Introduction
The landscape of nursing care is continuously evolving, integrating new research and technological advancements, particularly within the Systematization of Nursing Care (SNC). This systematic approach is increasingly vital in diverse healthcare settings globally, especially within Brazilian health services where its institutionalization is prominent [1]. The SNC framework hinges on the Nursing Process, a structured five-stage methodology encompassing assessment, nursing diagnosis, planning, implementation, and evaluation [1]. This process enhances the safety and reliability of nursing interventions [2].
Systematization of Nursing Care is indispensable across all nursing domains, but its significance is amplified in Intensive Care Units (ICUs). ICUs are specialized environments designed for critically ill patients requiring sophisticated care and continuous monitoring [3]. Despite the recognized importance of systematized care for these vulnerable patients and the positive perceptions of nurses towards this methodology [4]-[6], its consistent application in daily practice remains challenging. Obstacles include insufficient knowledge, lack of institutional or educational motivation, and inadequate resources [4]-[6].
Understanding the typical patient profile in an ICU setting is crucial for streamlining systematization, mitigating implementation challenges, and optimizing nursing care strategies [7]-[8]. By focusing on the nursing diagnosis phase, this study contributes to delineating the profile of ICU patients through identifying prevalent diagnoses.
A nursing diagnosis is a clinical judgment concerning an individual’s, family’s, or community’s responses to actual or potential health issues [9]. Accurate nursing diagnoses are foundational for selecting effective nursing interventions, ultimately driving patient outcomes for which nurses are accountable [10]. Investigating the most common nursing diagnoses in critical care patients is essential for pinpointing their primary healthcare needs. This knowledge enhances understanding among nurses and the broader healthcare community about the value of SNC, especially for critically ill populations. Furthermore, it can inform the development of targeted continuing education programs for ICU nursing teams.
This study aimed to identify the predominant nursing diagnoses applied in the care of critically ill patients within an ICU, and to verify their alignment with the NANDA International’s Taxonomy II diagnostic framework.
Methods
This descriptive, documentary study analyzed medical records from an ICU in a general hospital located in Fortaleza, Brazil. The research focused on records of patients over 18 years of age who were hospitalized and had nursing diagnoses documented within the first 24 hours of ICU admission. Records lacking initial nursing assessments or those of patients under 18 were excluded. Only one record was excluded due to the patient’s age. Data collection spanned from January to May 2016. A structured form was used to extract data, including age, gender, admission date, primary reason for hospitalization, and documented nursing diagnoses. Diagnoses were categorized into problem-focused and risk diagnoses, as defined by NANDA-I Taxonomy II [9]. Absolute and relative frequencies were calculated, along with 95% confidence intervals. The accuracy of diagnostic titles was not evaluated, as defining characteristics, related factors for problem-focused diagnoses, and risk factors for risk diagnoses were not assessed. The study adhered to national and international ethical guidelines for research involving human subjects.
Results
The study analyzed 69 patient records, with 38 (55.0%) from males and 31 (45.0%) from females. The patient ages ranged from 19 to 88 years, with an average age of 56.1 years and a median of 58 years. Age distribution showed 19.0% between 19-40 years, 24.0% between 40-60 years, and 46.0% aged 60 years and older.
Neurological conditions were the primary reason for ICU admission in 47.8% of cases, while gastrointestinal issues accounted for 27.5%. Pulmonary causes were the primary reason in 10.1% of cases but were also noted as a complication in 19.4% of cases initially admitted for non-pulmonary reasons. Detailed frequencies of hospitalization reasons are presented in Table 1.
