Nursing diagnoses in primary health care consultations to newborns

Objective: To describe and analyze nursing diagnoses established on newborns’ medical consultations in a primary health care service. Method: Descriptive, analytical and quantitative study performed in a primary health care clinic in São Paulo. Data were collected from the medical records of 37 children treated in 39 nursing consultations during their neonatal period. The identifi ed nursing diagnoses were analyzed regarding: frequency, classifi cation in strengthening or exhaustion in light of the health-disease process, and the correspondence with the essential needs of infants. Results: 372 diagnoses were identifi ed, most of them of strengthening (71%), such as effi cient development (n = 37) and effective growth (n = 36). Among the exhaustion diagnoses (29%), there was a predominance of risk for suffocation (n = 15) and impaired tissue integrity (n = 14). Most diagnoses corresponded to the need of physical protection and security. Conclusion: Families are strengthened in the care of the essential needs of newborns, however, preventing diseases is necessary. Descriptors: Nursing Diagnosis; Primary Health Care; Infant, Newborn; Child Development; Health Promotion. RESUMO Objetivo: Descrever e analisar os diagnósticos de enfermagem estabelecidos em consultas de recém-nascidos num serviço de atenção primária à saúde. Método: Estudo descritivo, analítico e quantitativo realizado num ambulatório de atenção primária à saúde em São Paulo. Os dados foram coletados nos prontuários de 37 crianças atendidas em 39 consultas de enfermagem no período neonatal. Os diagnósticos de enfermagem identifi cados foram analisados quanto a: frequência, classifi cação em fortalecimento ou desgaste frente ao processo saúde-doença, e correspondência com as necessidades essenciais das crianças. Resultados: Foram identifi cados 372 diagnósticos, sendo a maioria de fortalecimento (71%), como os de desenvolvimento efi caz (n = 37) e de crescimento efi caz (n = 36). Entre os diagnósticos de desgaste (29%) predominaram risco de sufocação (n = 15) e integridade da pele prejudicada (n = 14). A maioria dos diagnósticos correspondeu à necessidade de proteção física e de segurança. Conclusão: As famílias estão fortalecidas na atenção às necessidades essenciais do recém-nascido, porém a prevenção de agravos se faz necessária. Descritores: Diagnóstico de Enfermagem; Atenção Primária à Saúde; Recém-Nascido; Desenvolvimento Infantil; Promoção da Saúde. RESUMEN Objetivo: Describir y analizar los diagnósticos de enfermería establecidos en consultas de recién nacidos en un servicio de atención primaria de salud. Método: Estudio descriptivo, analítico y cuantitativo realizado en un ambulatorio de atención primaria de salud en São Paulo. Los datos fueron recolectados en los prontuarios de 37 niños atendidos en 39 consultas de enfermería en el período neonatal. Los diagnósticos de enfermería identifi cados fueron analizados en cuanto a: la frecuencia, la clasifi cación en fortalecimiento o desgaste frente al proceso salud-enfermedad, y la correspondencia con las necesidades esenciales de los niños. Resultados: Se identifi caron 372 diagnósticos, siendo la mayoría de fortalecimiento (71%), como los de desarrollo efi caz (n = 37) y de crecimiento efi caz (n = 36). Entre los diagnósticos de desgaste (29%), predominaron el riesgo de asfi xia (n=15) y la integridad de la piel perjudicada


