PSYCHOSPIRITUAL NURSING DIAGNOSES FOR PEOPLE WITH METABOLIC SYNDROME

Objective: to build listed nursing diagnoses directed to psychospiritual needs of people with metabolic syndrome. Method: this is a quantitative, descriptive and documentary study contemplating the following stages for the identification and validation by consensus (100%) of the relevant terms to the care with the priority of health; cross-mapping of terms identified with the 2017 version of the classification; construction of the statements of nursing diagnoses; cross-mapping of the statements constructed with the International Classification for Nursing Practice (ICNP), and the results are presented in the form of a figure. Results: rated to 135 terms in the context of psychospiritual needs, from which 24 were excluded because they involve the psychobiological and psychosocial needs, totaling 111 terms. Validated, then, 61 terms, allowing the establishment of eight listed diagnoses contemplating the psychospiritual needs, being that 50% were not classified. Conclusion: there were built the propositions of which half was not listed in the ICNP 2017, thus contributing to their development and for inclusion in the psychospiritual dimension in full nursing care directed to the audience and to the advancement of the Classification of Nursing. Descriptors: Nursing; Nursing Diagnosis; Standardized Nursing Terminology; Metabolic Syndrome; Spirituality; Religion. RESUMO Objetivo: construir enunciados de diagnósticos de enfermagem direcionados às necessidades psicoespirituais de pessoas com síndrome metabólica. Método: trata-se de um estudo quantitativo, descritivo, documental, contemplando as seguintes etapas de identificação e validação por consenso (100%) dos termos relevantes para o cuidado com a prioridade de saúde; mapeamento cruzado dos termos identificados com os da versão 2017 da classificação; construção dos enunciados de diagnósticos de Enfermagem; mapeamento cruzado dos enunciados construídos com os da Classificação Internacional para a Prática de Enfermagem (CIPE), e os resultados apresentam-se em forma de figura. Resultados: classificaram-se 135 termos no âmbito das necessidades psicoespirituais, dos quais 24 foram excluídos por envolverem as necessidades psicobiológicas e psicossociais, totalizando 111 termos. Validaram-se, então, 61 termos, permitindo a elaboração de oito enunciados diagnósticos contemplando as necessidades psicoespirituais, sendo que 50% não constavam da classificação. Conclusão: construíram-se os enunciados dos quais metade apresentou-se como não constante na CIPE 2017 colaborando, assim, para o seu desenvolvimento e para a inclusão na dimensão psicoespiritual no cuidado de Enfermagem integral direcionado ao público-alvo e para o avanço da Classificação de Enfermagem. Descritores: Enfermagem; Diagnóstico de Enfermagem; Terminologia Padronizada em Enfermagem; Síndrome Metabólica; Espiritualidade; Religião. RESUMEN Objetivo: generar diagnósticos de enfermería enumerados dirigidos a las necesidades psico-espirituales de las personas con el síndrome metabólico. Método: se trata de un estudio cuantitativo, descriptivo y documental, contemplando los siguientes pasos para la identificación y validación por consenso (100%) de los términos pertinentes al cuidado con la prioridad de la salud; cross-correlación de términos identificados con la versión 2017 de la clasificación; construcción de las declaraciones de diagnósticos de enfermería; cross-correlación de las declaraciones construidos con la Clasificación Internacional para la Práctica de Enfermería (ICNP), y los resultados se presentan en forma de una figura. Resultados: clasificación de 135 términos en el contexto de necesidades psico-espirituales, de los cuales 24 fueron excluidos porque implican la psicobiología y las necesidades psicosociales, por un total de 111 términos. Validado, entonces, 61 términos, permitiendo la creación de ocho diagnósticos enumerados contemplando las necesidades psico-espirituales, siendo que el 50% no estaban clasificados. Conclusión: construido si las proposiciones de las cuales la mitad no estaba incluida en la ICNP 2017, contribuyendo así a su desarrollo y para la inclusión en la dimensión psico-espiritual en plena atención de enfermería dirigida al público y a la promoción de la Clasificación de la Enfermería. Descriptores: Enfermería; Diagnósticos de Enfermería; Terminología Normalizada de Enfermería; Síndrome Metabólico; Espiritualidad; Religión. Specialist, Regional University of Cariri/URCA. Crato (CE), Brazil. Email: naianerolim@hotmail.com ORCID iD: http://orcid.org/00000001-9115-1485; Master, Federal University of Master, Federal University of Paraiba/UFPB. João Pessoa (PB), Brazil. Email: nunof05@hotmail.com ORCID iD: http://orcid.org/0000-0002-0102-3023; Master, Federal University of Cariri/URCA. Crato (CE), Brazil. Email: simonedamasceno@ymail.com ORCID iD: http://orcid.org/0000-0002-2841-7815; Doctors, Regional University of Cariri/URCA. Crato (CE), Brazil. Email: anamalencar@hotmail.com ORCID iD: http://orcid.org/0000-0003-0459-4291; Email: celida.oliveira@urca.br ORCID iD: http://orcid.org/0000-0002-8900-6833; Doctor, Regional University of Paraiba/UFPB. João Pessoa (PB), Brazil. Email: miriamnobrega@gmail.com ORCID iD: http://orcid.org/0000-0002-6431-0708 ORIGINAL ARTICLE Nascimento MNR, Félix NDC, Damasceno SS et al. Psychospiritual nursing diagnoses for people...

