ICNP® terminology subset to infants in Primary Health Care

Objectives: to describe the development of an ICNP® terminology subset for Nursing Consultation to infants in Primary Health Care. Methods: a methodological study, described in five stages, carried out from May to September 2018 with 15 nurses who identified diagnoses, results, interventions, and validated the subset content. Results: the subset developed consists of 86 nursing diagnoses and results and 178 interventions, organized in the fields of Theory of Basic Human Needs. Final Considerations: the subset contributed to implement the systematized Nursing Consultation, assisting nurses in decision making. Construction and validation consolidate evidence-based practice, bringing the subset closer to practical reality, in addition to contributing to infant health care qualification.


INTRODUCTION
Infant care, i.e., children older than one year (1) , is important in determining their quality of life. It is in childhood that cognitive, social and learning capacities are more sharply developed; however, dysfunctions in the body may arise which, when left untreated, are likely to cause negative consequences to the health of infants (2)(3) .
In Brazil, population estimates made for 2018 showed that the number of children under one year old was 2,774,484. Hospital morbidity records revealed an admission of 626,089 (22.56%) of these children (4) . The main causes recorded are mainly related to conditions originating in the perinatal period; diseases of the respiratory, genitourinary, nervous and digestive systems; infectious and parasitic diseases; congenital malformations, deformities and chromosomal abnormalities; skin and subcutaneous tissue diseases; endocrine, nutritional and metabolic diseases (5) .
Thus, surveillance and monitoring of child growth and development are considered to be a fundamental strategy to promote the health of infants and detect diseases early (3) . This monitoring is, especially, developed in the scope of Primary Health Care (PHC) in performing childcare Nursing Consultation (NC). Childcare aims to identify individual and comprehensive health needs; carry out periodic and systematic monitoring of growth and development; provide care; assess the results; promote child health and, consequently, reduce child morbidity and mortality (2,(6)(7) .
Health promotion actions carried out by nurses, during Childcare NC, are evidenced by attitudes that go beyond technicist practice. They cover the family, environmental, social, economic and cultural context of families, in addition to promoting health education, favoring child growth and development through a comprehensive view (2) .
In this regard, there is a growing interest and concern in building a language that can support the performance of nurses systematized and recognized worldwide. Thus, the International Classification for Nursing Practice (ICNP®) stands out as a tool to support effective clinical decision-making and in the description of professional practice in an organized way (8) . One of the ways to enhance ICNP® use is by building terminology subsets, consisting of statements of diagnoses, results and nursing interventions for a group of customers and selected health priorities (8)(9)(10) .
Considering that infant care requires a holistic and comprehensive view from nurses, this subset was built in light of Wanda Horta's Theory of Basic Human Needs (BNH) (11) . A subset was not identified in the researched literature for this age group in PHC.

OBJECTIVES
To describe the development of an ICNP® terminology subset for NC to infants in PHC.

Ethical aspects
The recommendations of Resolution 466 of 2012 were supported. This study was approved by a local Research Ethics Committee, under Opinion 2,630,923, on May 2, 2018.

Type of study
This is a methodological study recommended by the International Council of Nurses (ICN) (8) . It was described in five stages: identification of the focus/catalog customer; health priority documentation; ICNP® seven-axis model use; testing and validation with expert nurses; dissemination of an ICNP® terminology subset.

Study and study participants
This study is the result of a Professional Master's Degree Course in Nursing and is part of a research macro project entitled "Estratégias para a implementação da Sistematização da Assistência de Enfermagem no cuidado à mulher e à criança".
This study was carried out with 15 nurses working at PHC in a municipality in the Midwest of Santa Catarina, between May and September 2018. All nurses were selected through a search carried out in the Brazilian National Register of Health Facilities (Cadastro Nacional de Estabelecimentos de Saúde). Nurses and those working in child care at PHC were included. Nurses who were on leave due to leave or working in the position for less than six months were excluded.

