Introduction
In the realm of healthcare, nursing care constantly evolves, integrating new knowledge and technological advancements into its practices. A pivotal aspect of this evolution is the adoption and institutionalization of the Systematization of Nursing Care (SNC) across various healthcare settings. The SNC framework is anchored in the Nursing Process, a structured approach comprising five key stages: assessment (data collection), nursing diagnosis, planning, implementation, and evaluation. This systematic approach enhances the safety and reliability of nursing interventions, particularly in complex environments like the Intensive Care Unit (ICU).
The ICU is a specialized environment dedicated to the treatment of critically ill patients who require intricate care and continuous monitoring. For these vulnerable patients, the Systematization of Nursing Care is not just beneficial—it is paramount. Despite the recognized importance and generally positive perceptions of SNC among nurses, its consistent application in daily practice remains challenging. Barriers to implementation include gaps in knowledge, institutional or educational motivational deficits, and resource limitations, both material and human.
A deeper understanding of the patient profiles within ICUs is crucial for streamlining SNC implementation, mitigating associated challenges, and ultimately optimizing nursing care. By characterizing the common health issues and needs of ICU patients, healthcare providers can refine care protocols and enhance patient outcomes. This study, therefore, zeroes in on the nursing diagnosis phase of the Nursing Process, aiming to contribute to a more detailed profile of ICU patients by identifying the most frequently utilized nursing diagnoses.
Nursing diagnosis, as defined by NANDA International, is a clinical judgment concerning an individual’s, family’s, or community’s responses to actual or potential health problems. The accuracy and relevance of nursing diagnoses are foundational, as they directly inform the selection of nursing interventions and guide the achievement of desired patient outcomes for which nurses are accountable. Investigating the prevalence of specific nursing diagnoses in critical care settings is vital for several reasons. It helps to pinpoint the primary needs of this patient population, enhances comprehension among nurses and the broader healthcare community regarding the significance of SNC for critically ill individuals, and can guide the development of targeted continuing education programs for nursing staff working in ICUs.
This study aims to identify the most prevalent nursing diagnostic titles employed in the care of critically ill patients within an Intensive Care Unit. It further seeks to verify the alignment of these frequently used diagnoses with the standardized diagnoses outlined in NANDA International’s Taxonomy II, the globally recognized classification system for nursing diagnoses.
Methods
This research adopted a descriptive and documentary study design, utilizing data extracted from medical records at an Intensive Care Unit within a general hospital located in Fortaleza, Brazil.
The study population consisted of patients admitted to the ICU who had nursing diagnoses documented within the first 24 hours of their admission. The inclusion criteria were records of patients over 18 years of age hospitalized during the data collection period with documented initial nursing diagnoses. Exclusion criteria encompassed records lacking nursing documentation from the admission day and records of patients under 18 years of age (only one record was excluded based on age).
Data collection spanned from January to May 2016. A structured script was used to collect patient data from medical records, including age, gender, admission date, primary reason for ICU admission, and a dedicated worksheet for transcribing nursing diagnosis titles. The identified nursing diagnoses were categorized into problem-focused and risk diagnoses, as defined by NANDA-I Taxonomy II. Data analysis included calculating absolute and relative frequencies for each diagnosis and constructing 95% confidence intervals for proportions. It is important to note that this study did not evaluate the accuracy of the diagnostic titles in terms of defining characteristics or related/risk factors; the focus was solely on the prevalence of diagnostic titles used.
The study protocol adhered strictly to national and international ethical guidelines for research involving human subjects. Ethical approval was obtained, ensuring patient data confidentiality and compliance with all relevant regulations.
Results
The study analyzed a total of 69 patient records. Of these, 38 (55.0%) were male and 31 (45.0%) were female. The patient age range was 19 to 88 years, with a mean age of 56.1 years and a median age of 58 years. Age distribution showed that 19.0% of patients were between 19 and 40 years old, 24.0% were between 40 and 60 years, and 46.0% were 60 years or older.
