Validation of Anxiety by Brazilian Nurses

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PURPOSE. To examine the prevalence of nursing diag-noses among hospitalized patients with congestive heartfailure (CHF).METHODS. Patients in the cardiology unit with a diag-nosis of CHF types IIV (N = 26) were surveyed using aninvestigator-developed data collection tool to determinethe nursing diagnoses common to this patient population.FINDINGS. Activity intolerance was present in 100% ofpatients regardless of severity of CHF. Fluid volume excessInternational Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 1was present in 79% of patients with types I and II, and in92% with types II and IV. Sleep pattern disturbance oc-curred in 80% with types I and II, and in 90% with typesII and IV.CONCLUSIONS. CHF is considered a syndrome hav-ing several signs and symptoms, which evidences theneed for language standardization and systematic nurs-ing assistance.Author contact [Assis]: enfcinthia@bol.com.brPresented Papers: Nursing DiagnosisNursing Diagnoses in Patients With Congestive Heart Failure Cinthia Calsinski de Assis and Alba Botura Leite de BarrosPURPOSE. To explore and identify diagnostic compo-nents to amplify NANDA nursing diagnoses by modi-fying the root violence. Whereas violence is nondebat-able as a diagnostic concept in nursing, otheralternatives have not been identified in the two existingdiagnoses.METHODS. Using the case study method, this qualita-tive study sought to identify commonalties in a popula-tion of women who were donnas da casa (homemak-ers) in a small rural community of approximately 100families, typical of the Brazilian northeast. The sample of7 women was identified through a larger study that hadbeen based on health needs of the community. Data wereobtained through observation during a home visit and asemistructured interview based on NANDA TaxonomyII. Observations were focused on hygiene, manner ofdress, home environment, and physical and emotionalstate. Data were analyzed by content and clustered intomajor categories. From these a profile of the women andanother of the partners emerged.FINDINGS. Subjects ranged in age from 33 to 43 years,and number of children between 3 and 7. One of the 7women was literate; 5 were underweight; all wereslovenly attired. They appeared sad and older than theirage. The majority seemed relieved to unburden them-selves to the interviewers as they went through a gamutof emotions such as sadness, anguish, and irritability ex-pressed through crying, restlessness, changes in bodylanguage, and tone of voice. The shortage of beds wassupplemented by hammocks and mats or cardboard.The women spoke of being confined to their home andof male partners who drank on weekends, thus leavingthem with little money for necessities of life. There wereaccounts of beatings when the partner returned homeafter drinking, overt nonacceptance of children from pre-vious marriages, and general destruction of the familyenvironment. New children were regarded as just an-other mouth to feed.DISCUSSION. The profiles pointed to the necessity ofidentifying a new nursing diagnosis that would belinked, only tangentially, by the root violence to the twodiagnoses in NANDA Taxonomies I and II. This insightled us to consider that a new method of listingNANDA diagnoses, by root only, is imperative in theevolution of Taxonomy II. Proposed descriptors, Vic-tims of (Axis 3) and Domestic (Axis 6) would be identi-fied by Axes, thereby facilitating the process of classify-ing in the Domains and Classes. The two existingNANDA diagnoses, risk for other-directed violence andrisk for self-directed violence, are proposed for classifica-tion in Class 3, Violence, in Domain 11 of Taxonomy II.Safety/Protection could, by virtue of their modificationpower, find anchor in another domain such as Domain6, Self-Perception.CONCLUSIONS. Although Safety/Protection seemsthe most logical domain for classification by root, theaxes, dimensions of human responses, could pull the di-agnosis in another direction, thereby dictating othernursing interventions and nursing outcomesAuthor contact [Coler]: coler@funape.ufpb.brVictims of Domestic Violence: A Proposal for a Community Diagnosis Based on One of Two Domains of NANDA Taxonomy IIPatricia Serpa de Souza Batista, Fernanda Maria Chianca da Silva, Estella Maria Leite Meirelles Monteiro, and Marga Simon ColerFatigued Elderly Patients With Chronic Heart FailureAnna Ehrenberg and Inger EkmanPURPOSE. To compare descriptions of fatigue basedon the NANDA characteristics from interviews with el-derly people with congestive heart failure (CHF) anddata recorded by nurses at a Swedish outpatient heartfailure clinic. METHODS. Patients were screened for moderate to se-vere CHF. A total of 158 patients were interviewed usinga revised form of the Fatigue Interview Schedule (FIS)based on the NANDA characteristics. Of these patients,half (n = 79) were offered visits at a nurse-monitoredheart failure clinic. Nursing documentation of fatigue atthe heart failure clinic was reviewed based on theNANDA characteristics and