Nursing diagnoses identified in onco-hematologic patients : a cross-mapping study

Objective: To compare free terms from nursing records with a standard nursing diagnosis classification. Cross mapping retrospective study of nursing records of 24 medical files of patients hospitalized in an onco-hematological clinic of a university hospital in the state of Rio de Janeiro. 507 matching terms corresponding to 30 nursing diagnoses were found, validated with 194 repetitions in the 24 records, with an average of 8.1 nursing diagnoses per patient. There were predominance of diagnoses of Ineffective Protection, Risk of infection, impaired oral mucosa, Hyperthermia, risk of bleeding, fatigue, acute pain and imbalanced nutrition: less than daily needs. Building clinical protocols from the terms and nursing diagnoses found in this study is recommended, aiming at the systematization of nursing care and onco-hematology patient nursing process.


INTRODUCTION
Estimates of cancer incidence in Brazil, in 2012, reported that the onco-hematological diseases -especially the leukemias, which include acute myeloid, chronic myeloid, acute lymphoblastic and chronic lymphocytic leukemia, had rates of 4,570 new cases of disease in men and 3,940 in women.These values correspond to an estimated risk of five new cases per 100,000 men and four per 100,000 women 1 .
A common trait in onco-hematological diseases is the occurrence of hospitalization, whether by low immunity and the systemic, or due to chemotherapy.Normally, the hematologic changes expose patients to complications such as infection, pain, lesions of the oral mucosa, fatigue and malnutrition, which can worsen their clinical condition and interfere with their recovery 2 .
Of hematological changes commonly found, there is anemia, which predisposes the patient to fatigue, pallor, dyspnea and tachycardia, in addition to thrombocytopenia, which causes bleeding (especially when the platelet count is ≤ 20,000/mm 3 , increasing the risk of gastrointestinal and brain) hemorrhage.Neutropenia reduces leukocyte counts below 1500/mm 3 and exposes the patient to risk of infection, being equal to or lower than 1,000/mm 3 considered respectively as moderate and severe neutropenia 3 .
Therefore, it is important that nurses know these characteristics and identify them as the clinical focus of their attention, and evaluate the answers of the subjects experiencing this situation.The implementation of the Nursing Care System (NCS) with adequate human resources in Nursing, changes in health care models, investment in training with theoretical models for the system implementation, and the commitment and support of the professionals, arises in this scenario as a challenge 4 .
The definition of terms and the most common diagnostics in onco-hematological clinical practice is an important contribution to the implementation of the NCS.It is made possible with the direct attention to the patient by performing the five methodological steps of the nursing care process, namely: research, diagnosis, planning, implementation and assessment 5 .
However, one of the difficulties associated with the implementation of the nursing process are precisely the inadequate forms for registration 6 .One way to approximate the nursing practice with existing ratings is the cross-mapping, i.e., valuing the terms used in practice for construction of forms, adopting standardized languages .
Studies conducted in 1997 mapped the nursing nonstandardized interventions contained in internal data of hospitals, giving rise to the known Nursing Intervention Classification (NIC) 7 .Also, in 2004, the authors of a US study created a structural model of the information used in each step of the nursing process and mapped it in order to develop the standards in healthcare.
A review study examined the use of cross-mapping in nursing research demonstrating the relationship between the classification systems, the use of computers and the health services.Of the 26 studies analyzed in this review, three were related to oncology: a German, made in 2006, in which the authors' objective is to present the construction of a subsystem under the International Classification for Nursing Practice (ICNP ® ) for oncology patients; a Norwegian study, also conducted in 2006, in which the authors extracted terms used to indicate the signs and symptoms of 25 records of patients from oncology, mapping those to this medical area; and another one aiming to the development of a catalog of diagnoses, nursing interventions and outcomes for patients with multiple myeloma 7 .
