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Content Validation of the Operational Definitions of the Nursing Diagnoses of Activity Intolerance, Excess Fluid Volume, and Decreased Cardiac Output in Patients With Heart Failure Vanessa de Souza, RN, Sandra Salloum Zeitoun, RN, PhD, Camila Takao Lopes, RN, MsN, Ana Paula Dias de Oliveira, RN, Juliana de Lima Lopes, RN, PhD, and Alba Lucia Botura Leite de Barros, RN, PhD Vanessa de Souza, RN, is a Cardiology Nurse Specialist and Master’s Student at the Federal University of Sao Paulo, Sao Paulo, Sandra Salloum Zeitoun, RN, PhD, is a Critical Care Nurse Specialist and Full Professor at the Nursing Department, Paulista University, Sao Paulo, Camila Takao Lopes, RN, MsN, is a Cardiology Nurse Specialist, a Doctoral Student at the Federal University of São Paulo, and Nurse at the School Hospital, São Paulo University, São Paulo, Ana Paula Dias de Oliveira, RN, is a Cardiology Nurse Specialist and a Master’s Student at the Federal University of São Paulo, Sao Paulo, Juliana de Lima Lopes, RN, PhD, is a Cardiology Nurse Specialist and Professor at the Federal University of Sao Paulo, Sao Paulo, and Alba Lucia Botura Leite de Barros, RN, PhD, is a Full Professor at the School of Nursing, Federal University of Sao Paulo, Sao Paulo, Brazil.
Search terms: Heart failure, nursing diagnosis, validation study Author contact:
[email protected], with a copy to the Editor:
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OBJECTIVES: To consensually validate the operational definitions of the nursing diagnoses activity intolerance, excessive fluid volume, and decreased cardiac output in patients with decompensated heart failure. METHOD: Consensual validation was performed in two stages: analogy by similarity of defining characteristics, and development of operational definitions and validation with experts. RESULTS: A total of 38 defining characteristics were found. Operational definitions were developed and content-validated. One hundred percent of agreement was achieved among the seven experts after five rounds. “Ascites” was added in the nursing diagnosis excessive fluid volume. CONCLUSION: The consensual validation improves interpretation of human response, grounding the selection of nursing interventions and contributing to improved nursing outcomes. IMPLICATIONS FOR PRACTICE: Support the assessment of patients with decompensated heart failure. OBJETIVOS: Realizar a validação consensual das definições operacionais dos diagnósticos de enfermagem Intolerância à atividade, Volume de líquidos excessivo e Débito cardíaco diminuído em pacientes com insuficiência cardíaca descompensada. MÉTODO: Validação consensual em duas etapas: Analogia de semelhança das características definidoras e desenvolvimento de definições operacionais e validação com expertst. RESULTADOS: Foram encontradas 38 características definidoras para os diagnósticos de enfermagem. Suas definições operacionais foram desenvolvidas e seu conteúdo validado. Os resultados mostram que houve 100% de concordância entre os sete experts após cinco rodada. As definições operacionais foram classificadas com base no nível de concordânica. “Ascite” foi acrescentada ao diagnóstico Volume de líquidos excessivo.
© 2013 NANDA International International Journal of Nursing Knowledge Volume ••, No. ••, •• 2013
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Content Validation of the Operational Definitions
V. de Souza et al.
CONCLUSÃO: A validação consensual melhora a interpretação das respostas humanas, embasando a seleção de intervenções de enfermagem e contribuindo para melhorar os resultados. IMPLICAÇÕES PARA A PRÁTICA: Apoio à avaliação dos pacientes com insuficiência cardíaca descompensada.