compared with the contentin the patient interviews.FINDINGS. Tiredness was documented in 43 (75%)records and indicated in 36 patients based on patientscores on the FIS (X = 5.5; range 1 9). The most fre-quently recorded observation related to fatigue was thesymptom emotionally labile or irritable, followed bynotes on lack of energy and decreased performance. Pa-tients descriptions of their fatigue were expressed as adecreased ability to perform and a perceived need forPresented Papers: Nursing DiagnosisNursing Diagnosis Extension and Classification: Ongoing PhaseMartha Craft-Rosenberg and Saovaluck JirathummakoonBACKGROUND. The Nursing Diagnosis Extensionand Classification Project (NDEC) has been active for al-most a decade. The team began with the formation of ateam of investigators at The University of Iowa Collegeof Nursing. From 1994 until 2000 the research team con-sisted of 16 investigators who were experts in nursingcare across the lifespan. They also represented expertisein both qualitative and quantitative research. The aims ofthe NDEC research are to evaluate and revise NANDAdiagnoses, to validate the diagnoses using a clinical in-formation system, and to develop candidate diagnoses. MAIN CONTENT POINTS. Phase 1 of the NDEC re-search has yielded 116 refined and developed nursing di-agnoses that have been submitted to NANDA. Of these,65 have been approved and 54 appeared in Nursing Di-agnoses: Definitions and Classification, 19992000 alongwith 39 NDEC products. In the 20002001 edition, 7 di-agnoses refined by NDEC and 7 new diagnoses submit-ted by NDEC are included.As only about half the NDEC products have appearedin NANDA publications, the three-level review process (Di-agnosis Review Committee, membership, and Board) hasbeen discussed with the NANDA board. This request iscurrently being honored by the Diagnosis Review Commit-tee; however, review by the membership and review by theNANDA board is just beginning to move in this direction.Phase 2, clinical validation of the NDEC work, isbeing conducted at a long-term care facility. It will alsobe conducted at a large teaching hospital. All the NDECrefinement and development work has been submittedfor clinical validation. Currently validation is planned atthe label level only. Phase 3 involves identification of candidate diag-noses. Many of the candidate diagnoses were developedduring the concept analysis phase, when NDEC teammembers identified the need for additional diagnoses.Nurses in practice have submitted other candidate diag-noses. In total 195 candidate diagnoses have been identi-fied and placed into a database. In order for the NDEC team to make decisions regard-ing priorities for diagnosis development, the diagnosesin the candidate database are compared to diagnoses inother classifications that have already been developed.Several classifications are used for comparison includingthe Omaha System and the Home Health Care Classifi-cation. A large table is used to compare candidate labelto other labels. Candidate diagnosis included in otherclassifications will be given lower priority for develop-ment by NDEC. CONCLUSIONS. The NDEC work plan includes workon diagnoses to be resubmitted to the NANDA Diagno-sis Review Committee. It is hoped that the Web site forNLINKS will facilitate the work of diagnosis refinementand development. NDEC will continue to work with anyinvestigator who is seeking assistance. The last part ofthe work plan is resource acquisition and recruitment ofinvestigators to continue the refinement and develop-ment of diagnoses.Author contact [Craft-Rosenberg]:Martha-craft-rosenberg@uiowa.edu2 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003Presented Papers: Nursing Diagnosisadditional energy. Results indicated poor concordance inpatients descriptions and record content concerning fa-tigue. Whereas patients emphasized the physical charac-teristics of fatigue, nurses emphasised the emotional fea-tures. Decreased libido was linked to fatigue accordingto the patients but not according to the nurses records.Whereas cognitive characteristics of fatigue occurredrarely in the records, they were more frequent in the pa-tient interviews. DISCUSSION. Symptoms such as irritability and acci-dent-proneness may be seen as manifestations of the pa-tients experiencing the need for more energy or a feelingof decreased performance. These consequences of beingfatigued, rather than the different dimensions of fatigue,International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 3seemed to have been easy for the nurses to observe anddocument. Earlier studies indicate that poor observation,medication, and diet in patients with heart failure mightpartly be explained by cognitive impairment. CONCLUSIONS. Findings of this study highlight theneed for nurses to pay attention to the experience of fa-tigue in patients who suffer from CHF, and to validatetheir observations with the patients own expressions.Using the patients words and expressions and the diag-nostic characteristics of fatigue in recording can supportthe nurses in developing both understanding of