Nursing instrument to attend mothers who recently gave birth in primary health care

ABSTRACT

Objective:

To build a nursing instrument to attend mothers who have recently given birth in primary health care.

Method:

This is a methodological research developed in five stages: identification of empirical indicators associated with mothers who have recently given birth by reviewing integrative literature; evaluation of empirical indicators by focal group; instrument structuring by categorizing indicators; instrument validation using the Delphi technique; and application and development of diagnostic statements and nursing interventions.

Results:

The instrument comprises identification data on mothers who have given birth recently, on the assessment of their human needs, and on nursing Care items. In the final version, we selected 73 diagnoses and 155 nursing interventions.

Conclusion:

With the completion of this study, nurses will have an instrument for Nursing Care Systematization to attend mothers who have given birth recently in primary health care. Besides, this study will also work as a tool in research and teaching of Obstetric Nursing.

Key words:
Obstetric Nursing; Post-Partum Period; Nursing Care; Data gathering; Validation Studies

RESUMO

Objetivo:

construir um instrumento de Consulta de Enfermagem à puérpera na atenção básica.

Método:

trata-se de uma pesquisa metodológica desenvolvida em cinco etapas: identificação dos indicadores empíricos relativos à puérpera por meio de revisão integrativa da literatura; avaliação dos indicadores empíricos por grupo focal; estruturação do instrumento mediante a categorização dos indicadores; validação do instrumento pelos especialistas pela técnica Delphi; e aplicação e desenvolvimento das afirmativas de diagnóstico e intervenções de Enfermagem.

Resultados:

o instrumento é constituído por dados de identificação da puérpera, avaliação das necessidades humanas da puérpera e itens do cuidado de Enfermagem. Na versão final, foram selecionados 73 Diagnósticos e 155 Intervenções de Enfermagem.

Conclusão:

com a conclusão do estudo, a enfermeira disporá de um instrumento para Sistematização da Assistência de Enfermagem à puérpera na Atenção Básica. Além disso, o documento servirá como ferramenta ao ensino e à pesquisa em Enfermagem Obstétrica.

Descritores:
Enfermagem Obstétrica; Período Pós-Parto; Cuidados de Enfermagem; Coleta de dados; Estudos de Validação

RESUMEN

Objetivo:

construir un instrumento de Consulta de Enfermería para puérperas en la atención básica.

Método:

investigación metodológica desarrollada en cinco etapas: identificación de indicadores empíricos relativos a la puérpera mediante revisión integrativa de literatura; evaluación de indicadores empíricos por grupo focal; estructuración del instrumento mediante categorización de los indicadores; validación del instrumento por los especialistas aplicando técnica Delphi; y aplicación y desarrollo de las confirmaciones de diagnóstico e intervenciones de Enfermería.

Resultados:

el instrumento se conformó con datos de identificación de la puérpera, evaluación de necesidades humanas de la puérpera, e ítems del cuidado de Enfermería. En la versión final, fueron seleccionados 73 Diagnósticos y 155 Intervenciones de Enfermería.

Conclusión:

con la conclusión del estudio, la enfermera dispondrá de un instrumento para la Sistematización de la Atención de Enfermería a la puérpera en Atención Básica. Además, el documento servirá como herramienta de enseñanza e investigación en Enfermería Obstétrica.

Palabras clave:
Enfermería Obstétrica; Período Posparto; Atención de Enfermería; Recolección de datos; Estudios de Validación

INTRODUCTION

During the woman's life course, she experiences peculiar situations to the feminine self. Among these, we highlight the pregnant-puerperal period, extended from pregnancy to postpartum.

During pregnancy, the woman experience a state of adjustment because of the biological, psychological, and social changes caused by gestation and delivery, putting her in a vulnerable situation. Women who have given birth recently have to balance their role as a mother, partner, and housewife, which added to an unfavorable socioeconomic situation might be a risk to her pregnant-puerperal state⁽¹⁾.

According to the Brazilian Ministry of Health, the woman who has given birth recently and the newborn need a follow-up visit to the health unit, a medical home call in the period of 7 to 10 days of puerperium, and a medical or nursing appointment 42 days after childbirth⁽²⁾. In this context, we noted the lack of a systematized instrument to document all stages of nursing care to women who have given birth recently in primary health care.

