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Enfermería Global
versión On-line ISSN 1695-6141
Enferm. glob. vol.18 no.55 Murcia jul. 2019 Epub 21-Oct-2019
https://dx.doi.org/10.6018/eglobal.18.3.345201
Reviews
Nursing diagnoses in oncology palliative care: integrative review
1Nurse in intensive care at Placi Hospital. MSc student at Fluminense Federal University. Brazil.
2Nurse at the National Cancer Institute José Alencar Gomes da Silva - INCA. MSc student at Fluminense University. Brazil.
3Nurse, PhD, Associate Professor at the Aurora Nursing School of Afonso Costa - Federal Fluminense University. Researcher at CNPq / PQ2. Brazil. rosifesa@gmail.com
Objectives
To identify the nursing diagnoses found in oncological palliative care according to the NANDA-I taxonomy.
Methods
It is an integrative review of the literature in six stages. The search was carried out at the following bases: Medline, Scopus, Cinahl, Lilacs, Cochrane, Scielo and Web of Science, delimited last ten years, with the descriptors: "Diagnosis of Nursing" "Palliative Care at the Terminal of Life", "Nursing Oncology", from November to December 2017, 120 articles were found and ten articles were selected.
Results
According to the NANDA-I taxonomy, 32 nursing diagnoses were found, demonstrating the variability and multiplicity of diagnoses identified by nurses during the control of signs and symptoms in palliative care.
Conclusion
When identifying a diversity of nursing diagnoses occurring in patients with cancer palliative care, it is concluded that it is necessary to construct a nursing diagnosis of the syndrome to optimize the clinical reasoning of nurses in palliative care.
Key words: Nursing Diagnosis; Hospice Care; Oncology Nursing
INTRODUCTION
The need for palliative care is increasing at a rapid pace due to the aging of the world's population and the increase in cancer.1 Across the world, it is estimated that more than 20 million people need palliative care at the end of their lives each year. The largest proportion, 94%, corresponds to adults, of whom 69% are over 60 years and 25% are 15 to 59 years, and only 6% are children.1
The patient in terminal or end-of-life palliative care is anyone who has no indication of therapeutic treatment for curative purposes. The prognosis may be from days to months, the progression of the clinical condition will depend on each organism and the aggressiveness of the tumor. In the last 72 hours the individual may present classic clinical indicators such as lack of appetite, mental confusion, changes in vital signs, accumulation of upper airway secretion, hypocoratous and cyanotic skin, increased peripheral and central cell interstitial fluid, dry eyes, lack dry mouth.2,3
One of the principles of palliative care is to provide relief for pain and other symptoms.4 Thus, the nurse in palliative care should possess skills aimed at the systematic evaluation of symptoms.5
And, given the need to implement palliative care in health services around the world, it is necessary to provide quality nursing care to the interdisciplinary team, systematizing care by correctly identifying the problems, listing the precise nursing diagnoses , and set goals with the team, patients and family, to act with effective interventions.6
Therefore, the nursing process gives support to the nurse to provide organized assistance, achieving the objective of being with the patient and family, guiding the decision making of both. However, before implementing this management tool it is necessary to establish the problem, which is done with the nursing diagnoses.6
Nursing diagnosis can be conceptualized as a clinical judgment about a human response to health conditions / life processes, or a vulnerability to that response, by an individual, family, group or community.7 The nursing diagnosis establishes a basis for the selection of nursing interventions to achieve results for which the nurse is responsible.
There are three types of nursing diagnosis: the risk, the health promotion and the problem-focused, which also includes the diagnosis of the syndrome. The diagnosis of the syndrome is: "Clinical judgment relating to a grouping of nursing diagnoses that occur together, being better treated together and through similar interventions".7
Therefore, when proposing the nursing diagnosis Syndrome of deterioration of symptoms, it is believed to potentiate nursing care planning in the management of signs and symptoms in palliative care, and to optimize the diagnostic reasoning in clinical practice with the identification of the set of symptoms in a single diagnosis of appropriate palliative care syndrome.