Heart failure (HF), an increasingly prevalent clinical syndrome, has a gloomy prognosis in the short term and considerably reduces people’s quality of life, in addition to being an important issue in terms of public health budgets around the world (Bocchi et al., 2012). Acute decompensated heart failure (ADHF), a new-onset HF or decompensation of chronic HF, requires hospitalization, visits to the emergency department, or unplanned medical attention (Jessup et al., 2009). In the United States, there are five million patients, from 400,000 to 500,000 new cases a year, and more than one million inpatients presenting a high mortality rate, up to 7.2% in Brazil and 11% in the United States (Bocchi et al., 2009, 2012). In Brazil, diseases of the circulatory system are the primary causes of mortality, leading to increased hospitalizations, and consequently higher hospital costs (Brasil, 2009). HF is characterized by a set of complex clinical symptoms and is a common outcome of many cardiac diseases. Greater hemodynamic instability is observed in the advanced stages of the disease, and a higher prevalence of decompensation is expected, leading to hospitalizations and more frequent readmissions (Aliti, Linhares, Linch, Ruschel, & Rabelo, 2011; Lima et al., 2011; Montera et al., 2009). Many studies have shown that the nursing diagnoses (NDx) decreased cardiac output (DCO), excess fluid volume (EFV), and activity intolerance (AI) are frequently observed in patients with HF (Fusco & Shiotsu, 2011; Martins, Aliti, Joelza, & Rabelo, 2011; Rodrigues, Moraes, Sauer, Kalil, & Souza, 2011; Souza, Zeitoun, & Barros, 2011). Correctly identifying NDx related to fluid overload and DCO is paramount to improving the knowledge of nurses assisting heart patients, since appropriate nursing interventions are required to meet the needs of patients according to their true health condition (Aliti et al., 2011; Lima et al., 2011). Following this premise, NANDA-I (Herdman, 2012) is developing and encouraging studies designed to improve credibility and refinement of NDx’s defining characteristics (DCs). Validation studies confer precision and reliability to NDx through rigorous criteria that enable a safe and replicable methodology, leading at the same time to logical reasoning in clinical practice. Therefore, this study’s objective was to seek consensual validation among clinical experts concerning the operational definitions (ODs) of the defining characteristics of DCO, EFV, and AI among patients with decompensated HF. 2
Method This content validation was developed in three stages. Analogy by similarity of the nursing diagnoses DCO, EFV, and AI was verified in the first stage. This stage was necessary to eliminate redundancies of the DCs of the three NDx, since similarities and some repetitions were verified in the analysis. NANDA-I (Herdman, 2012) proposes 33 DCs for DCO, 25 for EFV, and eight for AI. The ODs selected for the three NDx were developed in the second stage. For that, a literature review was conducted using specific theoretical references to develop the ODs of the DCs concerning the three nursing diagnoses related to patients with ADHF, namely periodicals, guidelines, and recent books focusing on physical assessment and anamnesis. In the third stage, the ODs of the DCs concerning the three NDx underwent consensual validation by experts by means of the Delphi technique (Scarparo et al., 2012). This stage was necessary because the OD defines the method by which nurses assess the patient. For this reason, experts should validate the propaedeutic and specific instruments because these frequently change due to updated guidelines and developing consensus on the subject (Boery, Guimarães, & Barros, 2005). Conceptual definitions (CDs) do not require validation since concepts do not change over time; therefore, the CDs of previous studies were used (Barth, Aliti, & Rabelo, 2010; Boery et al., 2005; Oliva, 2003). The third stage sample was composed of seven nurse experts. The professionals met the following criteria in order to be considered experts (Galdeano & Rossi, 2006): being a nurse and/or physician specialized in cardiology and have at least 5 years of practice, teaching, or research regarding cardiac patients with decompensated HF; being linked to care, teaching, or research facilities in the state of São Paulo; and working with cardiac patients in intensive care units and/or in emergency departments. The instrument used to perform this stage of the study contained the DCs and their respective ODs, in which the experts should indicate whether they agreed or disagreed with the ODs and suggest alternatives. The profile of the studied population was individuals with New York Heart Association functional class III or IV, with left ventricular ejection fraction 90 mmHg and present (=1) if systolic BP < 90 mmHg. The measurement of pulmonary artery pressure (PAP) is performed through pulmonary artery catheterization. The range considered normal for average PAP is between 15 mmHg and 28 mmHg. This defining characteristic will be considered to be absent (=0) if average PAP is between 15 mmHg and 28 mmHg, present (=1) if average PAP > 28 mmHg, and not applicable (n/a) if the patient has not received pulmonary artery catheterization. CVP is obtained through a central venous catheter located in the right atrium and is measured by a multiparameter monitor or water column. Normal parameters in the electronic pressure transducer are: 0–8 mmHg in the midaxillary line and 8–12 mmHg in the sternal line. Normal parameters in the water