CASE STUDY

Nursing diagnoses, outcomes and interventions to elderly patients with diabetes: a case study

¹Federal University of Paraíba

ABSTRACT
Aim: identify nursing diagnoses, outcomes and interventions to an elderly with diabetes mellitus using the International Classification for Nursing Practice (ICNP®) 2011.
Method: a case study describing nursing assistance to identify nursing diagnoses, outcomes and interventions using ICNP® 2011.
Results: were prioritized nine diagnoses: dyspnea on minimal exertion; volume of excess fluid (edema); deficit of partial self-care to feed themselves; total self-care deficit for bathing, dressing, hygiene; diabetic wound in the left lower limb; skin integrity impaired in the abdomen; severe pain in the lower limbs; lack of adherence to treatment regimen and lack of knowledge about the disease.
Discussion: most checked nursing diagnoses is closely related to chronic diabetic complications, plus the physiological changes of aging.
Descriptors: Diabetes Mellitus; Elderly; Patient Care; Nursing Process; Nursing Diagnosis.

INTRODUCTION

In recent decades, Brazil has experienced an aging process of its population rapidly opening prospects according to latest population census for similar age pyramids of the European countries, being these transformations responsible to present challenges for all sectors⁽¹⁾.

Among the implications arising from the aging population, there is the increasing prevalence and chronic diseases (circulatory, pulmonary, osteoarticular, neuropsychiatric disorders and diabetes mellitus), constituting a major public health problem due to its high impact on morbidity, mortality, reduction quality of life and health care costs⁽²⁾.

Among the chronic diseases it's highlighted diabetes mellitus (DM), defined as a group of metabolic diseases characterized by hyperglycemia resulting from changes in the secretion and/or action of insulin. It is classified physiopathologically in four major clinical classes: type 1 diabetes, type 2 diabetes, another types of diabetes and gestational DM; may during their evolution, depending on the metabolic control, arise acute and chronic complications, microvascular and macrovascular, such as coronary heart disease, retinopathy, nephropathy, peripheral vascular disease, peripheral neuropathy, autonomic neuropathy, and others^(3,4).

Recent epidemiological data have shown the type 2 diabetes as one of the biggest increases in prevalence, acquiring epidemic proportions, especially in the elderly population, changing the current prevalence of 20% to 50% in the next two decades. The reason for this prevalence among the elderly is due to pathophysiological processes such as higher deposition of beta myelogenous, causing beta-cell dysfunction with lower insulin production and decreased lean body mass, increased body fat in the abdominal region and decreased physical activity, causing insulin resistance⁽²⁾.

In addition to the higher prevalence of involvement of chronic diseases, the elderly have a particular condition worsening health conditions, which is the development of Geriatric Syndromes (SG) - changes associated with organic aging and cumulative deleterious effects in the different systems that arise from diseases chronic, such as urinary incontinence, instability and increased risk of falls, secondary iatrogenic polypharmacy because of multiple comorbidities that accompany the DM, depression and dementia, making your treatment more complex⁽²⁾.

The DM patients, particularly the elderly, require a systematic follow-up by a multidisciplinary health team that provides the necessary tools for disease management in order to achieve normal blood glucose levels preventing acute and chronic complications, with a satisfactory adjustment to the lifestyle⁽⁴⁾.

In this perspective, as a member of the multidisciplinary team the nurse must be able to comprehensive care to this population, using the nursing process, considered a variation of the scientific reasoning that helps nurses to organize, systematize and conceptualize nursing practice⁽⁵⁾.

Show up studies focused on care for the elderly or diabetic^(4,5), but there is need for research on diabetic elderly, emphasizing the importance of investigating how is nursing assistance to the elderly with DM from the identification of nursing diagnoses, outcomes and interventions. Thus, we intend to contribute to the advancement of nursing knowledge in this area, in addition to supporting the development of a specific language of nursing to build these elements of practice with an international framework classification system such as the International Classification for Practice of Nursing –ICNP®.

Aiming to knowledge of scientific evidence for the comprehensive care to this population, this study was developed in order to identify nursing diagnoses, outcomes and interventions to an elderly with diabetes mellitus using the ICNP® 2011.