NANDA-I does not yet have a nursing diagnosis of syndrome that covers the most commonly diagnosed nursing diagnoses in palliative care and that could facilitate the elaboration of care planning and adherence to the use of taxonomy in the specialized services in palliative care.8,9,10
However, it was necessary the bibliographic survey to elaborate the proposal of the diagnosis under study, to search for the symptoms identified during the control of symptoms by the nurses in palliative care. For the preparation of this study we considered as symptoms, physical, psychological and social problems that interfere in the quality of life and can be evaluated by the professionals, family, caregivers or reported by the patients.11
According to NANDA-International (NANDA-I), for submission of new diagnoses a review of the relevant literature is necessary to demonstrate the existence of a substantial body of knowledge in support of the diagnosis and its components.7 Therefore, the objectives of this study were: to identify the nursing diagnoses found in oncology palliative care in order to support the construction of a proposal for the diagnosis of nursing "Syndrome of the deterioration of symptoms in palliative care" Diagnosis denominated Syndrome of the deterioration of symptoms in palliative care.
MATERIAL AND METHODS
The method adopted was the one of integrative revision of the literature, the method of Botelho, Cunha, Macedo was also used, going through the six steps proposed.12
In the first stage of this review, the research question was formulated: Which nursing diagnoses are found during the control of signs and symptoms in oncologic palliative care?
The search for articles was carried out in databases: Medline (Medical Literature Analysis and Retrieval System Online), Scopus, Cinahl (Cumulative Index to Nursing and Allied Health Literature), Lilacs (Latin American and Caribbean Health Science Literature Database), Cochrane Collaboration, Scielo and Web of Science in the period from November to December 2017.
For the data collection, the descriptors were used in English: “Nursing Diagnosis”, “Palliative Care”, “Nursing”, according to the dictionary of terms of theMesh (Medical Subject Headings).
In the second stage, the inclusion criteria were chosen for the study: articles that addressed the proposed theme responding to the guiding question addressing nursing diagnoses according to NANDA-I, articles that addressed the adult and / or elderly population, articles published in the last ten years.
In the third stage the primary selection of the articles was carried out by reading the titles and abstracts. And the secondary selection, after reading the full text and evaluating the suitability of the content with the proposed objective, peer evaluation was performed.
In this way,Figure 1 shows the relation of the articles found and the primary and secondary selection according to the strategies and database.
Of the 26 articles selected in the databases for reading the full text, 16 articles were excluded because they did not address oncological palliative care or did not address nursing diagnoses according to NANDA-I, of those excluded; three presented nursing diagnoses according to the CIPE.
For the fourth stage, a critical analysis of the studies was carried out; in the fifth stage the data analysis was performed with the characterization of the sample. After that, the nursing diagnoses of NANDA-I were highlighted.
And, in the sixth stage of the integrative review, the evidence obtained in the selected studies was analyzed, synthesized and discussed. Therefore, with the evidence obtained in the review, the proposal of the nursing diagnosis "Syndrome of the deterioration of symptoms" in cancer palliative care was discussed.
RESULTS
In order to approach the nursing diagnoses, the Standardized Language System (SLP) of the NANDA-I taxonomy was used as a base.
In the articles selected for this review, the nursing diagnoses found mostly dealt with the control of symptoms in oncologic palliative care, so as the study supports the elaboration of the creation of a diagnosis of syndrome, real diagnoses for signs and symptoms were selected. Table 1 presents the selected studies for this integrative review and its characterization.
According to the NANDA-I taxonomy 32 nursing diagnoses were found, demonstrating the variability and multiplicity of nursing diagnoses identified by nurses during the control of signs and symptoms in palliative care. Table 1 presents the nursing diagnoses found according to NANDA-I.
According to the NANDA-I taxonomy, the most commonly found nursing diagnosis was "Chronic pain", cited in 6 studies and in another 1 study that addressed "Acute pain" and "Chronic pain" simultaneously, "Suffering spiritual "quoted in 4 articles.
DISCUSSION
The limits found to reach the proposed objectives were the reduced numbers of studies that addressed the nursing diagnoses related to palliative care, a difficulty also found in one of the studies found, (8) unlike when the descriptor "Nursing diagnoses" was replaced by "Signs and symptoms" for the search of problems in oncological palliative care identified by nurses, which may indicate little use of languages standardized by nurses in palliative care.
