Introduction
The landscape of nursing care is continually evolving, driven by the integration of new knowledge and technological advancements. A cornerstone of this evolution, particularly within Brazilian healthcare, is the increasing emphasis on the Systematization of Nursing Care (SNC) across diverse healthcare settings [1]. The SNC framework is intrinsically linked to the Nursing Process, a structured approach comprising five essential stages: assessment (data collection or nursing history), nursing diagnosis, planning, implementation, and evaluation [1]. Embracing the Nursing Process enhances the safety and reliability of nursing interventions, establishing a more credible and effective care delivery system [2].
Systematized Nursing Care holds particular significance in intensive care units (ICUs), environments dedicated to managing critically ill patients who require intricate and continuous monitoring and care [3]. Despite the acknowledged importance of SNC for these vulnerable patients and the generally positive attitudes of nurses towards its implementation [4]-[6], challenges persist in its consistent application in daily practice. These hurdles often stem from factors such as insufficient knowledge, a lack of institutional or educational motivation, and inadequate resources, both material and human [4]-[6].
A deeper understanding of the patient profiles within ICUs is crucial for streamlining systematization efforts, mitigating implementation difficulties, and ultimately guiding more effective nursing care strategies [7]-[8]. Recognizing the critical role of SNC in caring for critical patients and acknowledging the complexities associated with its application, this study concentrates specifically on the nursing diagnosis phase. The aim is to contribute to a clearer understanding of ICU patient profiles by identifying the predominant nursing diagnoses encountered in this setting.
Nursing diagnosis is defined as 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 appropriate nursing interventions, thereby ensuring the achievement of desired patient outcomes for which nurses are accountable [10]. Investigating the most prevalent nursing diagnoses in critical care patients not only aids in pinpointing their primary healthcare needs but also enhances the awareness among nurses and the broader healthcare community regarding the value of Systematization of Nursing Care, especially for those in critical conditions. Furthermore, such insights can inform the development of targeted continuing education programs for nursing teams specializing in this patient population.
Therefore, this study aimed to identify the most common nursing diagnostic titles applied in the care of critically ill patients within an Intensive Care Unit and to ascertain their alignment with the NANDA International’s Taxonomy II diagnostic classifications.
Methods
This research adopted a descriptive and documentary approach, reviewing medical records from patients admitted to the Intensive Care Unit of a general hospital in Fortaleza, Brazil.
The study population included data from medical records of patients who were hospitalized during the data collection period and had documented nursing diagnoses within the first 24 hours of ICU admission. Records lacking initial nursing assessments or belonging to patients under 18 years of age were excluded. Only one record was excluded due to the patient’s age being under 18.
Data collection spanned from January to May 2016. A standardized form was utilized to extract data from patient records, including age, gender, admission date, and the primary reason for ICU admission. A separate worksheet was used to transcribe the identified nursing diagnosis titles. These titles were then categorized into problem-focused and risk diagnoses, as defined by NANDA-I’s Taxonomy II [9]. Absolute and relative frequencies of each diagnosis were calculated, and 95.0% confidence intervals for proportions were established. It’s important to note that the accuracy of the diagnostic titles themselves was not assessed, as the study did not evaluate defining characteristics for problem-focused diagnoses or risk factors for risk diagnoses.
The study protocol adhered to all ethical guidelines and regulatory standards for research involving human subjects, both nationally and internationally.
Results
During the study period, a total of 69 patient records were analyzed. Of these, 38 (55.0%) belonged to male patients and 31 (45.0%) to female patients. The patient age range varied from 19 to 88 years, with a mean age of 56.1 years and a median 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 old, and 46.0% were 60 years or older.
Analysis of the reasons for hospitalization, categorized by primary organ system involvement, revealed that neurological conditions were the leading cause for ICU admission in 47.8% of patients, followed by gastrointestinal issues in 27.5%. While primary pulmonary causes accounted for only 10.1% of admissions, pulmonary complications were noted as secondary issues 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 |
| Other* | 2.9 |
| Total | 100.0 |
*Exogenous intoxication and postoperative of mandibular excision
According to NANDA-I’s taxonomy II, nursing diagnoses are classified into 13 domains. In this study, the identified diagnoses spanned seven of these domains, as illustrated in Table 2.
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 |
| Total | 100.0 |
The domain of safety/protection was most prevalent (43.0%), followed by activity/rest (26.5%), and nutrition (13.6%). Domains such as elimination/exchange (5.8%), perception/cognition (5.6%), comfort (3.5%), and coping/stress tolerance (2.0%) were less frequently represented, each accounting for less than 10.0% of the total diagnoses.
The institution where the study was conducted employs a computerized system for SNC implementation, offering nurses a pre-established list of 22 nursing diagnostic titles. All 22 titles were identified in this research.