It discusses, worldwide, about the impact of chronic diseases on quality of life and morbidity of the population, in particular cardiovascular diseases, emphasizing the role of prevention of cardiovascular risk factors those make up the metabolic syndrome. Increases the cardiovascular risk in men and women in 34% and 16%, respectively, for the syndrome, characterized by the presence of three or more of the following diagnostic criteria: increased abdominal circumference, high blood pressure, fasting glucose, triglycerides and/or reduction of high density lipoprotein-cholesterol, which may be associated with type 2 diabetes mellitus and hypertension. 1 It is necessary to the process of systematic care pointing to the fulfillment of human needs affected, which interferes with the way in which the individual sees himself, changing the significance he attaches to life and existence, as well as spirituality. It stands out in the context of these needs directed to the person with the syndrome, the demand for integral care comprising not only the biological dimension, but also the social and the related to the subjectivity coming of soul and spirit, which may influence the healthdisease process, mainly in the cardiovascular context. 2 It is the assumption that people who have some involvement religious/spiritual have lower chances of presenting risk behaviors to health and, thus, the aid to cope with these individuals forward to modifiable risk factors, based on psychospirituality, must integrate the investigation of the nurse, to provide assistance to individuals, families and the community . 3 We highlight, in this study, the psychospiritual demands, defined as the need to establish a dynamic relationship with a superior being or entity, with the aim of reaching the spiritual well-being and have beliefs related to a sense of importance of life, in order to stabilize the body, mind and soul. These needs are defined as "religion" and "spirituality", understood, respectively, as the mode by which the individual expresses the spirituality through the adoption of values, beliefs and rituals that provide answers to key questions about life and death, involving the doctrine shared by a group, and an innate characteristic to the being can be considered as a philosophy of life, promoting behaviors and feelings of hope, love, faith, welfare, health and stability. 4 It is, thus, that spirituality is a broader dimension, not necessarily related to the religiosity, therefore, the two are not synonymous. It is pointed, by means of a recent study, both of which can contribute to the formation of beliefs and values, to encourage healthy behaviors and practices, provide social interactions and help in coping with crises and life transitions, because it influences the way of thinking of the individual, which is reflected in the attitudes toward health condition. 5 It is noted that the care centered on spirituality and religiosity must be structured in respect to cultural individuality and the vision of the world that patients have, and the perceptions of nurses are contributing factors to the integration of these dimensions, since these professionals need to be aware of the spiritual needs of individuals so that they can reflect and clarify their concerns regarding the psychospiritual balance. 6 Must be identified by nurses, these phenomena from terms that represent and, in particular, in individuals who have one or more risk factors to health, such as the cardiovascular, indicators of metabolic syndrome.
It has, for this purpose, the use of systems for the classification of nursing to facilitate the standardization of terms related to language of the profession, highlighting the International Classification for Nursing Practice (ICNP ® ), as well as the construction of assertions of diagnoses, results and nursing interventions for a health priority. There is built, in addition, listed nursing diagnoses from the ICNP ® for people with metabolic syndrome, based on the Theoretical Framework of Basic Human Needs; however, it has not been possible to contemplate the psychospiritual needs. 7 We sought, with this study, to fulfill this gap in knowledge, contributing to the development of the system of classification, the recognition of language related and the progress of scientific production, involving the dimensions of nursing care to the person with metabolic syndrome.
• Building listed nursing diagnoses directed to psychospiritual needs of people with metabolic syndrome.