In everyday life of health services, professionals, particularly nurses, when attending mothers who have given birth recently, prepare their own stages of postpartum care. This way, it lies under their responsibility to judge what is important to be observed, assessed or even questioned. Considering the lack of legitimate criteria to consider in the care of mothers who have given birth recently, the assistance provided in the postpartum appointment acquires an unsystematic character.

The reality of the exercise of attending woman who have given birth recently is far from the recommended in the practice of the Nursing profession according to the organs and laws that regulate it. To systematize the nursing care, professionals need to use a scientific method in their daily practices: the Nursing Process (NP). Accordingly, the resolution 358/2009 determined the implementation of NP in all public and private health units where professional nursing care occurs⁽³⁾.

When carried out in institutions that provide outpatient health services, households, schools, charitable associations, among others, the NP is named as nursing appointment. However, it is not fully implemented in public or private health institution yet.

Thus, we considered important to elaborate and validate an instrument with adequate scientific rigor to be used in nursing care of mothers who have given birth recently in primary health units. The level of agreement of above 70% among nurses who were part of the experts panel validated the instrument of nursing care to mothers who have given birth recently after hospital discharge.

In the construction of the instrument for the Nursing Care Systematization, we used the diagnostic and nursing interventions from the ICNP^®(4) terminology since it is a relevant methodology for nurses in professional practice. The results of the project CIPESC^®(5) were also employed. This project was developed in Curitiba by nurses from the Brazilian Association of Nursing, using the ICNP^® terminology adopted by Garcia and Cubas⁽⁶⁾.

Furthermore, the construction of our instrument was based on the International Essential Data Set for Nursing, dividing it in three categories, namely: the clients' demographic items, nursing care items, and service items⁽⁷⁾. However, the classification of psychobiological, psychosocial, and psychospiritual needs was based on the Theory of Basic Human Needs by Horta⁽⁸⁾. This study aimed to build an instrument to document nursing care to mothers who have given birth recently in primary health care.

METHOD

To build a nursing care instrument, we developed a five phase study of methodological type:

1. Identification of the empirical indicators by carrying out a comprehensive review of the scientific literature;

2. The evaluation of the first version of the instrument by focal group. In this stage, we considered the empirical indicators identified in the first phase of the study.

3. Instrument structuring by categorizing the empirical indicators of women who have recently given birth with focal group evaluation, according to Garcia and Cubas⁽⁶⁾;

4. The validation of the content and of the second version of the instrument using the Delphi Technique. This study used data on the institution, identification data on women who have given birth recently, and also data on the evaluation of the human needs of the ones who have given birth recently. After the first evaluation, the document was submitted to correction;

5. Selection and development of nursing diagnosis statements/nursing interventions and results based on the validated items. And, finally, the structuring of the instrument final version divided into parts: data on the institution and identification data on mothers who have given birth recently; human needs evaluation; nursing care planning - nursing diagnosis/results and requirements.

As this research involves human beings, we ensured the rights and duties regarding the scientific community, as well as for the subjects under study according to the Resolution 466/CNS 2012⁽⁹⁾. The project was submitted to the Research Ethics Committee of the Federal University of Rio Grande do Norte (CEP-UFRN) via Plataforma Brasil.

RESULTS

Results of the 1^st stage: Identification of empirical indicators of human needs in psychobiological, psychosocial and psychospiritual levels of mothers who have given birth recently with comprehensive review of the scientific literature.

Empirical indicators are experimental propositions used to measure and provide evidences on the concepts of a theory⁽¹⁰⁾. In this study, empirical indicators were considered changed manifestations of human needs of postpartum mothers.

For the identification of the empirical indicators of human needs in puerperium, during the months of January and February 2013 we searched for information on the postpartum period in the databases Scopus, Cinahl, Pubmed, Lilacs, and Cochrane, in the Journal of Midwifery and Women's Health, as well as in official documents of the Brazilian Ministry of Health and of the Nursing Regional Council of Rio de Janeiro.