patientsliving with CHF and strategies to help patients copewith their restricted ability in daily life. Author contact [Ehrenberg]: aeh@du.seEnvironmental Nursing Diagnoses: A Proposal for Further Development of Taxonomy IIPauline M. Green, Laura V. Polk, and Diann S. SladeBACKGROUND. The authors proposed a need for Tax-onomy II to include more environmental nursing diag-noses at the 14th Biennial Conference on Nursing Diag-nosis. Currently, Nursing Diagnoses: Definitions andClassification, 20012001 (NANDA, 2001) lists three diag-noses that focus on the environment: impaired environ-mental interpretation syndrome, risk for poisoning, andlatex allergy response. As communities, nations, and ge-ographic regions experience environmental health prob-lems on individual, local, national, and global levels,nurses need to take an active role in assessing, diagnos-ing, and treating clients who experience environmentalhealth effects of pollution, contamination, and poisoning.It is logical, therefore, to now examine the concept of en-vironment and its linkages with health in order to pro-vide a blueprint for further development of environmen-tal nursing diagnoses and expansion of Taxonomy II. MAIN CONTENT POINTS. Nursing theory has givenformal recognition to the importance of the relationshipbetween humans and the environment. The concept ofenvironment has become a well-known component ofthe nursing metaparadigm (Human, Health, Nursing,and Environment), and all the major theorists include anenvironmental component in their conceptual models.However, while nursing literature has formally acknowl-edged that human-environment interaction has an effecton health, theorists have failed to delineate the humanresponses that derive from this interaction. Other disci-plines such as biology and toxicology consider environ-ment as a set of compartmentsair, soil, water, biologi-cal systems and examine the effects that pollutantsexert on these compartments. Similarly, public healthviews environment as discrete compartments but, in ad-dition, examines the effects pollutants have on individu-als, groups, and society. Sociology has expanded its useof the term environment and now recognizes the com-plex interaction of the natural and social worlds. Anthro-pology also views environment as an emerging area ofstudy that explores how human behavior changes in re-sponse to interaction within the ecosystem. The authors again propose that NANDA expand thenumber of environmental nursing diagnoses containedin Taxonomy II and offer the following for considerationand comment. Four major headings will help classify thenursing diagnoses: (a) Individual (specify child or adult),(b) Family, (c) Community/Groups/Aggregates, and (d)Global. Under Individual diagnoses, we propose Ac-tual/Risk for Poisoning (specify type); Actual/Risk forPesticide Contamination (specify type: pesticide, house-hold, industrial); Actual/Risk for Adverse ReproductiveCapacity (specify male or female; causative agent [ethy-lene oxide, antineoplastic drugs, ionizing radiation]; Ac-tual/Risk for Pollution (specify type: air, water, soil, orbiological systems). Under Family diagnoses, we pro-pose Actual/Risk for Solid Waste Contamination (spec-ify type: trash, raw sewage); Actual/Risk for Indoor Pol-lution (specify type: tobacco, radon, pesticides, noise,lead, water); Actual/Risk for Outdoor Pollution (specifytype: aerosol or applied pesticides, noise, exhaust fumes).Diagnoses listed under individual are also applicable tothe family system. Under Community/Groups and Ag-gregates, we propose Actual/Risk for Community-WidePresented Papers: Nursing DiagnosisInfection (specify type: community-wide, specific groupor aggregate; specify type of infection and infectionsource: food borne, vector borne, zoonosis borne); Ac-tual/Risk for Workplace Environmental Exposure/Con-tamination (specify type of chemical or biological agent).Under Global, we propose Actual/Risk for Transbound-ary Environmental Exposure/Contamination (specifytype: solid waste, trash, sewage, acid rain, nuclear waste;specify originating and receiving countries); Actual/Riskfor Global Spread of Infection (specify type of infection:TB, hepatitis, Ebola virus).4 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003Clinical Validation in Spain of Dysfunctional Ventilatory Weaning Response Ana M. Gimnez and Pilar Serrano GallardoCONCLUSIONS. As nursing develops a greater appre-ciation for the health burden of environmental exposures,the profession can look to NANDA to offer leadership inthe area of environmental health nursing diagnosis re-search. The development of a schema containing specificenvironmental nursing diagnoses will provide a strongfoundation for achieving improved health outcomes.Author contact [Green]: pgreen@howard.edu Editors note: Full text of this presentation was published inIJNTC, 2003, Vol. 14, No. 1, pp. 1929.PURPOSE. To validate clinically the diagnosis of dys-functional ventilatory weaning response (DVWR) in order todetermine the incidence and identify the defining char-acteristics and related factors.METHODS. A