Clinical validation of defining characteristics of the NANDA-I nursing diagnosis “ineffective peripheral tissue perfusion” (00204) in patients with diabetic foot ulcers

The study aimed to clinically validate the defining characteristics (DCs) of the NANDA-I nursing diagnosis Ineffective Peripheral Tissue Perfusion (00204) in patients with diabetic foot ulcers. We conducted a cross-sectional diagnostic validation study at Rasoul Akram Hospital in Tehran during 2024–2025, involving 146 adult outpatients with type 2 diabetes and diabetic foot ulcers. Two trained, independent nurse raters evaluated eleven DCs measures through structured interviews and physical examinations. Impaired peripheral tissue perfusion was identified using colour or duplex Doppler ultrasound, which served as the reference standard. According to Fehring’s classification, DCs with a frequency exceeding 0.80 were designated as major, those between 0.50 and 0.80 as minor, and those below 0.50 as irrelevant. The overall clinical diagnostic validity (CDV) score was determined as the average of individual validation scores for each DC. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated for each diagnostic criterion. Statistical analyses were conducted using SPSS version 21, and inter-rater reliability was evaluated with Cohen’s kappa coefficient. Among 146 participants, 104 (71.2%) were diagnosed with ineffective peripheral tissue perfusion using colour Doppler as the reference standard. Altered skin characteristics (97.3% and 93.8%) and delayed peripheral wound healing (91.8% for both raters) were the most commonly observed DCs. Sensitivity ranged from 67.3% to 75.8% for the first researcher and from 68.9% to 73.1% for the second, while specificity varied considerably across DCs. Overall inter-rater agreement was excellent, with a mean Cohen’s κ of 0.85. The highest diagnostic accuracy was noted for delayed colour return after limb elevation (positive likelihood ratio > 10). The overall clinical diagnostic validity score was 0.79. This study provides evidence confirming the clinical validity of specific DCs for diagnosing ineffective peripheral tissue perfusion within nursing practice. Several DCs exhibited high sensitivity and exceptional inter-rater reliability, demonstrating their reliability in clinical settings. The most diagnostically valuable indicator was delayed colour return following limb elevation, although variations in specificity indicate that certain signs should be interpreted with caution.