METHOD

This is a case study with an elderly person with diabetes mellitus type 2, performed in a Clinical department of a public hospital in João Pessoa/PB, from February to March 2012, respecting the ethical aspects of Resolution 466/12 on ressearch ⁽⁶⁾ involving human subjects. It is noteworthy that the study is linked to a research project on systematization of nursing assistance approved under protocol nº 054/2007.

To develop the case study, we applied the nursing process in dynamic stages: data collection, diagnosis, planning and evaluation of nursing care. To collect data, we used the nursing history⁽⁷⁾ of the respective sector, which is based in the Theory of Basic Human Needs of Horta, being arranged by needs. We used the ICNP® 2011 to identify the nursing diagnoses, outcomes and interventions for the care of the elderly patient with type 2 DM.

To elucidate the diagnostic reasoning, it resorted to the construction of a conceptual map to show identification, relationship and group of constituent concepts of nursing diagnosis/outcomes. For this, we used the CMap Tools in its version 5.03, which is a software developed and freely distributed by the Institute for Human Machine Cognition at the University of West Florida ⁽⁸⁾, which allows the user to build, navigate, share and criticize models of knowledge represented with conceptual maps. Thus, they identified concepts considered in this study as signs, symptoms, risk factors and living conditions, which were organized hierarchically, presenting the relationship and the grouping between them through the conceptual map.

Thus, it was possible to identify them, sort them and group them watching their relations, for subsequent construction of affirmative nursing diagnoses and outcomes. It is noteworthy that in this study, we used the term "nursing diagnosis and outcome" to name these two elements of nursing practice, with a view that both use the same axes of ICNP® focus and judgment in its construction, and what determines the difference between them is the evaluation of the nurse about whether it is a decision about the client state, and problems and/or needs (diagnosis) or if is the answer given after implementation of interventions (outcome).

Based on the identification of diagnostic and outcome, it was possible to plan the nursing interventions performing the evaluation of the results achieved.

RESULTS

In this section, we present a clinical case of an elderly with diabetes mellitus to identify signs, symptoms, human responses to subsequent construction of nursing diagnoses/outcomes and interventions based on ICNP® 2011.

Clinical case
AJA, 67, brown, male, incomplete high school, retired, married, 53 kg, 1.60 m tall, born in João Pessoa, Catholic, coming from his home in a wheelchair. Medical diagnosis of decompensated congestive heart failure, coronary artery disease, diabetes mellitus decompensated, diabetic nephropathy, diabetic wound in the left lower limb. He complained of fatigue, dyspnea and edema (generalized). Needs/Self-care: bedridden, needing help bathing, to sanitize and dressing. Had impaired sleep and rest due to dyspnea and cough, accepting five meals a day, with good fluid intake, getting help from his children to care.

Showed himself little informed about his health problem. Physical exam: severe general condition, conscious, light spatial disorientation, communication difficult, the face of suffering, groaning, bedridden in anasarca, left eye with ocular prosthesis, decreased hearing acuity, central venous access presence in the left jugular vein, dyspneic , use of supplemental oxygen by nasal catheter, intermittent dry cough, regular heart activity, distended abdomen, presence of exudative erythematous scaly lesions, bowel sounds present, colúrica diuresis by indwelling urinary catheter presented albuminuria, preserved fecal eliminations, paresthesia of the lower limbs , decreased peripheral pulses, complaining of pain in the lower limbs (LLLL) (intermittent claudication), fissure in the left hallux, vesico-bullous lesion suppurative in his left lower limb. Vital signs - T: 36 ° C; P: 86 bpm; B: 19 breaths per minute; BP: 120x80mmHg.

Conceptual map - presentation of diagnostic reasoning
Before the presented case study, empirical indicators were evidenced that supported the process of clinical reasoning allowing the identification of 19 nursing diagnoses based on the patient's condition with chronic DM complications associated with the aging process. Priority was given to nine nursing diagnoses highlighted in bold, considering what would really be the focus of attention of nursing practice that can be viewed in the conceptual map (Figure 1).

