NANDA International Nursing Diagnoses for Children with Kidney Disease on Hemodialysis

— Objective: To identify the nursing diagnoses of NANDA international in children with kidney disease undergoing hemodialysis. Methods: Cross-sectional and descriptive study, carried out with 16 patients, at a pediatric renal therapy reference center in a city in northern Brazil. For data collection, the interview form was used together with data collection in the patients' medical records from January to March 2016. Results: 21 nursing diagnoses were identified, the most frequent of which were: risk of infection (100%); risk of vascular trauma (100%) and excessive volume (68.75%). Conclusion: The most frequent diagnoses are included in the domains security / protection and nutrition, referring to specific interventions and strengthening nursing practice in hemodialysis.


I. INTRODUCTION
The occurrence of a systemic disease implies, for a child, the need to cope with various changes in lifestyle, especially those caused by restrictions resulting from the disease, by the therapeutic and clinical control needs, as well as the possibility of recurrent hospitalizations. Renal Disease (DR) is one of these conditions, and consists of progressive and irreversible damage and loss of kidney functions [¹] .
Studies [1,2] demonstrate that technological innovations have brought significant improvements for the treatment of RD, however, this disease still has great repercussions for its patients, especially due to the limitations and the abrupt change in the child's routine for the effective treatment, which it is supported by diets, medicated drugs and some types of dialysis.
Hemodialysis stands out among the treatment modalities for kidney disease. This modality consists of the extraction of toxic nitrogenous substances from the blood and the removal of excess fluids accumulated in the body's tissues [2] .
The implementation of the Nursing Process (NP) in a pediatric hemodialysis sector is of fundamental importance, since this instrument supports nurses in the development of a specific care plan, covering the identification and monitoring of the adverse effects of treatment, patient care, complications resulting from the disease, in addition to the possibility of developing educational actions for promotion, prevention and treatment [3] .
The NP consists of stages that vary according to the established theoretical framework. Among its stages, the Nursing Diagnosis (DE) stage stands out, as it directly interferes with the success of the other stages of the nursing process. NDs are conceptualized as clinical judgments of the individual, family and / or community's responses to real or potential health problems and vital processes. They are scientific interpretations of the data collected, used to guide nursing planning, implementation and evaluation [4] .
Thus, with the objective of providing assistance aiming at a better adaptation of the child with kidney disease to the treatment of hemodialysis, and also to strengthen the professional care practice of nurses, this research aimed to identify the nursing diagnoses of NANDA International in children with hemodialysis kidney disease.

II. METHODOLOGY
A descriptive and cross-sectional research was carried out, with a quantitative approach, interviewing those responsible for the children seen at a referral center for renal therapy in a public hospital in the State of Pará and collecting data from the medical records of these children. The total sample of the research was composed of 16 children diagnosed with kidney disease and submitted to hemodialysis at the renal therapy center during the research period.
The inclusion criteria for data collection in the medical records were: child registered and submitted to hemodialysis in the referred renal therapy unit, being under treatment in the unit for at least 6 months, aged between 0 and 12 years. The exclusion criteria were: patients over 12 years old, children with mental disabilities and diagnosed with HIV and hepatitis B. For the interview with those responsible for the children, the inclusion criteria were: Being responsible for a child included and having more 18 years old. The exclusion criteria were: caregivers with mental illness, who do not communicate by speech and under 18 years old.
For data collection, an instrument divided into 3 cores was used: the first refers to socioeconomic aspects, the second refers to clinical aspects and the third refers to the adaptive problems proposed by Sister Callista Roy. The collection was carried out in a reserved room at the renal therapy center, before the beginning of the hemodialysis session of the child under the responsibility of the adult, between the months of January to March 2016.
For the structuring of the data, an individual process of clinical judgment of the nursing diagnoses was carried out, carried out in two phases: the analysis, which includes categorization of the data and the identification of gaps; and the synthesis, which is formed by grouping, comparing, identifying and relating the data [5] . Then, a database was built in the Microsoft Excel application, in which diagnoses were recorded and statistics were generated for data analysis.

III. RESULTS
The identified nursing diagnoses -which are distributed by frequency in Picture 1 -had an average per child of 7.8; median of 8; standard deviation of ± 2.32; maximum value of 12 and minimum of 5 per child.

International Journal of Advanced Engineering Research and Science (IJAERS)
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IV. DISCUSSION
Present in 100% of the sample, the nursing diagnosis Risk for Infection is defined as an increased risk of invasion by pathogenic microorganisms. This diagnosis is present in domain 11 (safety / protection), class 1 (infection) of the international NANDA [4] .
For hemodialysis, vascular access is necessary for the patient. In general, this access occurs through a catheter or arteriovenous fistula. Nursing and patient care are required to maintain access. Thus, although it is not possible to avoid multiple injuries (which increases the risk of infection) the nursing team must monitor the integrity of the vascular access, keeping alert to possible phlogistic signs that indicate infection [6] .
The diagnosis Risk of vascular trauma was also present in the entire sample. This diagnosis is found in domain 11 (safety / protection), class 2 (physical injury) of NANDA international. It is defined as risk of damage to the vein and surrounding tissues, related to the presence of catheter and / or infused solutions [4] .
It is true that, over the years, intravascular catheters have improved and new products have emerged. However, it is recommended that the team is always attentive, regardless of the type of catheter, to the relationship between its caliber and the vessel caliber, as the external caliber of the catheter close to the vessel caliber reduces the pericateter blood flow and intensifies friction between both. Therefore, the greater its variation, the better it will be to avoid phlebitis of physical origin triggered by contact. Another risk factor for vascular trauma is the time the catheter remains in the same insertion site. It is common to prolong this time in patients undergoing hemodialysis, which increases the chances of developing phlebitis, thrombophlebitis and infection [7] .
The excessive volume of liquids in the nursing diagnosis is defined as greater isotonic fluid retention. It belongs to the international domain 2 of NANDA (nutrition), class 5 (hydration) [4] .
The excess of fluids in renal patients undergoing hemodialysis can cause complications such as hypotension and cramps, due to the withdrawal of fluids and electrolytes, in addition to severe and irreversible cardiovascular changes. Therefore, it is essential that the nursing team has a different view for patients with excessive fluid volume [8] .

V. CONCLUSION
21 NANDA international NDs were identified, namely: Risk of infection, Risk of vascular trauma, Excessive fluid volume, Improved disposition for selfconcept, Improved disposition for family processes, Acute pain, Improved coping disposition, Intolerance to activity, Low self-esteem Situational, Anxiety, Risk of allergic response, Impaired gas exchange, Risk of electrolyte imbalance, Fatigue, Improved relationship disposition, Fear, Risk of deficient fluid volume, Imbalanced nutrition: less than bodily needs, Impaired physical mobility, Deprivation of sleep, Impaired sleep pattern.
The identification of NDs in children undergoing hemodialysis makes it possible to strengthen care practice, since the diagnoses lead to specific interventions. It can be highlighted that the identification of nursing diagnoses affirms nursing as a science, since diagnosing human responses to real or potential health problems is an essential practice of the profession.
The limiting factor of this study was the fact that it was carried out considering only the stages of investigation and nursing diagnosis of NP. Thus, the suggestion of carrying out research that covers all stages of the NP is valid, with a view to carrying out specific interventions and achieving results, aiming at a better quality of life for children with kidney disease undergoing hemodialysis.