Collection, and organization and analysis of data
Step 1 -Identification of the focus/catalog customer: infant, age group defined from the professional experiences of a master's student, when considering the need to contribute to the organization and improvement of child health care.
Step 2 -Documentation of health priority: the epidemiological profile of child health in the municipality was drawn up using the data available in the following Brazilian information systems: Mortality Information System (Sistema de Informação de Mortalidade), Live Birth Information System (Sistema de Informação sobre Nascidos Vivos), Hospital Information System of the Brazilian Health System (Sistema de Informações Hospitalares do Sistema Único de Saúde) and outpatient nature, in the health management system.
With these data in hand, four Focus Groups (FG) (12) were carried out with 15 nurses to create an ICNP® terminology subset and to support the process of construction, discussion, testing and validation. The script for each FG and its conduction were carried out by a master's student, by two professors and by a Scientific Initiation student.
Step 3 -ICNP® seven-axis model use: in the first FG, discussions were held about Wanda Horta's theory (11) , its concepts, propositions and principles, which allowed incorporating the theoretical model chosen for the subset construction. In the second FG, identification of nursing diagnoses and results was carried out by using the ICNP® seven-axis model, 2017. The epidemiological profile, based on information systems, and empirical evidence were used nurses' experiences, to develop a list of relevant terms for infant care. For each empirical evidence or epidemiological data, terms were selected that integrate the Focus axis (area of attention relevant to nurses) and another one of the Judgment axis (clinical opinion or determination related to the focus of nursing practice), minimally; or even represented by a clinical of Subconjunto terminológico da CIPE® para o lactente na Atenção Primária à Saúde Siega CK, Adamy EK, Sousa PAF, Zanatta EA.
Find (state, process, structure, function or altered behavior). The reference model of ISO 18.104:2014 is the basis for its writing. ICNP® pre-coordinated concepts were also used in the statements' final writing (13)(14) .
In the third FG, nursing interventions were selected for each identified diagnosis, considering ISO 18.104: 2014 (13)(14) from the terms of the Action axis (intentional process applied to infants) and target terms (entity affected by action). Thus, when necessary, the actions were qualified using the terms that correspond to route, time, place, and subject according to ICNP® as well as pre-coordinated concepts, in their final writing.
In the fourth FG, the subset content was validated, which corresponds to Step 4 -Testing and validation with expert nurses. Nurses tested the subset, during NC performance in childcare, for 30 days. In this research, the participating nurses were considered expert nurses. After testing, the subset was validated using Content Validity Index (CVI) containing five questions, which was assessed individually. The result of the assessment with a score equal to or greater than 0.80 of agreement rate was established as acceptable (15) .
CVI uses a Likert scale with a score from one to four, namely: 1 -Inadequate; 2 -Partially adequate; 3 -Adequate; 4 -Totally adequate. Score was calculated by adding the items' agreement, divided by the total number of responses. If any criteria did not reach the established agreement rate, the content would be revised for readjustment and, then, validation would be carried out (15) . There was no need for changes in this study, as the subset scored 1.0 (100%).
Step 5 -Dissemination of the ICNP® terminology subset: the subset was incorporated into Childcare NC and triggered movements to create a working group and a strategy schedule to create the Municipal Child Health Protocol.

RESULTS
The data obtained from the municipality's health management system revealed the registration of 1,219 children under one year old, able to implement Childcare NC, in August 2018 (16) . From January to August 2018, the municipality registered hospitalizations for: infectious and parasitic diseases (17); nutritional and metabolic endocrine diseases (4); respiratory system diseases (32); digestive system diseases (16); skin and subcutaneous tissue diseases (2); genitourinary system diseases (2); diseases originating in the perinatal period (65); congenital malformations, deformities, and chromosomal abnormalities (5); symptoms, signs and abnormal clinical and laboratory findings (3); injuries, poisoning and some other consequences of external causes (2) (17) .
The reason for attending children in Basic Health Units (BHU) in the city, in 2018, was due to problems related to situations that affect BNH: diseases of the respiratory system (369); infectious and parasitic diseases (42); nutritional and metabolic endocrine diseases (15); diseases of the skin and subcutaneous tissue (62); digestive tract diseases (69) (16) .
Thus, from the focuses of nursing care, the statements of diagnoses and the results of nursing were associated. For each nursing diagnosis identified, it was associated with nursing interventions resulting from Evidence-Based Practice (EBP) (scientific studies and / or experiences of nurses in childcare NC). ICNP® terminology subset for infants consisted of 86 nursing diagnoses and results and 178 nursing interventions, alphabetically ordered and conceptually organized, according to BNH (11) (Chart 1).