Figure 1 - priority nursing diagnoses in elderly with diabetes mellitus based on basic human needs affected. João Pessoa, 2012.

Based on the identification of diagnosis as shown in Figure 1, is presented in Figure 2 to illustrate the nursing diagnosis, outcomes and interventions planned for the elderly with diabetes mellitus and evaluation of nursing care.

In this situation, from the interventions implemented, the patient was kept in elevated decubitus, conscious, in use of venturi mask, monitored saturation of 98%. The edema showed a slight decrease, but it was possible to protect the skin of possible injury with use of cushions and change of decubitus. Presented a good food intake with accompanying and nursing staff assistance. He remained with oral and body hygiene preserved, without the presence of pressure ulcers, but still dependent on the nursing staff due to the impaired clinical condition. The left lower limb diabetic wound was debrided in surgical ward and remained in granulation stage; showed improvement of abdominal injury from dressings performed. The pain was minimized from comfort measures such as heating of the feet with socks and patient positioning associated with drug therapy.

Interventions related to health education have been implemented together with the family, responsible for elderly care, demonstrating a greater understanding of the importance of following the therapeutic regimen.

DISCUSSION

In this study, it appears that out of 19 nursing diagnoses identified, most are related closely to chronic complications of DM, plus the physiological changes of aging, showing a succession of events during the course of the disease by the lack of prevention of risk factors. This makes it possible to rethink the comprehensive care which should be provided to such clients from the Primary Attention so that cases like this are minimized.

Thus, will be discussed the nine nursing diagnoses that constituted the care planning, emphasizing that nursing assistance in this case was focused on minimizing complications.

Regarding the nursing diagnosis Dyspnea on Minimal Exertion, occured the permanence of the diagnosis during hospitalization, producing him discomforts, which prompted the need for supplemental oxygen, preventing from preserving sleep and rest and keeping him bedridden. It is defined by the ICN⁽⁹⁾ as "forced movement of air into and out of the lungs, shortness of breath associated with lack of oxygen in the circulating blood, feeling of discomfort and anxiety." In this case, it is associated with macrovascular complications of diabetes such as coronary artery disease that causes heart failure by reducing ventricular function causing lung congestion, characterized by shortness of breath, worsening especially at night, besides cough and peripheral edema.

The Coronary Artery Disease is considered a complication of higher comorbidity to be associated with higher incidence of acute myocardial infarction, death and need for revascularization and silent ischemia⁽³⁾. In the elderly, the risk of developing these complications is evident due to the prevalence that has to develop high blood pressure, one of the risk factors for macrovascular complications⁽¹⁰⁾.

This nursing diagnosis is observed in elderly patients with DM already afflicted with complications, nursing care in these situations are part of the Tertiary Care, focusing on the reduction of complications and rehabilitation.

As for the nursing diagnosis Volume of liquids excessive, installed in the patient in a progressive manner, required invasive interventions such as central venous access and urinary catheter due to the difficulty of peripheral venous access and penile edema, requiring the nursing staff a daily monitoring due to risk of the skin breaking.

This water retention framework is the result of chronic complications installed in elderly patients with diabetes, this study, such as diabetic nephropathy and coronary artery disease. Diabetic nephropathy consists of a main cause of chronic kidney failure, and its onset characterized by small amounts of albumin in the urine, called albuminuria and macroalbuminuria, proteinuria or clinical nephropathy in advanced stages⁽³⁾.

In order to avoid the conversion of microalbuminuria in macroalbuminuria, it highlights the importance of annual assessment of urine through the urine test for microalbuminuria as well as tests to evaluate serum and urine creatinine levels. Added to these measures are also pointed control of arterial hypertension, prevention or treatment of urinary tract infections, prevention of nephrotoxic substances, low-sodium and hypoproteic diet⁽¹⁰⁾.

Living with a chronic health condition can lead to situations related to the deficit of self-care. In the elderly, in a study, the nursing diagnosis of Self-care deficit was evaluated as a total in the bath activities, hygiene and dressing and as Partial self-care deficit in feeding activity, due to the clinical condition in which the patient was. However, it was noticeable how much the situation of dependence bothered him due their independence in performing these activities.

