Introduction

Nursing continues to seek consolidation and professional appreciation in an attempt to prevent its role from being subordinated to other professional categories, and for that, strives for nursing care to be performed in a methodological, organized and reflective manner, aiming at to solidify nurses as care managers.¹ In this context, the Nursing Process (NP) stands out as an efficient method to guide the practice of nurses in a systematic way.²

In Brazil, Resolution n. 358/2009 of the Federal Nursing Council (COFEN) determines that systematized care should be performed in all places where nursing practice takes place, public or private, and mentions the five stages that make up the NP, namely: assessment or nursing history; nursing diagnosis; care planning; implementation of nursing care; and evaluation.³

The first stage is the assessment of the nursing history. This is the moment when the information of the patient, the family and the place in which the individual lives is investigated so that the client’s profile can be traced. In the second stage occurs the identification and labeling of nursing diagnoses, through careful analysis of the information collected. The third stage includes the planning of nursing care to be provided focusing on obtaining the expected results that will be discussed with the patient and family in order to repair and/or attenuate health problems.²

The implementation of nursing care happens in the fourth stage of the NP, in which the previously established actions, therefore prescribed, are practiced. Finally, the fifth and last step of the NP consists of evaluation. At this stage, consideration will be given to interventions to the patient and records will be made regarding the response to the prescribed care plan.²

Nursing care provided according to the NP requires scientific basis and its use provides the nurse with means for care management, professional recognition and nursing knowledge/identity.^1,4-5

The prescription of nursing care is the nurse`s private role.³ However, it is important that the nursing team is engaged in this process, since the execution of care actions prescribed by the nurse is the task of the entire nursing team.⁶

The Intensive Care Unit (ICU) is designed to care for critically ill patients who require complex, specialized and uninterrupted care. Thus, the healthcare team working in this sector must have technical and scientific knowledge.⁷ To know the particularities and specificities of ICU patients, as well as their care needs, contribute to direct care planning and make nursing prescriptions appropriate to the needs of critically ill patients.⁶ This way, the following questions were asked: What are the nursing interventions prescribed for critically ill patients? Thus, the objective of the study was to identify the nursing interventions prescribed for adult patients admitted to the intensive care unit.

Method

This is a cross-sectional, documentary, quantitative cross-mapping study. The research was conducted in the ICU for adult patients of a public teaching hospital located in western Paraná, Brazil. This institution is a general hospital and had 215 beds exclusive to the demand of the Unified Health System (SUS). In turn, the ICU had 14 beds and the nursing staff was composed by a coordinating nurse, five nurses and 21 nursing technicians. The unit also had a permanent team of intensive care physicians and physiotherapists and specialized speech, nutrition and dental services.

It is important to highlight that this unit had a computerized system to store the nursing diagnoses (ND) and the nursing actions prescribed by nurses. NDs were documented according to the North American Nursing Diagnosis Association International (NANDA-I), whereas the nursing activities prescribed by nurses were freely recorded without following any standardized nursing classification.

The research was developed in three stages. In the first stage, it was verified the interest of nurses who made prescriptions in being part of the study by signing the Informed Consent Form (ICF). In the second stage, we selected the medical records that met the eligibility criteria in the study (to be a patient aged 18 years or older, having a nursing prescription record performed during ICU admission and having a consent form signed by the ICU prescribing nurse). Finally, in the third stage, data collection was performed for 30 consecutive days between June and July 2015.

In the data collection, a list of patients admitted to the ICU under study was consulted daily in the established time. If a new hospitalization was identified, the data of interest of the patient`s medical record were extracted. For this, the researchers elaborated a spreadsheet that was printed to perform the manual collection of nursing activities prescribed by nurses, and later cross-mapping with the Nursing Interventions Classification (NIC).⁸

NIC is a classification that standardizes nursing interventions and lists a range of profession-specific activities, whether independent or interdependent, covering all nursing specialties, and can be used in a wide range of fields (primary, tertiary, home, school, among others.). It is structured in three levels, consisting of seven domains, 30 classes and 554 interventions, totaling around 13,000 standardized nursing activities.⁸ Each classified nursing intervention has a concept, a list of possible activities to be performed and the bibliographies of reference. This way, NIC offers theoretical support for decision making by either experienced nurses and students or nurses beginning their professional careers.

