades do doente
e finalmente não reavaliam a eficácia das suas
intervenções.
Por fim, pode concluir-se que a questão de
investigação lançada e os objetivos propostos
para este estudo foram respetivamente respondidos e obtidos.
Emergem, no entanto, algumas reflexões. Para
a manutenção da qualidade de vida do doente com dispneia é fundamental uma correta
identificação e monitorização da dispneia.
Este procedimento deve ocorrer no início do
internamento e ser mantido periodicamente no decorrer do mesmo com recurso a um
instrumento de avaliação único em todo o
internamento. Recomenda-se a utilização de
EAN para avaliação da intensidade da dispneia porque a EAN é facilmente usada para
auto-relato de condições subjetivas e porque
se trata de uma realidade que avalia a dispneia
em repouso e funcional.
Nesta linha de pensamento, lança-se a inquietação de um estudo sobre a perceção da
equipa de enfermagem sobre o uso de escalas
de avaliação da dispneia para a mensuração
e a monitorização da dispneia. É importante
compreender se a equipa de enfermagem se
apresenta mais sensibilizada para a dispneia
na prestação de cuidados de enfermagem após
o uso de escalas de avaliação da dispneia.
Parece igualmente importante estudar se o
aumento da sensibilização da equipa de enfer-
Conclusão
A dispneia é uma experiência subjetiva, frequentemente descrita como uma sensação de
falta de ar ou uma dificuldade respiratória,
que provém da interação de múltiplos fatores
fisiológicos, psicológicos, sociais e ambientais.
Este estudo comparou os RE e os resultados
obtidos por autoavaliação da dispneia do
doente com recurso a uma EAN. De antemão
sabe-se que os enfermeiros não dispõem de
instrumentos de avaliação da dispneia, porém, segundo os resultados obtidos há pouca
discrepância entre a avaliação da dispneia na
Dispneia em cuidados paliativos: registos de enfermagem e a
autoavaliação da dispneia
Revista de Enfermagem Referência – IV – n.º 16 -2018
60
magem seria proporcional ao desenvolvimento de um plano terapêutico diferenciado para
o controlo sintomático de distintas intensidades da dispneia.
Do mesmo modo, urge a necessidade de um
estudo dedicado às intervenções de enfermagem dirigidas à dispneia e aos resultados esperados das mesmas.
Em suma, apesar das limitações e dificuldades
decorridas ao longo deste estudo, foi possível, através do método científico, responder
à questão de investigação e alcançar os objetivos propostos. A concretização deste estudo
permitiu aumentar os conhecimentos sobre
esta temática e alargar os horizontes para futuras investigações sobre esta problemática.
Considera-se necessária uma abordagem mais
sistematizada da dispneia em indivíduos com
doenças crónicas, progressivas e avançadas,
com necessidades paliativas.
J. (2016). The differential diagnosis of dyspnea.
Deutsches Ärzteblatt International, 113(49), 834845. doi:10.3238/arztebl.2016.0834
Coccia, C. B., Palkowski, G. H., Schweitzer, B., Motsohi, T., & Ntusi, N. A. (2016). Dyspnoea: Pathophysiology and a clinical approach. South African
Medical Journal, 106(1), 32-36. Recuperado de
http://www.samj.org.za/index.php/samj/article/
view/10324/7076
Costa, M. (2016). A intervenção dos enfermeiros no controlo da dispneia (Master’s dissertation). Instituto
Politécnico de Viana do Castelo, Escola Superior de
Saúde, Portugal.
Direção-Geral da Saúde. (2005). Programa nacional de
cuidados paliativos. Lisboa, Portugal: Autor. Recuperado de https://www.dgs.pt/areas-em-destaque/
plano-nacional-de-saude/programas-nacionais/programa-nacional-de-cuidados-paliativos.aspx
Feio, M. (2016). Dispneia. In A. Barbosa, P. R. Pina,
F. Tavares, & I. Galriça Neto (Eds.), Manual de
cuidados paliativos (3ª ed., pp. 219-229). Lisboa,
Portugal: Núcleo de Cuidados Paliativos/Centro de
Bioética/Faculdade de Medicina de Lisboa.