DISCUSSION
Developing a terminology subset is essential to support the assistance of nurses in infant care, as it allows professionals to carry out a careful and anchored assessment in a Standardized Language System (SLS) that favors health promotion actions; early identification of changes and aggravations to child health; and understanding of the growth and development process by the family (3) .
The nurses' actions, guided by terminology subsets, contribute to the clinical reasoning, planning and assessment of actions carried out in childcare NC. In this regard, ICN (8) proposes that the theoretical model chosen to structure a subset is at the discretion of the researcher, and should be in line with the practice, context, and customer. Thus, Wanda Horta's theory (11) aligns with this subset when she understands health as a state of dynamic equilibrium that can be affected, requiring, therefore, care.
In this ICNP® terminology subset, psychobiological needs related to oxygenation and risk of changes in the respiratory system were identified. A study (18) that analyzed the morbidity and mortality profile of high-risk neonates highlighted respiratory diseases as causing morbidities. Thus, in addition to the nursing interventions selected in this subset, it is important to highlight the need to check the infant's respiratory rate, as it is identified as one of the defining characteristics prevalent for respiratory infections (19) .
Infant nutrition, a psychobiological need identified in this subset, is also the subject of a study (20) that described the profile of the population under one year of age attended in Childcare NC. It was evidenced that the majority of infants were eutrophic  Guiding not to wear tight clothing on infants and discouraging umbilical band use; Guiding not shake infants while breastfeeding and after breastfeeding; Guiding diaper change, when necessary, to be performed before feedings, avoiding lying infants soon after breastfeeding; Guiding mother/father/caregiver about physiological reflux and gastroesophageal reflux disease; Positioning infants in supine position to sleep; Positioning infants with the head elevated after feeding for 20 minutes or until eructation;

Risk of diarrhoea Risk of impaired gastrointestinal system function
Scheduling follow-up appointment; Assessing the infant's bowel habits; Assessing signs of dehydration: mucosal moisture, turgor and skin elasticity, presence of tears and diuresis, sunken eyes and depressed fontanelles; Referring to appointment with a medical professional; Identifying the duration, frequency, intensity, appearance, consistency and odor of feces; Identifying the quantity and type of liquids or food ingested; Guiding the replacement of liquids and electrolytes through Oral Rehydration Therapy (ORT); Requesting family monitoring by a Community Health Agent.

Risk of sudden infant death Proper sleep Poor sleep
Scheduling follow-up appointment; Guiding infants to sleep in supine position, even those with gastroesophageal reflux, with their feet leaning against the lower edge of the crib; Guiding so that the mattress is firm and the size of the crib; Guiding so that the car safety seat and stroller are not used for regular sleep; Guiding so that the bed is not shared with parents; Guiding the relationship of sudden death and the mother's smoking habits as well as use of drugs and alcohol; Strengthening breastfeeding; Using only a sheet to cover infants, not covering their head and wear clothes for their heating.
To be continued Encouraging oral cavity hygiene to promote cleansing, massage the gum and accustom infants to mouth manipulation; Guiding mothers to avoid using tampons in the breast; Guiding mothers to sanitize the breast after feeding; Guiding mother/father/caregiver to perform oral hygiene of infants after feeding; Guiding mother/father/caregiver about pacifier damage and bottle use; Guiding mother/father/caregiver to sanitize the bottle, pacifiers and toys that come into contact with the infant's mouth; Guiding infant oral health care; Prescribe medication for infants according to the institutional protocol; Prescribe medication for application to the mothers' breasts after breast hygiene following an Institutional Protocol. Scheduling follow-up appointment; Administering antipyretic in accordance with an Institutional Protocol; Applying water compress at room temperature; Relieving excess clothing; Consulting mother/father/caregiver if infants took medication for fever; Consulting mother/father/caregiver about what medication infants usually take for fever; Referring to appointment with a medical professional; Monitoring and recording body temperature; Guiding mother/father/caregiver of infants with a temperature above 38ºC to seek health/emergency services; Guiding mother/father/caregiver about shower bath; Supporting the role of parents as promoters of child development; Referring to appointment with a medical professional; Guiding mother/father/caregiver about necessary encouragement for infants by using toys and games for child development (according to the age group); Guiding mother/father/caregiver on domestic accident prevention; Guiding mother/father/caregiver about the milestones of child development, according to the age group;

