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Clinical indicators to monitor patients with risk for ineffective cerebral tissue perfusion/Indicadores clinicos para el monitoreo de pacientes con riesgo de perfusion tisular cerebral ineficaz/Indicadores clinicos para monitorar pacientes em Risco de Perfusao Tissular Cerebral Ineficaz.


The documentation of care plans that foster care and patient safety, and that demonstrate the nursing contribution in the obtained results is essential to systematize the practice of nurses in different aspects of assistance in health. (1) In high complexity units, such as in the case of emergency services and intensive care, direct care, taken quick and safe decisions are frequent. The Nursing Diagnosis (ND) (2) (00201) Risk for Ineffective Cerebral Tissue Perfusion, defined as "Risk of reduction in the brain tissue circulation that may impair health" (2), is present in the Brazilian reality, in view of the increase in hospitalizations by cerebrovascular diseases in Brazil. (3) Different clinical situations place neurological patients in Risk for Ineffective Cerebral Tissue Perfusion. This ND has as risk factors presence of cerebral aneurysm, aortic atherosclerosis, dilated cardiomyopathy, encephalic traumatic brain injury, brain tumor, thrombolytic therapy, hypertension, among others. (2)

The neurological deficits that may occur, according to these risk factors, make these patients dependent of nursing interventions. It is noteworthy that the higher needs, the greater the urgency to plan their interventions. (4) To obtain desired results it is necessary to establish accurate diagnoses, objectives to be achieved and effective interventions. (5) The Nursing Outcomes Classification--NOC was developed to measure, using Likert scales, Nursing Outcomes (NO) that include health status, behaviors, reactions and feelings of the patient, family or comunity. (6) Are clinical indicators that help nurses in planning and assessment, that stages are fundamentals for the conduct of clinical best practices.

In Brazil, in recent years several studies have been conducted to validate NO to adult patients with ND (2) Acute Pain (7), Selfcare Deficit: Bathing/ Hygiene (8), Excess fluid volume (9) and children with Ineffective breathing pattern (10) and Deficient diversional activity. (11) It is evidenced a gap as regards the validation studies for nursing results to patients in Risk for Ineffective Cerebral Tissue Perfusion. The relevance of this study is founded on the contributions that brings nursing, to infer that the NO may help in determining the priority interventions, enabling monitoring of patients with this diagnosis. Thus, the aim of this study was to validate clinical indicators, according to the Nursing Outcomes Classification (NOC) (6), to monitor patients on Risk for ineffective cerebral tissue perfusion.


This is a study of content validation, carried out in two stages. At first there was a Consensus (12) on essentials nursing outcomes for assessment of patients with Risk of ineffective cerebral tissue perfusion. In the second stage, was done the content validation of NO indicators, based on the model Fehring. (13) The research was conducted in a university hospital in south of Brazil, recognized as an academic center of excellence in quality and patient safety by Joint Commission International. Actually has 865 beds, distributed in more than 60 specialties.

The Emergency Service is part of the Emergency Care Network, of the Brazilian Ministry of Health. The humanized care is provided by the host environment with risk assessment and classification according to the Manchester Triage System. It is composed of units of observation and hospitalization, with a unit specializing in vascular care. The Intensive Care Service has the capacity for 39 adult patients of different specialties. Among the therapeutic procedures performed, we highlight the postoperative period of several specialties, such as neurosurgery and vascular surgery.

The convenience sample consisted of 17 nurses of Emergency and Intensive Care Service. Inclusion criteria were: judge's nurses with two or more years of experience in caring for patients with Risk for Ineffective Cerebral Tissue Perfusion. No exclusion criteria were provided. However, it was considered essential to include qualified professionals in clinical practice of surveyed fields and with knowledge in the application of the diagnosis. They also have scientific production related to Nursing process (NP) and classifications. Most of them have been participated in the Hospital Committee of Nursing Process, which since 2000 works with the NANDA-I and Nursing Interventions Classification (NIC). (2) This group includes nurses and teachers/researchers academically connected to a public university in the south of Brazil, who meet to discuss the implementation, update and assessment of nursing process, with emphasis on individualized care and in qualified and insurance record, also conducting clinical studies based on these taxonomy. (11)

Data collection was conducted between November 2012 and August 2013. In the first stage of the study, of the 23 results contained in the link NOC-NANDA-I6 to the ND Risk for ineffective cerebral tissue perfusion (2), were selected the nine Suggested by NOC, because are results considered more approximate to the nursing diagnosis. (6) It is worth noting that in this edition of NOC6, there is no link to Risk for Ineffective Cerebral Tissue Perfusion, because it is based on the NANDA-I published in 2008. (14) After an instrument containing these nine NO. Considering the title and the definition of each one of the outcomes, participants should be point out, recommend or not recommend, for the assessment of the studied diagnosis.