Hayen, A., Herigstad, M., & Pattinson, K. T. (2013).
Understanding dyspnea as a complex individual experience. Maturitas, 76(1), 45-50. doi:10.1016/j.
maturitas.2013.06.005
Johnson, M. J., Close, L., Gillon, S. C., Molassiotis,
A., Lee, P. H., & Farquhar, M. C. (2016). Use of
the modified Borg scale and numerical rating scale
to measure chronic breathlessness: A pooled data
analysis. European Respiratory Journal, 47(6), 18611864. doi:10.1183/13993003.02089-2015
Mercadante, S., Aielli, F., Adile, C., Valle, A., Fusco,
F., Ferrera, P., … Porzio, G. (2016). Epidemiology and characteristics of episodic breathlessness in
advanced cancer patients: An observational study.
Journal of Pain and Symptom Management, 51(1),
17-24. doi:10.1016/j.jpainsymman.2015.07.020
Ordem dos Enfermeiros. (2005). Segurança do doente.
Recuperado de http://www.ordemenfermeiros.pt/
comunicacao/revistas/roe_17_julho_2005.pdf
Registered Nurses’ Association of Ontario. (2012).
Toolkit: Implementation of best practice guidelines
(2ªed.). Recuperado de http://rnao.ca/sites/rnao-ca/files/RNAO_ToolKit_2012_rev4_FA.pdf
Wade, J., Mendonca, S., Booth, S., Ewing, G., Gardener, A. C., & Farquhar, M. (2017). Are within-person numerical rating scale (NRS) ratings of
breathlessness ‘on average’ valid in advanced disease for patients and for patients’ informal carers?
BMJ Open Respiratory Research, 4(1), e000235.
doi:10.1136/bmjresp-2017-000235
Weingärtner, V., Scheve, C., Gerdes, V., Schwarz-Eywill, M., Prenzel, R., Otremba, B., … PAALiativ.
(2015). Characteristics of episodic breathlessness as
reported by patients with advanced chronic obstructive pulmonary disease and lung cancer: Results of a
Referências bibliográficas
American Nurses Association. (2010). Standards and
scope of respiratory nursing practice (2ªed.). Washington, WA: Autor.
American Thoracic Society. (2012). Dyspnea: Mechanisms, assessment, and management: A consensus
statement. American Journal of Respiratory and Critical Care Medicine, 159(1), 321-340. doi:10.1164/
ajrccm.159.1.ats898
Arrigo, M., Parissis, J. T., Akiyama, E., & Mebazaa, A.
(2016). Understanding acute heart failure: Pathophysiology and diagnosis. European Heart Journal
Supplements, 18(sup.), 11-18. doi:10.1093/eurheartj/suw044
European Association for Palliative Care. (2009) White
paper on standards and norms for hospice and palliative care in Europe: Part 1. Recuperado de
http://www.eapcnet.eu/LinkClick.aspx?fileticket=f63pXXzVNEY%3D&tabid=735
Bailey, P. H., Boyles, C. M., Cloutier, J. D., Bartlett, A.,
Goodridge, D., Manji, M., & Dusek, B. (2013).
Best practice in nursing care of dyspnea: The 6th
vital sign in individuals with COPD. Journal of
Nursing Education and Practice, 3(1), 108-122.
doi:10.5430/jnep.v3n1p108
Baker, K., Barsamian, J., Leone, D., Donovan, B. C.,
Williams, D., Carnevale, K., … Banzett, R. (2013).
Routine dyspnea assessment on unit admission.
The American Journal of Nursing, 113(11), 42-49.
doi:10.1097/01.NAJ.0000437112.43059.a0
Banzett, R. B., & O’Donnell, C. R. (2014). Should
we measure dyspnoea in everyone? European Respiratory Journal, 43(6), 1547-1550. doi:
10.1183/09031936.00031114
Berliner, D., Schneider, N., Welte, T., & Bauersachs,
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ANA RAQUEL MARGARIDO VAZ ALVES et al.