However, due to mild disorientation framework that the elderly was in all nursing interventions related to self-care were shared with relatives who accompanied him aiming the development of skills for home care.

The nurse can plan self-care practices for elderly people with DM according to the actual needs and can be changed if it contributes positively on his behavior through changes in lifestyle, reflecting the quality of life⁽¹¹⁾. Although the commitment to the strict control of blood glucose levels can not be safe or appropriate before the risk of hypoglycemia, prolonged hyperglycemia should be avoided.

Thus, for this type of client, it is important to draw up an individual plan and effective guided in the context of life by integrating the family, since there are some barriers to learning and self-care as decreased vision, loss of hearing, memory impairment, mobility and fine motor skills diminished, increased tremors, depression and isolation, diminished financial resources related to disability and other clinical disorders^(12,13).

The nursing diagnosis of Diabetic wound was identified in the left lower limb, presenting phlogistic signs and fissure, getting attention from the multidisciplinary team, involving interventions targeted to surgical debridement and daily dressing in order to prevent the risk of amputation.

They are also called "diabetic foot" and is one of the most common complications of diabetes. These are lesions on the feet of diabetic patients that occur as a result of neuropathy, in 90% of cases, peripheral vascular disease and deformities ⁽¹³⁾. The International Consensus on Diabetic Foot defines as infection, ulceration and/or destruction of soft tissues associated with neurological changes and various degrees of peripheral arterial disease (PAD) in the lower limbs⁽³⁾.

As a predisposing factor for the onset of ulcers in the lower limbs, it is appointed to diabetic neuropathy, which affects 50% of people with diabetes aged over 60 years, which may be present before the detection of the loss of protective sensation, resulting in increased vulnerability to traumas resulting in an increased risk of ulceration⁽³⁾.

Regarding nursing interventions for the care of the diabetic foot, it is highlightedeleven recommendations proposed by the Brazilian Society of Diabetes, especially those related to prevention and diagnosis, how to assess the knowledge, skills, barriers / limitations for the self-care of the person with DM; ensure that people with DM and family recognize the risks of complications in feet and preventive measures; patients, caregivers and healthcare professionals should recognize the loss of sensitivity as the main risk factor for plantar ulcers; classify the person with diabetes at risk category; promote pressure relief in the plantar region; and promote access to professional care and education in view of the individual needs and identified risk category⁽³⁾.

The nursing diagnosis Integrity of skin impaired was evident in the abdomen, in the inframammary region, caused by fungal infection due to the condition of being bedridden and the state of edema which makes it difficult to keep clean and dry this area.

The skin infections affect 20% to 50% of people with type 2 DM and when they are poorly controlled happen with a higher incidence and severity due to hyperglycemia cause immune dysfunction that makes it more vulnerable to infection and has an impaired healing process⁽³⁾.

In a study⁽¹⁴⁾, this nursing diagnosis was present in the elderly because they have skin changes related to the elasticity and hydration, making it more fragile and susceptible.

Considering such aggravating that diabetics and elderly have, skin care to prevent complications is an essential practice and should be part of prevention programs and control of DM, with the basic actions to maintain the health of the skin, moisturizing, hygiene, control, clothing, and protection⁽³⁾.

The nursing diagnosis of Severe pain in the lower limbs was an ever constant phenomenon in the elderly diabetic study, worsening at night, directing nursing assistance to promote comfort and relief of pain associated with drug therapy.

Referred pain is called intermittent pain and is characterized by pain in calves even resting accompanied of decreased of peripheral pulse resulting from progressive atherosclerotic obstruction process of the arteries of the lower limbs, characteristic of peripheral arterial occlusive disease (PAOD), gradually affecting the quality of life of diabetic patients ⁽³⁾. The prevalence increases with age and that the arterial changes are enhanced in elderly patients due to physiological cardiovascular disorders and decreased exercise/activity pattern that can enhance the risk factors for the development of PAOD^(15,10).