Pain was the most frequent symptom, however, it is observed that pain can trigger signs and symptoms such as dyspnea, anxiety, delirium, constipation among others.22,23
A study evaluating the impact of concurrent pain symptoms, neglected in patients who are on cancer palliative care, addressed pain, fatigue, nausea and vomiting, shortness of breath, lack of appetite, dry mouth, sleep problems, delirium and distressed feelings. The most reported symptom was pain (76.5%), followed by distressed feelings (49.8%), sleep problems (34.1%) and delirium (25.1%). The proportion of those neglected was more than a quarter (25.0-63.6%) for all symptoms except pain (12.8%). Significant associations were found between the negligence of shortness of breath and the concurrent delirium (odds ratio [OR] = 110.9); neglect of sleep problems and lack of concurrent appetite (OR = 9.1); and the sight of distressed feelings and competing dry mouth (OR = 27.7).24
The presence of simultaneous symptoms is likely to lead to negligence in the evaluation and control of some concurrent symptoms present in cancer patients. Therefore, comprehensive symptom assessments are required in daily clinical practice.11,24
Feelings of distress are commonly found in patients on cancer palliative care, among these feelings can be listed the nursing diagnoses found in this study: Anxiety, Anxiety related to death, Fear, Chronic sadness, Spiritual suffering, Grief, Hopelessness and Feeling of impotence. The feelings of distress cause discomfort and are present throughout the course of the terminal illness, and arise simultaneously with other clinical indicators, such as pain.25
Several are the difficulties to approach and to carry out the handling of each feeling, because it deals with a line of knowledge besides the technical knowledge pertinent to the profession of each member of the team. These symptoms interfere in the acceptability of adherence to treatment, and consequently in the management of other symptoms in the end-of-life phase.26
In a study of clinical validation of the nursing diagnosis "Spiritual Suffering", the defining characteristic "Suffering Expressed" presented the highest value of sensitivity and "Lack of meaning in life" presented the highest value of specificity, therefore it was concluded that patients with cancer are in a state of suffering related to the lack of meaning in life.21
Since the review allowed the identification of several nursing diagnoses individually for the care of individuals in oncologic palliative care, demonstrating the need for a nursing diagnosis that approaches syndromic form the signs and symptoms that they can present, optimizing and offering comfort to those patients.
The diagnosis of syndromic nursing comes with the proposal to comprehend and intervene fully in the physical, social, psychological and spiritual signs and symptoms that originate several nursing diagnoses. The syndromic approach will allow nurses to perform effectively and effectively.
According to NANDA-I the diagnoses of syndrome are explained by the clinical judgment of problems that occur simultaneously and that are better treated when together by similar interventions.7
Therefore, we propose a diagnosis of syndrome with the title: Symptomatic deterioration syndrome, according to the literature it should address physical, psychological, social and spiritual symptoms. There may be title changes after the diagnostic validation steps. The definition of the diagnosis was defined as: "Dynamic state of disequilibrium in disease aggravation that affects the state of physical, psychological, social, and spiritual health of the individual and leads to increased susceptibility to one or more set of symptoms." The defining characteristics according to the review and the clinical experience of the nurses were: Chronic pain (00133), Impaired sleep pattern (00198), Nausea (00134), Unbalanced nutrition: less than bodily needs (00002), Anxiety (00013), Diarrhea (00013), Fatigue (00013), Inadequate respiratory pattern (00032), Impaired comfort (00214), Spiritual distress (00066), Ineffective thermoregulation (00008), Constipation urine (00023), Weigh (00136). The related factors, which are the etiological and contributing factors for the presence of the diagnosis, are: Palliative care, End of life care, chronic diseases in advanced stage and Chronic physical incapacity.
After this review, it is suggested to support the diagnostic proposal to carry out a concept analysis for the nursing diagnosis of Symptomatic deterioration in palliative care, as well as clinical validation.
CONCLUSION
The field of palliative care oncology is an assistance scenario that is under construction, nursing has been providing important care to this population. Through standardization of language the nursing professional must have a perspicacious clinical reasoning to identify the high complexity human responses that this individual can demand generating several nursing diagnoses. We consider that there is a difficulty to elucidate and characterize them, due to the scarcity of an integral approach to the symptoms that the patient in oncologic palliative care can present in end-of-life care. Due to the multiplicity and variability of the nursing diagnoses, it is necessary to construct a nursing diagnosis of the syndrome in order to improve the clinical and diagnostic reasoning of nurses in palliative care, as it will allow simultaneous interventions for the best care of the individual. Directing the systematized planning of nursing, which enables a clear communication with the multidisciplinary team during the care provided. And automatically provides the minimization of the suffering of this patient bringing comfort.
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Received: October 08, 2018; Accepted: January 21, 2019