In the second stage the participants assessment indicators of the results validated the previous stage, through a five point Likert scale (1 = not important, 2 = slightly important, 3 = important, 4 = very important and 5 = extremely important). By filling these instruments, the judges attributed their clinical judgment as to the importance of each result (1st stage) and its indicators (2nd stage). Data analysis was performed using descriptive statistics, in Microsoft Excel 2010[R]. For the first stage of the study, it was considered a 100% consensus on concordant responses among nurses. Data from the second stage were analyzed using the Content Validity Index (CVI) by calculating the weighted averages of the scores assigned to each indicator, as it considered the following weights: 1=0.00; 2 = 0.25; 3=0.50; 4=0.75; 5=1.00. For the categorization of indicators were considered critical those [greater than or equal to] 0.80; that with mean between 0.50 and 0.79 were considered supplementary and those with values less than 0.50 were disposed. (13)

The ethical aspects were respected and the project was approved by the Research Ethics Committee of the institution, with the report no. 08.184. Participants signed a consent form.


The sample consisted of 17 judges nurses, among them ten (58.8%) had a specialization and four (23.5%) master degree. Regarding professional experience seven (41.17%) have been working between six to ten years in units included using the NP Of the participants, eight (47%) are members of the Committee of the Nursing Process, which is responsible for the conduct of this methodology in the studied hospital; adding to this, six (35%) nurses have publications related to the NP and NANDA-I2 ratings, and NOC. (6) Of the nine NO suggested by link NOC-NANDA-I (6), only the (0406) Cerebral Tissue Perfusion had 100% consensus according to the assessment of judges. This outcome is located in Domain II: Physiological Health and in the Class E--cardiopulmonary, measured by means of scales Severe deviation from normal range to No deviation from the normal range and Severe to None. These and other outcomes can be seen in Table 1.

The second stage of the study validated the content of the indicators of NO Cerebral Tissue Perfusion. (6) Of the 18 indicators, five (27.7%) were validated as critical, 12 (66.6%) supplementary and one (5.5%) was disposed. These data are shown in Table 2.


The NOC provides a professional language that can be used by nurses to identify and assessment the effects of nursing interventions in different environments of care. (6) The validation of these elements, according to the expertise of the nurses of clinical practice (15) may favor its applicability, once it helps to choose the most relevant clinical indicators, and facilitate rapid assessment of states of ineffective cerebral tissue perfusion risk. The consensus of the judges nurses as to NO Tissue Perfusion: Cerebral, defined as adequacy of blood flow through the cerebral vasculature to maintain cerebral function, (6) differed of a South Korean study in that the NO Neurological status: awareness has been validated as the most important for neurological patients. The Tissue Perfusion: Cerebral got 4.58 in score of importance, but its use in practice is moderate, according to the researches nurses. (16)

Neurological examination of the patient is essential in the care of critically ill patients. The assessment carried out by the nurse is based on three fundamental aspects: assessment of the consciousness level, examination of pupils and classification of motor response. Its frequency depends on the severity and type of cerebral event. One of the instruments most commonly used in this assessment is the Glasgow Coma Scale (GCS).17 The indicator Impaired neurological reflexes received greater CVI. In this sense, we can tailor the GCS in the operation of this indicator in addition to the Decreased level of consciousness, tracing parameters on the evolution of the patient. The advantages of using this scale include fast assessment, easy training of the nursing team, also provides a common language between professionals. (17)

Other indicators that were considered critical are related to blood pressure. The NOC (6) categorizes this vital sign on three indicators: Systolic blood pressure, Diastolic blood pressure and Mean arterial pressure. Hypertension (HTN) is one of the risk factors for Cerebrovascular Accident-stroke (CVA). It is noteworthy that the Systolic (SBP) and Diastolic Blood Pressure (DBP) are important indicators for the decision making of treatment with tissue plasminogen activator (tPA) intravenously, and as a criterion for exclusion of that thrombolytic therapy sustained SBP> 185 mmHg or sustained DBP> 110 mmHg. (18) Also, population studies of Brazilian cities revealed the prevalence of HTN above 30%. (19) In this sense, there is the importance of this indicator for clinical practice.

