Validação do diagnóstico de enfermagem resposta disfuncional ao desmame ventilatório

Abstract

The validation of tools used by nurses, such as nursing diagnoses, has been the subject of studies to establish their reliability and a way of developing knowledge and professional practice. Recently, NANDA International has listed a number of nursing diagnoses that will be removed from its taxonomy if new evidence of its validity is not established within the next two years. Those diagnoses include Dysfunctional Ventilatory Weaning Response (DVWR), which represents an important clinical condition in the daily practice of nurses working in intensive care units. In this regard, the present thesis was aimed to establish the validity of NANDA-I DVWR nursing diagnosis. This is a validation study developed in three stages: elaboration of a middle range theory (MRT) on dysfunctional ventilatory weaning; content analysis by judges; and analysis of the accuracy of the DVWR clinical indicators. For the first stage, an integrative review of literature was made as a basis for MRT development. We searched five databases: Scopus, MEDLINE, CINAHL, SciELO and LILACS, with descriptors "Ventilator Weaning", "Artificial Respiration" and "Critical Care". We identified 21 clinical indicators and 13 etiological factors of DVWR diagnosis from MRT. In addition, causal relationships were established between the diagnostic components identified. In the second stage, the content analysis of diagnostic elements and their respective conceptual and operational definitions elaborated in the previous stage was conducted, through evaluation by judges nurses. A value of 0.9 was adopted for Content Validation Index (CVI), to consider the adequacy of each individually evaluated item. The etiological factor Inadequate nutrition was considered statistically irrelevant for the diagnosis. Concerning the clinical indicators, all were considered relevant for identification of diagnosis, however, the Increase in respiratory rate over baseline, Respiratory distress and Respiratory fatigue demonstrated the need for adjustments by the judges' analysis. The third stage consisted in the accuracy analysis of the DVWR clinical indicators. Data collection was performed in two hospitals, with patients hospitalized in intensive care units submitted to weaning from mechanical ventilation. The data were obtained from observation and physical examination of patient, concomitant with the search for information in the medical record. The analysis included descriptive measures and central tendency. The Lilliefors test verified adherence to normal distribution. To verify the sensitivity and specificity of each indicator, the Latent Class Analysis method was applied. The indicators Respiratory distress and Use of accessory muscles showed high sensitivity (0.9998 and 0.9998, respectively). The indicators that presented high specificity (values above 0.85) to infer the DVWR were: Respiratory distress, Decrease in level of consciousness, Shallow Breathing, Facial expression of fear, Acidosis and Agitation. The estimated prevalence of DVWR diagnosis was 15%. It is concluded that the knowledge about accuracy of RDDV clinical indicators contributes to evidence the dysfunctional ventilatory weaning response, a fact that will make it possible to improve the nurse's assistance in the ventilatory weaning process.