In the comprehensive review of scientific literature, 98 empirical indicators were identified once they are associated with basic human needs, 46 of them being considered of psycobiological order, 51 of psychosocial order, and only 1 of them being of psycospiritual order.

Results of the 2^nd stage: Evaluation of the first version of the instrument - empirical indicators and their relation with the human needs evaluated by a focus group.

The preliminary version of the instrument constituted by the empirical indicators identified in the literature was evaluated by five experts using the focus group technique. It is worth to highlight that this is a research methodology composed of group interviews that, when used in the construction of indicators, aims at getting a consensus on the data found. These data will be subsequently analyzed by the researcher and transformed into instruments or devices⁽¹¹⁾.

Participants discussed human needs and their relation with empirical indicators until they came to an agreement. In the category of psysobiological needs, they selected the ones for oxygenation, hydration, food, elimination, sleep and rest, physical activity, sexuality, physical and environmental security, body care, physical integrity, vascular regulation, thermal regulation, neural regulation, perception of sense organs, therapy, and prevention.

As for the psychosocial needs, participants considered the needs for communication, being part of a group, recreation and leisure, emotional security, love and acceptance, self-esteem, self-confidence, self-respect, freedom and participation, health education/learning, self-realization and space. At this stage, there was no empirical indicator concerning psycospiritual needs.

Results of the 3^th stage: Instrument structuring by categorising the empirical indicators that affect the human needs of mothers who have given birth recently making use of the focus group evaluation, according to Garcia and Cubas⁽⁶⁾.

In this phase, from a total of 78 identified and categorized empirical indicators, we highlight 27 affected human needs, 16 of them being of psycobiological order, 10 of psycosocial order, and 1 psycoespiritual order. Afterwards, we carried out a categorization process guided by a set of information that professionals must collect from the clientele, as proposed by Garcia and Cubas⁽⁶⁾.

Following the categorization of indicators, the document was introduced to experts for the approval of the ones that would be part of the final version of the instrument. After signing and having the informed consent form in hands, nurses validated the instrument using the Content Validity Index (CVI)⁽¹²⁾.

Thus, they considered the total content valid, as the percentage exceed the previously established validation value of 70% of agreement. However, there were no suggestions for changes in the terminology of human needs for food.

Results of the 4^th stage: The validation of the content and of the second version of the instrument using the Delphi Technique.

We used the Delphi validation technique to obtain, compare, and guide the experts' judgment to come to an agreement on a particular subject⁽¹³⁾. The results showed that in the identification data mothers who have given birth recently, some items not obtained the minimum index of 70% of agreement to be considered valid, namely: responsibility for the family, need for physical activity, and also for love and acceptance.

Some experts considered not be the right time for practicing physical activities, being more important to assess whether the activity practiced by the mother is indeed inappropriate to her conditions in the period.

From the assessed items considered adequate, the agreement index was between 70 and 100%. They considered the content as valid, as the minimum percentage exceeded 70% of agreement. In this stage of assessment, participants suggested the inclusion and the exclusion of some components: to include "date of medical appointment", to exclude "age", and replace the term "delivery time" for "delivery data" with agreement index of 100%.

The experts suggested removing the question "is there satisfaction/pleasure in sexual relations?", and justified that during puerperium this aspect becomes irrelevant in the first week after childbirth. We have sent the changes to the participants once again for their approval, and, as we obtained 70% of CI, we excluded this question from the instrument. However, in the case of the first puerperal appointment, seven days after childbirth, this would be acceptable; however, after more days postpartum, it becomes relevant for us to investigate mothers' sexual satisfaction considering that usually sexual activities return in this period.

After these assessments, we also excluded the item: "housing conditions (good, regular, poor)", because, according to the experts, it is something that depends on the point of view. It obtained a 70% CI, thus being excluded from the instrument. Meanwhile, they suggested adding the "uterine height__cm" in the need for hormonal adjustment with 100% CI.

The exclusion of "most recent complete blood count result" and "most recent oncotic cytology result" was suggested once that, depending on the date of the examination, results might be outdated. The reached indexes were of 70% and 50%, respectively. Regardless of this assessment, we maintained the items. This is explained by a study carried out in England that included 279 mothers with 2 months postpartum, among which 115 had anaemia. Postpartum anaemia contributes with 25% of maternal deaths, being of great importance to investigate it and treat it properly⁽¹⁴⁾.

