674 NURSING PHENOMENA IDENTIFIED IN FAMILY PLANNING VISITS WITH ICNP-BETA VERSION 21

This descriptive, exploratory, retrospective survey, carried out at a family planning service, aimed to identify nursing phenomena during nursing visits according to the ICNP, Beta version 2. Data were collected based on 52 records of nursing visits, realized from October 2001 to December 2002. To conduct the crossmapping process, all identified nursing phenomena were joined, organized and compared according to the ICNP’s terms. Of the 51 identified nursing phenomena/diagnoses, 46 (90.2%) showed exact and partial concordance. The identified nursing phenomena can be used to assist nurses to provide care for clients in family planning services. The ICNP showed to be a comprehensive program, although some terms need to be reviewed and others enhanced. However, considering that it is an international classification applicable to several countries, the mapping process and cross-references were very satisfactory.


INTRODUCTION
The importance of an internationally standardized language in nursing has been acknowledged since Florence Nightingale and reinforced in 1989, during the Seoul Congress, when the International Council of Nursing (ICN) decided to start a project for the International Classification of Nursing Practice (ICNP), aimed at demonstrating concrete evidence about nursing's important contribution to health, by developing one single language that would be capable of involving global nursing around a common cause (1)(2)(3) .
The ICNP represents a landmark in the unification of all nursing practice element classification systems available in this area in the international sphere.In the construction process, although some existing classification systems already incorporated practice-related terms, there was a need to identify and include new terms associated with primary care and nursing practice in community health services, to be inserted in health information systems (4) .
In 1996, ICN published the ICNP, Alfa version, described in three steps: the identification of terms, the grouping of these terms and their ranking within the established groups, which takes the form of concept pyramids, where specific terms are located at the bottom and general terms at the top (5) .The Alfa version of the ICNP consisted in the organization of three concept pyramids: nursing phenomena, interventions and results (1,(6)(7) .
It was determined that, in general, the ICNP should be comprehensive, simple, consistent with a conceptual structure, based on a central nucleus, sensitive to cultural variations, capable of reflecting the nursing value system and usable complementarily or as a part of the disease and health classifications developed by the World Health Organization (1) .
Since the publication of the ICNP, Alfa version, ICN has received comments and criticism to assess and confirm this version, such as multinational validation, resulting from the verification of its use in the Telenurse project, which was led by Randi Mortensen in the European Community, as well as in other projects.This contributed to its reformulation and the development of the Beta version (8) .
In 1999, ICN presented the Beta version of the ICNP, demonstrating the project's dynamics, subject to continuous changes in nursing science and practice.Although nursing phenomena, actions and results continue as the main components, a multiaxial focus is adopted, since this allows for more than one division of the superior term, as well as for combinations between concepts and different axes and divisions, granting greater soundness to the classification and serving as the basis to diversify the expression of concepts (8) .
Next, version Beta 2 of the ICNP was issued to: "to establish a common language for describing nursing practice; to stimulate nursing research; to describe the nursing care of individuals, families and communities; to represent concepts used in the settings and specialty areas of nursing practice; to enable comparison of nursing data; to provide data about nursing practice that can influence nursing education and health policies and to stimulate nursing research" (9) .
In all over the world to face the challenge of universalizing their language and evidencing the elements of their practice, resulting in the approval of the proposal to develop an International Classification for Nursing Practice -ICNP) (11)(12) . The

OBJECTIVES
To identify nursing phenomena during nursing visits in a family planning service and to map them according to the International Classification for Nursing Practice (ICNP), Beta 2 version.

METHODS
A descriptive, exploratory and retrospective study was carried out at the Family Planning Service of UNIFESP/EPM, located in the city of São Paulo, Brazil.The information source was the nursing visit protocol (13) , organized according to the Functional Health Standards (14) , established at the UNIFESP family planning service since 1999, but with some modifications in the initial model.For this study, records were selected of women aged 20 or older, who were submitted to the first nursing visit and subsequent nursing visits.All nursing phenomena identified in the selected records were compiled and organized with a view to cross-mapping.The terms nurses used to describe nursing phenomena/diagnoses were compared with ICNP terms, that is, non-standardized data were mapped in a standardized language.An adapted version of concordance analysis was realized, i.e. if the term found corresponded exactly with the classification system term, concordance would be exact; if synonyms and similar concepts were found, concordance was partial; and, if the term found presented no similarity and the classification system, there was no concordance (15) .To present the analysis results, exact and partial concordance were joined, as the term's concept has the same meaning.
Moreover, two family planning specialists checked the results for correspondence between the terms found in the records and the ICNP.This paper only presents the nursing phenomena/diagnoses that achieved percentages of 40.0% or more, as these are the most representative.