column are: 6–10 cmH20 in the midaxillary line. This defining characteristic will be considered to be absent (=0) if within the normal range, present (=1) if above this range, and not applicable (n/a) if measure was not taken. A pitting edema confirms subcutaneous edema. The skin in the swollen area becomes smooth and shiny when edema is recent. Over time, the skin takes on an appearance like an orange peel, indicating thickening with punctuated retractions that correspond to hair follicles. Therefore, inspection and palpation are used during physical examination. This defining characteristic will be considered to be either absent (=0) or present (=1). The assessment is be done with the aid of a scale (instrument) gauged in kilograms. The patient should be weighed daily with the same clothes before breakfast with an empty bladder. The patient should be asked about prior weight. Weight gain above 1 kg/day suggests fluid retention. This defining characteristic will be considered either absent (=0) or present (=1). Clinical assessment of intake greater than output is performed by properly monitoring consumed and eliminated fluid volume through the use of graded measuring cups. The consumption of fluids greater than the elimination of fluids from the body characterizes intake greater than output. If possible, weight gain should be checked. This defining characteristic is considered either absent (=0) or present (=1). The assessment of subcutaneous edema by checking indentation produced by pressure has to be performed on the extremities accompanied by inspection of the face, looking for periorbital edema. Assessment for ascites and pulmonary auscultation to examine for rales should also be performed. This defining characteristic will be considered either absent (=0) or present (=1). The health professional has to tap on the lower regions of the abdomen to check for potential ascites. The ascetic fluid has a characteristic feature due to gravity, and a dull sound is expected while the gas-filled intestine floats on top. Palpation can also be used through the “fluid wave test” in which the examiner taps one flank while feeling the pulse transmitted in the form of a wave with the other hand on the opposite side. Abdominal circumference is also useful in checking the progression of ascites. This defining characteristic will also be considered to be either absent (=0) or present (=1). The patient has to be in a supine position at 45° to assess jugular vein distention. The bed headboard can be lifted or a pillow can be used to support the patient’s head in order to form a 45° angle between the patient’s back and bed. Assessment of each side will be performed with the patient’s head slightly turned to the opposite side. Jugular veins that remain turgid when the patient adopts a sitting or semi-setting position (forming a 45° angle between the back and bed) characterize jugular vein distention. This defining characteristic will be considered either absent (=0) or present (=1). The respiratory pace, depth, and rate are assessed. The latter will be verified through observation of the patient’s chest elevation for 1 min without him/her noticing it to avoid voluntary control of the movement. The amplitude, use of accessory muscles, as well as alterations such as Cheyne–Stokes and Biot respiration, have to be verified. The normal respiratory rate range in adults is 12–20 rpm. Symptoms are observed in patients with ADHF due to increased return of venous blood when the patient adopts a horizontal position. This greater amount of venous blood from the legs toward a failing heart causes additional accumulation of fluids in the lungs (pulmonary edema), leading to orthopnea (it occurs some time after the patient lies down in bed/adopts a horizontal position), paroxysmal nocturnal dyspnea (breathlessness at night that causes the patient to wake up suddenly and sit), and dyspnea at rest and/or with minimum activity. This defining characteristic will be considered absent (=0) if there is no change in respiratory rate or breathing pattern, or present (=1) if RR > 20 rpm or changes are observed in breathing pattern.
Changes in pulmonary artery pressure
Increased/decreased central venous pressure
Edema
Weight gain in a short period of time Intake greater than output
Anasarca
Ascites
Jugular vein distention
Change in breathing patterns
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Content Validation of the Operational Definitions
Table 1. Continued Defining characteristics
Operational definitions
Arrhythmias
Assessed by observing irregularities in the ECG monitor’s oscilloscope and by performing a detailed ECG, checking for the leads and intervals of the QRS complexes, PR, and changes in the P wave, in addition to verifying arrhythmic apical pulse. This defining characteristic will be considered either absent (=0) or present (=1). The 12-lead ECG is performed with the patient in comfortable supine position. Ideally, the result will be compared with prior exams. The following ECG changes are observed in ADHF patients: – Atrioventricular (AV) blocks. – First-degree AV block. In this situation, PR interval is lengthened beyond 0.20 s in adults. Each P wave is associated with QRS complexes. – Second-degree AV block, Mobitz type I: In this situation, delay of AV conduction is gradual. PR intervals become progressively longer until AV conduction is blocked and atrial beat is no longer conducted. – Second-degree AV block, Mobitz type II: In this situation, there is sudden interruption in the AV conduction. 