The cross mapping was also used to trace the phenomena identified in nursing visits of a family planning service, from the perspective of ICNP ® ; in another one, for Nursing Diagnoses (ND) in the elderly, according to Life Model and ICNP ® ; and in another, it established a database of Language Special Terms for Nursing Neonatal Intensive Care Unit, according to INCP ®8 .cross-mapping was also used to construct an instrument for Diagnostic Imaging Centers, so that the identified activities were mapped according to the Nursing Interventions Classification (NIC).An instrument for performing physical examination in adults and elderly was also proposed, according to the literature review and the ICNP ® .There are also authors who proposed to introduce and describe the method of cross mapping 7 .
However, only a small number of publications that used the ND in haematological field was observed, especially as regards the onco-hematology area, evidencing the need for studies with this classification and subject.
Identifying actual and potential diagnoses onco-hematology patients may face increases the possibility of preparing more reliable nursing care to the clinical needs reported by patients and thus achieve the nursing results, providing wellbeing to the patients.
Under these considerations, the present study aimed to compare terms from free nursing records and ND classification registers.

METHOD
This study used cross-mapping, based on the comparison of terms used in daily service and the existing classification systems, providing the adjustment required for its practical implementation 8 .This was therefore a documentary retrospective study, on the nursing registers into medical records of patients hospitalized in onco-hematology clinic of a university hospital in the state of Rio de Janeiro.
The selection criteria were: medical records of patients diagnosed with acute or chronic myeloid and lymphoid leukemia and their subclassification, hospitalized from January 1 st to December 31 st  First, we searched in the admission and discharge Main Logbook, which is filed in the Medical Archive and Statistics Department from the Documentation Service, information about the identification of hospitalized patients with a diagnosis of leukemia and lymphoma and their subclassifications in hematology clinic between January 1 st and December 31 st , 2011.After the selection of patients, the survey of records was scheduled in accordance with the availability of the Medical Documentation Service of the institution.
Of the 116 hospitalizations in the Hematology Department, 89 records were not part of the research for not presenting the declared medical diagnoses or presenting insufficient nursing service reports, preventing a deeper analysis.Thus, the sample consisted of the records of 27 patients, representing 23.3% of the population, making it possible to estimate the percentage of nursing diagnoses.However, of these 27 records, three were not available for study, as they were in digitization process and outpatient billing.So only 24 patient records with myeloid and acute or chronic lymphoid leukemia were part of the study.
Later, we started the research on the records previously scheduled, by the application of the data collection instrument.The consultation ranged from five to eight records, with an average duration of nine hours per day of research.
For collecting and analyzing data, we elaborated a script containing: (1) identification data of the patient; (2) a free description and transcript of nursing problems identified in the nursing records during hospitalization of the patients with leukemia in hematology department; (3) a comparison of the terms, in exact or partial way, with the standard classification; (4) an evaluation by experts, with full or partial agreement.
As a strategy to facilitate the search for terms, followed by a chronological and sequential analysis of records, i.e., from the time of admission until discharge or death, to obtain the largest amount of information that contribute to the inference of the ND.
Then we conducted the development of a ND from the terms of records (defining characteristics) highlighted by the researcher to describe the diagnoses.Subsequently, these were compared with the defining characteristics of the Nursing Diagnoses Classification NANDA-I.
Risk and other related factors were identified through interpretation of related terms, synonyms or similar concepts that somehow translate the hemodynamic changes caused by the base disease, thus influencing the search and increasing the partial combinations.
So we performed an analysis of combination, adapted so that if the term found matched exactly with the end of the classification system, the combination would be designated as exact; However, if the terms were synonymous, or using similar or related concepts, the combination would be designated as partial.Also, the terms presenting no resemblance to the classification system and with no possible combination would not be extracted from the records.
Fourth step corresponded to the analysis performed by three expert nurses (one specifically in nursing diagnosis and the other two in oncology), two of them being nursing PhD and active in medical-surgical clinic.The form filled out by the researcher was referred to the three specialist nurses in relation to excellent, substantial, moderate and low compliance with the defining characteristics/risk or related factors for each of the 164 diagnoses found.