INTRODUCTION
The neonatal period represents a vulnerable phase for the survival of an infant (1) . Worldwide, it is estimated that 2.9 million deaths occur in the first 28 days of life, mainly due to infections, intrapartum conditions and premature birth complications (2) . In Brazil, the rate of neonatal mortality represents from 60% to 70% of child mortality, and perinatal diseases and congenital malformations are its main causes (3) . Thus, the Ministry of Health recommends that primary health care professionals perform the first consultation of newborns and their families or a home visit in the first week of the child's life (4) .
Nursing consultation represents an important strategy for the strengthening of family care in promoting integral newborn development. Its objectives include monitoring growth and development, supporting exclusive breastfeeding, verifying neonatal screening and child's immunization, family orientation to identify signs of illness and to seek emergency services, promoting safe environments and affective care in order to build a bond between parents and newborns, among others (4) .
As an activity incorporated to primary health care actions, nursing consultation must be systematically performed according to the nursing process, contemplating the stages of data assessment (history), diagnosis, planning, implementation and evaluation. Nursing diagnosis represents the interpretation and grouping process of the data collected from the assessment and expressed the answers of individuals, families or human collectivity in a given moment of the health-disease process (5) .
Considering that determinants and constraints of the healthdisease process in newborns include the families' ways of working and living, identifying newborn diagnoses in childcare consultations contribute to recognize the potential strengthening and wastage in view of the health-disease process, as well as to understand the individuals as historical, social and political subjects, articulated with the family, environment and society context in which they are inserted (6) .
However, understanding newborns' needs also requires the support of theoretical references adequate to the specificities of the subject in development (7) . In this sense, Brazelton and Greenspan's benchmark of the irreducible needs of children (8)(9) can support the interpretation of diagnoses in order to capture the needs of newborns attended to in primary health care consultations. The irreducible needs of children are the foundation to establish experiences and fundamental care around which families, education, care, social security, legal and health systems must organize themselves (7)(8)(9) .
Evidence that support nursing care with newborns in primary health care are essential, however, there are few studies (10)(11)(12) on nursing diagnoses in newborns' health care follow-ups in primary health care.

OBJECTIVE
To describe and analyze nursing diagnoses established in newborn consultations in a primary health care service.

Ethical aspects
The study development complied with national and international ethical standards with research with human beings. The research project was approved by the Research Ethics Committee of the Federal University of São Paulo and authorized by the institution.

Study design, location and period
This is a descriptive and analytical study, with quantitative approach, conducted in an outpatient health care center of philanthropic character, and its operating structure corresponds to a basic health unit.
The outpatient clinic provides primary health care services, offering health follow-up appointments performed by nurses, doctors, nutritionists, psychologists, social workers, pharmacists and dentists, mostly for children, adolescents and women, in addition to routine laboratory examinations, pharmacy, immunization, drug administration and curatives. It is located in the southwestern region of Jabaquara, in the city of São Paulo -a region that has high social vulnerability levels, with 5,999 households in a situation of high vulnerability and 7,330 households with per capita income of up to 0.5 minimum wage (13) .
To decrease the chance of bias, data were collected by two members of the research team, from January to July 2017. The two researchers verified, independently, the records of nursing consultations in newborns' charts, filling an instrument specifically elaborated for this study. The data extracted, doubly checked, referred to clinical and sociodemographic variables of newborns and their families, and to the nursing diagnoses of each consultation.

Population, inclusion and exclusion criteria
Participants were selected from the list of nursing consultations conducted in the service, from January to December 2016, which totalized approximately 170 childcare consultations. Such consultations were conducted, mainly, by the nurse of the service, who is a PhD and specialist in pediatric nursing, that has been working for 20 years in the health service mentioned, or by neonatology nursing residents, under supervision of professors specialized in pediatric nursing of a public federal university in São Paulo.
in a nursing consultation in 2016. The exclusion criterion was the absence of chart records regarding nursing diagnoses. After analyzing the records of the 170 nursing consultations from 2016, 39 were included in the study because they were newborn consultations. Since all had at least one nursing diagnosis, none were excluded from the study.

Study protocol
The studied variables referred to clinical and sociodemographic characteristics of newborns and their families, and to nursing diagnoses. Regarding newborns, these variables included: gender, full term birth (gestational age ≥ 37 weeks), low birth weight (< 2,500g), type of delivery, hospitalization during the neonatal period, chronological age at the time of consultation (days or weeks of life) and household composition.
The diagnoses referred to the registers formulated by the professional in the consultation, being extracted exactly as they were in the patients' chart. Since 2015, nomenclatures from the International Classification for Nursing Practice (ICNP, 2015 version, Brazilian Portuguese) have been used, in order to standardize the language system adopted in diagnoses formulation, as well as to improve technical-scientific knowledge of nurses and professors that perform the consultation in the mentioned service.

