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Applicability of the NANDA-I and Nursing

Interventions Classication Taxonomies to
Mental Health Nursing Practice
Emi da Silva Thom, RN, MSN, Renata Cardoso Centena, RN, Andressa da Silva Behenck, RN,
Maiko Marini, RN, MSN, and Elizeth Heldt, RN, PhD
Emi da Silva Thom, RN, MSN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil, Renata
Cardoso Centena, RN, is a Graduate of the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto
Alegre, Brazil, Andressa da Silva Behenck, RN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS,
Brazil, and a Masters Student at the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre,
Brazil, Maiko Marini, RN, MSN, is an Assistant Nurse at the Municipal Health Department of Caxias do Sul, Caxias, RS, Brazil,
and Elizeth Heldt, RN, PhD is an Adjunct Professor in the Graduate School of Nursing/UFRGS, Porto Alegre, Brazil.

Search terms:
Mental health, nursing
appointment, nursing care
systematization, nursing diagnoses
and intervention
Descritores:
Consulta de enfermagem,
sistematizao da assistncia de
enfermagem, diagnstico e
intervenes de enfermagem,
sade mental
Author contact:
eliz.h@globo.com, with a copy to
the Editor: journal@nanda.org
PURPOSE: To assess the applicability of the systematization of nursing care
(NCS) to outpatient nursing appointments using the NANDA-I and Nursing Inter-
ventions Classication (NIC) taxonomies.
METHODS: Data were collected from 40 patients who had appointments with a
nurse who specialized in mental health. Nursing diagnoses (NDs) and interventions
were classied using the NANDA-I and NIC taxonomies, respectively.
FINDINGS: A total of 14 different NDs were detected (minimum of one and
maximum of three per appointment). The most frequently made diagnoses were
impaired social interaction (00052), anxiety (00146), and ineffective self-health
management (00078). A total of 23 nursing interventions were prescribed
(approximately two per appointment), of which the most frequent were socializa-
tion enhancement (5100), self-care assistance (1800), and exercise promotion
(0200). Signicant associations were found between the most frequently
detected NDs and the most commonly prescribed interventions (p > .05).
CONCLUSIONS: The NCS through the use of classication systems allows mental
health nurses to better identify and assist poorly adjusted patients.
IMPLICATIONS FOR NURSING PRACTICE: The assessment of the applicability
of the NCS to different areas of health care and types of medical assistance
contributes signicantly to the quality of nursing care.
OBJETIVO: vericar a aplicabilidade da Sistematizao da Assistncia de
Enfermagem (SAE) em consulta de enfermagem de sade mental ambulatorial
utilizando as taxonomias NANDA-I e NOC.
MTODO: Os dados foram obtidos de 40 pacientes que consultaram com
enfermeira especialista do programa de enfermagem em sade mental. Os NDs e
as intervenes foram denidos com base nas taxonomias da NANDA-I e da NIC,
respectivamente.
RESULTADOS: Foram identicados 14 diagnsticos de enfermagem (DE)
diferentes (mnimo de 1 e mximo de 3 por consulta) e os mais frequentes foram:
interao social prejudicada (00052), ansiedade (00146) e autocontrole inecaz
da sade. Dentre as intervenes de enfermagem foram identicadas 23
(aproximadamente 2 por consulta) e as mais frequentes foram: aumento da
socializao (5100) e assistncia no autocuidado (1800). Foi vericada associao
signicativa entre os ND e as intervenes mais frequentes (p < .05).
CONCLUSES: A SAE em consulta de enfermagem de sade mental ambulatorial
possibilita identicar as respostas desadaptadas e determinar as intervenes
prioritrias.
IMPLICAES PARA A PRTICA EM ENFERMAGEM: Avaliar a aplicabilidade
da SAE em diferentes especialidades e em diferentes modalidades de atendimento
contribui para a qualicao do cuidado em enfermagem.

168 2014 NANDA International, Inc.