descriptive, longitudinal, prospectivestudy was carried out over 2 years using a nonprobabil-ity quota sample of 80 patients from 3 different univer-sity hospitals in Spain divided into two groups: Group A(patients with 24 72 hours of mechanical ventilation)and Group B (patients with >72 hours of mechanicalventilation). Observation, interview, physical examina-tion, and chart review were used for data collection. Re-searchers designed an instrument to collect patient as-sessments. It was validated through a pilot study andincluded all the variables thought to be related with thephenomenon. A maximum of 10 observations per pa-tient was made in a period of 5 days. Each observationtook place in a framed time. At least two defining char-acteristics and a related factor had to be documented forthe investigators to determine the existence of DVWR. FINDINGS. The mean weaning time was 1.7 days (SD= 1.5). Based on research nurses judgment, 70% (n = 57)of patients had DVWR. There was no difference in the in-cidence of DVWR between patients from Groups A andB. The 80 patients provided a total of 267 observations.DVWR occurred in 146 (55%) observations based on re-searchers judgment, whereas DVWR was diagnosed in48 observations (25%) based on clinical nurses judgment. DVWR at time 1 was indicated by indicators and factorsin boldface were presented in more than one time shallowbreathing, gasping breaths, adventitious breath sounds, de-terioration in blood gases, increase in respiratory rate, bloodpressure increase, heart rate increase, slight accessory respi-ratory muscles, apprehension, diaphoresis, inability to co-operate, hypervigilance, and fatigue. Related factors in-cluded a history of ventilatory dependence greater than 1week, ineffective airway clearance, lack of trust in nurse,adverse environment, and anxiety. DVWR at time 2 wascharacterized by sleep pattern disturbance, pain, and hav-ing had previous DVWR were related factors. DVWR attime 3 included breathing discomfort, increase need foroxygen, agitation, and feeling warm. Related factors wereperception of futility regarding own ability to be weaned.Indicators and factors in boldface were presented in morethan one time. Adventitious breath sounds (OR = 9.2), ad-verse environment (OR = 21.9), and anxiety (OR = 43.12)were the variables resulting from logistic regression model. DISCUSSION. Nurses do not recognize DVWR as fre-quently as researchers, who are very familiar with theweaning process but have not been trained to make anursing diagnosis. It seems nurses associated the dysfunc-tional response only with the most severe manifestations.DVWR has a high incidence among patients who undergoa weaning process, regardless of the final outcome. Historyof ventilatory dependence >1 week has a protective effectagainst DVWR on day 1 of weaning. At time 1, the diver-sity of characteristics of DVWR was very broad, includingsevere manifestations. Although the risk of a new episodedoes not decrease, the severity appears to be milder in sub-sequent presentations. The nursing treatment received bythe patient during the first episode of DVWR might havean influence on the response in the following attempts be-cause most patients had only one episode. The increase inrespiratory rate, heart rate, and systolic blood pressure wasassociated with DVWR at all three observation times. Thismay be related to the fact that all the mentioned variableswere used as operational indicators of anxiety and thiswas the single related factor presented all the time. Adven-Presented Papers: Nursing DiagnosisPURPOSE. To explore the concept of discomfort andclearly identify this phenomenon; to compare and con-trast this concept with the accepted concepts of acutepain and chronic pain; and to develop a diagnosticallyuseful definition, including defining characteristics andrelated factors. METHODS. A wide range of published literature wasreviewed as were definitions for pain, discomfort, andcomfort from both English and medical dictionaries. Textson nursing classification language were scanned for inter-vention and outcome labels or definitions that suggest theconcept of discomfort. Audiotaped interviews with ex-pert clinicians were conducted to explore the presentationof pain and discomfort in the clinical realm using asemistructured format. Finally, Morses modified ap-proach to concept analysis using qualitative methodologywas used to perform an analysis of the diagnosis, usingthe literature review, interviews, and case studies as data.FINDINGS. The literature fell into four categories: (a)common definitions and related terms, (b) works sugges-tive of the concept of discomfort, (c) studies differentiat-ing pain and discomfort, and (d) studies equating painand discomfort or ambiguity in the use of terms. A lackof conceptual clarity was identified. The definitions of-fered were not congruent, referring to the selected termsin varying manners, including as states, actions, or ab-sences of the opposite term. Many works appeared to in-terchange the terms pain and discomfort for editorialreasons only, to avoid frequent repetition of a