61
descriptive cohort study. Palliative Medicine, 29(5),
420-428. doi:10.1177/0269216314563428
Wysham, N. G., Miriovsky, B. J., Currow, D. C., Herndon, J. E., Samsa, G. P., Wilcock, A., & Abernethy,
A. P. (2015). Practical dyspnea assessment: Rela-
tionship between the 0-10 numerical rating scale
and the four-level categorical verbal descriptor scale
of dyspnea intensity. Journal of Pain and Symptom
Management, 50(4), 480-487. doi:10.1016/j.jpainsymman.2015.04.015
Dispneia em cuidados paliativos: registos de enfermagem e a
autoavaliação da dispneia
Revista de Enfermagem Referência – IV – n.º 16 -2018
62
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Article Analysis 2
Article Citation
and Permalink
(APA format)
Point
Article 1
Article 2
Description
Description
Broad Topic
Area/Title
Define Hypotheses
Define
Independent and
Dependent
Variables and
Types of Data for
Variables
Population of
Interest for the
Study
Sample
Sampling Method
How Were Data
Collected?
© 2019. Grand Canyon University. All Rights Reserved.
Article Analysis: Example 2
Article Citation
and Permalink
Utens, C. M. A., Goossens, L. M. A., van Schayck, O. C. P., Rutten-van Mölken, M. P.
M. H., van Litsenburg, W., Janssen, A., … Smeenk, F. W. J. M. (2013). Patient
preference and satisfaction in hospital-at-home and usual hospital care for
COPD exacerbations: Results of a randomised controlled trial. International
Journal of Nursing Studies, 50, 1537–1549.
doi.org/10.1016/j.ijnurstu.2013.03.006
Link: https://www.ncbi.nlm.nih.gov/pubmed/23582671
(Include permalink for articles from GCU Library.)
Point
Description
Broad Topic
Area/Title
The differences in preference and satisfaction based upon hospital care location for
COPD exacerbations.
Define
Hypotheses
Hypothesis not stated. Below is an example from the study:
H0: There is no difference in satisfaction levels based upon treatment location.
H1: There is a difference in satisfaction levels based upon treatment locations.
Define
Variables and
Treatment Location – categorical – “home treatment” and “hospital treatment”
Satisfaction – Ordinal Scale (1-5)
© 2019. Grand Canyon University. All Rights Reserved.
Types of Data
for Variables
Preference – categorical “home treatment” and “hospital treatment”
Population of
Interest for the
Study
COPD exacerbation patients from five hospitals and three home care organizations
Sample
139 patients
69 from the usual hospital care group
70 from the early assisted discharge care group
Sampling
Method
Mixed methods; quantitative was randomized sampling
How Were Data A questionnaire with both open-ended questions and questions with a scale of 1-5 (p.
Collected?
1539)
2
RESEARCH PAPER (ORIGINAL)
ARTIGO DE INVESTIGAÇÃO (ORIGINAL)
ISSNe: 2182.2883 | ISSNp: 0874.0283
Available: https://doi.org/10.12707/RIV17086
Liver transplant recipients: nursing therapeutics
during follow-up
A pessoa submetida a transplante de fígado: terapêuticas de enfermagem no follow-up
La persona sometida a un trasplante de hígado: terapias de enfermería en el seguimiento
Liliana Mota*; Fernanda Santos Bastos**; Maria Alice Correia Brito***
Abstract
Background: The implementation of nursing therapeutics adjusted to the actual needs of liver transplant recipients
can have a significant impact on transplantation outcomes since, after transplantation, patients are encouraged to
change the way in which they manage their therapeutic regimen towards success.
Objective: To identify the nursing foci and the interventions implemented to address the healthcare needs of liver
transplant recipients.
Methodology: Qualitative, retrospective study conducted at a transplant center, using descriptive statistics to analyze nursing records between July 2010 and September 2014.
Results: The most common nursing focus was susceptibility to infection (67.30%) with the implementation of
interventions related primarily to the teaching action type. Most of the interventions (57.07%) were related to the
observing action type.
Conclusion: The follow-up of liver transplant recipients focuses essentially on bodily processes and the monitoring
of signs and symptoms of disease complications.
