Mental health assistance: identification of nursing diagnoses in a community mental health service

Objective: to map and identify nursing diagnoses targeted at night care users in a Psychosocial Care Center according to NANDA-I Taxonomy. Method : this is a descriptive-exploratory study, of documentary research type of 319 records in medical records. It was held in a Psychosocial Care Center III in Goiás, from 2014-2018. Nursing diagnoses and records were extracted with non-standardized language. Results: 813 records of nursing diagnoses identified in 53 different titles, in 10 domains, were identified. The most frequent diagnosis was risk for self-extermination. The domain with the highest number of diagnostic records was activity/ rest. There was a predominance of diagnoses focused on the problem. Final considerations : mapping contributes to the planning of evidence-based nursing interventions and to the strengthening of professional identity in mental health. It is evident the need for practices that go beyond the symptoms in a preventive perspective, with a view to comprehensiveness. Descriptors: Nursing Diagnosis; Community Mental Health Centers; Nursing Process; Mental Health Assistance; Psychiatric Nursing. RESUMO


INTRODUCTION
Psychosocial Care Centers (CAPS -Centros de Atenção Psicossocial) are community mental health services linked to the Brazilian Unified Health System (SUS -Sistema Único de Saúde) and are considered strategic points of Psychosocial Care Network to assist people with mental disorders and problems related to the use of alcohol and other drugs (1) . CAPS are structured in modalities, modality III being responsible for serving users every day of the week, for 24 hours a day (2) .
The assistance provided by CAPS is carried out by a trained multidisciplinary team, in line with the change in the logic of assistance in mental health from an exclusive to an inclusive model, by extrapolating technical actions and reaching relational actions (3) , differing from the model of psychiatric hospitals. Among the multidisciplinary team that works in this service, the nursing team stands out, which is the core of knowledge that works 24 hours in type III services.
Night care (NC) is a therapeutic proposal of CAPS III, consisting of a hospitality action during the night that uses users' remoteness from conflicting situations and aims to manage crisis situations, aiming at the resumption/rescue of interpersonal relationships, family and/or community life (4) . This is a contemporary proposal, of a holistic character, with a view to training the people attended to participate in the care and recovery (3) . Mental health nursing clinic includes biological, subjective and social elements of the health-disease process. This implies using light care technologies, such as qualified listening, building bonds and readiness to care, aiming at the reconstruction of subjectivity; however, for this to happen, the work tools must be expanded (5) .
Nursing offers health care to users, meeting their physical, psychological and social needs through individual or group care. These actions must be systematized, in compliance with COFEN Resolution 358/2009, which provides for the Systematization of Nursing Care (SNC) in services with professional nurses (6) , it can be applied in different scenarios of health care and levels of complexity, such as in Primary Health Care (7) , in the hospital context (8) , in a prison unit (9) , in an Intensive Care Unit (10) , in the pediatric environment (11) and also in psychosocial care (12) A tool that is exclusive to nurses' work and that contributes to the SNC consolidation is the Nursing Process (NP), composed of five stages: data collection or nursing history, nursing diagnosis, nursing planning, nursing implementation and assessment (6) .
It is worth highlighting the importance of assistance provided by nurses to be guided by a nursing theory and by a classification system that enables care in a single language. These systems are related to some NP phase. Especially NANDA-I, for the definition of nursing diagnoses, has a prominent role in the professional practice of nurses, as it allows the systematization and organization of care, being the first step in the choice of actions that will later be put into practice for minimize damage to users' health (13)(14) .
A careful assessment conducted by nurses guides and qualifies assistance to users of mental health services, since this professional collects, analyzes and interprets data, with clinical judgment on the health condition and/or life process existing in a person, family, group or community; then, based on nursing diagnosis(es), a care plan is proposed that minimizes suffering or ceases the existing demand (15) .
NANDA-I Taxonomy offers ways to guide research and categorization in areas of concern for a nurse. It has 244 nursing diagnoses grouped into 13 domains and 47 classes. Domain is an area of interest that is divided into classes, which are groupings with common attributes. Nurses deal with responses to health problems/life processes among individuals, families, groups and communities. These responses are the central concern of nursing care, occupying the circle assigned to the profession. A nursing diagnosis can be focused on a problem, a state of health promotion or a potential risk (15) .
The NP aims to qualify the care offered to service users, since it offers interactive, complementary and multidisciplinary care, provides the direction and organization of nursing actions, in addition to ensuring greater autonomy before the health team, continuity of care and nurse approach -user/family and nurse-team (16) . Nursing diagnosis (ND) is the second phase of NP, representing a clinical judgment of nurses on responses of individuals, the family or the community, being the basis for the selection of nursing interventions and the achievement of successful results (15) .
NDs in hospital settings are thought of in the biological and social context. The purpose of psychiatric nursing is not only clinical diagnosis or drug intervention, but the commitment to provide a better quality of life for service users (17) .
According to a study published in 2017, which analyzed articles published in relation to the NP theme in mental health, Brazil was the country that presented the most studies in this area, corresponding to a total of six articles (31.6%) (17) . This fact highlights the need to develop further investigations in this field, considering the expansion of mental health services in their various modalities and the relevant role of professional nurses in this field.
The identification of a ND profile plays an important role, as it contributes to subsidize nurses' interventions, elucidate cohesion in the most appropriate dimension and direct focuses for permanent education. Mapping the conditions of the assisted clients, which requires nursing interventions, contributes to the strengthening of professional identity, from the clear visualization of the phenomena that are taken into account in the nursing domain (18) .
Research related to this topic is relevant to highlight the nurse's practice in mental health. However, there is still an incipience of SNC in mental health. Nursing actions and records should cover topics such as interpersonal relationships, nursing history, physical and mental examination, diagnosis and nursing planning. The NP, linked to other work processes, has the potential to produce expanded health care in mental health (18) .