RESULTS AND DISCUSSION
The analysis considered 52 records, representing the first nursing visit and subsequent visits, as described above, and identified 51 nursing phenomena/diagnoses.Forty-six (90.2%) of these presented exact and partial concordance, demonstrating the ICNP's documentation range (Table 1).It should be reminded that, even when the nursing visit protocol was used, listing diagnostic options to be chosen, various terms were recorded in natural/ local language.The main goal was concordance between the involved concepts, and not necessarily word-for-word comparison.
Table 2 shows the nursing phenomena/ diagnoses with a frequency of 40.0% or higher, which will be discussed below.

Health improving behavior
The frequency of the nursing diagnosis Health improving behavior was 86.5% (Table 2).This diagnosis will need to be specified.In this study, it is related to the family planning theme separately and in combination with other activities, such as breast self-exam, Pap smear and regular exercise programs.
It is surprising that this diagnosis is not present in 100% of the examined records, as it is a diagnosis of well-being.The client's visit to the family planning service already demonstrates her interest in health promotion.Professionals may simply have forgotten to include this diagnosis in the women's records.
The ICNP uses the term Health seeking behavior as a nursing phenomenon, which is part of the focus of nursing practice axis and is defined as "self care activity with the specific characteristics: Predictable manner for identifying, using, managing and securing health care resources, expectations related to acceptable ways to request and attain assistance from others" (10) .Some authors define this diagnosis as the "active seeking (by a person in stable health) of ways to alter personal health habits and/or the environment in order to move toward a higher level of health" (14,(16)(17) .
Health promotion should be considered as the motivation to increase the well-being and develop the potential for health and prevention, avoiding diseases, detecting them early or preserving the ideal level of functioning when the disease is present.It should be reminded that nurses have an important responsibility and opportunity to help women to understand the risk factors, motivating them to adopt lifestyles that prevent the disease (18) .What family planning is concerned, some studies in this area also demonstrate the presence of this diagnosis, as the client expresses the desire to seek information to promote her health (13,19) .

Risk for altered health maintenance
The nursing diagnosis Risk for altered health maintenance (65.4%) presented a similar meaning: "Risk for the absence of health seeking behavior".This diagnosis is part of the likelihood axis, absent, judgment and health seeking behavior, whose meaning is the opposite of altered health maintenance.
The latter is part of the focus of nursing practice axis.
Although this term was not found in the ICNP, the structured diagnosis presents the same meaning.Lack of financial resources and time were factors related to this diagnosis, as the records mentioned some clients who could not purchase the contraceptive method, vaginal cream, antihypertensive agents, among others, if the service did not offer these free of charge.
Limited financial resources and awareness lead to a lack of access to care, delays to seek health care, less preventive activities and little precise information about health and the health care system (18) .
Lack of time was indicated as a factor that impeded the monthly realization of the breast selfexam.

Altered health maintenance
As described above, the nursing diagnosis Fear of pregnancy can also exert influence, as sexuality is not only restricted to the genitalia and physical functioning, but covers psychological, emotional, social, cultural and spiritual components.
Some authors call this diagnosis ineffective sexuality patterns, defined as "expressions of concern regarding own sexuality" (16) .This diagnosis is also defined "as the state in which the individual presents or is at risk for sexual health changes.Sexual health is the integration of somatic, emotional, intellectual and social aspects of the sexual being, in a way that enriches and strengthens personality, communication and love" (17) .
In comparison with the ICNP, the most adequate diagnosis was altered, impaired or ineffective sexual intercourse.Sexual intercourse is a nursing phenomenon from the focus of nursing practice axis, which is defined as a type of interdependent action, with the following characteristics: behavioral expression of sexual desires, values, attitudes and activities among individuals.Altered, impaired or ineffective are part of the judgment axis.The first is defined as "the affirmation that something changed, was modified or adjusted", the second as "the affirmation that the nursing phenomenon is weakened or damaged", and the third as "the denial that the desired result is produced strongly and successfully" (10) .This demonstrates that the meanings of the terms found are similar to the ICNP.