On of the deleterious effects that the PAOD can cause, it is relevant to the attention of health professionals for the early detection of risk factors (smoking, diabetes mellitus, hypertension, dyslipidemia, platelet aggregation, diabetic foot) and cardiovascular profile changes, thus improving mortality and quality of life of patients⁽³⁾.

It is believed that the educational support to people with diabetes involves behavior modification, avoiding a major nursing diagnoses Lack of adherence to therapeutic regimen identified during the study, responsible for the severity of chronic complications installed in elderly diabetic and in quality of life. This nursing diagnosis in elderly favors hospitalization or contributes to extend the duration of hospitalization⁽¹⁶⁾.

By emphasizing the importance of adherence to therapeutic regimen, this is characterized as adopting self-care behavior that includes activity; healthy eating; monitoring; medication; troubleshooting; healthy coping; and reduction of risks; with an educational approach to empowerment, the responsible to promote these changes in behavior, since it is a training patients and their families in the daily management of diabetes, which give them autonomy and shared responsibility with the team of professionals who assist them⁽³⁾.

The nursing diagnosis Deficient knowledge about the disease and treatment was evident in the admission of this patient on the severity of chronic complications of DM already installed, being himself a young elderly and no family involvement (companions) in his treatment plan. This fact surprised the team due to the existence in our country of Public Policies that cover specific programs for chronic conditions such as “Hiperdia” for hypertension and diabetes mellitus beyond the Elderly Statute.

This fact provides a reflection on how the information in the health services are being discussed, and the importance of the degree of understanding of users, especially the elderly, with their specific limitations, as well as causing concern if the health professionals hold the knowledge and pedagogical skills able to offer tools to the health problem management with a view to self-care.

It is necessary to a critical analysis of health professionals, including nurses, about their educational activities for care of aging population with its own characteristics and complex requiring specific actions⁽¹⁷⁾.

Given the difficulties of users with DM, it is recommended the implementation of an education program in diabetes, so that users are involved in all phases of the educational process to take responsibility for their therapeutic role, from knowledge and skills that instrumentalize for self-care⁽¹⁸⁾.

With this approach, an education program in DM would be a dynamic alternative to the empowerment of the individual making it able to adopt new behaviors and thereby ensure more autonomy and independence to the elderly in search for better quality of life facing the health problem.

For the American Association of Diabetes Educators, diabetes education is an interactive, collaborative and continuous process involving people with diabetes and their teacher, which includes the assessment of individual special educational needs; the identification of specific individual goals for self-management of the disease; educational and behavioral interventions aimed to help the individual to identify self-management goals; and assessing the ability of individuals to achieve the goals of self management; setting the nurse as the predominant health professional in this therapeutic modality⁽³⁾.

CONCLUSION

When performing this case study can be seen that this elderly person with DM presented nursing diagnoses intimately related to chronic complications of the disease by the lack of prevention of risk factors for its evolution. It is clear the importance of health education role in DM patients with a focus on shared responsibility between staff and patients for the prevention of risk factors and minimizing complications of the disease. The basic principles in the treatment of elderly patients do not differ, in general, of the established to younger diabetic patients, however, the elderly have special features (cognitive impairment and functional disability) related to the aging process that need to be considered during the nursing care.

It highlights the importance of systematic care for the elderly diabetes patients by providing a better understanding of the causes and ways that lead to complications of the disease providing a treatment that best suits his health needs.

REFERENCES

1. Ministério da Saúde (Brasil). Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022.  Brasília: Ministério da Saúde; 2011.

2. Lerário AC. Peculiaridades do tratamento do idoso com diabetes. Capítulo 9. In: E-book Diabetes na prática clínica. Sociedade Brasileira de Diabetes [ internet ] 2011 [ cited 2012 Jan 20 ] Available from:http://www.diabetesebook.org.br

3. Sociedade Brasileira de Diabetes (Brasil). Cuidados de enfermagem em Diabetes Mellitus. Itapevi: A.C. Farmacêutica; 2011.

4. Teixeira CRS, Becker TAC, Citro R, Zanetti ML, Landim CAP. Validação de intervenções de enfermagem em pessoas com diabetes mellitus. Rev Esc Enferm USP. 2011;45(1):173-9.