International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
E. S. Thom et al.
Outpatient clinics play an important role in providing
multidisciplinary services to nonhospitalized patients. Over
recent years, these services have been made increasingly
available in an attempt to reduce hospital admission rates
and increase the efcacy of preventive and health promo-
tion programs. However, studies suggest that nurse practi-
tioners at these services have been unable to meet patient
demand (Osinaga, Furegato, & Santos, 2007), especially in
cases of mental illness, which are highly prevalent and
insufciently addressed by health services (Caixeta &
Moreno, 2008).
In southern Brazil, university hospitals comprise an
important part of the health system, as they are able to
provide assistance to patients at different stages of treat-
ment. Psychiatric wards are available for acute cases, psy-
chosocial care centers (CAPS) provide rehabilitation
services, and outpatient clinics assist with treatment main-
tenance through nursing appointments (Franzen et al.,
2012). Outpatient nursing care is largely managed by the
Mental Health Nursing Program, a specialized public health
service developed to assist patients with mental disorders.
The program targets patients with mental disorders or mal-
adaptive functioning and their families, and assists them
through nursing appointments whose main therapeutic tool
is the nursing process itself (Heldt & Rodrigues, 2006).
The operationalization of the nursing process was facili-
tated by the development of the NANDA-I taxonomy for
coding nursing diagnoses (NDs) (Herdman, 2010) and the
Nursing Interventions Classication (NIC) (Dochterman &
Bulechek, 2008), which, together, led to the systematiza-
tion of nursing care (NCS). Mental health nursing interven-
tions based on NDs may be implemented so as to prevent or
treat diseases, or for health promotion purposes. The NIC
taxonomy is based on group nursing interventions to
improve health outcomes (Dochterman & Bulechek, 2008).
In outpatient health visits, interventions to improve coping
skills are developed with the patient through goal setting
and agreements (Heldt & Rodrigues, 2006).
In the context of these interventions, the implementa-
tion of a diagnostic system in clinical practice allows nurses
to identify with greater clarity the patient care needs for
which they are responsible (Cianciarullo, Gualda, Melleiro, &
Anakubi, 2005). A number of studies have assessed the
applicability of the NANDA-I and NIC taxonomies to mental
health settings (Frauenfelder, Mller-Staub, Needham, &
Van-Achterberg, 2011; Laguna-Parras, Jerez-Rojas, Garca-
Fernndez, Carrasco-Rodrguez, & Nogales-Vargas-
Machuca, 2013). However, most of these studies were
conducted with inpatient populations, which are quite dis-
tinct from outpatient samples. The fundamental difference
between these two settings is the duration of the interac-
tion between the nurse and the patient, which is approxi-
mately 24 hr in inpatient settings but only 40 min, on
average, in outpatient settings. The stages of patient care
also differ between these two settings. While for inpatients
the focus of medical interventions is mostly on acute
signs and symptoms, outpatient treatments focus on the
Mental Health Nursing and Taxonomies
maintenance of well-being and health promotion (Franzen
et al., 2012). A study of outpatient mental health care found
that the NCS improves the efcacy of nursing appointments,
as it allows the nurse to know and work with the patient, his
family, and the community, as well as to promote and main-
tain health (Beteghelli, Toledo, Crepschi, & Duran, 2005).
However, the study was qualitative and focused only on the
description of the most frequent diagnoses.
A recent review of the NANDA-INIC taxonomies in
mental health noted the scarcity of publications on the use
of these taxonomies in mental health settings. Of the
articles included in this review, 10 examined the frequency
of different NANDA-I and/or NIC diagnoses, and 4 assessed
care plans. The authors of this study also discussed the lack
of studies in this area (Escalada-Hernndez, Muoz-
Hermoso, & Marro-Larraaga, 2013). Therefore, to address
this gap in the literature, the present study sought to assess
the applicability of the NCS to outpatient nursing appoint-
ments using the NANDA-I and NIC taxonomies.
Methods
This cross-sectional study was performed in a university
hospital, which, in addition to providing medical services,
was involved in teaching and research activities. The par-
ticipating patients were referred from other health units
due to maladaptive responses to stress or psychiatric diag-
noses (Heldt & Rodrigues, 2006).
The sample consisted of 40 consecutive patients who
attended nursing appointments between February and
March 2010. All participants were over 18 years old.
Appointments lasted an average of 40 min and were con-
ducted by a nurse who specialized in mental health. The NDs
and interventions were classied using the NANDA-I and
NIC taxonomies, respectively.
During the appointment, nurses performed a mental
state examination (MSE), an anamnesis, and a physical
examination on each patient (Franzen et al., 2012; Heldt &
Rodrigues, 2006). The alterations in psychological function-
ing, as well as the signs and symptoms identied using the
MSE, helped guide clinical decisions and classify patients as
being well or poorly adjusted to their circumstances. The
signs and symptoms on which the NDs were based con-
sisted of alterations in the following psychological domains:
affect and mood, attention, behavior, conscience, intelli-
gence, language, memory, orientation, thought, and
sensory perception (Heldt, Marini, & Tom, 2011).
Data were collected from electronic patient records
immediately after the appointment. A protocol was devel-
oped to standardize the collection of data on sociodemo-
graphic variables, clinical comorbidities, diagnoses, and
nursing interventions.
Continuous variables were described as mean and stan-
dard deviation (SD), while categorical variables were
expressed as relative and absolute frequencies. Chi-square
and Students t tests were used to verify the association
between nursing interventions and NDs. The signicance
169
Mental Health Nursing and Taxonomies E. S. Thom et al.