OBJECTIVE
To map and identify nursing diagnoses targeted at night care users in a type III Psychosocial Care Center according to NANDA-I Taxonomy.

Ethical aspects
The ethical-legal precepts were respected in accordance with the rules and guidelines provided for in Resolution 466/2012 (19) . Data collection took place after approval of the project by the Institutional Review Board (IRB) of Universidade Federal de Goiás.

Type of study
This is a documentary, descriptive-exploratory study with a qualitative approach, carried out in the medical records of users to map NDs performed by nurses at a type III CAPS.

Study setting
It was carried out in a type III CAPS, designed to assist people in mental distress, in a municipality in the metropolitan region of Goiânia, Goiás, Brazil. Data collection was carried out from March 2018 to April 2019.

Data source
Intentional non-probabilistic sampling, in which the inclusion criteria were the medical records of users attended in the NC modality, from 2014 to 2018, the period of implantation of SNC in that service. Duplicate medical records and those that did not have nursing records related to clinical judgment that is made in the second stage of NP were excluded. There were 217 medical records of users with NC records and, considering the exclusion criteria, 209 medical records of users treated in this modality were analyzed.

Data collection and organization
The data were collected with the aid of a semi-structured instrument, based on an analysis of a form implemented in CAPS III as a guide for carrying out SNC. NANDA Taxonomy was chosen because the referred form, built in 2013 and updated in 2015, was based on NANDA-I 2015-2017 (15) . The instrument consists of the following information from users: medical record number at the institution, sex, age, education, medical diagnosis, demand for NC, length of stay at NC, nursing history, ND, nursing prescriptions, nursing interventions, goals, results achieved and NC exit conditions.