For studied ND, besides the management of blood pressure and assessment of the level of consciousness, there is a direct relationship of these indicators with the monitoring risk status, or not, of ineffective cerebral perfusion. It is known that cerebral perfusion pressure (CPP) is defined as the mean arterial pressure (systolic blood pressure + 2x diastolic blood pressure/3) minus intracranial pressure values (ICP). From that, the CPP values lower than 60 mmHg, are insufficient (20), in this case, therapeutic actions should be initial for ineffective brain tissue perfusion. (21) However, the Intracranial pressure indicator was not considered critical by judges to evaluate the status of the risk of ineffective cerebral tissue perfusion.2 This assessment may have occurred because of the ICP continuous monitoring not be practical in emergency units. Corroborates this inference the fact that the sample contain a larger number (n = 12) of nurses coming this practice field, or the fact that this ND was real until the edition of NANDA-I (version 2007-2008)14, and has been updated in hospital nursing prescription system under study for risk of ineffective cerebral tissue perfusion in 2011.

Increased ICP can produce pupillary changes, and the indicator that evaluates this state is present in the result Neurologic State (6), which had Consensus of 85.71%. The inclusion of this indicator in the NO Cerebral Tissue Perfusion (6), would be of great value, because it is of clinical evidence in the assessment of critic neuropatient. Among the supplementary indicators, we highlight those related to neurological signs or symptoms such as Agitation, Impaired Cognition, Syncope, Restlessness, Unexplained Anxiety, listlessness, Vomiting and Hiccoughs, The variability of these indicators with CVI between 0.79 and 0.50, could facilitate the clinical examination in accordance with the state of the result, but also during the initial inspection of the patient with suspected acute brain injury, based on the initial score of the indicator, thus monitoring the outcome of nursing care.

The supplementary indicators Headache, Fever and Cerebral angiography findings are directly related to the prognosis of the severity of critical neurological patient, for example, the Headache was present in 43.9% of patients with some kind of pain, ranked at stages II, III and IV of Manchester protocol (22), and the sum of these symptoms may both increase blood pressure, as the ICR determining changes in cerebral perfusion pressure. In what concerns the control of body temperature, it is considered critical and should be monitored intensively, within the first 72 hours, in the case of stroke (23) and acute critical patient encefalico (24) to improve neurological prognostic, in this case is verified the importance of the indicator Fever.

Is highlighted the indicator Cerebral angiography findings, with CVI 0.68, which is related with imaging test results. This examination is a valuable tool to investigate vascular diseases or abnormalities related to the permeability of the cerebral circulation. Nurses perform a series of clinical care related to the procedure, including the neurological assessment. (25) Its CVI (0.68) was relatively low, in this sense, would be conducting a follow-up to check its use before and after the nursing interventions for patients with Risk for ineffective cerebral tissue perfusion. The result of this examination directs the decision-making of other professionals, and can be connected to the assessment of other nursing diagnoses. Similarly, the Carotid bruit indicator was disposed by the judges. In this sense, as the neurological clinical manifestations vary in intensity and the degree of commitment, means that the use of these indicators can be used in accordance with the patient's risk factors for risk of ineffective cerebral tissue perfusion and stratified according to magnitudes of NOC scales. (6) Using this relevance, and accuracy of nurses in the assessment of critically ill patients, approaches the Nursing Process and classifications of evidence-based practice.


The study selected and validated clinical indicators, according to the Nursing Outcomes Classification (NOC) to monitor patients with Risk for ineffective cerebral tissue perfusion. In the first stage of the study the result Cerebral Tissue Perfusion showed 100% consensus, according to the assessment of the judges, and in the second stage, of the 18 indicators of this nursing result, five (27.7%) were validated as critical (Impaired neurological reflexes, Systolic blood pressure, Diastolic blood pressure, Reduced level of consciousness and Mean arterial pressure), 12 (66.6%) were validated as supplementary (Agitation, Impaired cognition, Intracranial pressure, Syncope, Vomiting, Cerebral angiography findings, Headache, Restlessness, Fever, Unexplained anxiety, listlessness and Hiccughs) and one indicator (5.5%) was disposed (Carotid bruit).