Results analysis and statistics
Considering that promoting child health care in the perspective of collective health means to reduce health vulnerabilities and risks related to determinants and constraints (14) of the healthdisease process, the identified nursing diagnoses were analyzed and classified in strengthening or wastage nursing diagnoses in view of this process (15) . The diagnoses of strengthening in view of the mentioned process represent normality and present judgements such as "effective", "suitable" and "normal". The ones related to wastage in view of the health-disease process represent abnormalities or risk for damage and are composed of judgement terms such as "damaged", "stopped" and "altered".
The nursing diagnoses were also analyzed according to Brazelton and Greenspan's frame of reference of irreducible needs of children (8)(9) . These needs are related to the survival and development of individuals, regardless of ethnic origin, social class, physical or mental condition (8)(9) . The authors define six sets of irreducible needs: ongoing nurturing relationships; physical protection, safety and regulation; experiences tailored to individual differences, developmentally appropriate experiences; limit setting, structure, and expectations; and stable, supportive communities, and cultural continuity. The choice of this frame of reference is justified by its fitness to child development process in a comprehensive perspective of human development, which considers the interactive processes of children with their environment (7) . As such reference was not elaborated in the perspective of nursing care, another text was used on a nursing care proposal according to the irreducible needs for this diagnosis classification (16) .
Data were tabulated in an Excel spreadsheet and analyzed in the Epi Info 7 software. Categorical variables are presented according to absolute and relative frequencies, and the numeric variables according to descriptive statistics with mean, standard deviation, maximum and minimum values. The bivariate analysis was conducted to verify the association between clinical and sociodemographic characteristics of the newborn and the occurrence of nursing diagnoses of wastage in view of the health-disease process. For this, the Student's t-test was applied for continuous variables, and the chi-squared test or Fisher's exact test were applied for the categorical variables, with a confidence interval of 95% and significance level of 5%.

RESULTS
In 2016, 37 newborns were assisted in 39 nursing consultations. The newborns were from 1 to 27 days old, with an average of 15 days and mode of 10 days of life. Most of them were male (51.3%), born at term (88.6%), with normal childbirth (67.6%), without low birth weight (96.7%), and without hospitalization in the neonatal period (87.9%).
It was observed that most newborns' families was composed of the parents and their biological children (58.3%); 30.6% of at least one parent, one or more children and one or more family member, related or not (grandparents, uncle, stepmother or stepfather); and 11.1% of the families was composed of only one parent, who was the mother of the child in all cases.
The ICNP nomenclature was the most used to formulate the diagnoses or the focuses of practice. In total, 372 diagnoses were formulated in the 39 consultations, with an average of 9.5 diagnoses per consultation. This total was composed by 48 diagnostic statements, and 17 of them were of strengthening and 31 of wastage in view of the health-disease process.
The strengthening nursing diagnoses regarding the healthdisease process were more frequent (70.9%), as shown in Table  1, when compared to wastage nursing diagnoses (29.1%).
In Table 1, it can be observed that all children had the diagnosis of effective newborn development, and more than 97% of effective growth. Most of the strengthening diagnoses regarding the health-disease process was related to the need for physical protection and safety, and two diagnoses represented the meeting of the need for ongoing nurturing relationships.
Wastage nursing diagnoses appeared less frequently, reaching a maximum of 40.5% children (Table 2). However, there was a higher number of diagnostic titles in this group, showing variability in situations of risk or vulnerability perceived by nurses.
In the analysis of nursing diagnoses according to the frame of reference of the irreducible needs of children, it was verified that the most part corresponded to the need of physical protection and safety (Table 1 and 2). In this need, the diagnoses were relative to the promotion and maintenance of body integrity, and the prevention and treatment of diseases, including: breastfeeding, immunization, sunbathing, sleeping, body hygiene, evacuation and colic, breathing, cutaneous, infectious disorders, insufficient weight gain and nutritional risk.
The irreducible need of ongoing nurturing relationships was the second most contemplated need, with diagnoses relative to the interactions between family members and the newborn, to the bond building, competences and difficulties of relatives to exercise their parental role, as well as possible modifications in the dynamic or on family processes due to the arrival of a new member.
The need for stable, supportive communities, and cultural continuity was observed only in one diagnosis, which reports the existence of problems related to the security in the community the family lived.
There were no identified diagnoses related to the need for experiences tailored to individual differences, developmentally appropriate experiences nor limit setting, structure and expectations.
Clinical and sociodemographic characteristics of the 37 newborns were analyzed regarding their association with wastage nursing diagnoses in view of the health-disease process, as shown in Table 3. However, it was verified that six medical records had no information on the presence of low birth weight (<2,500g), four did not inform on the eventual hospitalization in the neonatal period, two would not inform on full term birth (gestational age ≥ 37 weeks), two did not inform the type of delivery and one had no information on family composition.  The data suggest that the lowest mean age was associated to the occurrence of wastage nursing diagnoses in view of the health-disease process. Other clinical and sociodemographic characteristics of newborns, such as gender, type of delivery, low birth weight, prematurity, hospitalization in neonatal period and family type showed no association with wastage nursing diagnoses.