Data analysis
For analysis, content analysis was used, in the thematic modality, going through pre-analysis, material exploration and treatment of results (20) .
In the pre-analysis phase, each medical record analyzed was identified by a number, according to the data collection sequence. The answers were transcribed in a spreadsheet using the Microsoft Excel program, version 2007.
Material exploration consisted of identifying terms and expressions, occurring by reading the data in full, in which the statements contained in and not contained in NANDA-I were identified. Those not listed in NANDA-I were grouped by similarity (20) . Therefore, for data organization and systematization, cross--mapping of statements found with NDs was used according to NANDA-I 2018-2020 classification. This being a useful method in the analysis of non-standardized nursing languages, its procedure consists of comparing similar data, and then determining its semantic equivalence with an internationally standardized language (21) .
NDs' statements were grouped according to NANDA-I terminology classification and arranged in their domains and classes. Thus, the cross mapping took place with the classification of NDs of NANDA-I, their defining characteristics, related factors, risk factors.
In the treatment of results, validation of statements found, constant and not constant in the NANDA-I classification were performed. The statements in non-standardized language were presented under diagnoses titles, according to NANDA-I, 2018-2020, and in the full writing, collected from the medical records. The framework was analyzed, considering statements of NDs, defining characteristics, related and risk factors, considering cross-mapping.
Finally, NDs were grouped based on the domains and classes of NANDA-I Taxonomy, 2018-2020. The data were submitted to analysis of relative and absolute frequencies of the main NDs using the Microsoft Excel program, version 2007. The domains were used as a guide for data analysis.
The guidelines for conducting qualitative studies were followed according to guidance from the Equator network, according to the international protocol COnsolidated criteria for REporting Qualitative research (COREQ). As it is a documentary study, some of the criteria of this protocol did not apply.

RESULTS
Among the 209 medical records, the prevalent age group of participants was 36 to 50 years (41.5%), mostly female (62%) and the majority education level was incomplete primary school (23.2%).
In the nursing notes found in 319 NC situations, 813 terms and expressions of NDs were evidenced. With the cross mapping, they obtained 53 different titles of NDs, comprising 22 classes and ten domains, among the 13 domains of NANDA-I Taxonomy, according to Table 1.
Perception/cognition domain was quite registered, mainly related to class cognition, evidenced in acute confusion, impaired memory and disturbed thought processes diagnoses, the latter being removed from NANDA in 2011. From class communication, prevalence of impaired verbal communication was observed diagnosis. It was also observed that, of the 13 existing domains, three were not included in the records, namely sexuality, principles of life and growth and development.