PSYCHOBIOLOGICAL NEEDS -NEUROLOGY REGULATION
Performing assessment and annotation of child development milestones in a Child Health Booklet; Verifying with mother/father/caregiver what they think and/or perceive about the infant's development process.

PSYCHOBIOLOGICAL NEED -IMMUNOLOGICAL REGULATION
Inflammation (mild, moderate, severe) Improved inflammation Adherence to the immunization regimen Improved skin integrity Non-adherence to the immunization regimen Risk of impaired skin integrity Scheduling follow-up appointment; Assessing skin integrity; Assessing characteristics of the lesion and the skin around it; Referring to appointment with a medical professional; Encouraging body hygiene; Guiding mother/father/caregiver about the importance of body hygiene; Advising the importance of vaccines and to keep vaccination scheduling up to date; Requesting family monitoring by a Community Health Agent; Using scissors or nail clippers with a rounded tip and for exclusive use of for infants to cut the nails; Wearing clothing appropriate to the temperature; Verifying the infant's vaccination status.

Risk of infection
Scheduling follow-up appointment; Assessing body hygiene state; Assessing umbilical stump skin integrity; Demonstrating technique for umbilical stump hygiene; Performing umbilical stump hygiene with 70% alcohol whenever necessary; Keeping the umbilical stump clean and dry; Guiding mother/father/caregiver about basic care with the umbilical stump and body hygiene; Guiding mother/father/caregiver not to use umbilical band and other products on the umbilical stump; Requesting family monitoring by a Community Health Agent.

PSYCHOBIOLOGICAL NEEDS -CELL GROWTH REGULATION
Delayed growth (or growth delay) Growth within normal limits Risk of delayed growth (or delayed growth) Risk of disproportionate growth Scheduling follow-up appointment; Measuring the anthropometric parameters: weight, height, head circumference, thoracic and abdominal; Performing bone, dental and physical-motor development assessment; Recording the information in the Child Health Booklet and assessing the related graphics; Observing breastfeeding (infant position, grasp, suction and the mother's breast); Guiding mother/father/caregiver on a routine of childcare appointments; Verifying with mother/father/caregiver what they think and/or perceive about the infant's growth process.

