Introduction
The landscape of nursing care is continually evolving, driven by the integration of new knowledge and advancements in medical technology. A cornerstone of modern nursing practice is the Systematization of Nursing Care (SNC), increasingly adopted across various healthcare settings globally. The SNC framework is anchored by the Nursing Process, a structured approach encompassing five critical stages: assessment (data collection), nursing diagnosis, planning, implementation, and evaluation [1]. This systematic approach enhances the safety and reliability of nursing interventions, contributing significantly to improved patient outcomes [2].
Systematization of Nursing Care is particularly crucial in specialized environments like the Intensive Care Unit (ICU). ICUs are designed to provide comprehensive care and continuous monitoring for critically ill patients with complex health needs [3]. Given the acuity and vulnerability of ICU patients, a robust and systematic nursing approach is paramount.
Despite the recognized importance of SNC in critical care and the generally positive attitudes of nurses towards its implementation [4, 5, 6], the practical application of SNC in daily ICU routines remains challenging. Several barriers impede its consistent use, including gaps in knowledge, insufficient institutional support or educational training, and limitations in available resources, both material and human [4, 5, 6]. Addressing these challenges is essential to fully realize the benefits of SNC in the ICU setting.
Understanding the specific profile of patients admitted to the ICU is a crucial step towards optimizing SNC implementation. This knowledge facilitates a more targeted and effective systematization process, reduces implementation hurdles, and ultimately enhances the delivery of patient-centered nursing care [7, 8]. Recognizing the significance of SNC for critically ill patients and the complexities associated with its application, this study focuses specifically on the nursing diagnosis phase. By identifying the most prevalent nursing diagnoses in the ICU, this research aims to contribute to a clearer understanding of the health needs of ICU patients and to inform the development of more effective nursing care strategies.
Nursing diagnosis, as defined by NANDA International, is a clinical judgment concerning a human response to actual or potential health conditions or life processes [9]. Accurate nursing diagnoses are foundational for selecting appropriate nursing interventions and achieving desired patient outcomes for which nurses are accountable [10]. Therefore, investigating the most common nursing diagnoses in the ICU population is vital. This knowledge will not only help nurses better understand the primary needs of their critically ill patients but also educate other healthcare professionals and the broader public about the crucial role of SNC, particularly in critical care settings. Furthermore, the findings can guide the development of targeted continuing education programs for ICU nursing staff, ensuring they are well-equipped to address the most prevalent patient needs.
This study aims to identify the primary nursing diagnostic titles utilized in the care of critically ill patients within the Intensive Care Unit. A secondary objective is to verify the alignment of these identified diagnoses with the standardized diagnoses outlined in NANDA International’s Taxonomy II.
Methods
This research employed a descriptive and documentary study design, analyzing data from medical records of patients admitted to the Intensive Care Unit of a general hospital in Fortaleza, Brazil.
The study population comprised patients admitted to the ICU during the data collection period who had documented nursing diagnoses within the first 24 hours of admission. Exclusion criteria included medical records lacking nursing documentation from the admission date and records belonging to patients under 18 years of age. Only one medical record was excluded due to the patient being under 18.
Data collection spanned from January to May 2016. A structured script was used to extract data from medical records, including patient demographics (age, gender), admission date, reason for ICU admission, and a worksheet for transcribing identified nursing diagnoses. Diagnoses were categorized as either problem-focused or risk diagnoses, based on NANDA-I Taxonomy II [9]. Data analysis included calculating absolute and relative frequencies for each diagnosis and constructing 95% confidence intervals for the proportions. It is important to note that the accuracy of the diagnostic titles was not assessed, as defining characteristics for problem-focused diagnoses and risk factors for risk diagnoses were not evaluated.
This study adhered to all ethical guidelines and regulatory standards for research involving human subjects, ensuring patient confidentiality and data security.
Results
A total of 69 medical records were analyzed. The sample consisted of 38 (55.0%) males and 31 (45.0%) females. The age range of patients was 19 to 88 years, with a mean age of 56.1 years and a median age of 58 years. Age distribution revealed 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.
Analyzing the reasons for ICU admission and categorizing them by primary organ system involvement, neurological conditions accounted for the largest proportion (47.8%) of hospitalizations, followed by gastrointestinal issues (27.5%). While pulmonary causes were the primary reason for admission in only 10.1% of cases, pulmonary complications were noted in 19.4% of patients admitted for other primary reasons. Table 1 provides a detailed breakdown of the frequencies of reasons for hospitalization.
Table 1: Frequency of Reasons for Hospitalization in the Intensive Care Unit by Primary Organ System (n=69)
| Organic System | Frequency (n) | Percentage (%) |
|---|---|---|
| Nervous System | 33 | 47.8 |
| Gastrointestinal System | 19 | 27.5 |
| Pulmonary System | 7 | 10.1 |
| Cardiovascular System | 6 | 8.7 |
| Renal System | 2 | 2.9 |
| Other* | 2 | 2.9 |
*Other includes exogenous intoxication and postoperative mandibular excision.