Experts were contacted by the researcher by invitation letter sent via electronic mail providing information about the purpose of the study, the adopted methods and the willingness/availability to participate in research.Those who agreed to participate as diagnosticians signed the Informed Consent Form (ICF).
To analyze the data collected, we created a spreadsheet in Excel ® for Windows software, with a descriptive analysis of frequency distributions.To assess the degree of agreement between the researcher and the experts, we decided by the Kappa index, analyzed using the Statistical Package for the Social Science (SPSS) software, version 13.0.The Kappa index was defined as a measure of association to describe and test the degree of agreement, i.e., the reliability and accuracy of an assessment 8 .Kappa values > 0.7 are considered as a good level of agreement 8 .For ND creation purposes, only nursing data that had substantial and excellent agreement were included.
Formal authorization for use of medical records was requested to the participants, who were informed of the objective of the study.After agreeing to participate, they signed the Informed Consent Form (ICF).The project was approved by the Research Ethics Committee of the University Hospital Antonio Pedro, under protocol 144.119, fulfilling the recommendations of Resolution 466/2012 of the National Council of Health of Ministry of Health, which regulates research involving human subjects.

RESULTS
Most records were of male patients (16; 66.7%), with ages ranging from 26-83 years and an average age of 44.2.About marital status, 13 patients were single, seven were married, two were separated and two were widows.12 patients informed having children, six patients reported having no child and six did not provide information.With regard to education, 13 records did not contain this information; of the others, four indicated incomplete primary education, two indicated complete Nursing diagnoses identified in onco-hematologic patients Sousa RM, Santo FHE, Santana RF, Lopes MVO primary education, two informed incomplete high school, two completed high school and two reported incomplete higher education.
There were some difficulties to determine patients' occupation in data from medical records, as nine had no information on it; two patients were mechanics and two were housewives; store manager, computer technician, assistant props, mason, caregiver, retired, industrial yard, student, operator of construction machinery and mining, automotive electrician, school inspector were occupations cited by one patient each.In relation to medical diagnosis, most (13; 54%) had acute myeloid leukemia; Six (25%) acute lymphocytic leukemia; one (4.2%) reported chronic myeloid leukemia; one had T-cell leukemia lymphoma; one had hairy cell leukemia; and one reported a non-specified leukemia.
With regard to hospitalization time, it was observed that the minimum duration ranged from 1 to 76 days of hospitalization, with a median of 20.4 days.About the therapeutic treatment used by hospitalized patients with leukemia, 18 (75%) carried chemotherapy and blood therapy as the base treatment for the malignancy.Of these, only one (4.2%)underwent bone marrow transplantation with improvement of clinical condition and discharge for outpatient follow-up.Other three (12.5%)patients used only hemotherapy as therapeutic treatment.
Table 1 presents the key terms found in medical records which are considered clinical indicators, i.e. risk and other related factors and defining characteristics of the presence of ND in the population studied.
In Table 2, there are the ND identified in hospitalized oncohematological patients, according to NANDA-I classification, grouped according to domains, in the first column.Second and third columns present the concordance ratings of the three experts in absolute numbers of 194 occurrences of 30 diagnoses, i.e. a total 582 of reviews.Of these, 462 showed excellent and 114 a substantial agreement; the six others were discarded.The total number of diagnoses and their percentage with respect to the prevalence of diagnoses are properly presented.In other words, a nursing diagnosis representing 100% of the sample means that the referred diagnosis has been identified in all patients.
Noteworthy is the presence of 194 NDs in 24 onco-hematological patients hospitalized, with an average of 8.1 per patient, thus assuming the high demand for skilled and comprehensive nursing care.
As for the agreement of evaluators, moderate agreement was obtained from the Cohen's Kappa (k = 0.330; p = 0.094), which was significant only at the 10% level.However, when setting the value of Kappa for prevalence, we obtained high and statistically significant agreement at 1% (k = 0.902; p < 0.001).