DISCUSSION
The findings of this study showed that strengthening nursing diagnoses in view of the health-disease process had a lower diversity and an increased frequency when compared with wastage diagnoses. This finding demonstrates that the approach in the childcare nursing consultation privileged aspects to be praised and reinforced, also considering health problems situations. In addition, the results showed that wastage nursing diagnoses in view of health-disease process appeared with a frequency significantly higher in younger newborns.
The diagnoses that were related to potential strengthening of newborns, such as their efficient development, growth, evacuation, adequate sleep, exclusive breastfeeding and adherence to the immunization regime, were also the most frequent in other studies, as follows.
A study on consultations of children from zero to three years (10) identified that the most frequent nursing diagnoses were those related to adequate growth of the child (25%), to adequate child development (26%), to the adherence to the immunization regime (10%), efficient evacuation (12%) and adequate sleep (12%).
In this study, the analysis of nursing diagnoses through the frame of reference of irreducible needs of children and social determination of the healthdisease process allowed us to verify that the health perspective that guides nurses in childcare has moved beyond biological aspects, even though these were the most frequent.
The need for physical protection and safety of the child is the one that mostly corresponds to the biological aspects and it is the most generally observed in health actions. Several researches (10,15,17) highlight the identification of nursing diagnoses that are related to the need to offer protective environments against physical and physiological insults (7) , such as what was observed in this study, which matches newborns situation of absolute dependence on their caregivers regarding their physical and emotional well-being.
Among the diagnoses that indicate wastage, those related to the need for physical protection and safety also prevailed, and their relation with cultural and social factors involved in the families' ways of caring is observed. The diagnoses of risk for suffocation, present in 40.5% of these children, can be related to parent-infant cosleeping, to the use of objects in the crib and to the newborn lateral or ventral decubitus as a sleeping position.
In addition to accidental suffocation, previous studies show that several risk factors related to sudden infant death syndrome, such as prematurity, male gender, passive smoking, newborn overheating and ventral decubitus (18)(19) . Studies performed in England (19) and in the Unites States (20) stressed the greater risk for sudden infant death in families in situation of social vulnerability, as well as the influence of parental behavioral aspects, such as the belief that the baby is not in risk when they practice co-sleeping, being their decision-making process guided by the perception of what would bring comfort to the child and make them sleep. Although the nurse should prevent accidental suffocation, promoting safe sleep practices, such as the guidance for the infant to sleep in a dorsal decubitus position, without blankets or other objects, in a crib with a firm mattress and in the parents' room (21) , it becomes crucial to consider the families' way of life, especially those in situation of social vulnerability, with scarce alternatives to the parent-infant co-sleeping.
The diagnosis of impaired tissue integrity, in this study, corresponded to the presence of diaper dermatitis and miliaria in babies and had similar prevalence to other studies with newborns. One of these studies identified that this diagnosis in 14.3% of hospitalized neonates in rooming-in (22) , and another in 11% of pre-terms in ambulatory monitoring (23) . The diagnoses related to the need for ongoing nurturing relationship and stable and supportive communities, which were in the second position regarding frequency, show the apprehension of knowledge concerning the importance of interacting with the child, as well as supporting the family, as essential aspects related to child health.
A study (17) that adopted the same frame of reference of irreducible needs showed that the facilitators of child safety for children under one year old include parents' presence and involvement, constant vigilance for physical and emotional protection, stimulating experiences of development, and supportive networks for the care of the child at home.
Nursing diagnoses that were related to the irreducible need for ongoing nurturing relationships, such as effective bonding and parent role, highlight that child health care implies to care for their development, understanding it as a phenomenon of continuity and change of biopsychological characteristics depending on reciprocal interaction processes of children with their context (7) . In this sense, a nursing consultation must strengthen families in the construction of their parenting, since, in the development process, children need positive interactions and proper care, performed by adults committed to their health and well-being (24) . The identification of such diagnoses in the scenario of this study points out to a larger view of child health care that can implement this strengthening of safe emotional interactions and promote healthy development of the child.
Although this expansion of the focus of care in the analyzed consultations is observed, the absence of diagnoses related to the need for experiences tailored to individual differences, developmentally appropriate experiences nor limit setting, structure and expectations is suggestive that there is still no incorporation of these aspects in newborns consultations.