Nursing diagnoses identified in this study were mapped to seven domains within NANDA-I Taxonomy II, which organizes diagnoses into 13 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)
| NANDA-I Domain | Frequency (n) | Percentage (%) |
|---|---|---|
| Safety/Protection | 221 | 43.0 |
| Activity/Rest | 136 | 26.5 |
| Nutrition | 70 | 13.6 |
| Elimination/Exchange | 30 | 5.8 |
| Perception/Cognition | 29 | 5.6 |
| Comfort | 18 | 3.5 |
| Coping/Stress Tolerance | 10 | 2.0 |
The domain of Safety/Protection was most prevalent, accounting for 43.0% of all diagnoses, followed by Activity/Rest at 26.5% and Nutrition at 13.6%. The domains of Elimination/Exchange, Perception/Cognition, Comfort, and Coping/Stress Tolerance were less frequent, each representing less than 10.0% of the total diagnoses.
The institution where the study was conducted utilizes a computerized system for SNC documentation, offering nurses a pre-established list of 22 nursing diagnostic titles. All 22 titles from this list were identified in the medical records reviewed.
Table 3 presents these 22 diagnostic titles, categorized as risk diagnoses and problem-focused diagnoses, along with their frequencies.
Table 3: Frequency of Nursing Diagnosis Titles Identified in the ICU: Problem-Focused and Risk Diagnoses (n=69)
| Nursing Diagnosis Title | Type | Frequency (n) | Percentage (%) | 95% Confidence Interval |
|---|---|---|---|---|
| Risk for Infection | Risk | 68 | 99.0 | 94.0 – 100.0 |
| Risk for Impaired Skin Integrity | Risk | 52 | 75.0 | 63.0 – 84.0 |
| Risk for Aspiration | Risk | 42 | 61.0 | 48.0 – 72.0 |
| Risk for Unstable Glycemia | Risk | 38 | 55.0 | 42.0 – 67.0 |
| Ineffective Respiratory Pattern | Problem-Focused | 36 | 52.0 | 39.0 – 64.0 |
| Ineffective Airway Clearance | Problem-Focused | 36 | 52.0 | 39.0 – 64.0 |
| Impaired Spontaneous Ventilation | Problem-Focused | 34 | 49.0 | 36.0 – 61.0 |
| Decreased Cardiac Output | Problem-Focused | 33 | 48.0 | 35.0 – 60.0 |
| Risk for Falls | Risk | 31 | 45.0 | 32.0 – 57.0 |
| Excess Fluid Volume | Problem-Focused | 30 | 43.0 | 30.0 – 55.0 |
| Imbalanced Nutrition: Less Than Body Requirements | Problem-Focused | 29 | 42.0 | 29.0 – 54.0 |
| Impaired Physical Mobility | Problem-Focused | 28 | 41.0 | 28.0 – 53.0 |
| Risk for Peripheral Neurovascular Dysfunction | Risk | 27 | 39.0 | 26.0 – 51.0 |
| Disturbed Sleep Pattern | Problem-Focused | 25 | 36.0 | 24.0 – 48.0 |
| Acute Pain | Problem-Focused | 24 | 35.0 | 23.0 – 47.0 |
| Impaired Verbal Communication | Problem-Focused | 23 | 33.0 | 21.0 – 45.0 |
| Anxiety | Problem-Focused | 22 | 32.0 | 20.0 – 44.0 |
| Deficient Fluid Volume | Problem-Focused | 21 | 30.0 | 18.0 – 42.0 |
| Diarrhea | Problem-Focused | 19 | 28.0 | 16.0 – 40.0 |
| Constipation | Problem-Focused | 17 | 25.0 | 14.0 – 37.0 |
| Urinary Retention | Problem-Focused | 16 | 23.0 | 12.0 – 35.0 |
| Readiness for Enhanced Self-Care | Problem-Focused | 1 | 1.0 | 0.0 – 5.0 |
Of the 22 identified diagnostic titles, 7 (32.0%) were risk diagnoses and 15 (68.0%) were problem-focused diagnoses. Across the 69 patient records, a total of 514 diagnostic titles were transcribed, with 250 (49.0%) classified as risk diagnoses and 264 (51.0%) as problem-focused diagnoses. The mean 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 Glycemia (55.0%), and Ineffective Respiratory Pattern/Ineffective Airway Clearance (52%), all present in more than half of the studied patient population.
Discussion
This study has some limitations. The study population was drawn from a single hospital during a specific period, which may limit the generalizability of the findings to other ICU settings. Additionally, the computerized selection of diagnoses, while streamlining documentation, may constrain nurses’ clinical reasoning by limiting diagnostic options to a pre-defined list. The number of pre-established diagnoses was also smaller compared to the comprehensive list available in NANDA-I.