Table 3 lists these 22 diagnostic titles, categorized as either problem-focused or risk diagnoses, along with their respective 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 glycemia | 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/hygiene self-care deficit | Problem-Focused | 45.0 |
| Risk for thermal injury | Risk Diagnosis | 43.0 |
| Imbalanced nutrition: less than body requirements | Problem-Focused | 42.0 |
| Constipation | Problem-Focused | 39.0 |
| Urinary retention | Problem-Focused | 38.0 |
| Acute confusion | Problem-Focused | 36.0 |
| Deficient fluid volume | Problem-Focused | 33.0 |
| Disturbed sleep pattern | Problem-Focused | 30.0 |
| Readiness for enhanced self-care | Problem-Focused | 29.0 |
| Anxiety | Problem-Focused | 28.0 |
| Risk for injury | Risk Diagnosis | 26.0 |
| Impaired verbal communication | Problem-Focused | 25.0 |
| Impaired oral mucous membrane | Problem-Focused | 23.0 |
| Situational low self-esteem | Problem-Focused | 22.0 |
| Diarrhea | Problem-Focused | 20.0 |
Of the 22 identified diagnostic titles, seven (32.0%) were risk diagnoses, and fifteen (68.0%) were problem-focused diagnoses. A total of 514 diagnostic titles were documented, 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 frequently documented nursing diagnoses were risk for infection (99.0%), risk for impaired skin integrity (75.0%), risk for aspiration (61.0%), risk for unstable glycemia (55.0%), and ineffective breathing pattern/ineffective airway clearance (52.0%), all observed in more than half of the studied patient population.
Discussion
This study is limited by its single-center design, which may restrict the generalizability of findings to other ICU settings. Furthermore, the use of a computerized system with pre-selected diagnoses may constrain nurses’ clinical reasoning, potentially reducing the diagnostic process to a selection task rather than a comprehensive assessment. The number of pre-established diagnoses was also limited compared to the extensive list in NANDA-I.
However, identifying the most frequent nursing diagnoses in this ICU provides valuable insights into the typical profile of critical patients. This information can assist healthcare professionals in tailoring interventions and improving nursing care outcomes for this patient population.
The higher prevalence of male patients in this study is consistent with other research [10], while some studies have reported a slight predominance of females in ICU populations [11]-[13], suggesting a relatively balanced gender distribution overall. The age distribution in this study, with a significant proportion of patients aged 60 and above, aligns with findings from other ICUs, where older adults constitute a substantial percentage of admissions [14].
The high frequency of neurological conditions as primary admission diagnoses may reflect the hospital’s specialization as a regional referral center for neurosurgery and clinical neurology. Other studies have reported different primary admission causes, with pulmonary (28.7%) and cardiological (28.7%) diseases being more prevalent, followed by neurological (12.0%) and gastrointestinal (10.7%) conditions [10].
It is noteworthy that the 22 diagnostic titles used in the institution correspond to 29 unique diagnoses within NANDA-I’s Taxonomy II [9] (representing 11.1% of the 261 diagnoses in the taxonomy). This discrepancy arises because the computerized system groups several related NANDA-I diagnoses under single selectable titles.
The finding that 49.0% of the identified diagnoses were risk diagnoses highlights a strong emphasis on proactive care, addressing potential health problems before they manifest. The average of 7.5 diagnoses per patient falls within the range reported in other studies, which have shown averages as high as 19.4 [15] and as low as 1.3 [10], indicating considerable variability across settings.
This variability likely reflects regional differences in SNC implementation and particularly in the diagnostic phase. The number of available and utilized diagnoses also varies significantly, with some studies reporting as few as 13 [12] and others as many as 71 distinct nursing diagnoses [15], contrasting with the 22 titles in this study.
Among the most frequent risk diagnoses, risk for infection consistently appears with high prevalence across multiple studies [12], [14]-[16], as do risk for impaired skin integrity and risk for unstable glycemia, often exceeding 50.0% [14]-[15]. This consistency suggests a strong awareness among nurses regarding these common patient vulnerabilities in critical care.
Other frequently reported risk diagnoses in the literature include risk for constipation (100.0%) [14], risk for disuse syndrome (86.0%) [15], risk for aspiration (85.7%) [12], and risk for fluid imbalance (78.0%) [15].
Among problem-focused nursing diagnoses, self-care deficits are frequently documented in other studies, including bathing/hygiene self-care deficit (100.0%) [12], [14], deficit in self-care: bathing and/or hygiene (98.1%) [16], intimate hygiene self-care deficit (93.0%) [14], and feeding self-care deficit (85.7%) [12].
Other prevalent problem-focused diagnoses include interrupted family processes (93.0%) [14], impaired physical mobility (85.7%) [12], ineffective tissue perfusion (80.0%) [12], constipation (71.4%) [12], acute confusion (71.4%) [12], ineffective airway clearance (70.0%) [15], impaired social interaction (68.0%) [15], and impaired oral mucous membrane (63.0%) [15].
Analysis of these prevalent diagnoses reveals a concentration within domains 4 (activity/rest) and 11 (safety/protection) of NANDA-I [9], a finding supported by other research [13], [17]. This distribution underscores the nursing focus on patient safety and functional independence in the ICU setting.
Despite the progress in SNC implementation, further efforts are needed to promote its effective and widespread adoption. The true contribution of nursing within the ICU setting to patient care quality remains potentially underrecognized and underutilized [15].
Conclusion
This study successfully identified the primary nursing diagnostic titles utilized in the care of critically ill patients within the studied ICU and confirmed their representation within NANDA-I’s taxonomy II. Twenty-two nursing diagnostic titles were identified, with a near-equal distribution between risk and problem-focused diagnoses. All titles available in the institution’s computerized system were found in the patient records analyzed.
However, discrepancies were noted between the institution’s pre-defined titles and the more granular diagnoses in NANDA-I, particularly the practice of grouping multiple NANDA-I diagnoses under single selectable options within the computerized SNC system. Further research and standardization efforts are needed to optimize the application of nursing diagnoses and the Systematization of Nursing Care in intensive care settings, ensuring comprehensive and patient-centered care.
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