Aim: to construct a bank of specific nursing language terms for patients with pressure injury using the International Classification for Nursing Practice (ICNP®). Method: this is a terminological study performed in a hospital in the Northeast of Brazil. The work consists in the accomplishment of the identification and collection of the terms, the extraction of the terms of the medical records, the elimination of repeated terms, normalization of the terms, cross-mapping between the terms extracted and the terms in ICNP®, refinement of the terms, and validation of the expressions of the bank of terms. Results: 391 terms that were submitted to cross-mapping and validation of experts were identified, resulting in 370 terms, of which 225 were constant and 145 were not constant in ICNP®. Conclusion: the identified terms valorized pathophysiological aspects, which support the planning of the care and evaluation of the results of the nursing interventions based on the physiological aspects.
Descriptors: Terminology; Nursing Records; Pressure Ulcer.
Pressure injury is the result of prolonged compression over an area of the patient's body, reducing blood circulation and minimizing the distribution of blood, nutrients and oxygen in this area, thus triggering tissue destruction and death(1). Nursing plays an important role in the care of people with pressure injuries, which can be seen through the Systematization of Nursing Care (SNC). Considering the need to implement SNC to the person with pressure injury, the importance of the use of terminologies that allow the documentation of patterns of care should be highlighted(2). The International Classification for Nursing Practice (ICNP®) consists of a standardized terminology of the nursing language. Its structure of terms allows the collection, description and systematic documentation of nursing practice(3).
to construct a bank of specific nursing language terms for patients with pressure injury using ICNP®, based on the Theory of Basic Human Needs.
This is a terminology study, guided by the first and second stages of the guidelines for the elaboration of terminological subsets of ICNP®(4). The work consists in identifying and collecting terms relevant to nursing practice related to pressure injury, extracting terms from records and eliminating repeated expressions, normalizing terms, performing cross-mapping between extracted terms and the terms in the ICNP® version 2015, the refinement of terms, and validation of the bank of terms. The sample consisted of 77 patients with pressure injury, hospitalized in a hospital located in the Northeast of Brazil and 12 experts. Data were collected between November and December 2017 in the nursing records in the medical records. They were then typed into a Word® file, converted to Portable Document Format (PDF). For the extraction of the terms the computational tool Poronto was used, resulting in a list of terms arranged in Excel® worksheet. The validation of the terms was carried out by selected experts in the Platform Lattes of the National Council of Scientific and Technological Development (CNPq – Conselho Nacional de Desenvolvimento Científico e Tecnológico). The research was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte with Certificate of Presentation for Ethical Assessment No. 76777017.20000.5537.
391 terms that were submitted to the process of cross-mapping and validation by experts, resulting in 370 terms, were identified. Of these, 225 were included and 145 were not included in the ICNP®. The terms were categorized according to the levels of Wanda Horta's Theory of Human Needs, distributed as follows: psychobiological - oxygenation (35), hydration (20), nutrition (21), elimination (34), sleep and rest (09), activity, body mechanics, mobility and locomotion (28), body care (09), physical and cutaneous-mucosal integrity (89), thermal, hormonal, neurological, cellular growth, vascular (20) and therapeutic (51) regulation; psychosocial - security (09), love (02), freedom (02), communication (07), gregarious (04), orientation in time and space (15), acceptance (05), self-fulfillment (01), self-esteem (04), participation (02), self-image (01), and attention (02). No terms that fit the psycho-spiritual needs were identified.
The fact that most of the identified terms have been classified as being included in ICNP® ensures the reliability of this terminology as a technological tool for insertion into information systems and registration of clinical practice worldwide with a view to the scientific and technological development of the profession(3). The validation of 75 terms considered not included in ICNP® also draws attention in this study, and provides indications of the use of a language of its own in the care of people with pressure injury. Therefore, it is necessary that the terms used in this specific area can be described and inserted in ICNP®, guaranteeing the dynamism and continuous evolution of this terminology, as recommended by the International Council of Nursing(4). Finally, most of the terms were grouped into psychobiological needs, due to the description in the nursing records of the clinical manifestations and physiological changes correlated with the formation of the pressure lesion; however, the social and spiritual factors that make up the psychosocial and psycho-spiritual needs cannot be neglected during nursing care, since they aid in patient recovery.
The identified terms valorized the physiopathological aspects, a fact that supports the planning of the care and the evaluation of the results of the nursing interventions based on the physiological aspects. As future work, after the construction of the ICNP® terminology subset for people with pressure injury, clinical validation is suggested to support evidence for practice.
Received: 12/12/2017 Revised: 08/09/2018 Approved: 08/09/2018