singleterm. Other works treated the terms as distinct withoutproviding a definition for either. Clinicians expressedsupport for the concept of discomfort as a diagnosticconcept separate from pain, and provided insight into thecomplex interrelation of pain/discomfort in the physicalsense, and emotional discomforts such as fear. Additionally,support appeared for the concept of environmental discom-fort, a class in the taxonomy that currently has no accepteddiagnostic concepts. However, clinicians were not able toarticulate clearly the concept of either discomfort or pain,generally discussing them in terms of assessment findings.The concept analysis for the proposed diagnosis discomfortinitially focused on concept delineation, but moved into aformat of concept clarification because of the lack of consen-sus on the clinical manifestations of discomfort. DISCUSSION. The goal of establishing discomfort as anursing diagnosis is to facilitate clinicians ability to iden-tify an anecdotally common phenomenon that requiresnursing interventions and outcome evaluation. The pre-liminary data on this diagnostic concept is insufficient todemonstrate defining characteristics or related factors.Additional study is required. CONCLUSIONS. Data suggest that discomfort may bea phenomenon distinct from either acute pain or chronicpain; there is no clear consensus, however, among clini-cians. The label discomfort may not, in fact, be the mostclinically useful, and a new term may need to be devel-oped. Perhaps the diagnostic concept should be labeledphysical discomfort for clarity, and a new term be devel-oped or explored as the diagnostic label that communi-cates the concept of generalized physical discomfort.Further research must be done to validate the nursing di-agnosis discomfort, regardless of the final label. The ac-ceptance of a nursing diagnosis addressing discomfortwould be beneficial to clinicians, providing guidance forinterventions and supporting the choice of outcomemeasures. It may be possible to develop a research toolto obtain data regarding patient experiences of discom-fort based on the findings of this study, which in turncould lead to an objective assessment tool. Author contact: sclamont@salud.unm.eduInternational Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 5titious breath sounds, adverse environment, and anxietycan be considered predictors of DVWR.CONCLUSIONS. DVWR has a high incidence, although itis not well recognized by clinical nurses. Training nursescould increase the reliability of the diagnosis process in clini-cal practice. DVWR has different manifestations across theweaning process. Anxiety reduction, clearing the airway,and controlling environmental stimuli may prevent DVWR.Author contact [Gimnez]: agimenez@hpth.insalud.esEditors note: Full text of this presentation was published inIJNTC, 2003, Vol. 14, No. 2, pp. 5364.Discomfort as a Potential Nursing Diagnosis: A Concept Analysis and Literature ReviewScott Chisholm LamontPresented Papers: Nursing Diagnosis6 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003PURPOSE. To analyze the association between thedefining characteristics of decreased cardiac output (DCO),identified by noninvasive methods, and the cardiacindex (CI), obtained by thermodilution.METHODS. DCO was defined as cardiac indices 2.5L/min/m2. Univariate statistical tests were applied toanalyze the association between defining characteristicsand DCO. The first phase of the study consisted of a lit-erature search for defining characteristics of DCO, for-mulation of operational definitions for each characteris-tic, and selection of the characteristics to be clinicallystudied. In the second phase, the selected defining char-acteristics were assessed in 49 postoperative heartsurgery patients (X = 63.4 years; 59% female, 72% hadundergone coronary artery bypass graft). On all surgicaldays one of the authors, a critical care nurse, identifiedthe patients who met the inclusion criteria (>18 years;submitted to cardiopulmonary bypass; with pulmonaryartery catheter emplaced for a maximum period of 72hours), assessed them according to the selected definingcharacteristics, measured the CI by thermodilution, as-sessed other parameters depending on the presence of apulmonary artery catheter, and collected informationabout drugs the patient was receiving.FINDINGS. Eighty-seven defining characteristics wereidentified. After a detailed analyses, 42 were selected forstudy. Of these, 10, depending on whether they had apulmonary artery catheter, served either as a dependentvariable (CI) or as a descriptive variable; 32 were the in-dependent variable. Twenty-four patients had DCO and25 did not. The range of cardiac output readings in pa-tients with DCO was 2.03.9 L/min; in patients withoutDCO it was 4.0 8.9 L/min. The correlation coefficientbetween DCO and CI was 0.928 (p80% in patients withDCO: altered central venous pressure, alteredhemoglobin/hematocrit, hyperglycemia, altered cardiacenzymes, decreased peripheral perfusion, and slow in-testinal peristalsis. Five variables had frequencies be-tween 50% and 80%: decreased peripheral pulses, dys-rhythmia, altered chest radiography, blood pressurevariations, and edema. Only two variables were associ-ated with DCO: decreased peripheral pulse (p = 0.00)and decreased peripheral perfusion (p = 0.00) becausethey were more frequent in patients with DCO. Olig-uria/anuria was identified in 1 patient with DCO and in2 without. There was statistical association between olig-uria/anuria and diuretics (p = 0.01). There was no associ-ation between other drugs (vasoactive, sedatives) and se-lected defining characteristics.DISCUSSION. The variables with frequencies >80% inpatients with DCO are typical findings after heart surgery.The results of association tests suggest that decreased pe-ripheral pulses and decreased peripheral perfusion, of allthe independent variables studied, are good indicators ofDCO. However, they also occurred in patients withoutDCO. Although there was no association between olig-uria/anuria and DCO, the use of diuretics masked identifi-cation. Considering that intensive care patients arepromptly treated at the first sign of oliguria, it is difficult touse this variable to diagnose DCO in the clinical context.CONCLUSIONS. Decreased peripheral pulses and de-creased peripheral perfusion must be kept as definingcharacteristics of DCO. A practical application of the re-sults of this study is that the peripheral perfusion is animportant parameter to assess the hemodynamic state ofpostoperative heart surgery patients. The introduction ofever-more sophisticated and potentially more accuratetechnologies that are not always indicated or availableposes the risk of neglecting noninvasive clinical assess-ment techniques. Proper nursing education should in-clude the teaching of noninvasive assessment of patientsand the development of perceptual and cognitive skillsnecessary to make the professional able to obtain and in-terpret, as accurately as possible, the data observed.Author contact [Oliva]: key@maringa.com.brDecreased Cardiac Output: Validation With Postoperative Heart Surgery PatientsAna Paula Vilcinsky Oliva and Din de Almeida Lopes Monteiro da CruzInternational Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 7Presented Papers: Nursing DiagnosisValidation of Anxiety by Brazilian Nurses Neuza Oliveira and Tnia C. M. ChiancaPURPOSE. To validate the nursing diagnosis of anxietyas applied by expert Brazilian nurses and cliniciansusing the NANDA defining characteristics translatedinto Portuguese, and to compare their judgment. METHODS. A descriptive, exploratory, and compara-tive study was conducted using the Diagnostic ContentValidation (DCV) model. A convenience sample of 120nurses familiar with nursing diagnoses answered asemistructured questionnaire that included demographicdata, the definition, and a list of defining characteristicsof anxiety. Three defining characteristics of the nursingdiagnosis fear were added to the list as distractors. Sub-jects were asked to rate each defining characteristic on ascale from 1 (not at all characteristic) to 5 (very character-istic). Descriptive analysis was used to identify the nurseexperts and clinicians. Assigned weights were deter-mined for each characteristic: 1 = 0, 2 = 0.25, 3 = 0.50, 4 =0.75, and 5 = 1. Variance analysis using F statistics tocompare averages and chi-squares for frequency distri-bution were applied. The defining characteristics withweight ratios >.80 were considered critical, those withweight ratios >.50 and 4 days.Data were collected every other day until the patientwas weaned, discharged, or expired. The WRAS is com-prised of two subscales: the physiological/behavioral(PPBB) subscale and ventilatory subscale (VVV). FINDINGS. A content validity index of 0.88 indi-cated that the variables and their scoring ranges wereappropriate for the study population. Interrater andtest-retest reliability measures were 0.93 and 0.92, re-spectively. Internal consistency (Cronbachs alpha,p8 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003Presented Papers: Nursing Diagnosisand analyzed by principal component extraction withvarimax rotation, resulting in a two-factor solutionwith strong loadings for 17 variables. In addition, pre-liminary one-way analysis of variance showed statisti-cal significance (p3 days of mechanical ventilation are an expen-sive patient population for acute care hospitals. Fortypercent to 42% of mechanically ventilated patients eitherfail the initial spontaneous breathing trial (24%) or areextubated and require reintubation (16% 18%). Theweaning process for long-term mechanically ventilatedpatients has fiscal and psychosocial ramifications for thepatient, family and friends, and healthcare providers. Author contact: perryag@tetranet.netEvaluating Nursing DiagnosesLeann Scroggins and Marcelline HarrisBACKGROUND. Two concerns about the accuracy ofnursing diagnoses that are well described in the literatureinclude the reliability with which nurses identify and as-sign diagnoses, and the validity of defining characteris-tics for specific nursing diagnoses. Methods to estimatereliability emphasize the consistency