The NOC (6) proved to be valid in the studied context, in the opinion of judges, allowing the identification of clinical indicators to monitor patients with Risk for ineffective cerebral tissue perfusion. This validation can facilitate the assessment of conditions of risk and early intervention to minimize the consequences of ineffective cerebral tissue perfusion. These findings need to be validated clinically to verify the changes in the health status of the patient after the nursing interventions. Also, check the psychometric properties of the NOC scales, in order to offer better perspectives of its use for patients. A possible limitation was the research with judge's nurses in just one institution, although it could be argued that the studied hospital has over 40 years of experience in the use of Nursing Process. Since 2000 uses the terminology of nursing diagnoses of NANDA-I in clinical practice, in addition to prescription of care mapped to the NIC, and has been studying the inclusion of the NOC in the electronic patient record. Moreover, the studied units are reference in field of cerebrovascular care. The methodology used was adequate; however, a larger sample of judges, egalitarian, of both services, could maximize the impact of the findings. Validation for patients with certain neurological diseases or signal of neurological commitment could discriminate use of these clinical indicators.


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Miriam de Abreu Almeida [1]

Marcos Barragan da Silva [2]

Bruna Paulsen Panato [3]

Ana Paula de Oliveira Siqueira [4]

Mariana Palma da Silva [5]

Bruna Engelman [6]

Isis Marques Severo [7]

Aline Tsuma Gaedke Nomura [8]

[1] RN, Ph.D. Universidade Federal do Rio Grande do Sul--UFRGS--, Brasil. email:

[2] RN, Ph.D candidate. UFRGS, Brasil. email:

[3] Undergraduate nursing student. UFRGS, Brasil. email:

[4] RN, Master candidate. UFRGS, Brasil. email:

[5] Undergraduate nursing student. UFRGS, Brasil. email:

[6] Undergraduate nursing student. UFRGS, Brasil. email:

[7] RN, Ph.D candidate. UFRGS, Brasil. email:

[8] RN, Master. UFRGS, Brasil. email:

Article linked to research: Validacao de Resultados de Enfermagem segundo a Nursing Outcomes Classification--NOC na pratica clinica de um hospital universitario.

Subventions: Fundo de Incentivo a Pesquisa e Evento (FIPE) do Hospital de Clinicas de Porto Alegre, RS Brasil.

Conflicts of interest: none.

Receipt date: September 25, 2014.

Approval date: November 4, 2014.
Table 1. Distribution of Concordance Index of Nursing Outcomes for
diagnosis Risk for Ineffective Tissue Perfusion: Cerebral

Nursing outcomes                               Concordance
                                                Index (%)

Tissue Perfusion: Cerebral                       100.00
Cognition                                         85.71
Neurological Status                               85.71
Neurological status: Consciousness                85.71
Level of agitation                                85.71
Acute level of confusion                          85.71
Seizure Control                                   71.42
Neurological status: Central motor control        71.42
Tissue perfusion: Cell                            71.42

Table 2. Score distribution of indicators of Tissue Perfusion:


Critical(CVI [greater than or equal to] 0.80)

Impaired neurological reflexes                    0.89
Systolic blood pressure                           0.87
Diastolic blood pressure                          0.85
Decreased level of consciousness                  0.85
Mean blood pressure                               0.81

Suplemmentary (CIV [greater than or equal to] 0.50 a 0.79)

Agitation                                         0.77
Impaired Cognition                                0.77
Intracranial pressure                             0.75
Syncope                                           0.75
Vomiting                                          0.72
Cerebral angiography findings                     0.68
Headache                                          0.68
Restlessness                                      0.68
Fever                                             0.62
Unexplained Anxiety                               0.54
listlessness                                      0.52
Hiccoughs                                         0.50


Carotid bruit                                     0.45
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Title Annotation:Original article
Author:Almeida, Miriam de Abreu; da Silva, Marcos Barragan; Panato, Bruna Paulsen; Siqueira, Ana Paula de O
Publication:Investigacion y Educacion en Enfermeria
Article Type:Ensayo
Date:Jan 1, 2015
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