Regarding the need for religion and spirituality, we excluded the question: "Do you enjoy life? Why?". Experts considered it vague and embarrassing, and, therefore, we excluded it from the instrument since we obtained 80% of CI. After the application of the suggested alterations, we obtained a set of essential data to be collected about mothers who have given birth recently, considering these mothers are in their home environment and are seen from a holistic perspective that approaches their biological, psycosocial, and spiritual aspects. From the assessed and validated items, we corrected the second version of the instrument.

Results of the 5^th stage: Instrument structuring by applying and developing nursing diagnosis statements/nursing interventions and results.

In the final drafting of the instrument, we selected 73 nursing diagnoses and 155 nursing interventions based on ICNP^® terminology, according to Garcia and Cubas⁽⁶⁾. There were changes regarding the nursing diagnoses and interventions to avoid their repetition in more identified needs. The changes we have made are associated with the needs for food, elimination, sleep and rest, physical and environmental security, body care, and, finally, breastfeeding.

DISCUSSION

The speech on human needs for food is now "to encourage food intake according to nutritional needs, food preferences, and socioeconomic conditions". Considering the economical reality of the Brazilian population, we assumed that this is an essential factor for some of the families in what concerns the planning of their diet.

In the need for elimination, we added the nursing intervention "to advise patients to do Kegel exercises", since exercises attenuate the symptoms of urinary incontinence as they help with female pelvic muscle strengthening and perineal re-education⁽¹⁵⁾.

By applying nursing interventions on the need for sleep and rest, we developed the following interventions in this study: to advise patients to rest and sleep while the newborn sleeps; to advise patients to prioritize activities; to advise patients to delegate activities to other people. These are not included in the theoretical reference by Garcia and Cubas⁽⁶⁾.

We grouped the nursing diagnoses and interventions associated with breastfeeding in the category of need for health education and learning once they were also among other needs. Our idea is to give nurses more visibility concerning breastfeeding, thus being important to gather all interventions in one item. Breastfeeding is essential during puerperium, particularly when considering the establishment of a healthy diet for children and the strengthening of the bond between mother and child.

When applying the nursing interventions, we realized the need for development of the following: to stimulate breastfeeding; to advise patients to breastfeed in quiet places; to advise patients to return to the Health Unit; the child's vaccination schedule; and growth and development monitoring.

As for the structuring of nursing attendance to mothers who have given birth recently, we observed that the Resolution 358/2009 of the Brazil's Federal Council of Nursing on Nursing Care Systematization. This resolution states that, when performed in outpatient clinics and households, among others, nursing care corresponds to the NP organized in five interrelated, interdependent, and recurring stages: data gathering, nursing diagnosis, nursing planning, implementation, and evaluation⁽³⁾.

Figure 1 shows the final version of the nursing instrument to attend mothers who have given birth recently in primary health care.

Box 1
Final version of the nursing instrument to attend mothers who have given birth recently in primary health care