It is a descriptive and documentary study, whereas the spiritual dimension in the production of nursing care to the person with metabolic syndrome opting, in this study, for the Referencial of Basic Human Needs, according to Horta. 4,8 We selected this referencial because the syndrome lacks an assistance covering all the dimensions that comprise the human being as an indivisible whole and not only in the biological and social dimensions, in addition to having been used in another study with the same design and health priority.

METHOD INTRODUCTION
This study was developed from four stages of Brazilian Model: 9 identification and validation of relevant terms to the care with the priority of health; cross-mapping of terms identified with the terms of the ICNP ® 2017; construction of the statements of nursing diagnoses and cross-mapping of the statements constructed with those contained in the 2017 version of the ICNP ® .
Held in the first stage, a documentary research on the strategies of care and the prevention of chronic diseases, as well as the clinical relevance and cultural, for nursing practice directed to people with metabolic syndrome, through the electronic address of the Ministry of Health and the Brazilian Society of Cardiology, as well as the search for scientific articles, in the Virtual Health Library, to identify the state of the art on the theme and its specificity. Using health sciences descriptors (DeCS): syndrome X metabolic (at the time), Nursing, spirituality and religion.
There were used the following inclusion criteria: free availability in the Portuguese language, being the language compatible with the extraction tool of terms; originality of the article, because the revisions, in addition to extensive, usually repeat terms contained in the original studies, not being relevant to the identification of new terms and publication in the period from 2005 to 2016, to contemplate the maximum possible indexed publications.
There was shown the absence of articles related to aspects of psychospirituality in syndrome. We performed this way, a new search, using the same inclusion criteria; however, only with the DeCS Nursing, spirituality and religion. It was considered that these beheld the object of study in a general way and that the terms to be extracted would be validated as to whether involving the metabolic syndrome.
Compiled the articles in a file converted to PDF format and, subsequently, applied on PORONTO, semi-automatic tool for the extraction of terms in Portuguese. Entered the articles, then, in an Excel spreadsheet for Windows ® 2016, favoring the process of normalization and standardization refering to the reading end to end, the spell, the analysis and the exclusion of synonyms, the adequacy of the tenses and grammatical gender, and the number of acronyms that identify certain terms, being excluded terms belonging to other areas and those already contained in studies that contemplated the psychobiological and psychosocial needs of people with metabolic syndrome developed by other authors 7 and those also used as a basis in the stage of construction of the listed diagnostics.
It was used for the validation of terms, the technique of validation by consensus, 18 proposal in this randomized studies in the context of nursing, in which a particular group of clinical nurses, based on recognized knowledge and clinical practice in the area, analyzes the terms and the respective operational definitions with the aim of consolidating a collective and consensual opinion (100%) about the relevance of the phenomenon studied.
Adopted the following criteria for the selection of experts: being a nurse, to have professional activity for at least four years, and being an author, co-author and/or supervisor of works about the theme directed at the metabolic syndrome and its components. Invited members to participate in the quality of collaborators and the agreement was formalized with the signing of the Informed Consent Form. It was identified, by means of the validation, a list of terms considered relevant, approved in the context of psychospiritual needs of a person with metabolic syndrome, being included in an Excel spreadsheet, in alphabetical order, for use in the subsequent stages.
It developed in the second stage, the crossmapping of the terms previously validated with the terms contained in the ICNP ® 2017. Built two spreadsheets in Excel for Windows ® 2016: one with the terms validated and another with the terms of the ICNP®. Crossed the spreadsheets through the Access Program for Windows ® 2016, for the identification of the terms listed and non-listed in the ICNP ® , which were subsequently analyzed for similarity and the scope with respect to the terms listed. Rated if the terms not included in this study as the model of the seven axes of the ICNP ® . It originated with these procedures, a bank of terms of the Nursing language related psychospiritual needs of person with metabolic syndrome.
It contemplated in the third stage the construction of the statements of nursing diagnoses, from a single description that included terms from the axes Focus and Judgement or a clinical finding, according to ISO  with the concepts diagnostics, inserted into two Excel spreadsheets for Windows ® 2016: in a spreadsheet there were entered the propositions of nursing diagnoses built in this research and, on the other, the diagnostic concepts contained in the ICNP ® 2017, and subsequently analyzed to determine similarity and coverage among those listed.