1:1 AV conduction with a fixed PR interval is observed, and then a P wave is blocked followed by a new 1:1 AV conduction with PR similar to the previous ones. The frequency of interruption may vary, such as 5-1, 4-1, 3-1. – Third-degree AV block or complete heart block: In this case, atrial impulses fail to propagate to the ventricles and depolarize, causing accessory pacemaker in the lower chambers to assume the ventricular rhythm. Therefore, there is no correlation between atrial and ventricular electric activity, which are shown in the ECG as P waves not related to QRS. A third-degree AV block can either be intermittent or permanent. A left bundle branch block (LBBB) occurs when the electric stimulus is delayed or prevented from proceeding through one of the branches of the bundle of His. Ventricular activation is delayed due to the slow activation (cell to cell) of the ventricle with the blocked branch. The ECG manifestation of this activation delay is a prolonged QRS duration (>0.12 s), with the T wave opposed to the QRS delay. – Supraventricular arrhythmias: Atrial fibrillation: a disorganized atrial electric activity (P wave is absent in the ECG; there is only an irregular line) that leads to irregular heart rate and most often to irregular RR intervals. It is divided into AF with slow ventricular response (HR < 60 bpm) and AF with rapid ventricular response (HR > 100 bpm). Atrial flutter: the rhythm secondary to the organized electric activity forms a macro-reentrant circuit that propagates along the walls of the right atrium. F waves present a characteristic saw-toothed pattern that is inverted in the ECG lower leads and generally upright in V1. Characteristically, F waves in DI and VL leads are of low voltage. - Ventricular arrhythmias: Ventricular tachycardia: The ventricular rhythm has a widened QRS, rate above 100 bpm and lasts more than 30 s. This defining characteristic will be considered absent (=0) or present (=1) if electrocardiogram change is determined. Assessing one’s skin condition includes checking and palpating the skin, feeling for changes in texture and other aspects that may reflect peripheral vasoconstriction, which causes the skin to become wet and cold. This defining characteristic will be considered either absent (=0) or present (=1). Assessed by palpating peripheral pulses (radial, pedal, or brachial) with low amplitude. This defining characteristic will be considered absent (=0) or present (=1). The measure of pulmonary vascular resistance is obtained through a pulmonary artery catheter. Normal values are: 20 dyn/s/cm3 to 130 dyn/s/cm3, which are calculated through the thermodilution method in units of dyn/s/cm3. This defining characteristic will be considered absent (=0) if values are within the established parameters, present (=1) if values are 130 dyn/s/cm3, or not applicable (n/a) if the patient does not have a pulmonary artery catheter. The measure of systemic vascular resistance is obtained through pulmonary artery catheterization. Normal values are: 700 dyn/s/cm3 to 1.600 dyn/s/cm3, calculated through the thermodilution method in units of dyn/s/cm3. This defining characteristic is absent (=0) if values are within the established parameters, present (=1) if values are 1600 dyn/s/cm3, or not applicable (n/a) if the patient does not have a pulmonary artery catheter. Oliguria is verified by the relation of urine elimination by kg/hr. The normal value is 1 ml/kg/hr. Clinical assessment is performed by recording urine output using graded measuring cups or periodically measuring the content of the collection bag in patients with bladder catheterization. Urine output below 0.5 ml/kg/hr or below 400 ml/24 hr in adults characterizes oliguria. This defining characteristic will be considered absent (=0) if output is normal or present (=1) if output is < 0.5 ml/kg/hr. Observation of whether skin is cold and pale, and capillary refill is >3 s by lightly palpating the digital pulp of the upper and lower limbs. This defining characteristic will be either absent (=0) or present (=1).
ECG alterations
Cold and clammy skin
Decreased peripheral pulses Increased/decreased pulmonary vascular resistance
Increased/decreased systemic vascular resistance
Oliguria
Prolonged peripheral capillary perfusion
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Content Validation of the Operational Definitions
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Table 1. Continued Defining characteristics
Operational definitions
Changes in skin color
Assessed by checking the skin color in the patient’s face, extremities, and labial mucosa. Cyanosis, which is characterized by bluish discoloration and/or paleness due to decreased peripheral blood flow, may be observed. This defining characteristic will be considered absent (=0) or present (=1) if skin is pale or cyanotic. May be reported by the patient or be apparent through signs of anguish, distress, uneasiness, worry, impatience, greediness, and physiological changes (BP and pulse). It may be related to a specific or unspecific object. This defining characteristic will be either absent (=0) or present (=1). Assessment is performed through observation of uneasiness and psychomotor movement. This defining characteristic will be absent (=0) or present (=1). Fatigue is assessed through the frequency and type of activity that causes it, period of the day, and whether there is a change in respiratory rate. Fatigue may manifest through tiredness, dyspnea, tachypnea, chest pain, and hypoxemia either accompanied of activities or not. Does the patient report shortness of