Keywords: self care; liver transplantation; nursing care; information systems
Resumo
Resumen
Enquadramento: A implementação de terapêuticas de
enfermagem adequadas às reais necessidades da pessoa
submetida a transplante de fígado pode ter impacto
significativo nos resultados da transplantação pelo facto
de, após transplante, a pessoa ser convidada a reformular a forma como é capaz de gerir o seu regime terapêutico em prol do sucesso.
Objetivo: Identificar os focos e intervenções implementados pelos enfermeiros em resposta às necessidades de
cuidados identificadas na pessoa submetida a transplante de fígado.
Metodologia: Estudo qualitativo, retrospetivo, realizado num centro de transplantação, com recurso à análise
estatística descritiva da documentação de enfermagem
no período de julho de 2010 a setembro de 2014.
Resultados: O foco de enfermagem mais frequentemente identificado é a suscetibilidade à infeção (67,30%),
com a implementação de intervenções essencialmente
no âmbito do ensinar. A maioria das intervenções implementadas (57,07%) é do âmbito do observar.
Conclusão: O acompanhamento da pessoa submetida a
transplante de fígado centra-se essencialmente nos processos corporais e na vigilância de sinais e sintomas de
complicação da doença.
Marco contextual: La implementación de terapias de
enfermería adecuadas a las necesidades reales de la persona sometida a un trasplante de hígado puede tener un
impacto significativo en los resultados del trasplante por
el hecho de que, después de este, se invita a la persona
a reformular la forma en que es capaz de gestionar su
régimen terapéutico para que tenga éxito.
Objetivo: Identificar los focos e intervenciones implementados por los enfermeros en respuesta a las necesidades de cuidados identificados en la persona sometida
a trasplante de hígado.
Metodología: Estudio cualitativo, retrospectivo, realizado en un centro de trasplante, en el que se utilizó el
análisis estadístico descriptivo de la documentación de
enfermería en el período de julio de 2010 a septiembre
de 2014.
Resultados: El foco de enfermería identificado con más
frecuencia es la susceptibilidad a la infección (67,30%),
con la implementación de intervenciones esencialmente
en el ámbito de la enseñanza. La mayoría de las intervenciones implementadas (57,07%) es del ámbito de la
observación.
Conclusión: El seguimiento de la persona sometida a
un trasplante de hígado se centra esencialmente en los
procesos corporales y en el control de los signos y síntomas de complicación de la enfermedad.
Palavras-chave: autocuidado; transplante de fígado;
cuidados de enfermagem; sistemas de informação
Palabras clave: autocuidado; trasplante de hígado;
atención de enfermería; sistemas de información
*Ph.D., Adjunct Professor, School of Health – North, Portuguese Red Cross – North, 3720-126, Oliveira de Azeméis, Portugal [saxoenfermeira@gmail.com]. Contribution to the article: literature search,
data collection and statistical analysis, discussion of results, and article writing.
**Ph.D., Adjunct Professor, Nursing School of Porto, 4200-072, Porto, Portugal [fernandabastos@
esenf.pt]. Contribution to the article: statistical data analysis, discussion of results, article revision.
***Ph.D., Adjunct Professor, Nursing School of Porto, 4200-072, Porto, Portugal [alice@esenf.pt].
Contribution to the article: statistical data analysis, discussion of results, article revision.
Revista de Enfermagem Referência
Received for publication: 13.10.17
Accepted for publication: 11.01.18
Série IV – n.º 16 – JAN./FEV./MAR. 2018
pp. 19 – 26
Introduction
needs in daily practice. It is from the productive interaction between health professionals and patients that the quality of life
of the populations can be improved (Brion,
2014; Noël et al., 2014).
Transplantation is the only treatment option
that increases the live expectancy of patients
with advanced liver diseases. Liver transplantation was initially a high-risk procedure, but
advances in surgical techniques and immunosuppressive therapies have significantly improved post-transplantation survival (Yang,
Shan, Saxena, & Morris, 2014). Patients undergoing transplantation are encouraged to
readjust the way in which they manage their
life/disease to ensure their quality of life and
the success of transplantation. According to
Mota (2011), the most common causes of
liver disease are deviant behaviors, namely
alcohol abuse (34%) and hepatitis (30%),
which puts into evidence the need to readjust the way in which individuals manage
their health/illness process after transplantation.