Data manually extracted from the prescribed nursing activities were transferred to Microsoft Office Excel^® 2013 software and then submitted to descriptive statistical analysis using the Statistical Package for the Social Sciences (SPSS), version 20. Data analysis was performed by means of descriptive statistics, in percentage proportion, and by the interquartile range, being considered as the most frequent activities, which presented distribution from the quartile 75%.

The research was conducted according to the norms of Resolution n. 466/2012 of the National Health Council, receiving a favorable opinion from the Institutionalized Research Ethics Committee (CEP) through opinion n. 1,025,731/2015.

Results

A total of 32 medical records were evaluated in the established time frame. Of these, 29 met the inclusion criteria of the study. We identified 725 nursing activities prescribed at the time of admission of the critically ill patient, which were mapped according to the NIC classification.

Most of the medical records (n=16; 55.18%) were of male patients. The average age of hospitalized patients was 51.27 years, ranging from 18 to 75 years, with the largest portion of hospitalized individuals (n=12; 41.37%) being over 60 years old.

The 725 prescribed nursing interventions were mapped according to the seven domains, 30 classes and 554 NIC-classified nursing interventions. Table 1 shows the distribution of prescribed interventions according to the interventions of that classification.

Table 1 – Distribution of nursing activities prescribed on ICU admission, mapped according to NIC nursing interventions. Cascavel, 2015

Prescribed Nursing Interventions	n	%
Skin care: topical treatment	113	15.59
Pressure management	85	11.73
Monitoring	72	9.93
Infection control	63	8.69
Bleeding Precautions	47	6.49
Tubes and drain care	45	6.20
Neurologic management	32	4.41
Positioning	32	4.41
Fever treatment	29	4.00
Hypothermia treatment	29	4.00
Oral Health Maintenance	28	3.86
Airway suctioning	28	3.86
Eye care	27	3.73
Intravenous maintenance	25	3.45
Bath	24	3.31
Hair care	24	3.31
Enteral tube feeding	16	2.20
Incision site care	6	0.83
Total	725	100

According to interquartile range, nursing interventions with absolute frequency equal to or greater than 51 were considered the most frequent interventions because they were contained in the 75% quartile, as follows: “Skin Care: topical treatments” (n=113; 15,59%), “pressure Management” (n=85; 11.73%), “Monitoring” (n=72; 9.93%) and “Infection Control” (n=63; 8.69%).

Table 2 shows the distribution of nursing interventions prescribed according to the NIC classification.

Table 2 –Distribution of nursing interventions prescribed at the time of admission of critically ill ICU patients, mapped according to NIC classification. Cascavel, 2015.

Classes of Nursing Intervention Classification	n	%
Skin/Wound Management	204	28.15
Self-Care Facilitation	148	20.42
Risk Management	135	18.62
Tissue Perfusion Management	72	9.93
Thermoregulation	58	8.00
Neurological Management	32	4.41
Immobility Management	32	4.41
Respiratory Management	28	3.86
Nutritional Support	16	2.20
Total	725	100

The results of Table 2 show that of the 30 classes in the NIC classification, nine were used by nurses when prescribing nursing care at the time of ICU admission. According to the interquartile range, the classes with absolute frequency equal to or greater than 141 were considered the most frequent classes because they were in the 75% quartile, as follows: “Skin/Wound Management” (n=204; 28.15%) and “Self-Care Facilitation” (n=148; 20.42%).

Finally, Table 3 illustrates the nursing interventions prescribed according to the domains of the NIC classification.

Table 3 – Distribution of nursing interventions prescribed at the time of admission of critically ill ICU patients, mapped according to the NIC classification domains. Cascavel, 2015.