Nursing instrument to attend mothers who have given birth recently
Health Department		Name of the Health Unit
Identification data on mothers who have given birth recently
Name:		Area:	Medical record no.
Address:		Date of 1st medical appointment _/_/_ Date of 2nd medical appointment _/_/_
Education level __ years	Born on _/_/_	No. of children __ Age of the last child __ Gesta__Para_
Date of delivery___/__/___Date of hospital discharge ___/__/___ Postpartum days________
Delivery/birth data: □ normal □ cesarean□ forceps □ term □ preterm □ postterm
Evaluation of the human needs of mothers who have given birth recently
PSYCOBIOLOGICAL
Oxygenation: FR _________rpm □ Cough □ Expectoration
Hydration: □ Frequency of liquid intake – how many cups a day:__________
Food Weight _______ kg - Height _______ cm BMI _______ Appetite: □ maintained □ increased □ decreased Difficulty of access to food - Explain why:
Elimination: Urinary elimination -characteristics/frequency: ______________ □ Burning/painful sensation during urination Intestinal elimination -characteristics/frequency: ___________________
Sleep and rest:□ Rest during the day □ Sleep during the day – Duration: __□ Sleep well at night – Duration: __
Sexuality and reproduction: □ Postpartum sex □ Use of birth control methods - Which one:
Physical and environmental security: □ Lives in risk/violent areas Domestic hygiene conditions □ good □ regular □ poor □ Presence of insects/rodents □ Is the mother a victim of violence? Of which kind? □ emocional □ physical □ sexual Does the mother make use of □ tobacco□ alcohol □ illicit drugs
Body care: □ Personal appearance □ good □ regular □ poor - Personal hygiene conditions □ good □ regular □ poor Domestic hygiene conditions □ good □ regular □ poor □ Does the mother do the housework? Which?
Physical integrity: Characteristics of the skin: □ without wounds □ with wounds - local/type ______________ Tone: ______ □ Inflammation signs - local _______ Breast conditions: □ without wounds □ engorged □ turgid □ presence of abscess
Vascular regulation TA ____x____ mmHg - FC___ bpm ou P ____ bpm □ Postpartum vaginal bleeding/lochia - Quantity □ light □ moderate □ severe Caracteristics of lochia □ sanguineous □ serosanguineous □ serosa □ purulent □ Edema - local_________+/++++ ____
Thermical regulation Temp. _______ºC □ Does the mother usually feel cold? □ Does the mother usually have chills?
Neurological regulation: □ Settled in time/space □ Anxious □ Presence of affection □ Presence of attention □ Presence of good humor □ Comprehensive language □ Preserved sensorial perception □ Preserved thinking process □ Mental confusion □ Preserved memory
Hormonal regulation: □ Uterine involution - Uterine height ______ □ Presence of milky secretion - Of type □ colostrum □ milk □ blood □ purulent - □ Does the baby look satisfied? - Glucose ________mg/dL - mg/dL- Most recent oncotic cytology □ normal □ changed - Total blood count: _________ red blood cells _____ Hg _______ Ht (pregnant card)
Sensorial perception: □ Pain - specify □ Discomfort - specify
Treatment and prevention: □ Does the mother use iron supplements? □ Does the mother need reference service - specify ______________ □ Does the mother have a preexisting disease? - specify _____________ □ Is the mother under some kind of treatment? - specify ______________ □ Soropositive for______□ specify __________________ □ Your family adhered to a therapeutical health service
PSYCHOSOCIAL AND PSYCOSPIRITUAL
Communication and social abilities: Presence of good familiar communication □ Planned parenthood □ Familiar conflict - of type __________________________________□ Presence of familiar interaction □ Do you usually trust in people? □ Are your older children happy with the baby arrival?
Recreation and leisure: Do you usually practice recreation and leisure activities? Which?
Emotional security: Are you facing this phase with: □ joy □ sadness □ difficulty □ fear □ security □ insecurity □ anxiety □ comfort □ discomfort □ overload □ irritation □ lots of crying for no reason □ negative feelings
Self-esteem, self-confidence, self-respect: Regarding your body image, do you feel: □ satisfied □ dissatisfied As a mother: □ satisfied □ dissatisfied
Freedom and participation: □ Do you have any employment bonds? □ Are you receiving the paid maternity leave? □ Are you part of some social group?
Health education and learning: □ Exclusive breastfeeding - Specify the reason______________________ □ Do you feel the need for help while breastfeeding? - What kind of help? _________________________________________________ □ Would you like to ask something about your postpartum? ______________________________________________________________ □ Would you like to ask something about how to take care of the child? ____________________________________________________
Self-realization: □ Do you have the support of your family and/or friends in this new phase? □ Do you have the support of your family with the baby?
Space: No. of rooms in the house_____ Number of family members ____ □ Do you have privacy? Where is the child sleeping? □ with the parents □ with the siblings □ in their own room □ other_________________
Religiosity and spirituality: □ Does the mother search for help with your spiritual problems? □ Does the mother feel good when searching for it?
Nursing care planning to mothers who have given birth recently
Nursing diagnosis	Nursing intervention		Results
□ Changes in the mother's breathing pattern □ Productive cough	□ Encourage the mother to cough □ Perform pulmonary auscultation □ Encourage the mother to visit the Health Unit		□ Improved □ Worsened □ Unalterated □ Solved
□ Inadequate liquid intake	□ To advise the mother concerning the need for liquids intake		□ Improved □ Worsened □ Unalterated □ Solved