PSYCHOBIOLOGICAL NEEDS -VASCULAR REGULATION
Altered skin color (Jaundice -mild, moderate, severe) Normal skin color Knowledge of the mother/father/caregiver about proper skin color Lack of knowledge of the mother/father/ caregiver about skin color Scheduling follow-up appointment; Increasing the frequency of breast milk supply; Assessing jaundice location and intensity; Assessing breastfeeding; Referring to appointment with a medical professional; Encouraging breastfeeding on demand; Guiding mother/father/caregiver about jaundice; Sunbathing with infants without clothes, before 10 a.m. and after 4 p.m,, for up to 10 minutes; To be continued Chart 1 (80.2%), at nutritional risk (2.1%) and with some degree of malnutrition (17.7%). Therefore, NC is important in childcare in the identification and early referral of infants, evidenced by the referrals made by the nurse to the pediatrician, when changes in the physical examination (70.6%) and when infants received a prescription of vitamin A and iron (19.6%) (20) . Diarrheal diseases were the second leading cause (29.2%) of morbidity in the study (18) carried out with high-risk neonates. Of a total of 70.8% of children who fall ill until the age of six months, 12.5% required hospitalization, reinforcing the importance of the nursing diagnoses and results identified and selected for the present subset related to elimination (18) .
The terminology subset is an essential tool for Childcare NC, as it facilitates the investigation of factors that influence the health of infants and contribute to the nurses' clinical reasoning and decision making, aiming at the protection and promotion of child health (9) . Furthermore, early identification and intervention of problem situations are essential to prevent the progress of a clinical condition and its worsening (20) .
Growth assessment is important for monitoring infants' health and nutrition conditions, carried out through clinical and social history, physical examination and data provided by parents. Child development assessment occurs according to the development milestones, i.e., it refers to the construction of human identity evidenced in the progressive transformations, maturation, learning, psychic, and social aspects (21)(22) .
The plurality of nursing diagnoses and results identified in this subset are related to the focus of child growth and development (cell growth, nutrition, neurological regulation, immune regulation, thermal regulation, sleep, and rest). These findings reinforce a study (3) that considered Nursing Process (NP) implementation relevant to children in their different phases, thus building statements of nursing diagnoses by steps of child growth and development.
Among the psychobiological needs, situations that affect the infant's skin and mucous membrane integrity were also identified. Nursing diagnoses and results focus on child morbidity situations, meeting the local health diagnosis. In this regard, problems related to skin and mucous membrane integrity were observed in other studies (6,20,(23)(24) , which selected these nursing diagnoses, mainly diaper dermatitis, miliaria, heat erythema, diaper erythema, perineal and oral candidiasis.
Psychosocial needs for love, security, attention and participation related to family interactions were listed in the subset presented here. These needs are aligned with the aspects that involve the infant's development and that occur in a relatively short period of time, requiring the effective participation of the family. Situations related to parenting reflect behavioral manifestations in childhood, in which practices involving parent engagement in care, in communication, expression of affection and in constructive conflict resolution strategies are considered positive practices (6,25) .
Validation by nurses consolidates EBP and brings the terms that make up the subset closer to the practical reality, thus contributing to infant health care qualification through Childcare NC.
ICNP® use assists nurses in clinical reasoning in decision making through EBP and registration of professional practice, contributing to the prerogatives of Resolution COFEN (Conselho Federal de Enfermagem -Brazil's Federal Council of Nursing) 358 of 2009 (26) . Moreover, NC guides care and documents the nurses' practice, and implementing a care based on a nursing theory entrusts theoretical and scientific foundation to its actions (14,27) .

Limitations of the Study
This study resulted in diagnoses, results and nursing interventions centered on psychobiological and psychosocial needs, with a focus on morbidities and infant growth and development. In Chart 1 (concluded) of Subconjunto terminológico da CIPE® para o lactente na Atenção Primária à Saúde Siega CK, Adamy EK, Sousa PAF, Zanatta EA.
this regard, it is necessary to advance studies on the theme to create and propose new terms that contemplate other needs provided in Theory, in order to complement this subset and qualify child care in PHC.

Contributions to nursing
This subset cooperates with the ICN recommendation in building ICNP® catalogs. It contributes to the description of professional practice through a unified nursing language. In addition, it enables effective and safe care for infants and their families through the implementation of systematic actions; therefore, it contributes to early detection of health problems and providing care aimed at health promotion, resulting in quality of care.

FINAL CONSIDERATIONS
The ICNP® terminology subset, developed in this study, is an important tool in PHC due to its compatibility with nurses' experiences during Childcare NC. Moreover, using a SLS organizes the nurses' work process, contributing to safe and effective care for infants.
Subsets also collaborate to implement a systematic childcare NC and for the use of specific nursing diagnoses, results and interventions for infants, contributing to NC registration; internationally recognized terminology of specialized nursing practice languages is applied, favoring communication between health professionals, with a view to comprehensive care.
It is necessary to incorporate the subset into care protocols, in order to strengthen the guidance and organization of professional practice, given its importance in contributing to quality and safety of child care through evidence-based actions.