Regarding the primary reasons for ICU admission, neurological conditions were the most prevalent, accounting for 47.8% of hospitalizations, followed by gastrointestinal issues at 27.5%. Pulmonary causes were the primary reason in 10.1% of cases, but respiratory complications were noted in 19.4% of patients admitted for other primary reasons. Table 1 details the frequencies of admission reasons based on involved organ systems.
Table 1
Frequency of Reasons for Hospitalization in the Intensive Care Unit by Organ System (n=69)
| Organ System | Frequency (%) |
|---|---|
| Nervous System | 47.8 |
| Gastrointestinal System | 27.5 |
| Pulmonary System | 10.1 |
| Cardiovascular System | 4.3 |
| Renal System | 2.9 |
| Endocrine System | 2.9 |
| Others* | 4.3 |
*Exogenous intoxication and postoperative mandibular excision
NANDA-I Taxonomy II organizes nursing diagnoses into 13 domains. The diagnoses identified in this study were categorized into seven of these domains. Table 2 illustrates the distribution of diagnoses across these domains.
Table 2
Frequencies of Nursing Diagnoses in the ICU, Organized by NANDA-I Taxonomy II Domains (n=514)
The most dominant domains were Safety/Protection (43.0%) and Activity/Rest (26.5%), 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, each representing less than 10.0% of the total diagnoses.
The healthcare institution where the study was conducted employs a computerized SNC system, offering nurses a pre-established list of 22 nursing diagnosis titles for selection. All 22 titles from this list were identified in the patient records reviewed. Table 3 lists these 22 diagnostic titles, categorized as risk diagnoses and problem-focused diagnoses, along with their respective frequencies.
Table 3
Frequency of Nursing Diagnosis Titles in the ICU: Risk and Problem-Focused 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 | 42.0 |
| Risk for Falls | Risk Diagnosis | 39.0 |
| Imbalanced Nutrition: Less Than Body Requirements | Problem-Focused | 38.0 |
| Constipation | Problem-Focused | 35.0 |
| Diarrhea | Problem-Focused | 33.0 |
| Acute Confusion | Problem-Focused | 32.0 |
| Deficient Fluid Volume | Problem-Focused | 30.0 |
| Disturbed Sleep Pattern | Problem-Focused | 29.0 |
| Anxiety | Problem-Focused | 28.0 |
| Impaired Verbal Communication | Problem-Focused | 26.0 |
| Pain: Acute | Problem-Focused | 25.0 |
| Risk for Peripheral Neurovascular Dysfunction | Risk Diagnosis | 23.0 |
| Impaired Urinary Elimination | Problem-Focused | 22.0 |
| Risk for Latex Allergy Reaction | Risk Diagnosis | 19.0 |
| Nausea | Problem-Focused | 16.0 |
| Ineffective Thermoregulation | Problem-Focused | 15.0 |
| Deficient Knowledge | Problem-Focused | 13.0 |
The 22 identified titles comprised seven risk diagnoses (32.0%) and 15 problem-focused diagnoses (68.0%). In total, 514 diagnostic titles were transcribed, with 250 (49.0%) classified as risk diagnoses and 264 (51.0%) as problem-focused diagnoses. The average number of diagnoses per patient was 7.5, ranging from 3 to 22.
The most prevalent diagnostic titles 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 occurring in more than half of the studied patient population.
Discussion
This study has certain limitations. The data were collected from a single ICU in one hospital, which may limit the generalizability of the findings to other ICUs or healthcare settings. Furthermore, the use of a computerized system with a pre-defined list of diagnoses could constrain nurses’ clinical reasoning, potentially reducing the diagnostic process to selecting from a limited set of options. The number of pre-established diagnoses was also limited compared to the comprehensive NANDA-I taxonomy.