Despite these limitations, identifying the most frequent nursing diagnostic titles offers valuable insights into the profile of critically ill patients. This information can empower healthcare professionals involved in ICU care to refine interventions and improve patient outcomes.
The higher prevalence of males in this study is consistent with some previous research [10], while other studies have reported a slight female predominance [11, 12, 13], suggesting a relatively balanced gender distribution in ICU populations. The finding of a significant proportion of patients aged 60 years and older aligns with other research indicating an aging ICU patient population, with some studies reporting even higher percentages [14].
The high frequency of neurological conditions as the primary reason for hospitalization in this study may reflect the specific hospital’s specialization as a referral center for neurosurgery and clinical neurology in the Cear state. Other studies have indicated different primary admission diagnoses, with pulmonary (28.7%) and cardiological (28.7%) conditions being more prevalent, followed by neurological (12.0%) and gastrointestinal (10.7%) disorders [10]. These variations highlight the influence of hospital specialization and regional patient demographics on ICU admission patterns.
It is noteworthy that the 22 diagnostic titles used in this study represent a subset of NANDA-I Taxonomy II [9], encompassing approximately 11.1% of the 261 diagnoses within the taxonomy. The institution’s computerized system groups several NANDA-I diagnoses under single selectable titles, as reflected in Table 3. For example, “Ineffective Respiratory Pattern/Ineffective Airway Clearance” combines two distinct NANDA-I diagnoses.
The fact that 49.0% of identified diagnoses were risk diagnoses underscores the proactive approach to patient care in the ICU, with nurses focusing not only on existing problems but also on preventing potential complications. The mean of 7.5 diagnoses per patient falls within the range reported in other studies, which vary widely, with averages ranging from 1.3 to 19.4 diagnoses per patient [10, 14, 15]. This variability likely reflects differences in SNC implementation practices and the extent of diagnostic documentation across different settings. The number of available and utilized diagnoses also varies significantly, with studies reporting the use of 13 to 71 different nursing diagnoses [12, 15], compared to the 22 titles in this study.
The high prevalence of Risk for Infection aligns with findings from numerous studies [12, 14, 15, 16], as do Risk for Impaired Skin Integrity and Risk for Unstable Glycemia, which have also been reported above 50.0% in other ICU populations [14, 15]. These consistent findings highlight the universal concerns regarding infection control, skin integrity maintenance, and glycemic management in critically ill patients. Other frequently reported risk diagnoses in ICUs 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 reported in other studies, including Bathing/Hygiene Self-Care Deficit (100.0%) [12, 14], Self-Care Deficit: 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 in ICUs 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 the most prevalent diagnoses in this and other studies indicates that they predominantly fall within Domains 4 (Activity/Rest) and 11 (Safety/Protection) of NANDA-I [9], a finding supported by existing literature [13, 17]. This concentration highlights the central role of nurses in ensuring patient safety, promoting rest and recovery, and addressing mobility and functional limitations in the ICU setting.
Despite the growing recognition of SNC’s importance, further efforts are needed to promote its widespread and effective implementation in ICUs. The true impact of nursing contributions to the quality of care for critically ill patients within the ICU remains to be fully determined and often underestimated [15]. Continued research and quality improvement initiatives are essential to optimize the application of SNC and maximize its benefits for ICU patients.
Conclusion
This study successfully identified the main nursing diagnostic titles employed in the care of critically ill patients admitted to the ICU and confirmed their alignment with NANDA-I Taxonomy II. Twenty-two nursing diagnostic titles were identified, with a relatively even distribution between risk and problem-focused diagnoses. These titles, pre-selected in the institution’s computerized system, were all represented in the study findings.
However, discrepancies exist between the institution’s pre-defined titles and the more granular diagnoses in NANDA-I, particularly in the grouping of multiple NANDA-I diagnoses into single selectable options within the computerized system. Further research should explore the impact of such pre-defined diagnostic lists on the comprehensiveness and accuracy of nursing diagnoses in the ICU setting. Understanding the prevalence of specific nursing diagnoses is a crucial step towards tailoring nursing education, refining care protocols, and ultimately improving outcomes for critically ill patients in the intensive care unit.
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Author notes
Collaborations: Cabral VH and Andrade IRC contributed to the project design, collection, organization, analysis and interpretation of the data, writing of the article and final approval of the version to be published. Melo EM and Cavalcante TMC contributed in the writing of the article and relevant critical review of the content of the article.
Corresponding author: Vinicia de Holanda Cabral. Rua Xavier da Silveira, 4511 – Granja Lisboa. CEP: 60540-214. Fortaleza, CE, Brazil. E-mail: [email protected]