DISCUSSION
The data of this research show that nurses from a CAPS III identified NDs predominantly in three domains, according to NANDA Taxonomy: activity/rest, perception/cognition and safety/ protection. In psychiatric institutions, more diagnoses present in activity/rest and safety/protection domains were also identified. However, in CAPS III, NDs related to domain perception/cognition stood out and, on the other hand, in psychiatric institutions, NDs related to domain coping/stress tolerance were more identified (3) .
In activity/rest domain, insomnia and disturbed sleep pattern NDs prevailed, but there were also records of relevant NDs related to self-care and the development of physical activities. Changes in the sleep pattern are problems frequently reported by CAPS users. In general, they are associated with mood swings, personal problems (involving the family and social context), uncomfortable environments for rest and also the absence or inadequacy of activities during the day (3,22) .
For users in psychological distress, the deficit or loss of self--care capacity is evidenced by the precarious conditions of body and oral hygiene that negatively affect social life and trigger the development of physical diseases by pathogens. Consequently, users may need help from the nursing staff or third parties (23) . Users with activity intolerance, impaired physical mobility and/ or impaired walking NDs have difficulties or are unable to follow some activities developed at CAPS, especially those related to physical exercises and body expression, and it is necessary to redirect therapeutic actions to restore mobility. of them, with caution, so that no injuries occur, such as falls. Physical activity can be used as a therapeutic action to treat sleep disorders and encourage self-care readiness, as it improves the subjective and objective perception of sleep quality and quality of life (24) . The fall risk ND comprises safety/protection domain, described in this study in 2.21% of the NC. The fall results in morbidity, mortality and fear of suffering another fall. Therefore, the environmental assessment, in addition to a careful user assessment, including the use of medications that can alter the ability to get up and move independently, are important actions to identify fall risk. This assessment allows timely corrective action to prevent this incident (25) .
Still in safety/protection domain, there was a significant amount of ND related to the diagnoses related to risk for self mutilation and risk for self-extermination, which is the most frequent in this study. The percentage of NDs that identifies the risk of self-inflicted violence and self mutilation was higher than that of risk for violence: self-directed or directed at other ND, a result that is different from another study that assessed the prevalence of ND in inpatients in a psychiatric environment, the risk of violence directed at others being the third most prevalent ND (26) . Psychiatric environments along the lines of institutionalization are characterized by confinement from the outside world, isolation and containment, total observation and surveillance, in addition to deprivation of autonomy. This stressful environment can generate more exacerbated reactions, being configured as a risk of violence directed at others.
It is worth considering that, in the study by Frauenfelder et al (2018), the most frequent NDs were ineffective coping and ineffective health maintenance, these NDs being risk factors for risk for self-extermination, as they are related to the weak coping capacity, that must be worked on in the therapeutic relationship that strives for the autonomy and self-management of life in a healthy way (26) . These data indicate the urgent need for actions to protect the lives of these people in psychological distress, and the insertion in the NC modality is a strategy of the psychosocial model of care and protection. However, the myth of dangerousness still appears rooted in common sense, allowing the fear of users of mental health services, causing the treatment of these people to continue in the form of segregation in hospitalizations in a psychiatric hospital environment (26)(27) .
In safety/protection domain, the impaired dentition ND also stands out and may be the result of institutionalization or aging processes. However, it is considered that self-care deficit ND, in activity/rest domain, can also be related to deficit in oral hygiene. Once again, the need is emphasized that interventions to promote psychosocial rehabilitation should include the promotion of encouragement to carry out activities of daily living, with oral and body hygiene (28) .
The impaired skin integrity ND, to a lesser extent referred to in this study, is related to self-inflicted violence, evidenced by the self mutilation ND record, as well as neglect of care and difficulty in maintaining health given psychic conditions. In this regard, it is urgent for nursing to think about the care plan with a focus on safety/protection. The findings in this domain point to the complexity of nursing care, with a view to comprehensive care in the context of mental health to avoid institutionalization; therefore, care plan must include Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial) services.
In perception/cognition domain, there is evidence of important ND that allow to propose NP aimed at psychic alterations, with emphasis on psychoses. The data showed that this domain corresponded to 17.11%, the most incident being: disturbed thought processes, disturbed sensory perception, acute confusion, impaired memory and impaired verbal communication; meanwhile, to a lesser extent, are communication, readiness for enhanced, chronic confusion, deficient knowledge related to cognitive limitations and unstable emotional control. In a university hospital in Switzerland, NDs belonging to perception/cognition domain corresponded to 7% of the sample (26) , a much less significant data in parallel with the findings of this investigation (19.31%).
The disturbed thought processes ND was mentioned in this study 76 times in the records, although it was removed from NANDA-I in 2011. Considering this, this ND has relevance to the mental health scenario, a fact that suggests a review and consequent inclusion of diagnosis at NANDA-I that meets the specificities of symptomatology with changes related to thought processes and sensory perceptions (26) . However, the comparison between international researches requires important considerations related to the differences between the study settings, since the cultural, social and human development aspects are important social determinants of health. Furthermore, the models of care can be diverse and even contradictory, which requires parsimony in analysis of data.
The record of acute confusion and chronic, impaired memory and deficient knowledge related to cognitive limitations NDs denotes the relevance of nurses to think of articulated NP as the premises of the psychosocial care model, especially interventions that foster interaction and social insertion. Changes in the levels of orientation, memory, thinking, behavior and perception are indicated as interfering in the socialization of users (3) . The way in which nursing interventions will be implemented may vary if there is no ideological, ethical and technical clarity of the care model provided by a community service. It is worth mentioning that, in most cases, interventions aimed at this clinical judgment must involve varied skills and interdisciplinary work.
Another important aspect to be considered is the lower incidence of diagnosis chronic confusion (0.62%), when compared to diagnosis acute confusion (2.09%), and it may be emphasized that CAPS is an important service for attending to crisis situations, and not only to persistent illnesses. Welcoming the mental health crisis in territorial services is an important indicator of quality of the care network (29) . In the model of psychosocial care to which CAPS is inserted, it is suggested that the approach to the crisis should take place with RAPS support, with an emphasis on community health services and in a perspective of transversal knowledge and power among team professionals multidisciplinary and users, for effective care to complex situations, such as moments of crisis in mental health (30) .