The way in which patients experience their
health/illness transition will have a significant impact on future behaviors, and, consequently, on the success or lack of success
of transplantation. Nurses monitor patients
throughout this process and, in addition to
the interventions aimed at bodily processes,
they should also facilitate the development
of relevant skills. The major challenge of liver transplant recipients is their ability to incorporate self-care requisites, namely those
related to the management of the therapeutic regimen.
Therefore, it is essential to identify nursing foci and interventions and understand
their purpose. Nursing records should describe the interventions aimed at promoting
transplant recipients’ healthy adaptation to
their new condition (Mota, Cruz, & Costa,
2016). In this study, a retrospective analysis will be performed to the data collected,
processed, and recorded by nurses in the information system in force, with the purpose
of identifying nursing foci and interventions
implemented to address the care needs of
liver transplant recipients.
The continuous improvement of care delivery depends on a critical-reflexive analysis and comparison of the interventions to
the best evidence available with the purpose
of better responding to the patients’ actual
Background
Successful clinical practices in liver transplantation require experienced health professionals and the active participation of both
patients and families in the therapeutic plan
(Baldoni et al., 2008). Given the complexity
of the surgical procedure, the success of the
liver transplantation requires a complex hospital infrastructure and a multi-professional
team that has received training on the procedure and is able to monitor immunosuppressed patients who are severely weakened
by the disease (Nogara, Wiederkher, Benghir, Zalli, & Helena, 2009).
In Italy, Baldoni et al. (2008) designed a
program aimed at monitoring transplant recipients from the pre-transplantation to the
post-transplantation phase. The objectives of
this program were to provide an efficient education to patients, meet health professionals’ needs regarding what and how to teach,
acquire effective communication skills, and
monitor the education process. This study
puts into evidence the importance of implementing nursing therapeutics aimed at empowering patients for self-care.
In patients’ health/illness transition process,
“nurses are the professionals who can best
act as facilitators in the transition process
due to closer contact and greater knowledge
of the patient’s reality and needs” (Mota,
Rodrigues, & Pereira, 2011, p. 25).
The area of nursing therapeutics allows nurses to identify the best intervention for health
maintenance and promotion in response to
health aspects that are relevant to nursing
practice (focus; Conselho Internacional de
Enfermeiros, 2016). Thus, nursing therapeutics can be integrated into the domains
of prevention, promotion or intervention.
In the area of transplantation, therapeutic
self-management is relevant to nursing practice due to its significant impact on the success (Mota et al., 2016). It is a multidimen-
Revista de Enfermagem Referência – IV – n.º 16 -2018
Liver transplant recipients: nursing therapeutics during follow-up
20
sional and complex concept that emerges as
one of the main challenges of liver transplant
recipients.
According to Ryan and Sawin (2009), the
concept of therapeutic self-management is
composed of three components: a process,
a program or intervention, and an outcome.
The process refers to the use of self-regulation skills to manage chronic conditions, including activities such as setting goals, monitoring and identifying signs/symptoms,
decision-making, planning and engaging
in specific behaviors, self-evaluation, and
management of physical, emotional, and
cognitive responses associated with changes in health behaviors. Therapeutics should
be designed by health professionals with the
purpose of preparing people to assume the
responsibility for managing their chronic
illness and engaging in health promotion
activities.
Patient education is often used as an intervention aimed at optimizing the process of
therapeutic self-management. It is a method
of providing information with the purpose
of increasing knowledge and satisfaction, as
well as leading to changes in health behaviors. Therapeutic self-management programs
should facilitate the development of skills
and activities designed to improve behaviors, reduce health care costs, and improve
quality of life and well-being (Ryan & Sawin, 2009).