Table 1: Frequency of reasons for hospitalization in the Intensive Care Unit according to the main organic systems involved (n=69)
| Organic System | Frequency (%) |
|---|---|
| Nervous System | 47.8 |
| Gastrointestinal System | 27.5 |
| Pulmonary System | 10.1 |
| Cardiovascular System | 7.2 |
| Endocrine System | 2.9 |
| Renal System | 1.4 |
| Others* | 2.9 |
| Undetermined | 0 |
*Exogenous intoxication and postoperative of mandibular excision
Nursing diagnoses were categorized into seven of the 13 NANDA-I Taxonomy II domains. Safety/protection (43.0%) and activity/rest (26.5%) were the most prevalent domains, followed by nutrition (13.6%). Elimination/exchange (5.8%), perception/cognition (5.6%), comfort (3.5%), and coping/stress tolerance (2.0%) domains were less frequent (under 10.0%). Domain distribution is shown in Table 2 and visually represented in Figure 1.
Table 2: Frequencies of the nursing diagnoses of the researched Intensive Care Unit, organized according to the domains of NANDA-I’s taxonomy II (n=514)
| NANDA-I Domain | Frequency (%) |
|---|---|
| Safety/Protection | 43.0 |
| Activity/Rest | 26.5 |
| Nutrition | 13.6 |
| Elimination/Exchange | 5.8 |
| Perception/Cognition | 5.6 |
| Comfort | 3.5 |
| Coping/Stress Tolerance | 2.0 |
Figure 1: Distribution of Nursing Diagnoses by NANDA-I Taxonomy II Domains in an Intensive Care Unit. This chart illustrates the frequency of nursing diagnoses categorized under NANDA-I domains, highlighting the predominance of Safety/Protection and Activity/Rest in critical care settings.
The institution utilized a computerized SNC system with 22 pre-established nursing diagnosis titles, all of which were identified in this study. These titles are organized in Table 3, categorized as risk and problem-focused diagnoses, along with their frequencies.
Table 3: Frequency of titles of nursing diagnoses identified in the Intensive Care Unit; problem-focused and risk diagnoses (n= 69)
| Nursing Diagnosis Title | Type | Frequency (%) |
|---|---|---|
| Risk for Infection | Risk Diagnosis | 99.0 |
| Risk for Impaired Skin Integrity | Risk Diagnosis | 75.0 |
| Risk for Aspiration | Risk Diagnosis | 61.0 |
| Risk for Unstable Blood Glucose | Risk Diagnosis | 55.0 |
| Ineffective Breathing Pattern/Ineffective Airway Clearance | Problem-Focused | 52.0 |
| Impaired Physical Mobility | Problem-Focused | 49.0 |
| Risk for Falls | Risk Diagnosis | 48.0 |
| Bathing Self-Care Deficit | Problem-Focused | 45.0 |
| Risk for Peripheral Neurovascular Dysfunction | Risk Diagnosis | 41.0 |
| Imbalanced Nutrition: Less Than Body Requirements | Problem-Focused | 39.0 |
| Constipation | Problem-Focused | 38.0 |
| Deficient Fluid Volume | Problem-Focused | 36.0 |
| Disturbed Sleep Pattern | Problem-Focused | 32.0 |
| Readiness for Enhanced Self-Care | Problem-Focused | 29.0 |
| Urinary Retention | Problem-Focused | 26.0 |
| Acute Pain | Problem-Focused | 23.0 |
| Anxiety | Problem-Focused | 20.0 |
| Decreased Cardiac Output | Problem-Focused | 17.0 |
| Diarrhea | Problem-Focused | 14.0 |
| Impaired Verbal Communication | Problem-Focused | 12.0 |
| Risk for Deficient Fluid Volume | Risk Diagnosis | 10.0 |
| Risk for Electrolyte Imbalance | Risk Diagnosis | 9.0 |
Among the 514 diagnostic titles recorded, 250 (49.0%) were risk diagnoses and 264 (51.0%) were problem-focused diagnoses, averaging 7.5 diagnoses per patient (range: 3 to 22). The most prevalent diagnoses were risk for infection (99.0%), risk for impaired skin integrity (75.0%), risk for aspiration (61.0%), risk for unstable blood glucose (55.0%), and ineffective breathing pattern/ineffective airway clearance (52.0%), all observed in over half of the studied population.