Domains of Nursing Intervention Classification	n	%
Complex Physiological	394	54.34
Basic Physiological	196	27.03
Sefaty	135	18.62
Behavioral	-	-
Family	-	-
Health System	-	-
Community	-	-
Total	725	100

From the results of Table 3, it is possible to see that the nursing interventions prescribed for critically ill patients were comprised in three of the seven domains in the NIC classification. According to the interquartile range, the domains with absolute frequency equal to or greater than 196 were considered the most frequent domains because they were contained in the 75% quartile, namely: “Complex Physiological” domain (n=394; 54.34%) and “Basic Physiological” (n=196; 27.03%).

Discussion

According to the findings, of the 554 possibilities for nursing interventions classified in the NIC,⁸ 18 were prescribed to critically ill patients at the time of ICU admission. The interventions “Skin Care: Topical Treatments” (n=113; 15.59%), “Pressure Management” (n=85; 11.73%), “Monitoring” (n=72; 9.93%) and “Infection Control” (n=63; 8.69%) were the most frequently prescribed interventions (Table 1).

Looking at the results, it can be seen that in general, the “Skin Care: Topical Treatments” and the “Pressure Management” were highlighted. This fact can be attributed to the mobility deficit that critically ill patients have due to their clinical severity and/or factors that hinder their body movement. The patients in intensive care are bedbound, with limitation or difficulty in moving in bed, which requires greater care to maintain skin integrity.⁹

It is highlighted that the intervention “Management” is nonetheless a “skin care”, as it relates to tissue perfusion, that is, the prevention and/or treatment of skin lesions. Thus, based on the high numbers of pressure injuries in patients in need of intensive care, nursing, together with the multidisciplinary team, must plan and execute their actions in order to prevent skin lesions.⁹

“Monitoring” intervention was also often prescribed. According to the NIC, this intervention is defined as: continuous acquisition, interpretation and synthesis, with the purpose of obtaining patient data to support the nurse’s clinical decision making.⁸ This intervention encompasses a series of care related to general monitoring of critical patient, who requires permanent supervision. Therefore, it is interpreted that this is not a specific intervention, but may increase the safety of critically ill patients by the close supervision of the nursing staff to their general health and evolution.

Care such as capillary blood glucose control is included in the “Monitoring” intervention, since a critically ill patient may have elevation in glycemic levels, even if not diabetic.¹⁰ Another relevant care that is inserted in the “Monitoring” intervention is the control of the breathing pattern. Most ICU patients are on mechanical ventilation (MV), and in these cases the observation of the breathing pattern is extremely important, as it includes the evaluation of signs and symptoms of possible pulmonary infection, use of accessory muscles, pulmonary auscultation evaluation, saturation level control, among others.¹¹

Infection Control also emerges as a frequently prescribed nursing intervention. Given the high number of invasive procedures performed during ICU stay, care to prevent the diagnosis of risk of infection from becoming a real diagnosis becomes essential.¹² Therefore, it is necessary that the health team recognize the factors that trigger Healthcare-Associated Infections (HAI), as well as appropriate preventive measures, according to the best evidence.¹³

As shown in Table 2, the nursing interventions prescribed for the study patients were included in nine of the 30 NIC⁸ classification classes, the most frequent being: “Skin/Wound Management” (n=204; 28.15%) and “Self-Care Facilitation” (n=148; 20.42%).

The findings of this study were similar to those obtained in a research conducted in a private ICU of the State of Minas Gerais (Brazil), which identified among the most frequent classes the “Skin / Wound Control”, the “Self-Care Facilitation” and the “Risk Management”¹⁴. The high frequency of such classes may be justified by the particularities of critically ill patients, as they are individuals with high care dependency, in need of basic and intensive care aimed at the recovery of their health, and that due to their vulnerability, are subject to various risk situations.^15-16

The “Skin/Wound Management” class covers the two most commonly prescribed nursing interventions: “Skin Care: Topical Treatments” and “Pressure Management”; the “Risk Management” class encompasses the other two most frequent interventions: “Monitoring” and “Infection Control”; The class “Self-Care Facilitation” includes several prescribed interventions related to the patient’s body hygiene: “Oral Health Maintenance”, “Eye Care”, “Bath” and “Hair Care”.

Body hygiene is essential to prevent other health problems, as it removes dead cells and decreases the patient’s resident and transient microbiota.¹⁷ Thus, it should be noted the low proportion of prescribed interventions regarding: bathing , eye care, and hair care, which, although possibly are routine care, need prescription by the nurse in order to reinforce its relevance.