Study limitations
Although this study analyzed data referring to 39 nursing newborn consultations and their families, some limitations include the small sample size and their unicentric character. Future researches expanding the number of families and their sociodemographic diversity can generate new evidence related to nursing diagnoses in childcare consultations of the newborn, as well as recognizing children's irreducible needs of a particular population.
Although the theoretical frame of reference of irreducible needs of children was not anchored in the collective health frame of reference, used in this study to classify the diagnoses in strengthening and wastage categories in view of the health-disease process, it is a specific frame of reference to child population, and it is considered that its use allowed to verify gaps that can be improved to reach completeness in newborn care. Future studies that considered both children's particularities and other aspects of social determination of the health-disease process may expand the understanding on the topic.

Contributions to the field of Nursing
Our study contributed to generate evidences regarding the adoption of a frame of reference specific to children in order to analyze nursing diagnoses that occurred in the clinical practice during consultations in the context of primary health care of the child. No studies were found that established a correlation between nursing diagnoses and the constructs of these irreducible needs of children's frame of reference. Our results demonstrated diagnoses related to the need for ongoing nurturing relationships, physical protection and safety, and stable and supportive communities.
The interpretation of nursing diagnoses according to the frame of reference of irreducible needs of children allows the nurse to plan care aiming to enrich the opportunities for the development of children's intellectual, emotional, social and physical skills in the home environment. The care that meet the needs for physical protection and safety, as well as for nurturing relationships, involve protective and safe environments, in addition to loving and empathetic interactions, so that the child feels loved and desired (7)(8)(9) . The experiences and opportunities of good relationships in the first years of life help to create a strong foundation, generating values, cognitive skills and sociability in future life. Therefore, the daily care of small children is fundamental for them to grow and develop to be physically healthy, emotionally safe and respected as social subjects (24) .
Considering the needs of each children and their families in their context of life, the nurse should seek to promote integral and integrated development, especially in the first three years of life, in order to improve family care practices. A expanded childcare clinic implies including sectors of early childhood education, social development and others so that it can act articulately with health professionals and with families to promote integral and integrated child development (25) .
Finally, the analysis of nursing diagnoses according to potential strengthening and wastage in view of the healthdisease process also favored the recognition of the healthdisease profile of the studied population, providing guiding elements of nursing care actions with newborns, their families and communities.

CONCLUSION
The most frequent nursing diagnoses were those related to strengthening in view of the health-disease process, such as the effective newborn development and growth. Nursing diagnoses indicating wastage were also present, especially risk for suffocation and impaired tissue integrity. The analysis of diagnoses according to the frame of reference of irreducible needs of children highlighted the need for physical protection and safety of newborns. Our results suggest that families are strengthened for newborn care, however there is a need for practices that strengthen family care and prevent child health problems.