breath, weakness, and lack of energy? Is there a correlation between fatigue and insomnia or interrupted sleep? What are the activities that cause fatigue? Or is it constant? This condition can be observed by the interviewer or may be reported by the patient and has to be assessed together with the patient. This defining characteristic will be either absent (=0) or present (=1). Auscultated with the stethoscope diaphragm from the apices of the lung bases comparing one side of the chest with the other side, symmetrically. This procedure is ideally performed with the patient in a sitting position to check the dorsal region. The following may be observed: – Subcrepitant rales: adventitious breath sounds characterized by discontinued and nonmusical clear sounds that can either be acute or deep (acute rales—low amplitude, short duration, and loud; deep rales—high amplitude, long duration, and low tone). – Crepitant rales: consist of adventitious pulmonary sounds heard on auscultation at the end of inhalation. Their frequency is high, and they are caused by the presence of fluid in the alveoli and terminal bronchiole. They initially manifest in the bases and can progress to other pulmonary areas. This defining characteristic will be considered either absent (=0) or present (=1). Pulmonary congestion is assessed through clinical assessment (auscultation) and chest X-rays. This defining characteristic will be considered absent (=0) if not shown during auscultation or present (=1) if shown on X-ray and pulmonary auscultation. The radiographic findings of pulmonary congestion are: – Hilum of lung: is augmented with the presence of fluid redistributed in the pulmonary vessels. Alveolar edema, which shows a butterfly pattern, emerges in the cases where there is delayed manifestation and is more frequently observed in the region of the hilum of the lung. – Cephalization of the vascular network: the earliest sign of pulmonary venous congestion is the redistribution of the blood flow to the apex of the lung. – Kerley B lines: an increase of fluid is observed in the interlobular septa, leading to the appearance of Kerley lines, which represent thickening of the interlobular septa by fluid accumulation and swelling of lumpy nodes. There are three types: A, B, and C. A lines occur in the upper lobes, B lines occur in the costophrenic sulci, and C lines occur on the bases with oblique paths. Kerley B lines that appear in HF patients are characterized by short lines (1–2 cm) that are perpendicular and adjacent to the pleura. – Increased cardiac area: cardiothoracic ratio is greater than 0.5 cm. An increased cardiac area may be present even without pulmonary congestion. Assessed through chest X-rays and clinical assessment. Dyspnea, tachypnea, chest pain, and hypoxemia (if there is significant ventilatory impairment) may be observed. Bimanual palpation of the chest, particularly the posterior region of the chest, enables detecting difficulty in expanding the lung, when one side is compared with the other, and also an absence of tactile fremitus, that is, the absence of palpable vibration in the chest’s external wall when the patient says “ninety nine.” In addition to diagnostic support provided by X-rays, tapping and auscultation are used during the clinical assessment of pleural effusion. The accumulation of fluid in the pleural area is visible in an X-ray, and produces a dull sound when tapped on and a reduced or absent vesicular murmur. This defining characteristic will be absent (=0) or present (=1). Laboratory data concerning hemoglobin (Hb) and hematocrit (Ht) are checked using cognitive rationale based on values found and respective normal parameters (Hb: 13.5–18 g/dl for men and 11.5–16.4 g/dl for women; HT: average of 42% for men and 39% for women. This defining characteristic will be considered absent (=0) if Hb/Ht are within normal range or present (=1) if the occurrence is 1.3 mg/dl, or not applicable (n/a) if the patient is not tested. Verified based on information provided either by the patient or family member concerning significant changes in mental condition, by observing behavioral changes such as hyperactivity, and by asking what the patient is feeling, especially in the face of critical situations. It is a lasting reaction different from what the patient usually presents. This defining characteristic will be either absent (=0) or present (=1). Pulmonary capillary pressure (PCP) is obtained through pulmonary artery catheterization. Its normal range is between 4 mmHg and 15 mmHg. This defining characteristic will be considered absent (=0) if PCP is between 4 and 15 mmHg or present (=1) if PCP > 15 mmHg, and not applicable if the patient does not have a pulmonary artery catheter. Observation of episodes of rapid and whooping inhalation preceded by a rapid and profound exhalation in which air is forcibly expelled from lungs through previously closed vocal cords that move away and vibrate, producing a characteristic sound or based on the patient’s verbal report. It will be considered to be either absent (=0) or present (=1). Assessed through the apical pulse with the stethoscope bell and/or through the heart rate observed with an ECG monitor’s oscilloscope. Normal parameters in adults are >100 bpm or 45% or present (=1) if EF < 45%. The measurement of left ventricular stroke work index is obtained through pulmonary artery catheterization by calculating cardiac output using the thermodilution method. This defining characteristic will be considered absent (=0) if 50 g/m2/bpm, present (=1) if 50 ml/bpm, present (=1) if