□ Poor nutrition □ Excess of body weight □ Weight loss	□ Encourage eating habits that follow the mother's nutritional needs, food preferences and socioeconomic conditions. □ Assess the need for a change in eating habits □ Encourage dietary re-education □ Schedule an appointment with a nutritionist		□ Improved □ Worsened □ Unalterated □ Solved
□ Changes in the mother's urinary elimination □ Constipation	□ Encourage the mother to control the sphincter during urination □ Advise the mother to do the exercises of Kegel □ Advise the mother on intimate hygiene □ Schedule a medical appointment □ Identify the factors that can contribute to constipation □ Do research on the mother's eating habits □ Encourage the increase in water intake □ Encourage the increase in the consumption of vegetables, fruits, and foods high in fiber. □ Encourage the mother to take walks		□ Improved □ Worsened □ Unalterated □ Solved
□ Fatigue □ Insomnia □ Ineffective rest □ Ineffective sleep	□ Identify the reason for the mother's sleep disturbances □ Encourage the mother to rest □ Point out the factors that interfere in sleep, such as coffee, black tea, nicotine, soft drinks, long naps during the day, extreme temperatures, improper ventilation, inadequate lighting, noises □ Advise the mother to limit nap time from 20 to 30 minutes in the morning or afternoon □ Teach relaxation techniques □ Advise the mother to rest and sleep while the newborn sleeps □ Advise the mother to prioritize the activities □ Advise the mother to delegate activities to others		□ Improved □ Worsened □ Unalterated □ Solved
□ Changes in the mother's sexual pattern □ Ineffective family planning	□ Encourage the mother's verbalization of her feelings, perceptions, and fears □ Clarify that situations of stress and the postpartum period can interfere in sex life □ Give information on the use of contraceptive methods □ Disconsider contraceptive methods for family planning		□ Improved □ Worsened □ Unalterated □ Solved
□ Exposure to socio-environmental violence □ Domestic violence □ Use of alcohol □ Use of tobacco □ Use of illicit drugs □ Risk of suicide	□ Advise the mother to avoid risk behaviours □ Assess the environmental hygiene conditions during the follow-up visit □ Give information on the consequences of using tobacco, alcohol and/or drugs not only for herself bur also for the child □ Identify if the mother has family and community support □ Advise the mother to attend to heath services for women victims of violence □ Advise the mother to participate of a support group □ Identify risk of suicide □ Establish a support relationship □ Involve the family in the support and monitoring of the mother □ Communicate situations of violence to the competent authority □ Advise the mother to attend a medical appointment		□ Improved □ Worsened □ Unalterated □ Solved
□ Inadequate self-care: bathing/hygiene and clothing	□ Encourage habits of hygiene and clothing according to the mother's conditions and to the weather □ Advise the regular exchange of postpartum sanitary napkins		□ Improved □ Worsened □ Unalterated □ Solved
□ Breast engorgement □ Nipple fissures □ Breast inflammation □ Contaminated surgical wound □ Changes in skin tone (specify local) □ Risk for impaired tissue integrity □ Infection (specify local)	□ Hand express breastmilk □ Offer the milk to the child with a small spoon or cup □ Advise breast exposure to the sun: 15 minutes in the morning before 10 a.m., or in the afternoon after 4 p.m. □ Cleaning of the nipple with breast milk before and after feeding the baby □ Discourage the excessive handling of the nipples □ Discourage the use of soap, cream, and ointment in the nipples □ Advise that hands need to be washed before handling the breasts □ Monitor the healing process of the surgical wound □ Put a dressing in the infected surgical wound □ Monitor signs of infection □ Examine episiorrhaphy		□ Improved □ Worsened □ Unalterated □ Solved
□ Edema □ Lochia (specify the type and if the case is light, moderate, severe) □ Increased blood pressure	□ Put the mother's legs up □ Examine pulse timing characteristics □ Examine uterine involution □ Observe lochia characteristics □ Monitor liquid loss □ Request for total blood count test □ Treat cases of anaemia □ Guide the bleeding cases identified in follow-up visits to the Health/Maternity Unit □ Minister antihypertensive drugs □ Control blood pressure □ Give information on the preventive measures to avoid the increase of blood pressure		□ Improved □ Worsened □ Unalterated □ Solved
□ Increased body temperature	□ Check body temperature □ Minister antipyretic drugs □ Keep the mother warm □ Encourage liquid intake □ Guide the mother to the Health Unit if the fever persists		□ Improved □ Worsened □ Unalterated □ Solved
□ Anxiety □ Changes in mental activities: level of conciousness □ Changes in mental activities: orientation (time, space, self, others) □ Confusion	□ Assess the mother-child relationship □ Assess the changes in the level of consciousness □ Investigate the presence of factors that contribute to mental confusion □ Keep the mother informed about people, time, space □ Avoid asking questions that the mother may not know how to answer □ Keep the mother located in time and space (give her things such as a clock, a calendar, a mirror) □ Plan playful activities to stimulate the memory □ Use simple sentences during communication □ Involve the family in the recovery process of the mother's mental capacities □ Stimulate physical leisure activities □ Guide the mother to a Mental Health Unit		□ Improved □ Worsened □ Unalterated □ Solved
□ Retarded uterine involution □ Low milk supply □ Unstable blood glucose	□ Give information on the observation of lochia (characteristics and quantity) □ Examine uterine involution □ Help the mother during lactation □ Explain the physiological changes involving decreased lactation □ Advise the mother to let the child suck freely □ Verify capillary blood glucose □ Give information on the importance of monitoring blood glucose □ Give information on the signs and symptoms of hypoglycemia and hyperglycemia □ Guide the mother to the Health Unit/Hospital		□ Improved □ Worsened □ Unalterated □ Solved