Table 1. Nursing Diagnoses and Respective Domains According to NANDA-I

Domain Nursing diagnoses (code) n (%)b

Health promotion Ineffective health maintenance (00099) 2 (5)
Ineffective self-health management (00078)a 11 (27)
Nutrition Imbalanced nutrition: more than body requirements (00001) 2 (5)
Risk for unstable blood glucose level (00179) 1 (2)
Activity/rest Disturbed sleep pattern (00198) 2 (5)
Perception/cognition Disturbed sensory perception (visual) (00122)c 1 (2)
Disturbed thought processd 2 (5)
Self-perception Hopelessness (00124) 5 (12)
Chronic low self-esteem (00119) 3 (7)
Role relationships Impaired social interaction (00052)a 16 (40)
Coping/stress tolerance Anxiety (00146)a 14 (35)
Ineffective coping (00069) 1 (2)
Safety/protection Impaired skin integrity (00044) 1 (2)
Comfort Chronic pain (00133) 2 (5)
a
Most frequent diagnoses.
b
Frequency with which NDs in each domain were detected during outpatient visits.
c
Diagnosis removed from NANDA-I 20122014.
d
Diagnosis removed from NANDA-I 20092011.
ND, nursing diagnosis.

level was set to p < .05. Data were analyzed using the
Statistical Package for Social Sciences (SPSS) software,
version 18.0 (SPSS, Inc., Chicago, IL, USA).
This research was approved by the research ethics com-
mittee of the Porto Alegre Clinical Hospital (HCPA) under
protocol number 08-305.
Findings
Twenty six (65%) of the patients who attended mental
health nursing appointments during the study had gradu-
ated middle school, while 14 (35%) had also nished high
school.
Most patients (n = 28; 70%) regularly used medication.
Antidepressants were the most frequently reported drugs
(n = 21; 52%). A number of patients also had additional
medical diagnoses (n = 36; 90%), of which the most fre-
quent were type 2 diabetes mellitus (n = 22; 55%) and
systemic arterial hypertension (n = 20; 50%). Of the nine
(22%) patients with mental disorders, six (15%) had been
diagnosed with depression, two (5%) with schizophrenia,
and one (2%) with generalized anxiety disorder.
A total of 14 NDs were identied, with a mean of 1.5
diagnoses per patient (SD = 0.55; minimum of 1, maximum
of 3) and a total of 63 diagnostic statements. The most
frequently made NDs were impaired social interaction
(00052) (n = 16; 40%), anxiety (00146) (n = 14; 35%), and
ineffective self-health management (00078) (n = 11, 27%).
The most frequently impaired domains were role relation-
ships (n = 16; 40%), coping/stress tolerance (n = 15; 37%),
and health promotion (n = 13; 32%) (see Table 1).
The nursing interventions conducted and the diagnoses
for which they were prescribed are displayed in Table 2. The
most frequently prescribed interventions were socialization
enhancement (5100), self-care assistance (1800), and exer-
cise promotion (0200).
The results of analyses of the relationship between
nursing interventions and the most frequent NDs are dis-
played on Table 3. Signicant associations were found
between the socialization enhancement (5100) and nutri-
tion management (5246) interventions with the impaired
social interaction (00052) (p < .001) and ineffective self-
health management (00078) (p = .039) diagnoses, respec-
tively. No signicant associations were found between
other NDs and interventions (p > .05).
Discussion and Implications
The present results demonstrated that the NANDA-I and
NIC taxonomies are applicable to outpatient mental health
nursing appointments. The NCS in outpatient appointments
contributed signicantly to clinical interventions. The most
frequent NDimpaired social interactionwas associated
with socialization enhancement interventions and was
found to be highly prevalent in the mental health setting.
These ndings are in agreement with a recently published
review, which reported that the frequency of the impaired
social interaction diagnosis in mental health settings has
been particularly high in the past 20 years (Escalada-
Hernndez et al., 2013).
Studies suggest that making decisions about interven-
tions based on a thorough assessment of patient health is
an important part of responsible patient care. The system-
atization of interventions contributes signicantly to this
process, as it allows for more efcient medical decision
making and helps provide solutions to problems that may
arise during patient care (Pereira, Stuchi, & Arreguy-Sena,
2010). Socialization enhancement interventions help
patients develop or rene interpersonal skills, and assist
patients in daily routine activities. Such interventions
underscore the importance of studying health and disease