Despite these limitations, identifying the most frequent nursing diagnoses provides valuable insights into the typical needs of critical care patients. This knowledge can inform healthcare professionals in tailoring interventions and enhancing nursing care within ICUs.
The higher prevalence of male patients in this study aligns with findings from other research in critical care settings. While some studies have reported a slight female predominance, the overall gender distribution in ICU populations tends to be relatively balanced. The age distribution, with a significant proportion of patients aged 60 years and older, is also consistent with demographic trends in ICU admissions.
The high frequency of neurological conditions as primary admission reasons may reflect the specialized nature of the study hospital as a regional referral center for neurosurgery and clinical neurology. In contrast, other studies have indicated pulmonary and cardiological diseases as more frequent primary causes for ICU admission, followed by neurological and gastrointestinal conditions.
It is important to note that the 22 diagnostic titles available in the institution’s computerized system correspond to 29 distinct diagnoses within NANDA-I Taxonomy II. This indicates some level of aggregation within the institution’s system, where multiple related NANDA-I diagnoses may be grouped under a single title for ease of selection by nurses.
Approximately half (49.0%) of the diagnoses identified were risk diagnoses, highlighting a proactive approach to care planning that considers potential future health problems alongside existing issues. The average of 7.5 diagnoses per patient falls within the range reported in other similar studies, which exhibit considerable variability, possibly due to regional differences in SNC implementation and variations in the number of diagnoses utilized. This variability underscores the need for standardized approaches to nursing diagnosis in critical care.
The high prevalence of Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Unstable Blood Glucose aligns with findings from numerous other studies. These consistent findings across different settings emphasize the universal vulnerability of ICU patients to these specific risks and the attentiveness of nurses to these potential issues. Other frequently reported risk diagnoses in the literature, such as Risk for Constipation, Risk for Disuse Syndrome, Risk for Aspiration, and Risk for Fluid Imbalance, further highlight common areas of concern in ICU patient care.
Among problem-focused diagnoses, self-care deficits are frequently reported in other studies, including Bathing/Hygiene Self-Care Deficit and Feeding Self-Care Deficit. Other prevalent problem-focused diagnoses identified in prior research encompass Interrupted Family Processes, Impaired Physical Mobility, Ineffective Tissue Perfusion, Constipation, Acute Confusion, Ineffective Airway Clearance, Impaired Social Interaction, and Impaired Oral Mucous Membrane.
Analysis of the most frequent diagnoses in this study and in the broader literature indicates a concentration within domains 4 (Activity/Rest) and 11 (Safety/Protection) of NANDA-I Taxonomy II. This concentration reflects the critical nursing priorities in the ICU setting, which are heavily focused on ensuring patient safety, preventing complications, and supporting basic physiological functions and mobility. It underscores the central role of nurses in maintaining patient well-being and preventing harm in this high-acuity environment.
While this study and others highlight the application of SNC and nursing diagnoses in ICUs, further efforts are needed to promote and expand the effective utilization of SNC in routine practice. The true impact of nursing contributions to the quality of critical care remains somewhat undefined and potentially undervalued. Continued research and quality improvement initiatives are essential to fully realize the benefits of SNC for critically ill patients.
Conclusion
This study successfully identified the primary nursing diagnostic titles used in the care of critically ill patients within the studied ICU and confirmed their presence within NANDA-I Taxonomy II. The 22 identified diagnostic titles were distributed relatively evenly between risk diagnoses and problem-focused diagnoses. These titles, provided to nurses via a computerized system, were all represented in the study findings.
However, discrepancies were noted between the institution’s pre-defined diagnostic titles and the more granular diagnoses within NANDA-I. Specifically, the institution’s system grouped certain NANDA-I diagnoses into single, broader categories for selection during the SNC process. This aggregation, while potentially simplifying the selection process, may also limit the specificity and comprehensiveness of nursing diagnoses in practice. Future research should explore the impact of such aggregated diagnostic lists on the quality and effectiveness of nursing care planning and patient outcomes in the ICU setting.
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