DISCUSSION
The key terms found in the records of nurses in the medical records were referring to: hospitalization, patient's hematologic conditions (hemoglobin, neutrophils, platelets), therapeutic treatments performed, venous access conditions, body temperature, bowel eliminations, type and location of pain, diet acceptance, nausea and vomiting, and anxiety.These terms provided subsidies for validation by the ND experts.
We observed a predominance of diagnoses of ineffective protection, risk of infection, impaired oral mucosa, hyperthermia, risk of bleeding, fatigue, acute pain and imbalanced nutrition: less than daily needs.Such diagnoses showed moderate agreement among experts.
Study emphasized that the exposure of onco-hematologic patients is proportional to the number of days of hospitalization, because during hospitalization, in addition to the underlying disease, the patients are subjected to invasive procedures and chemotherapy itself, which compromises their immune system exposing them to infections and, consequently, leading to longer hospitalization.
The risk of infection was associated with increased environmental exposure to pathogens, immunosuppression, invasive procedures, inadequate primary (broken skin) and secondary defenses (decreased hemoglobin and leukopenia) and medicine (immunosuppressive).
Patients with leukemia, when hospitalized, are exposed to pathogenic microorganisms due to the hospital environment, base disease itself, or the therapeutic treatment required for their recovery, which includes the use of an intravenous access for administration of immunosuppressive drugs prescribed.
Approximately 80% of patients with chronic lymphocytic leukemia have infectious complications at some point during the course of disease 9 .Infections were the main complications and secondary cause of death in treatment of leukemia 10 , demonstrating the importance of considering the Ineffective Protection and Infection Risk in the implementation and documentation of the nursing process.
In our sample cases, mortality rate was high (66.7%),and sepsis or septic shock (37.5%) the leading cause of death.Two (8.3%) deaths were due to infection with aspergillus sp., which can occur by neutropenia caused by prolonged therapy and concomitant corticosteroids or prolonged broad spectrum antibiotic treatment 9 .

Continuation...
Considering that the immunity system of patients with chronic lymphocytic leukemia presents various defective aspects and multiple disorders often coexist in the same patient, the humoral immunodeficiency has been considered the primary defect in leukemia.However, it is increasingly recognized that defects in T cells and natural killer (NK) cells, as well as neutrophil dysfunction and defects in complement system significantly contributes to the immunodeficiency state and, therefore, should be screened 9 .
Neutropenia, the humoral and cellular dysfunction, the hypogammaglobulinemia, as well as the damage to oral mucosa predispose patients to infection.The diagnosis of impaired oral mucosa was observed commonly in patients.It is characterized by difficulties to swallow, mouth sores, bleeding, gingival hyperplasia, mucosal pallor, oral discomfort, difficulty to speak and to eat, oral pain, coated tongue and halitosis.
Mucositis is an inflammation of the oral mucosa dose-dependent of several chemotherapeutic agents, and is characterized as the most common side effect of chemotherapy reaching up to 40% of patients on anticancer treatment 11 .The pain caused by mucositis is so intense that it can interfere in patients' nutrition and often leads to the need of analgesics, and the interruption of the treatment protocol.Moreover, it can still be a gateway to local and systemic secondary infections, which may even cause patients to die 11 .This is because cancer chemotherapy acts on cells which are in mitosis, both neoplastic and healthy cells.Thus, since the cells of the oral mucosa are in a constant process of mitosis, they are also affected, creating the lesions known as oral mucositis, causing pain and oral discomfort, difficulty to speak and eat, and even to perform oral hygiene, generating consequently coated tongue and halitosis.And as the mucosa is injured, this settles an opening for the invasion of pathogens, increasing even more the risk of infection.Thus, there is the importance of nurses in early identification of oral lesions as well as in the prevention of opportunistic infections, since this professional is the one responsible for oral hygiene and maintaining its integrity.