with which clinicaldata relevant to indicators and etiologies are interpretedbetween and among nurses. Methods to estimate validityemphasize concept analysis and development, and ex-pert nurse, clinical, and construct validation. Althoughappropriately discussed as separate issues, they arehighly interrelated. If the construct and predictive valid-ity of clinical data as defining characteristics of specificnursing diagnoses have not been established, variabilityin nurses identification and assignment of those nursingdiagnoses is inevitable. Unfortunately, methods by whichto concurrently examine these issues are not described.Further confounding the situation is that it is notknown whether nurses interpret and record clinical datadifferently depending on the schema or context in whichthose data are presented and used. For example, memoryproblems are a defining characteristic of disturbed thoughtprocess, indicators of memory deficit/problems are pre-sent in instruments such as the Mini Mental Status Exam,and many generic nursing assessment flow sheets simi-larly contain some type of cognition indicator. The signifi-cance of this is that the notion of reusable clinical dataentered once at the point of care and used across multiplealgorithmically derived applications in computer-basedsystems with inference capabilities (e.g., diagnostic deci-sion support and terminologic systems with automatedterm composition) has been assumed but not evaluated.MAIN CONTENT POINTS.1. Accuracy in the nursing diagnosis literature com-monly refers to issues of both reliability and validity.2. Reliability studies have emphasized interrater agree-ments between and among nurses.3. Validity studies have emphasized content validity, al-though there are isolated examples of construct andpredictive validity studies.4. The context in which a nurse completes a clinical as-sessment may present a confounding influence on theaccuracy of nursing diagnosis if nurses interpret clini-cal cues differently depending on the purpose forwhich the assessment is completed.5. The ability of both humans and computer-based sys-tems to reason accurately about nursing diagnoses isseriously constrained when the reliability and validityof clinical indicators in association with presence orabsence of specific diagnoses are not known.CONCLUSIONS. Research is needed to clarify themethodologic issues associated with the design andanalysis of studies, concurrently examine the accuracy ofnursing diagnoses, and also evaluate assumptions re-lated to the notion of reusable clinical data in com-puter-based systems when those data are recordedwithin different contexts or schemas. Although the de-sign of such a study is complex, it is critical to continuedwork on the accuracy and validity of nursing diagnoses. Author contact: scroggins.leann@mayo.eduPURPOSE. To develop and validate self-assessmentand proxy assessment versions of two measurement in-struments for fatigue, the Dutch Fatigue Scale (DUFS),based on NANDA characteristics and the Dutch Exer-tion Fatigue Scale (DEFS).METHODS. Cross-sectional designs were employedto test content, construct, and criterion-related validity;internal consistency; sensitivity; specificity; and useful-ness of both scales among patients with heart disease,International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 9postpartum women, and patients living in a home forthe elderly.FINDINGS AND CONCLUSIONS. Both scales showed sufficient reliability and validity. The DUFS (scale coefficient H = .48; KR-20 = .79) issuitable as a measurement instrument for the assess-ment of patients fatigue. The DUFS may be used reli-ably and validly for group-level comparisons. The DEFS (scale coefficient H = .61; Cronbachs alphaPresented Papers: Nursing DiagnosisConstruction and Validation of a Scale for the Measurement of Body ImageCludia Maria Ramos Medeiros Souto and Telma Ribeiro GarciaPURPOSE. To construct and validate a scale for themeasurement of body image in nursing practice.METHODS AND FINDINGS. Construction of the scaleitems was based on a literature review. A list of 81 itemswas drawn up and, after careful analysis, reduced to 43items. Content validity of the 43 items was evaluated byseven experts, who were asked to mark their agreementor disagreement as to whether the items referred to theconcept of body image. In order to avoid bias in the an-swers, 5 items were added to serve as confounding vari-ables. Nine items (including the 5 confounding ones) wereeliminated because they did not reach the minimum valueof interrater agreement to be retained (0.80). Test/retestwas used to verify the reliability of the measure. An instrument including the 39 retained items wastested twice with a sample of 24 volunteers. Pearsonscorrelation coefficient was 0.71. Three items achievinglow scores were discarded. To determine construct valid-ity, the 36 remaining items were tested with a sample of375 students in undergraduate courses at the Health Sci-ences Center of the Federal University of Paraba, Brazil.Three analytical procedures evaluation of the internalconsistency of the