170
E. S. Thom et al. Mental Health Nursing and Taxonomies

Table 2. Nursing Interventions Prescribed for the Most Frequent Nursing Diagnoses (ND)

Nursing diagnoses (code) Nursing intervention (code)a n (%)b

Impaired social interaction (00052) 16 (40)

Behavior modication (4360)
Behavior modication: social skills (4362)
Exercise promotion (0200)
Self-care assistance (1800)
Self-concept enhancement (5390)
Socialization enhancement (5100)
Anxiety (00146) 14 (35)
Anxiety reduction (5820)
Behavior modication: social skills (4362)
Exercise promotion (0200)
Facilitating the mourning process (5290)
Improving the support system (5440)
Nutrition management (5246)
Self-care assistance (1800)
Ineffective self-health management (00078) 11 (27)
Anxiety reduction (5820)
Behavior modication (4360)
Behavior modication: social skills (4362)
Drug use prevention (4500)
Exercise promotion (0200)
Nutrition management (5246)
Self-care assistance (1800)
Self-esteem enhancement (5400)
a
According to the Nursing Interventions Classication (NIC, 2008).
b
Frequency with which interventions for each ND were prescribed during outpatient visits.

Table 3. Association Between Nursing Interventions and the Most Frequent Nursing Diagnoses

Nursing diagnoses

Impaired social Anxiety Ineffective self-health

Nursing intervention (code) interaction (00052) (00146) management (00078)

16 (40%) 14 (35%) 11 (27%)

Self-care assistance (1800) 5 (31) 3 (21) 2 (18)
Socialization enhancement (5100) 8 (50)** 1 (7)
Exercise promotion (0200) 4 (25) 4 (29) 2 (18)
Behavior modication: social skills (4362) 3 (18) 3 (21) 2 (18)
Nutrition management (5246) 2 (14) 4 (36)*

Data presented as absolute frequencies and percentages (%). Fishers exact test.
*p < .05; **p < .001.

from a biopsychosocial standpoint in mental health clinics
(Dochterman & Bulechek, 2008).
Ineffective self-health management (a component of
the health promotion domain) was one of the most fre-
quently made NDs in the present study and was found
to be associated with nutrition management interventions.
This intervention was not specically designed for mental
health patients, which shows that nursing practitioners
must see patients in their totality. This diagnosis was
also associated with the prescription of anxiety reduction
interventions, which, on an interesting note, were not
found to be associated with an ND of anxiety. These data
support previously reported associations between anxiety
and chronic diseases (Coelho et al., 2009), which were
present in 90% of the sample, and the relationship
between these conditions and ineffective self-health
management (Freitas et al., 2011; Morilla-Herrera,
Morales-Asencio, Fernndez-Gallego, Berroblanco-Cobos,
& Delgado-Romero, 2011). As a whole, these ndings
support the idea that when a patient is assessed in his
totality during a mental health nursing appointment, the
interventions prescribed and the NDs made are likely to be
related.
Although a number of patients received a disturbed
thought process ND, the prevalence of this diagnosis was
not as high as has been reported in other publications over
the past 20 years (Escalada-Hernndez et al., 2013). This
nding may be attributable to the distinct nature of outpa-
tient samples. It is also important to note that the fact that
this ND was removed from the NANDA-I 20122014 tax-
onomy (Herdman, 2012) limits the use of this classication
system in mental health services.

171
Mental Health Nursing and Taxonomies
The present results evidence the efcacy of the NCS in
nursing appointments in outpatient health settings. These
measures allow nurses to make NDs and to prescribe inter-
ventions other than hospital admittance. The use of classi-
cation systems is one way to enhance the accuracy the
interpretations of patient cues, apply adequate interven-
tions, and achieve positive outcomes through NCS (Marini &
Chaves, 2011).
Some of the limitations of the present study include the
small sample size and the cross-sectional design, which pre-
vented the assessment of the results of the interventions
prescribed. However, to the authors knowledge, this is
one of the rst studies to investigate the applicability of
the NANDA-INIC taxonomy to outpatient mental health
settings.
The present ndings underscore the need for further
research on the use of the NANDA-I classication system in
mental health care. We suggest that future studies focus on
(a) the Nursing Outcomes Classication system, (b) the inci-
dence and prevalence of different NDs, (c) the accuracy of
NDs, and (d) clinical content validity of these diagnoses. In
this way, nursing care could be further systematized and
more effectively applied to mental health outpatient
settings.
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