Mental illness can favor a state of changes in the subject's personal and ideal perceptions of themselves and lead to manifestations of NDs belonging to self-perception domain (31) , which is composed of the self-concept, self-esteem and body image classes (15) . In this 9 of study, the predominance of hopelessness, low situational and chronic self-esteem NDs was observed in self-perception domain, followed by body image disorder and risk for compromised human dignity. Hopelessness is understood as a subjective state in which an individual sees limited personal alternatives available and is unable to mobilize energies for his own benefit. Low self-esteem, on the other hand, is a negative perception of their own value and ability, which can lead to compromising human dignity, due to the perceived loss of respect and honor, and which can compromise health (15) . Stressful events and stigmatization are related factors for low self-esteem; this, in turn, foreshadows the disturbance of body image and hopelessness (31) and risk to human dignity. Even with the process of deinstitutionalization, one of the main difficulties of these people is social stigma, fueled by the ignorance of the population and the media (16) .
People with mental illnesses, facing discriminatory experiences, withdraw socially as a way to face and protect themselves, resulting in internalized stigma (32) . Internalized stigma is when a person is aware of the stigma attributed to them, agreeing and applying to themselves the negative stereotypes about their illness. This internalization of stigma aggravates the symptoms of mental disorder, resulting in isolation, low self-esteem, guilt, hopelessness and compromised human dignity (16) .
Social stigma and internalized stigma, added to mental illness, are associated with coping/stress tolerance domain, with NDs anxiety, fear, ineffective individual coping, impaired mood regulation, chronic sadness, stress overload, adjustment disorder, impaired resilience, compromised family coping. These are related to NC due to causing intense suffering, and this health care is necessary for recovery and prevention of diseases.
The anxiety ND presented a much higher frequency among other NDs associated with coping/stress tolerance domain and may be related to the fact that some of its defining characteristics are also ND, such as insomnia and fear, and also because they are defining characteristics and/or related factors of other NDs identified, such as change stress syndrome, post-trauma syndrome, among others. In addition to its definition encompassing portents of stress, when it is conceptualized as a vague and uncomfortable feeling of discomfort or fear, accompanied by an autonomic response, the source of which is generally unknown to individuals (15) .
Anxiety is a medical/psychiatric ND; in this regard, it is important to have a multidisciplinary assessment and communication between the team, because, when analyzing whether a diagnosis is already identified as a medical diagnosis, there is no reason to name it as a ND, and the nurse must then explore other focuses of the problem, factors of risks and health promotion, with a view to greater integrality in care. It is also renamed as ND in this case if there is any other different perspective that nursing would bring to its phenomena, different from medicine (15) .
In this sense, CAPS nurses should focus on interventions to control anxiety and stressors for building self-esteem, strengthening social support and aspects that generate quality of life, to increase psychic resistance to stigma, playing a central role in the recovery (33) . A study carried out identified that the family, understood as an important social support, has contributed little for the person in psychological distress to live more satisfactorily with the disorder, reinforcing the internalized stigma and bringing serious consequences for subjects (16) . The inclusion of the family in the Unique Therapeutic Project (PTS -Projeto Terapêutico Singular) stands out as an important strategy, which, many times, is invisible as the focus of intervention and support, being only asked to be responsible for subjects in psychological distress (34) .
Resistance to stigma, the ability to resist, neutralize or not be affected by the stigmatization of mental illness, plays an important role in treatment (32) . This mechanism is a form of personal strength that can be fostered by professionals in mental health services. With that, patients can overcome their internalized stigma and be able to live life the way they want (33) .
Quality of life and positive psychosocial aspects are associated with resistance to stigma (33) , such as experiencing a good family relationship, having and participating in leisure activities outdoors, social contacts with close friends, optimism and adequate night sleep (35)(36) . Such factors, when worked on users' PTS, can raise subjects' cognitive and/or behavioral efforts to control the demands related to well-being, expressed in their desire to increase knowledge about strategies to control stress and improve their social support, which is the coping, readiness for enhanced ND.
It is evident that diagnoses related to health maintenance are little applied, consequently, there is little NP that covers this specificity. For activity/rest domain, self-care, readiness for enhanced ND was frequent (0.62%); in perception/cognition domain, there was also a low incidence of communication, readiness for enhanced (0.62%) ND, as well as in coping/stress tolerance domain, with the occurrence of for coping, readiness for enhanced (0.12%). There is a need to explore more diagnostic concepts, in a preventive and health maintenance perspective, in a biopsychosocial context, so that it can favor comprehensive care and, consequently, a better state of health and quality of life for users.
The great predominance of ND with a focus on the problem is worrying, and it is worth further investigations on its causal factors. A literature review study (17) highlights the difficulty of nurses working in mental health services to assess psychic aspects, as their training in reading relationships is fragile.
Nursing assessment cannot be restricted to psychopathological symptoms and psychiatric diagnosis, as the focus of care must be directed to the recognition of the unique meaning of the experience of psychological distress in the social, political and cultural context of users (37) . NDs are found targeting the levels of basic needs, to the detriment of subjective or more complex needs (38) .
In this study, the majority of NDs are in the category focused on the problem, data evidenced in other studies (3,17) . In role relationship domain, the predominant ND was impaired social interaction, followed by dysfunctional family processes. In comfort domain, the social comfort class (risk for loneliness, social isolation and risk for social isolation) predominated, followed by acute pain NDs. An investigation (26) crossed NDs and medical diagnoses, and the NDs most identified were related to psychosocial needs in all groups of medical diagnoses, also perceived in this study.
We observed that, of the 13 domains existing in NANDA-I, three were not included in any NP record carried out, namely sexuality, principles of life and growth and development. Other studies also highlight the need for attention with the NDs belonging to these domains, whether due to the absence of NDs in the domains of sexuality and principles of life (16) , or aspects of vulnerability and sexual 9 of Mental health assistance: identification of nursing diagnoses in a community mental health service Pinho ES, Souza ACS, Moreira ACGC, Nogueira LEFL, Limongi AMS, Silva NS, et al. behaviors with potential risk with the identification of diagnoses in CAPS users, such as problematic sexual behavior, impaired sexual performance and lack of knowledge about sexual behavior (39)(40) . Mental health assistance in Brazil is guided by Psychosocial Rehabilitation principles and the rescue of subjectivity as the ethical matrix for directing treatment. Constructing the NP is important, considering its base in nurse-patient relationship, with a focus on the uniqueness and participation of users, as they play an important role in their treatment, i.e., when delineating the ND, one must consider users' experience, not the psychiatric diagnosis assigned to them (37,40) .
Even when the social relationship before psychological distress is present and of quality, it is common for them to be rare, or even non-existent after the process of mental illness. This occurs due to frequent individuals' behavioral changes that result, in most cases, in difficulties in both family and social relationships (41) . There is a legitimate need for mental health nurses to have knowledge of the expanded clinic to serve users and improve their health conditions when dealing with people, with their social, subjective and biological dimension (17) .