The nursing process includes assessment, diagnosis, and intervention, and results from
the constant interaction between people and
the environment. Nursing therapeutics include both the contents and the objectives of
nursing interventions (Meleis, 2007). Thus,
nursing therapeutics also reflect the intentionality of nursing interventions. “One
single intervention can have several intentionalities, which are very much related to
how it is performed, and contribute to the
development of several competencies; multiple interventions, and on different topics,
contribute to a single intentionality” (Bastos, 2012, p. 330).
As a result, it is essential to identify the nursing therapeutics implemented by nurses in
order to analyze how liver transplant recipients are follow-up with the purpose of con-
tinuously improving care interventions and
care quality.
Research question
What are the most common nursing foci
and interventions that nurses identify in the
post-liver transplant consultation?
Methodology
The study was carried out at the Hospital
Center of Porto (Centro Hospitalar do Porto, CHP), where data from outpatients was
electronically recorded by nurses on a nursing
practice support system (Sistema de Apoio à
Prática de Enfermagem, SAPE) using standardized language (International Classification for Nursing Practice, ICNP), in its beta
version.
This exploratory study used a qualitative approach to retrospectively analyze nursing records found in SAPE regarding outpatient
post-liver transplant consultations. Data refer
to the period between July 2010 (first computerized records in the CHP) and September
2014 (beginning of a broader project to which
this study has contributed). The information
gathered, processed, and documented by
nurses in all nursing consultations (referred to
as contactos de enfermagem in the information
system in use) with liver transplant recipients
during this period was analyzed. In data analysis, the conceptual principles of the ICNP
served as basis for the definition of nursing
foci and the corresponding judgments for the
elaboration of diagnoses, as well as for the
definition of nursing actions and areas that
should be taken into account in the design
of interventions that respond directly to nursing diagnoses identified in the production of
nursing-sensitive outcomes (referential integrity). Data were exported from the electronic
information system to a database. Data were
then subjected to descriptive statistics using
the IBM SPSS software, version 22.0.
Anonymity was ensured by omitting the patient’s medical record number and personal
identification, as well as by omitting the identification of the nurses making the records.
Revista de Enfermagem Referência – IV – n.º 16 -2018
LILIANA MOTA et al.
21
The study was approved by the Board of Directors of the CHP.
hospital. A total of 1460 nursing consultations were analyzed (all consultations recorded
in the system in use during the period under
analysis). According to these data, each patient
has, on average, five nursing consultations (SD
= 4, ranging from 1 to 42 consultations).
The most common nursing focus identified by nurses was susceptibility to infection
(67.30%), followed by therapeutic self-management (16.40%; Table 1).
Results
Outpatients’ nursing records result mainly
from the consultations scheduled by the physician; thus, patients have a nursing consultation
when they attend a medical consultation at the
Table 1
Nursing foci in outpatient consultations
Foci
N
%
Susceptibility to infection
640
67.30%
Therapeutic self-management
156
16.40%
Surgical wound
59
6.20%
Wound
28
2.94%
Adherence to therapeutic regime
20
2.10%
Hypertension
6
0.63%
Traumatic wound
6
0.63%
Pain
4
0.42%
Edema
4
0.42%
Knowledge
3
0.32%
Diarrhea
3
0.32%
Others
22
2.32%
Total
951
100.00%
Table 2 shows the nursing interventions with
referential integrity towards the most commonly
identified nursing focus. Most interventions fo-
cused on the domain of teaching about prevention of complications, signs of infection (self-control: infection; self-monitoring: infection).
Table 2
Interventions with referential integrity towards the focus susceptibility to infection
Interventions
N
Teaching about prevention of complications
98
Teaching about signs of infection
41
Teaching about susceptibility to infection
34
Teaching about preventing of infection
31
Teaching about self-monitoring: infection
24
Surveying signs of infection
24
Teaching about/Encouraging self-control: infection
17
Assisting the person with identifying self-control strategies: infection
8
Maintaining/Initiating contamination prevention measures
4
Revista de Enfermagem Referência – IV – n.º 16 -2018
Liver transplant recipients: nursing therapeutics during follow-up
22
Due to the impact of the nursing foci therapeutic self-management on liver transplantation,
the 156 records on this nursing focus were also
analyzed to understand how nurses identified
the corresponding nursing diagnoses (Table 3).