We analyzed and discussed the data whereas the national and international literature involving the theme. This study was derived from a larger survey entitled "Proposal from a Terminology Subset of the ICNP ® for clients with metabolic syndrome", approved by the Research Ethics Committee of the Regional University of Cariri, as Presentation Certificate for Consideration in Ethics (CAAE) 51129615.8.0000.5055, in compliance with the Resolution of the National Health Council N 466/2012. We identified 28 articles and, by means of a careful reading, we selected eight,  because they were associated with the clinical condition studied and psychospiritual needs. There were extracted using the tool PORONTO, 4,980 unique terms that were submitted to the process of normalization and standardization, being excluded 4,845 items without relation with the psychospiritual needs, resulting in 135 terms classified within the scope of psychospiritual needs, according to the theoretical reference used in this study.
Excluded, then, 24 identical terms, extracted and validated, involving the psychobiological and psychosocial needs of people with the syndrome, consolidating the total of 111 terms, which were placed in a form and submitted to the validation process by consensus, verifying the relevance of each term regarding the use and relevance to the language of nursing care directed to the person with metabolic syndrome in his psychospiritual needs.
Counted with the participation of three nurses specialists, a leader, the main researcher of the study, which has been responsible for the manual registration of the terms validated and considerations of specialists, and the advisor of the research. It has been found that the specialists were aged between 35 and 52 years old, with an average of 21.5 years of training, being two masters and a PhD, all researchers in the field of metabolic syndrome. We worked this process in the course of two days, with a total duration of three hours and five minutes. Presented the opinion of each expert as to the relevance of each term, being subsequently revised by the group.
Led the group to which the experts could discuss how the differences to obtain 100% consensus and thus consolidating the relationship of 61 validated terms, it is important to highlight that this debate was fundamental for the confirmation of the relevance of these terms in relation to the psychospiritual needs of people with metabolic syndrome, as evidenced by the scarcity of publications on the subject.
It noted that, during the stage of crossmapping of terms validated with the terms of the ICNP ® , version 2017, 22 constant terms, classified as equal or similar; of these, 18 terms comprised the axis focus and four terms were part of the action. Categorized the terms more comprehensive, more restricted and those who did not present correlation as not listed and organized in seven axes of the ICNP ® , aggregates to the constant terms, consolidating the standardized language, as shown in figure 1.    Exposes itself, in this study, the discussion about the psychospirituality in health care and nursing, especially in terms of health risk, whereas these demands seem to be in the background in the literature. It should be emphasized the need for an increase of discussions about this context, so that you can compose an effective care plan, individualized and integral, from a Nursing classification system compatible with this proposal, as the ICNP ® .

Seven-axis of ICNP ® N (%) Validated and Mapped terms
It is noted that the discussion, due to the nature of the theme, becomes abstract and subjective, which confers no weakness to care as a factor that composes the comprehensiveness, since be careful consists in an indivisible whole.
It establishes that the nurses should provide assistance to patients, in a systematic and integral way, making necessary the planning of this activity, based on the nursing process, and the insertion of the psychosocial and psychospiritual needs, as well as attend the psychobiological in health care, considering the theoretical reference used. Achieves this possibility in this study, when dealing with the identification of these phenomena in people with metabolic syndrome, corroborating the highlight of the theme with respect to cardiovascular risk factors those can be controlled or reversed, once identified by clinical judgment of nurses and registered with the use of terms representing them.
It is observed that the psychospirituality should be inserted in the routine care in health and nursing, especially when it focuses on health promotion, the prevention of cardiovascular diseases and their complications, such as active factors in the recovery and in coping with the health condition, helping to establish the social and cultural acceptance. 4,19 One must promote this insertion through the theoretical foundation and construction of knowledge based on a methodological rigor that present relevant results for the scope of practice of integrality of human needs by means of identification of needs/actual or potential problems.
It is perceived that the terms extracted, mapped and validated in this study contribute to the construction of a body of knowledge in the area, since there are needed clarification and standardization of terminology to strengthen the nurses in the care process involving the needs of people with metabolic syndrome in its totality. There is, then, the demand to unify these terms with the other studies, 7 consolidating the terminology for nursing care to be targeted at people with this syndrome.
It is emphasized, in relation to the listed diagnoses constructed from the terms validated and mapped, which researches with similar methodological design, involving the nursing care of cardiovascular and metabolic syndrome, 13,20 not contemplated the psychospiritual needs of individuals in their construction, reaffirming the need for the development of studies about the psychospiritual dimension.