5. Becker TAC, Teixeira CRS, Zanetti ML. Diagnósticos de enfermagem em pacientes diabéticos em uso de insulina. Rev Bras Enferm. 2008;61(6): 847-52.

6. Ministério da Saúde (Brasil). Resolução nº 466/12. Diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União 12 dec 2012; Seção 1. 

7. Virgínio N. Validação de instrumento de coleta de dados de enfermagem para clientes hospitalizados [ dissertação ]. João Pessoa: Centro de Ciências da Saúde, Universidade Federal da Paraíba; 2003.

8. Institute for Human and Machine [ homepage ]. Cognition-CmapTools. University of West Florida. [ Cited 2012 Mar 10 ] Available from: http://cmap.ihmc.us

9. International Council of Nurses (Unites States of America). Classificação Internacional para a Prática de Enfermagem Versão 2011. [ cited 2013 Jan 24 ] Available from:http://www.icn.ch/images/stories/documents/pillars/Practice/icnp/translations/icnp-Brazil-Portuguese_translation.pdf

10. Smeltzer SC, Bare BG, Hinke JL, Cheever KH. Brunner&Suddarth Tratado de enfermagem médico-cirúrgica. 11. ed. Rio de Janeiro: Guanabara Koogan; 2009.

11. Borba AKOT, Marques APO, Leal MCC, Ramos RSPS. Práticas educativas em diabetes Mellitus: revisão integrativa da literatura. Rev Gaúcha Enferm. 2012;33(1):169-76.

12. Silva LMC, Palha PF, Barbosa GR, Protti ST, Ramos AS. Aposentados com diabetes tipo 2 na Saúde da Família em Ribeirão Preto, São Paulo - Brasil. RevEscEnferm USP. 2010;44(2):462-8.

13. Rezende KF, Nunes MAP, Melo NH, Malerbi D, Chacra AR, Ferraz MB. Internações por pé diabético: comparação entre o custo direto estimado e o desembolso do SUS. Arq Bras Endocrinol Metab. 2008;52(3):523-30.

14. Nascimento SS, Oliveira DF, Barbosa LR, Stival MM. Julgamento clínico de enfermagem em idosos portadores de Diabetes Mellitus fundamentado na teoria do déficit do autocuidado. Anuário da Produção de Iniciação Científica Discente, 2008;11(12):91-106.

15. Pereira DAG, Lustosa LP, Murta FN, Prata KO, Saraiva PS, Cunha-Filho IT. Avaliação do equilíbrio estático em pacientes fisicamente ativos com doença arterial obstrutiva periférica – um estudo piloto. Ter Man. 2011;9(41):49-53.

16. Nóbrega OT, Karnikowski MGO. A terapia medicamentosa no idoso: cuidados na medicação. Cien Saude Colet. 2005;10(2):309-13.

17. Souza LM, Lautert L, Doll J, Silva MCS. Nursing consultation to elderly people based on andragogy: a review article. (Online)[ internet ]. 2009 Feb 3;[ cited 2012 June 10 ] 8(1). Avaliable from:http://www.objnursing.uff.br/index.php/nursing/article/view/2119

18. Oliveira KCS, Zanetti ML. Conhecimento e atitude de usuários com diabetes mellitus em um Serviço de Atenção Básica à Saúde. RevEscEnferm USP. 2011;45(4):862-8.

All authors participated in the phases of this publication in one or more of the following steps, according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial participation in the planning or preparation of the manuscript or the collection, analysis or interpretation of data; (B) preparing the work or performance of critical review of the intellectual content; (C) approval of the submitted version. All authors declare for any purposes that are their responsibilities related content to all aspects of the manuscript submitted to OBJN. Ensure that issues related to the accuracy or completeness of any part of the article have been properly investigated and resolved. Absolving, so the OBJN of any joint participation in any imbroglios on the matter at hand. All authors declare that they don't have conflict of interest, whether financial or of relationship, to influence the drafting and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_final_13-06-2013.pdf

Received: 07/16/2014
Revised: 06/03/2016
Approved: 06/03/2016