measure through item-total correlationlevel, analysis of the contribution of each specific itemusing Cronbachs alpha coefficient (), and the verifica-tion of the dimensionality of the measure using principalcomponents analysis were carried out. Four compo-nents were extracted, cumulatively explaining 41.2% ofthe variance in the 36 items of the scale. Following thisanalysis, 10 items were eliminated. After that exclusion, asecond extraction was done, generating a five-factor so-lution with an eigen value of 1.00 and a cumulative ex-plained variance of 54.1%. The 26 items yielded an =0.90, indicating a high internal consistency of the scale.Three more items were eliminated because they reducedthe previously obtained value of item-total correlationand their removal contributed, although only slightly, toimproved performance of the Cronbachs alpha coeffi-cient. A third extraction was done for the 23 retaineditems. Five components were extracted, cumulatively ex-plaining 58.2% of the variance in the items of the scale( = 0.91). Based on the total score obtained by each participantand on the distribution of those scores, two criteriagroups were created a lower group that had 30% ofthe lowest scores, and an upper group that had 30% ofthe highest scores in the distribution. Using a Student t-test, all 23 items were able to discriminate among sub-jects belonging to the upper and lower criteria groups(pBACKGROUND. A Delphi study was completed in1992. In the interim, sample statements were used tobegin development of a questionnaire for ultimate test-ing of the concepts of dependence, independence, andinterdependence. The statements have been used overseveral years in questionnaires given to students, adultsin church groups, and individuals from a clinical cohortwho have been in therapy with one of the authors. Cer-tain statements are being considered for deletion be-cause they may not be mutually exclusive; they will re-main part of the questionnaire, however, until testing iscompleted.MAIN CONTENT POINTS. Dependency is well de-scribed as a disorder in psychiatric literature; however,the concept should be considered for inclusion in thenursing nomenclature. No attention has been given to in-dependence as a disordered state of being, and interde-pendence has not been included in the nomenclatureeven though the term is frequently used in nursing liter-ature to describe interactions between people.10 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003Nurses have long taken care of clients with problemsof dependency or independence; however, while depen-dency has constituted a major focus of caregivers, inde-pendence has been ignored since it has traditionally beenconceived of as a healthy behavior only. Clients oftenpresent with what is being termed defensive indepen-dence as opposed to dysfunctional independence. Inter-dependence is considered to be a healthy state of beingand may be a way of defining strengths, depending onthe degree to which it is demonstrated in given individu-als. Recognizing that people tend to lack objectivityabout themselves, a companion questionnaire is in de-velopment for use with spouses, partners, or any whohave a close relationship with the client. The items arematched but are written as My spouse/friend. . . . CONCLUSIONS. The client questionnaire will lend it-self to research by clinical nurse specialists or nurse prac-titioners who work with clients having relationshipproblems. Author contact [S. Whiting]: sylviawhiting@aol.comPresented Papers: Nursing Diagnosis= .91) is suitable as a measurement instrument for theassessment of patients exertion fatigue. The DEFSmay be used reliably and validly in clinical practice atindividual level. Scale items are considered weak if H < .40, medium ifH < .50, and strong when H .50. Using these criteria,the DUFS may be classified as a high medium scaleand the DEFS as a strong scale. Comparisons of the average DUFS sum scores be-tween nonfatigued and fatigued subjects, as well asbetween patients with chronic heart failure and post-natal women, and correlation coefficients performedwith sociodemographic factors (age, gender, educa-tion) show that the DUFS may be used as a reliableand valid measurement tool for the accurate assess-ment of patients fatigue. Comparison of the assess-ments of nonfatigued and fatigued domiciliary heartpatients (self-assessment) and their significant others(proxy assessment) also show evidence of the reliabil-ity and validity of the DUFS as a measurement toolfor the accurate assessment of patients fatigue. Comparison of the assessments of nonexertion fatigueand exertion fatigue between domiciliary heart pa-tients (self-assessment) and their significant others(proxy assessment) show that the DEFS is a reliableand valid measurement tool for the accurate assess-ment of patients exertion fatigue.Author contact [Tiesinga]: L.J.Tiesinga@med.rug.nlThe Conceptual Development of Dependence, Independence, and Interdependence as PotentialNursing DiagnosesSylvia M. Anderson Whiting and Judith A. Whiting

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