□ Pain (specify local and intensity)	□ Encourage the mother to complain when she feels pain □ Help the mother to relieve her pain □ Guide the mother to attend a medical appointment		□ Improved □ Worsened □ Unalterated □ Solved
□ Maintenance of altered health □ Inadequate adhesion to the treatment □ Inadequate adhesion to the diet	□ Involve the family in the resolution of the mother's health problems □ Encourage the mother to take part of groups □ Give information on the therapy to be followed □ Give information on the diet to be followed		□ Improved □ Worsened □ Unalterated □ Solved
□ Ineffective familiar communication □ Conflicting attitutes among family members □ Inadequate social interaction □ Potential for inadequate fatherhood/motherhood □ Risk of social isolation □ Risk of feeling lonely	□ Asses the family's support dynamics □ Identify the communication barrier of the family □ Suggest opportunities for family members to get together and discuss the situation □ Observe the mother's and child's behaviour during breastfeeding □ Observe the interaction father/mother/children □ Help the development of especial abilities □ Help the family to recognize the strong points in their relationship □ Encourage the interaction with friends, family, and community groups □ Guide the mother to family counseling		□ Improved □ Worsened □ Unalterated □ Solved
□ Insufficient recreation and leisure activities	□ Identify social facilities for recreation and leisure activities □ Encourage the participation in recreation and leisure activities		□ Improved □ Worsened □ Unalterated □ Solved
□ Anxiety □ Postpartum depression □ Fear (specify) □ Hopelessness □ Feeling incapable □ Sadness	□ Assess behaviors that might indicate anxiety □ Give information on the emotional changes in puerperium □ Help the mother to relax □ Help the mother to identify a supportive system □ Develop a supportive relationship with the mother □ Develop a relationship with the family □ Involve the family in the mother's care and in household activities □ Monitor symptoms of postpartum depression □ Guide the mother to a Mental Health Unit		□ Improved □ Worsened □ Unalterated □ Solved
□ Low self-esteem □ Little trust in others	□ Stimulate maternal self-confidence □ Give information on personal care □ Help the mother to identify her positive qualities and possible opportunities □ Observe changes in self-esteem □ Discuss the predictable physical alterations with the mother □ Explain the process of self-image recomposition □ Reinforce the positive aspects □ Promote active listening □ Encourage visits from friends, relatives and significant people □ Help with establishing realistic goals		□ Improved □ Worsened □ Unalterated □ Solved
□ Low initiative □ Lack of willpower □ Indecision □ Limited citizenship rights (specify) □ Inadequate decision-making process	□ Help family members to assess their own behaviour □ Encourage the freedom to express feelings □ Encourage the decision-making process		□ Improved □ Worsened □ Unalterated □ Solved
□ Insufficient knowledge on postpartum related aspects □ Insufficient knowledge on breastfeeding □ Insufficient knowledge on newborn care □ Inadequate knowledge (specify the topic: health condition, medications, exams, treatments, among others) □ Inadequate use of contraceptive methods	□ Give information on the care of surgical wounds/episiorrhaphy □ Encourage exclusive breastfeeding □ Teach the process of hand expressing and storing breast milk □ Observe breastfeeding and how the mother handles the breasts □ Teach the right positioning of the newborn during breastfeeding □ Teach the mother a comfortable position for breastfeeding □ Stimulate the mother to breastfeed according to the child's demand □ Help the mother to breastfeed □ Give information on the nutritional needs of the newborn □ Give information on the need for breastfeeding in a calm location □ Talk about the myths and beliefs around breastfeeding □ Identify people that can help with the breastfeeding process □ Give information on the care of breasts and nipples □ Explain contraception methods □ Help the mother to identify the informations she is more interested in □ Advise the mother to return to the Health Unit, and give information on the child's vaccination schedule and on the monitoring of the child's growth and development		□ Improved □ Worsened □ Unalterated □ Solved
□ Conflicting performance of the parents' role as mother/ father □ Ineffective performance	□ Encourage the parents to express their feelings and concerns □ Assess the impact of child birth on the parents role and relationships □ Encourage the participation of the parents in child care □ Give information on the child's health conditions to the parents □ Advise the mother on the importance of the mother-father-child relationshio □ Count on other family members in child care		□ Improved □ Worsened □ Unalterated □ Solved
□ Lack of privacy □ Inadequate personal space	□ Advise the parents to have a private space □ Explain to the family the mother's need for privacy □ Advise the use of home spaces to respect the family members need for privacy		□ Improved □ Worsened □ Unalterated □ Solved
□ Anguish □ Perception of the lack of meaning in life	□ Assess the family's spiritual beliefs □ Support the mother's or the family's spiritual practices □ Encourage the expression of feelings concerning life, ego, emotion, subjectivity, beliefs, myths, expectations, among others □ Talk about the visit of the spiritual leader at home		□ Improved □ Worsened □ Unalterated □ Solved
Observations
Nurse:	COREN:

CONCLUSION

This instrument was based on the theory of basic human needs and on the International Essential Data Set for Nursing, followed the thermilogy adopted by Garcia and Cubas, which by its turn is according to the language proposed by ICNP^®. The development of this instrument was structured in three sections, namely: the identification data of the mother who have given birth recently, human needs assessment, and nursing care planning.

Our suggestions are associated with the future clinical validation of the instrument. So that it will be possible to test its operation in practice. The ICNP^® terminology is little used among nurses of the Brazilian context, which makes it difficult for us to know if other nurses would approve the same diagnosis/results and nursing interventions applied in this study. We consider this activity is dependent of theoretical basis, clinical trials, and assistential practice.

The instrument developed and validated will help the mother who has given birth recently in a systematized way, contributing to the operation of the nursing process in the context of the Brazilian primary health care. In addition, it will enable the establishment of diagnoses/results and nursing interventions using the ICNP^® terminology. We recommend that the document for the nursing consultation be used from the first week postpartum to around the 40^th day postpartum, preferably at home, i.e. inside the mother's home environment. Similarly, we consider important to include this taxonomy as a teaching tool in graduation courses, since students, professors, and nurses who work directly in the field show lack of knowledge on this classification.

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Publication Dates

• Publication in this collection
  Mar-Apr 2016

History

• Received
  01 June 2015
• Accepted
  01 Nov 2015