Sleep pattern disorder
Sleep pattern disorder was observed in 44.2% of the analyzed records, and is defined as "the interruption in the duration and quality of sleep, causing discomfort or interference with desired living activities" (14) or as sleep pattern disturbance, which is "the disturbance, during a limited time period, in the quantity or quality of sleep" (16) .According to the study framework, sleep is a nursing phenomenon, defined as "Rest with the specific characteristics: Recurring lowering of bodily activity marked by reduced consciousness, not awake accompanied with not aware, depressed metabolism, immobile posture, diminished bodily activity, diminished but readily reversible sensitivity to external stimuli" (10) .
As the ICNP considers multiple axes, its nomenclature can be flexible, with additions and modifications.Thus, terms like disturbed or altered sleep, impaired sleep and/or interrupted sleep can be used as convenient.
During the climacteric, women can present sleep disorders, due to hormonal changes, causing vasomotor symptoms.What contraception is concerned, women with sleep alterations cannot use the baseline body temperature method, due to increased failure rates.

Knowledge deficit
The knowledge deficit about contraceptive methods, breast self-exam and Pap smear represented 42.3%.Knowledge is defined as status with the specific characteristics: Specific content of thinking based upon acquired wisdom or learned information or skills, cognizance and recognition of information (10) .
Not performing the Pap smear and/or the breast self-exam is though to be due to lack of knowledge about the importance of these procedures, and not using contraceptive agents or using them incorrectly due to a lack of information.

Moreover, various clients face difficulties to
learn what is transmitted to them.Thus, it is essential that family planning service users receive neither incomplete nor biased information, and that their doubts and anxieties are solved in the best possible way.
Therefore, at the UNIFESP/EPM Family Planning Service, the participatory teaching methodology is used in the groups, promoting information and experience exchange, facilitating interaction among group members and with the team and identification of their interests, allowing for reflection and knowledge acquisition needed for the free and conscious choice of contraceptives, after the decision to avoid or delay pregnancy.Moreover, visual resources are used, including anatomical models, cartoons and the contraceptive methods themselves.
It should be emphasized that only knowledge is not sufficient to provide healthy behaviors.Women need to be convinced that they have a certain degree of control over their lives and that healthy habits represent a reliable investment (18) . .
No studies were found about the influence of leisure activities and the number of sexual relations, or about whether the latter also constitutes a way of releasing energies and stress.

CONCLUSION
The most prevailing nursing phenomena/ diagnoses were: health seeking behavior (86.5%), mainly in terms of family planning; risk for absence of health behavior (65.4%), due to the absence of financial resources to purchase the contraceptive method; absence of health seeking behavior (51.9%), related to the non-acquisition of healthy habits, including the non-realization of the breast self-exam and the Pap smear, although the women were aware of their importance; altered/ impaired sexual intercourse (44.2%); disturbed/ impaired sleep (44.2%) due to organic changes, concerns and knowledge deficit (42.3%) about the selected contraceptive method and the breast self-exam, demonstrating the importance of preventive actions in this area.
The ICNP showed to be a comprehensive program, as most of the nursing phenomena identified in the records presented exact and partial concordance.Some terms evidently need to be reviewed and others added but, considering that it is an international classification applicable to different countries, the mapping process and cross-references were satisfactory.
Data were collected from 52 records that attended to the sample inclusion criteria, for which the visits occurred between October 2001 and December 2002, after authorization by the service responsibles and approval of the research project by the University's Ethics Commission.
Altered health maintenance (51.9%) is the opposite of health seeking behavior.In the ICNP, it is denominated absence of health seeking behavior.In this case, the diagnosis was attributed due to the nonrealization of the breast self-exam, non-realization of the Pap smear, use of noxious substances like alcohol, tobacco and drugs, intentional abortion and non-use of contraceptives.In this study, the clients knew how to perform the breast self-exam and were aware of the importance of the Pap smear, but did not practice it out of shame, lack of concern because they did not believe anything would happen to them and their partner's lack of understanding about the need to abstain from sexual relation to collect the test material.Altered sexuality patternsThe nursing diagnosis Altered sexuality patterns was found in 44.2% of the records, mentioning absence of libido, absence of orgasm and/ or dyspareunia.

Table 1 -
Analogy of nursing problems/phenomena/diagnoses identified in patient files at a family planning service, presenting exact and partial concordance with ICNP, version Beta 2 Exact and partial concordance were joined so as to verify what terms of a standardized language like the ICNP could cover a natural/ local language used in a family planning service during nursing visits.

Table 2 -
Distribution of nursing problems/ Recreation deficit, found in 40.4% of the records.This showed that many women do not involve in recreation activities, which is an important indicator that contributes to the population's quality of life.Work overload, countless daily requirements, insufficient financial resources, lack of creativity, depression and/ or other diseases may have resulted in this diagnosis.