Discussion
This study is limited by its single-center design and the use of a pre-defined, computerized list of diagnoses, which may constrain nurses’ clinical reasoning and limit the scope of diagnoses beyond the 22 pre-established options. The number of available diagnoses was also fewer compared to the comprehensive NANDA-I taxonomy.
However, identifying the most frequent nursing diagnoses in critical care offers valuable insights into the typical health needs of ICU patients. This information can guide healthcare professionals in tailoring interventions and improving nursing care delivery in critical settings.
The higher prevalence of male patients in this study aligns with some research [10], although other studies in different ICUs have reported a slight female predominance [11]-[13], suggesting a near gender balance in ICU admissions. The significant proportion of patients aged 60 and over (46.0%) is consistent with findings in other ICUs, some reporting even higher percentages [14].
The high incidence of neurological reasons for hospitalization likely reflects the study hospital’s specialization as a referral center for neurosurgery and clinical neurology within Cear state. In contrast, other studies indicate pulmonary and cardiac conditions as more frequent primary reasons for ICU admission, followed by neurological and gastrointestinal issues [10].
The 22 diagnostic titles used in the institution correspond to 29 unique diagnoses from NANDA-I Taxonomy II [9] (approximately 11.1% of the 261 diagnoses in the taxonomy). This is due to the institution’s computerized system grouping related diagnoses under single selectable titles.
The near equal distribution between risk diagnoses (49.0%) and problem-focused diagnoses (51.0%) underscores the proactive approach to patient care, emphasizing both current problems and potential future risks. The average of 7.5 diagnoses per patient falls within the range reported by other studies, which vary considerably from as low as 1.3 to as high as 19.4 diagnoses per patient [10], [14], [15]. This variability likely reflects differences in SNC implementation and the number of diagnoses used or available to nurses across different settings.
The high prevalence of risk for infection aligns with multiple studies [12], [14]-[16], as do the significant frequencies of risk for impaired skin integrity and risk for unstable blood glucose, all exceeding 50% in this and other research [14]-[15]. These findings highlight nurses’ vigilance and awareness of common risks in critical care. Other frequently reported risk diagnoses in similar studies include risk for constipation, risk for disuse syndrome, risk for aspiration, and risk for fluid imbalance [12], [14], [15].
Among problem-focused nursing diagnoses, self-care deficits are frequently reported in other studies, including bathing/hygiene self-care deficit and feeding self-care deficit [12], [14], [16]. Other prevalent problem-focused diagnoses identified in literature include interrupted family processes, impaired physical mobility, ineffective tissue perfusion, constipation, acute confusion, ineffective airway clearance, impaired social interaction, and impaired oral mucous membrane [12], [15].
Analysis of these prevalent diagnoses indicates a concentration within NANDA-I domains 4 (Activity/Rest) and 11 (Safety/Protection) [9], a finding corroborated by other research [13], [17]. This domain emphasis reflects the critical nursing priorities of patient safety and functional autonomy in the ICU.
Despite the implementation of SNC, continued efforts are needed to promote its effective and expanded use. The tangible contribution of nursing care to the quality of critical patient outcomes in ICUs remains to be fully quantified and is often underestimated [15].
Conclusion
This study identified the primary nursing diagnoses used in the care of critically ill patients in an ICU and confirmed their presence within the NANDA-I Taxonomy II framework. Twenty-two nursing diagnostic titles were identified, with a near-equal distribution between risk and problem-focused categories. These titles, provided to nurses via a computerized system, were all represented in the study findings.
However, discrepancies exist between the institution’s provided titles and the full scope of NANDA-I diagnoses, notably the grouping of multiple diagnoses into single selectable options within the computerized SNC system. Further research and standardization efforts are needed to ensure comprehensive and accurate application of nursing diagnoses in critical care settings.
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