Signals, concerning the constructed and classified set outs in the sphere of "religiosity", the relevance of this dimension in the patient's quality of life and, consequently, coping diseases, essential points in nursing care. 21 It is now that the religious belief is confidence in a force or higher power, 14 the possibility of finding meanings for the treatment of situations that limit the quality of life of individuals with cardiovascular risk, playing an important role as a coping strategy, with a significant impact on physical health, being singled out as a determinant of positive outcomes in the treatment, as well as in the strengthening of social and family relationships for the therapeutic support. 22 Makes it, from the propositions which involve this dimension, the process of identification and registration of these phenomena, collaborating for the nursing process directed to the target public.
It appears that, in this case, individuals can make use of religious beliefs, positive or negative, being essential to recognize as these may influence the treatment itself and how they provide comfort or suffering, performing the integrative approach possible. 23 Denotes that the nurse must be aware of these needs and respect them, opening a space for the manifestations of religiosity and spirituality in production environments of care. Configures whether this behavior as an ally in the promotion of health, with a focus on the reduction of risks. 24 It stands out among the diagnoses made involving the spirituality, the wording anguish, constant also in the NANDA Taxonomy-International, 25 highlighting in studies that treat chronic conditions related to metabolic syndrome,  being referenced as the feelings experienced by people in situations of health, for them, unknown, causing anxieties that need of family support in the management of treatment, which implies concern on the part of the professionals, who should always consider this factor of insecurity of individuals in the care plan.
It is pointed in the literature, in relation specifically to the spiritual anguish, that impairment due to health conditions that require change of life style, as the metabolic syndrome, the individual becomes the face threats to the normal state of life, which are related to fear, anxiety and anguish that pervades the spiritual dimension. It is, therefore, the relevance of the stimulus to healthy habits added to the feeling of spiritual well-being, with the potential to collaborate with the process of health care, coupled with the reduction of internal conflicts and personal to each patient and interfering in health. 14 It makes difficult, in clinical practice, the establishment of connections between these needs in the context of care, due to its subjective character and individual, aggravated by the absence of recommended care routine and established, being the situation more complex when it involves the spiritual and religious character. Must be identified, in particular, the nursing care directed to people with metabolic syndrome and the potential psychospiritual problems, considering the possible impact that may be generated in this dimension, which is facilitated by the results of this study.
There is, therefore, a positive and significant relationship between spiritual well-being and coping with cardiovascular risk factors, which influence the treatment and recovery of people with a higher contribution in the spiritual and religious components. 28 It is suggested that nursing must benefit from the assessment of these aspects, as well as other factors that compose the religiosity and spirituality of patients during the collection of data and the subsequent action plan, explaining its importance in the clinical context.
It is noted that the construction of the statements of psychospiritual nursing diagnoses for people with metabolic syndrome, using the ICNP ® , has practical implications, since it offers grants for the nurse to understand and record, with reliability, the needs of these individuals in the face of this dimension of care. It has, moreover, the practicalities of a planning of nursing interventions in the dimensions of religiosity and spirituality, from the identification of the demands of these patients, promoting the sense and the resignification of health condition and your clinic in the integral perspective. 26 Enables, through the use of this system of classification, the implementation of the nursing process with satisfactory results, 29 based on evidence and clinical reasoning of the nurse, promoting subsidies that documented the practice of nursing and its specific contribution in the context of the promotion of psychospiritual well-being.
Present themselves, based on the results of this study, possibilities of nursing diagnoses involving the psychospiritual needs of people with metabolic syndrome, it is important to highlight that these must not be confined to listed in this study, besides being applied in other situations of care. Fall, also, these possibilities in expanding the field of action in the care directed to the syndrome, in which, after almost a century of first publications on the theme, there prevails the emphasis biologicist still evident in the literature. 30 Must use appropriate tools and standardized language for the identification of psychospiritual needs of the population, whereas the psychospirituality can contribute to the process of care and adherence to clinical follow-up of the metabolic syndrome, which may be a positive response of the individual and the collective, reducing the morbidity and mortality due to noncommunicable chronic diseases.
Built eight listed nursing diagnoses directed psychospiritual needs of people with metabolic syndrome, using the ICNP ® , being half not listed in the ICNP ® 2017, collaborating, therefore, for the development and the inclusion of psychospiritual dimension in full nursing care directed to the audience and to the advancement of the classification. It is concluded, therefore, that this study contributes to the advancement of knowledge concerning the standardized language in nursing, providing evidence for the elaboration of instruments to record and the planning of psychospiritual care of people with metabolic syndrome.