El proceso de enfermería en las consultas de puerperio en las unidades de Atención Primaria de Salud

Análisis documental sobre los prontuarios de consultas de enfermería durante el puerperio realizadas en unidades de atención primaria en el interior del estado de São Paulo. Se analizó qué etapas se registraron, la secuencia de las etapas y el abordaje de las cuestiones psicosociales. Los datos se presentan en frecuencia, porcentaje y el contenido del cuidado reportado.

Resultados:

Se analizaron 341 prontuarios. De ellos, el 100% presentó Historia; el 62,2%, Diagnóstico de Enfermería; el 5,3%, Planeación; el 99,1%, Ejecución; y el 50,1%, Evaluación. En cuanto a la secuencia de las etapas el 47,5% de los prontuarios presentaron tres etapas. En la incorporación del principio de integralidad, se observó una mayor presencia del enfoque biológico.

Conclusión:

Este estudio evidencia el cambio en la práctica del enfermero, con esfuerzos para realizar el registro del Proceso de Enfermería, y que la integralidad del cuidado se constituye como un desafío para superar el cuidado fragmentado y descontextualizado de las condiciones de vida de las personas.

DESCRIPTORES:
Enfermería de Atención Primaria; Periodo Posparto; Proceso de Enfermería; Enfermería Maternoinantil

History	Medical records (n=341)
History	Freq.	%
Number of pregnancies	215	63.1
Primigravidae	73	34.0
Gravida 2	73	34.0
Gravida 3	38	17.6
Gravida ≥ 4	31	14.4
Parity	217	63.6
Primiparous	82	37.7
Multiparous	135	62.3
Abortion	207	60.7
None	173	83.6
One	26	12.5
Two or more	12	3.9
Pregnancy	303	88.8
Unplanned	300	99
Planned	03	1.0
Prenatal	112	32.8
Unified Health System	93	83.1
Health plan	18	16.1
Did not perform	01	0.8
Type of birth	324	95.1
Normal	208	64.2
Cesarean section	116	35.8
Companion in the postpartum consultation	82	24.5
Unaccompanied	26	31.8
Husband	45	54.8
Relatives	11	13.4
Breastfeeding	153	44.8
Exclusive breastfeeding on demand	133	86.9
Mixed breastfeeding	18	11.8
Artificial feeding	02	1.3

Districts	History (n=341)		Diagnosis (n=341)		Planning (n=341)		Implementation (n=341)		Evaluation (n=341)
Districts	Freq.	%	Freq.	%	Freq.	%	Freq.	%	Freq.	%
North (n=117)	117	100.0	110	94.0	15	12.8	115	98.3	82.0	70.1
South (n=77)	77	100.0	21	27.3	-	-	77	100.0	66.0	85.7
East (n=41)	41	100.0	26	63.4	-	-	40	97.6	16.0	39.0
West (n=101)	101	100.0	50	49.5	03	3.0	101	100.0	7.0	6.9
Center (n=5)	05	100.0	05	100.0	-	-	05	100.0	-	-
Total (n=341)	341	100.0	212	62.2	18	5.3	338	99.1	171.0	50.1

Districts	Five Steps (n=12)	Four Steps (n=100)		Three Steps (n=162)		Two Steps (n=67)
Districts	H/ND/P/I/E	H/ND/P/I	H/ND/I/E	H/ND/I	H/I/E	H/ND	H/I
North (n=117)	12	03	68	25	02	02	05
South (n=77)	-	-	16	05	50	-	06
East (n=41)	-	-	05	20	11	01	04
West (n=101)	-	03	05	42	02	-	49
Center (n=5)	-	-	-	05	-	-	-
Total (n=341)	12	06	94	97	65	03	64

NP steps	Most frequent contents in the registers
History	Biological Aspects: Weight, height, body mass index, blood pressure, capillary glycemia, delivery, vaccine status, serology, blood typing, pregnancies, deliveries, abortions, number of prenatal consultations, gestational age and age of the puerperal woman, postpartum days, pathologies, pregnancy complications, presence of sexually transmitted infections, physical exam of breast and body, nutritional habits, use of drugs of abuse, use of medication, breastfeeding, newborn care, type of feeding, and use of contraceptive methods.
History	Psychosocial aspects:Planned pregnancy, family support, companion, psychoemotional aspects, vulnerability, risk of domestic violence, mother-child bond, and profession.
Diagnosis	Biological aspects: Appropriate breastfeeding, intact mammary gland, appropriate body hygiene, appropriate vaccine status, excoriated nipples, postpartum with no changes so far, pregnancy prevention, postpartum signs/symptoms, nipple fissure, preventive medicine/health maintenance, nipple with no solution of skin integrity, birth with no complications for born alive infant, normal birth postpartum, risk of perineal infection, risk of mastitis, difficulties in maternal breastfeeding, breast pain due to milk letdown, inappropriate sleep, altered rest.
Diagnosis	Psychosocial aspects:Mother-child bond preserved.
Planning	Biological Aspects: Stimulating breastfeeding up to the age of 6 months; orientating on nourishment, breast care, breastfeeding, contraceptive methods, and signs of breast with complications, confinement, care of their own bodies, care of newborn.
Planning	Psychosocial aspects: Stimulate the mother-child bond, orienting labor rights and maternity leave, evaluate the risk of family violence, verify family support.
Implementation	Biological aspects: Orientation on nourishment, care towards the newborn, breast care, puerperal woman's body hygiene, breastfeeding on demand, importance of the exclusive breastfeeding up to six months of age, use of contraceptive methods, confinement, use of condom for prevention of sexually transmitted infections, consultation scheduling.
Implementation	Psychosocial aspects: Mother-child bond stimulus; orientation on labor rights and maternity leave; risk of family violence evaluated; family support verified.
Evaluation	Biological aspects: Evaluation of the breasts and breastfeeding, evaluation of vaccine status, newborn weight gain.
Evaluation	Psychosocial aspects: Positive bond between mother and newborn, risk of family violence, appropriate comprehension, and participation in the offered orientations.

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Angelina Lettiere Viana, Av. dos Bandeirantes, 3900, Campus Universitário - Bairro Monte Alegre, CEP 14040-902 - Ribeirão Preto, SP, Brazil. angelina.lettiere@usp.br