Although not contained in the 75% quartile, prescribing activities in the “Risk Control” class shows the relevance of care that promotes patient safety. The institutions’ attention on this subject happens worldwide since patient care is provided by human beings who, in turn, are subjected to errors.¹⁸ Due to its strategic position in care management, nurses are a common actor required to implement and monitor patient safety actions.¹⁹

As shown in Table 3, the nursing activities prescribed for critically ill patients in the hospital under study were included in three of the seven domains of the NIC classification, the most frequent being: “Complex Physiological” (n=394; 54.34%) and “Basic Physiological” (n=196; 27.03%).

The results of the present study corroborate previous findings, also in the Brazilian context, in which the largest number of activities prescribed for critically ill patients were contained in the domains “Complex Physiological”, “Basic Physiological” and “Safety” .¹⁸ The interpretation of such findings enables the understanding that ICU nursing care aims at maintaining the life of the seriously ill patient.

It is important to highlight that the critically ill patient presents a deficit in self-care, justifying the high frequency of prescribing activities contained in the “Basic Physiological” domain.⁸ The core of nursing is human care, which, in its profession bases, consists of the evidence that proper body and environmental hygiene assists in restoring health.²⁰

Although prescribing nursing actions in other domains of the NIC classification are commonly less frequent, it is believed that they have adequate applicability to critically ill patients, since they have a “family”, are inserted in a certain “community” and are part of a “health system”.

The low number of prescriptions contained in the psychosocial focus domains may be related to inadequate working conditions, as it is common to find care units with excessive number of patients, reduced staff, high workload routines and excessive workload.²¹ In this context, nurses may end up prioritizing prescriptions for biological care. However, not valuing nursing care that goes beyond curative actions can weaken the rise of the profession, and possibly contribute to the maintenance of the biomedical care model.

Conclusion

It was concluded that the most frequent nursing interventions for the critically ill patient were focused on the maintenance of life, through actions that involve the physiological control. Still, safety actions also emerged through a concentrated nursing intervention.

The study points out that, due to the clinical instability of critically ill patients, intensive care nurses possibly prioritize prescribing care aimed at meeting physiological dysfunctions over care that meets behavioral, family, psychosocial and spiritual needs. Another point to highlight is the low proportion of interventions related to body care.

The small sample and the impossibility of inferring the results for other realities are expressed limitations to the research. However, it is believed that the study contributes to the systematized practice of nursing, in particular by disclosing the use of international classification in the context of intensive care, which strengthens the work of nursing care management in ICU and also, in line with the consolidation of nursing as a science.

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Autor correspondente

Fabiana Matos

E-mail: fabianamatos@hotmail.com

Endereço: Rua Monjoleiro, nº: 125, Tropical, Cascavel-PR

CEP: 85807-300

Authors Contribuitions

1 – Kalliny Nathiara de Oliveira Stralhoti

Substancial contribuitions in conception and designing of the work just like in collection, analysis and interpretation of datas. Participation in writing of the article and in its critical revision. As well as for approval of the final version of the article for publication.

2 – Fabiana Gonçalves de Oliveira Azevedo Matos

3 – Débora Cristina Ignácio Alves

Participation in writing of the article and in its critical revision. As well as for approval of the final version of the article for publication.

4 – João Lucas Campos de Oliveira

Participation in writing of the article and in its critical revision. As well as for approval of the final version of the article for publication.

5 - Djulia Camila Berwanger

Participation in writing of the article and in its critical revision. As well as for approval of the final version of the article for publication.

6 - Drieli Wawzeniak de Anchieta

Participation in writing of the article and in its critical revision. As well as for approval of the final version of the article for publication.

Como citar este artigo

Stralhoti KNO, Matos FGOA, Alves DCI, Oliveira JLC, Berwanger DCI, Anchieta DW. Nursing interventions prescribed for adult patients admitted to intensive care unit. Rev. Enferm. UFSM. 2019 [Acess at: Year Month Day];vol e23: P1-P16. DOI:https://doi.org/10.5902/2179769233373