Nurses tend to focus on dimensions that in-
fluence therapeutic self-management, thus
intervening on issues related to self-administration of medication, carrying out treatment, prevention of complications, diet, lifestyle, physical exercise, medication regimen,
and response/reaction to medication.
Table 3
Dimensions of the focus therapeutic self-management identified by nurses during consultations
Dimensions
N
Knowledge
131
Skill learning
9
Efficacy (Judgement)
9
Caregiver knowledge
3
Therapeutic self-management opportunity (potentiality)
3
All nursing interventions implemented by
nurses (7858) were analyzed and classified
according to the action type (Table 4). In the
observing action type, 34.0% of the interventions were related to monitoring, that is, they
aimed at “scrutinizing somebody or something
on repeated or regular occasions” (Conselho
Internacional de Enfermeiros, 2016, p. 67),
which may include monitoring vital signs,
weight, abdominal drain, abdominal perimeter, and bowel elimination, among others.
In the surveying action type, nurses tend to
focus more on monitoring wound dressing,
wound healing, pain, urinary output, diet,
signs of hypo/hyperglycemia, bowel elimination, and abdominal drain.
Table 4
Nursing interventions during outpatient consultations, according to the action type
Observing
Informing
Attending
57.07%
21.47%
6.35%
Surveying
13.83%
Monitoring
34.0%
Assessing
4.89%
Identifying
0.65%
Verifying
3.70%
Teaching
17.89%
Instructing
2.28%
Training
0.98%
Explaining
0.15%
Guiding
0.17%
Facilitating
0.41%
Motivating
0.89%
Assisting
1.43%
Relating
3.51%
Preventing
0.11%
Managing
4.46%
Performing
10.65%
Revista de Enfermagem Referência – IV – n.º 16 -2018
LILIANA MOTA et al.
23
Finally, nurses’ interventions related to the
teaching action type were also analyzed (Table
5). The topics most commonly addressed by
nurses during the outpatient consultation after
liver transplantation were: medication regimen,
physical exercise/rest, therapeutic self-management, infection, diet, prevention of complications, treatments, and sexual activity.
Table 5
Nursing interventions related to the teaching action type
Nursing interventions related to teaching
N
Medication regimen
196
Physical exercise/rest
193
Therapeutic self-management
177
Infection
119
Diet
118
Prevention of complications
98
Treatments
84
Sexual activity
12
Others (examinations, relaxation techniques, surgery…)
88
Discussion
sue of time deserves particular attention, not
only in terms of patients’ needs (the duration
of the process of health/illness transition)
but also health professionals’ availability (the
amount of time allowed by the system).
According to the nurses, the most common
health-related topic during the outpatient
consultation after liver transplantation is
susceptibility to infection. To identify this
topic, nurses focused on the fact that the success of liver transplantation depends on the
transplant recipients’ commitment to daily immunosuppressive therapy (Rodrigue,
Nelson, Hanto, Reed, & Curry, 2013). As
a result of immunosuppression, liver transplant recipients become susceptible to bacterial, viral, and fungal infections, as well as to
the reactivation of a preexisting latent condition (Pedersen & Seetharam, 2014). During
the outpatient consultation, nurses often
identify this health-related topic as relevant
to nursing practice because opportunistic
infections are the leading cause of morbidity and mortality after liver transplantation
(Pedersen & Seetharam, 2014). The risk of
infection in liver transplant recipients depends on the level of exposure to infectious
agents and the extent of immunosuppression (Fishman & Issa, 2010).
In the period under analysis, a total of 1460
nursing consultations led to nursing records,
which means that, although there may have
been more nursing consultations, the lack of
documentation makes them impossible to be
quantified/analyzed. Thus, this result should
be interpreted with caution, and an initial
analysis does not show a small number of
consultations per year. During the consultation, in addition to implementing the care
plan, nurses must document the information
gathered, processed, and recorded in SAPE.