Study limitations
The difficulties found related to the fragility of NP records in medical records are considered limiting, which demanded the need to do cross-mapping by similarity of terms to make the ND groupings. Moreover, because it was performed in only one service, the study does not allow data extrapolation.

Contributions to nursing
The results of this study, when identifying the NDs aimed at users attended in NC according to NANDA-I Taxonomy, can subsidize the qualification of assistance in community mental health services through the implementation of continuing health education processes. Finally, further studies are suggested, including expanding the comprehensive scope of the implementation of NP in CAPS, including the identification of organizational barriers that interfere in the care actions that are developed in these services.

FINAL CONSIDERATIONS
This study allowed the identification of NDs targeted at users attended in NC at a CAPS III, according to NANDA-I Taxonomy.
The most frequent domains were activity/rest, safety/protection and perception/cognition.
The study showed that disturbed thought processes NDs, which were removed from NANDA-I, previously present in perception/ cognition domain, are frequently observed in nursing care and are important to guide NP and nursing practice in the context of mental health and psychosocial attention.
An analysis reveals that mental health nursing practice has been directed to biological and psychological problems, to the detriment of actions to identify risk and health promotion ND, in which investment in care strategies based on biopsychosocial dimensions is foreseen.
It is noteworthy that the data collection process evidenced the need to qualify the nursing records in the medical records. This is also essential to systematically highlight the practice of nursing in this context of mental health. We emphasize, for future studies of this type, that the use of software to assist in the cross-mapping of information related to NDs can be used to facilitate data analysis.
These results are important to reflect on nursing practice in the context of a community service of psychosocial care, for the care of users who are in NC at CAPS.