Prevalence of hyperthermia diagnosed in these patients was detected by at least one temperature measuring ≥ 38º C. Associated with chemotherapy, febrile neutropenia exists when
In this study, ten patients showed neutrophil count < 1,0x10 9 /L.When patients with febrile neutropenia receive the first medical care in emergency, they're apparently stable; however, febrile neutropenia is a medical emergency and requires immediate attention because clinical deterioration occurs within days or even hours 13 .We observe here the importance of nursing in the early identification of risk factors, signs and symptoms of hyperthermia, and in the monitoring of the leukocyte count in order to analyze the presence of FN and contribute to the reduction of complications arising from it and consequently any infection and death due to sepsis.
The risk of bleeding was related to the inherent coagulopathy (thrombocytopenia).That's because these patients, besides having a drop in the number of platelets, also manifested the symptoms resulting from this reduction, such as the petechiae, bleeding gums, bruising, melena, epistaxis, intestinal bleeding, bleeding in the sclera, hematemesis and hematoma.
The incidence and severity of thrombocytopenia in patients with leukemia vary depending on the type and stage of the disease.It can be developed due to the use of chemotherapy or by the accumulation of abnormal blast cells in the bone marrow.Thrombocytopenia is one of the interveners to the quality of life of onco-hematology patients 14 , and this clinical manifestation should, therefore, be a focus of nursing intervention.
The diagnosis of fatigue was explained in part by the myelosuppression caused by disease, by the treatment that reduces the levels of hemoglobin and so by the decreased blood oxygen rates, generating tissue hypoxia.In order to reduce the demand for oxygen, the patient stays a longer time in bed, prostrate and listless, with reduced mobility which leads to weakness, and as its complications, muscle atrophy and/or pressure ulcers, which may compromise recovery and worsen the clinical state.
Unlike other patients, people with cancer have no reduction in their fatigue after their rest, which makes this symptom more striking than the pain, depression and nausea 15 .If not properly identified, the fatigue can weaken the cancer patient, interfere with treatment and harm the quality of life 16 .These patients often feel discouraged and fail to perform their activities of daily living, isolating themselves socially because their physical conditions do not contribute to the continuity in social life, and there's also the distance from their work environment -hence the importance of its detection and intervention by the nurses.
Fatigue diagnosis, however, is particularly complex to achieve as it requires from the nursing professional accurate knowledge and observation to identify its defining characteristics, since it is determined from a subjective judgment.Therefore it is important to include the terms of the investigation of fatigue diagnosis in onco-hematology nursing care protocols.
Acute pain identified from the verbal reports of patients is also a diagnosis commonly observed in cancer patients -particularly the onco-hematology patient, due to the infiltration of leukemic cells in the bone marrow, liver and spleen.Cancer pain has characteristics of both acute and chronic pain.As well as acute pain, cancer pain is directly associated with tissue injury.When this pain persists or worsens, it can serve as a sign of disease progression and create a sense of hopelessness, as patients believe it is not worth continuing to live this way, losing the meaning of life 17 .
Thus, we observe that the pain, whatever its intensity, is a problem to clinical recovery, deserving special attention by the nursing staff, especially the nurses in charge of its management and control, providing comfort and well-being.
The unbalanced nutrition was identified by reports on inadequate, less than the daily recommended food intake; wound oral cavity; lack of interest in food and pale mucous membranes.Its importance is associated with the implications of worsening in other NDs, including the perception of well-being of the patient.
Any food ingested by the onco-hematology patients must first be boiled and cooked including the fruit, which, in turn, contributes to the loss of appetite and lack of interest in food.Therefore, it is essential that the nursing staff, as a whole, is engaged in stimulating the oral intake of food and fluids, and instruct the patients about the importance of this preparation and the need of good nutrition to their recovery.

Table 1 .
Terms found in the medical records of patients hospitalized with leukemia.Niterói, 2012

Table 2 .
Nursing diagnoses found in patients hospitalized with leukemia.Niterói, 2012