Nurses should be willing to implement an action plan that is adjusted to the actual needs
of patients who are in a particularly vulnerable situation as a result of their specific health/
illness transition experiences. “In this process,
“giving time” is an essential therapeutic dimension, because it will allow the person to
become aware of what has changed and what
is going to be different” (Brito, 2012, p. 149).
It should be noted that the Ordem dos Enfermeiros (2014), in the guidelines for calculation of safe nursing allocations, establishes a
mean time of 30 minutes for outpatient consultations and 75 minutes for home consultations (includes travel time). Therefore, the is-
Revista de Enfermagem Referência – IV – n.º 16 -2018
Liver transplant recipients: nursing therapeutics during follow-up
24
According to Carvalho, Salviano, Carneiro,
and Santos (2007, p. 685), “the entire health
team should emphasize the prevention and
control of infection in immunosuppressed
patients”, which is in line with the nursing
interventions implemented by nurses within
the domain of infection. According to the results of serological testing and epidemiological history, most nursing interventions are of
the teaching action type because prophylactic
strategies are based on the patient’s known or
likely exposures to infection (Fishman, 2007).
The analysis of the interventions implemented by nurses during the period under analysis
showed that 57.07% of them are of the observing action type, with the purpose of “noticing and carefully watching somebody or
something” (Conselho Internacional de Enfermeiros, 2016, p. 70). Therefore, this type
of intervention does not translate into nursing-sensitive outcomes. It should be noted
that these parameters, as observed by nurses,
emerge from “physicians’ perception of the
usefulness of those data in the early detection
of intercurrent complications” (Mota, 2010,
p. 69). The relevance assigned to information
does not focus on the decision-making process, rather “the relevance of information is
closely linked to the nature of the data, rather
than to the business logic of looking at the
resource – information” (Mota, 2010, p. 104).
With regard to the informing action type,
which represents 21.12% of the implemented interventions, 16.94% of them were of
the teaching action type aimed at “giving
systematic information to somebody about
health-related subjects” (Conselho Internacional de Enfermeiros, 2016, p. 40), which
may result in nursing-sensitive outcomes.
In the teaching/instructing/training triad,
teaching means providing systematic information, instructing means adding a technical
component, and training means developing
technical skills through repetition. Based on
the above, the most common interventions in
the model in force were of the teaching action type, which may be associated with the
priority areas for nurses during outpatient
post-transplant consultations. In general,
these consultations do not include an instrumental component and, therefore, do not focus on the development of skills.
In the teaching domain, the priority area for
nurses is the medication regimen because
liver transplant recipients need to adhere to
immunosuppressive therapy (Rodrigue et al.,
2013) for successful transplantation.
Conclusion
Among the multiple health-related aspects
which are relevant to nursing, nurses record
aspects that focus particularly on the patient’s condition as a transplant recipient (as
a patient taking immunosuppressive medication). Therefore, susceptibility to infection
was identified in more than 60% of nursing
consultations with these patients, during
which the most common interventions related to teaching about prevention of complications and control of infection. Infection is
a leading cause of post-transplantation morbidity and mortality. Therapeutic self-management is another relevant nursing focus,
with Knowledge being the most important
dimension for the diagnosis. In response to
the identified health needs, nurses usually
implemented interventions of the observing
action type. With regard to the informing action type, nurses implemented interventions
that focused on regimen characteristics, such
as medication, diet, therapeutic self-management, prevention of complications, treatment, physical exercise/rest, signs of infection, and sexual activity. The implemented
nursing therapeutics have referential integrity
with the health-related aspects identified by
nurses. Nurses were deeply concerned with
patients’ self-monitoring and ability to early
identify changes in body responses that could
suggest the presence of complications.
The analysis of the nursing foci and interventions recorded by nurses proposes a reflection
on the need to improve the documentation process during clinical practice. The greater visibility of nursing care will have a significant impact
on the continuous improvement of care quality.
Further studies should be developed to analyze
the amount of time required or spent by nurses
on the implementation of care plans, with the
purpose of understanding the association between nurse staffing and the health care needs
of liver transplant recipients during follow-up.
Revista de Enfermagem Referência – IV – n.º 16 -2018
LILIANA MOTA et al.
25
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