ICNP® terminology subset to infants in Primary Health Care

a methodological study, described in five stages, carried out from May to September 2018 with 15 nurses who identified diagnoses, results, interventions, and validated the subset content.

Results:

the subset developed consists of 86 nursing diagnoses and results and 178 interventions, organized in the fields of Theory of Basic Human Needs.

Final Considerations:

the subset contributed to implement the systematized Nursing Consultation, assisting nurses in decision making. Construction and validation consolidate evidence-based practice, bringing the subset closer to practical reality, in addition to contributing to infant health care qualification.

Descriptors:
Infant; Primary Health Care; Standardized Nursing Terminology; Nursing Theory; Nursing Process

DAGNOSIS/ NURSING OUTCOMES	NURSING INTERVENTIONS
PSYCHOBIOLOGICAL NEED - OXYGENATION
Risk of impaired respiratory system function	Scheduling follow-up appointment; Assessing whether infants are alert, active, fatigued, cyanotic, with inspiratory, expiratory difficulty, expiratory groan; Referring to appointment with medical professional; Identifying the presence of cough and its characteristics, nasal congestion, fever above 38ºC, vomiting, diarrhea, abdominal pain; Auscultating; Requesting family monitoring by a Community Health Agent.
PSYCHOBIOLOGICAL NEED - NUTRITION
Effective breastfeeding Exclusive breastfeeding Interrupted breastfeeding Impaired breastfeeding	Scheduling follow-up appointment; Assisting manual milking of the breast; Assisting infants in correct grasping of the mother's breast; Assessing the position of mothers and infants during breastfeeding; Assessing weight gain;
Infant feeding behavior (effective/impaired) Knowledge of mother/father/caregiver about infant feeding (impaired/improved) Difficulty breastfeeding Lack of knowledge of mother/father/caregiver about infant feeding Lack of knowledge of mother/father/caregiver about breastfeeding	Assessing interpersonal relationships between mother/father/caregiver and infant during breastfeeding; Demonstrating different positions for breastfeeding; Demonstrating manual breast milking; Referring mothers for appointment with a medical professional; Referring infants for appointment with a medical professional; Encouraging exclusive breastfeeding until the 6^th month; Clarifying mother/father/caregiver's doubts about breastfeeding; Encouraging breastfeeding on demand; Examining the mothers' breast; Guiding to keep bras clean and dry; Guiding mothers to expose the breast to the sun before 10 a.m. and after 4 p.m, for 10 minutes; Guiding the importance and benefits of breastfeeding; Guiding mothers on the importance of depleting the breast before offering the other and in the next breastfeeding start with the last breast offered; Guiding mother/father/caregiver about breast milk composition; Positioning infants correctly; Performing compress and warm bath on the mother's breasts; Perform manual milking of breasts whenever necessary; Conducting home visit by the Health Team; Performing measurement of anthropometric measurements; Requesting family monitoring by a Community Health Agent.
Altered swallowing (reflux) (mild, moderate, severe) Improved swallowing (mild, moderate) Normal swallowing	Scheduling follow-up appointment; Assessing the development and weight gain of infants; Referring to appointment with a medical professional; Referring to a nutritionist; Guiding not to wear tight clothing on infants and discouraging umbilical band use; Guiding not shake infants while breastfeeding and after breastfeeding; Guiding diaper change, when necessary, to be performed before feedings, avoiding lying infants soon after breastfeeding; Guiding mother/father/caregiver about physiological reflux and gastroesophageal reflux disease; Positioning infants in supine position to sleep; Positioning infants with the head elevated after feeding for 20 minutes or until eructation;
PSYCHOBIOLOGICAL NEED - ELIMINATION
Risk of diarrhoea Risk of impaired gastrointestinal system function	Scheduling follow-up appointment; Assessing the infant's bowel habits; Assessing signs of dehydration: mucosal moisture, turgor and skin elasticity, presence of tears and diuresis, sunken eyes and depressed fontanelles; Referring to appointment with a medical professional; Identifying the duration, frequency, intensity, appearance, consistency and odor of feces; Identifying the quantity and type of liquids or food ingested; Guiding the replacement of liquids and electrolytes through Oral Rehydration Therapy (ORT); Requesting family monitoring by a Community Health Agent.
PSYCHOBIOLOGICAL NEED - SLEEP AND REST
Risk of sudden infant death Proper sleep Poor sleep	Scheduling follow-up appointment; Guiding infants to sleep in supine position, even those with gastroesophageal reflux, with their feet leaning against the lower edge of the crib; Guiding so that the mattress is firm and the size of the crib; Guiding so that the car safety seat and stroller are not used for regular sleep; Guiding so that the bed is not shared with parents; Guiding the relationship of sudden death and the mother's smoking habits as well as use of drugs and alcohol; Strengthening breastfeeding; Using only a sheet to cover infants, not covering their head and wear clothes for their heating.
PSYCHOBIOLOGICAL NEED - BODY CARE
Mother/parent/caregiver's ability to perform improved care Mother/father/caregiver's knowledge about improved infant body hygiene Mother/father/caregiver's knowledge about improved oral hygiene Lack of mother/father/caregiver knowledge about infant care Lack of mother/father/caregiver knowledge about oral hygiene Hygiene (impaired/improved) Improved skin integrity Risk of mother/parent/caregiver's ability to perform impaired care Risk of impaired skin integrity	Scheduling follow-up appointment; Assessing skin integrity; Assessing hygiene state; Demonstrating technique for performing body, oral and genital hygiene, Encouraging body and oral hygiene; Guiding mother/father/caregiver about the importance of body and oral hygiene; Guiding mother/father/caregiver to wear clothes appropriate to the room temperature; Performing genital region hygiene with each diaper change; Performing oral hygiene of infants, gums and tongue, and after eruption of incisors, at least once a day; Conducting home visit by the health team; Requesting family monitoring by a Community Health Agent; Changing diaper after bowel movements and whenever necessary.
PSYCHOBIOLOGICAL NEED - SKIN AND MUCOUS MEMBRANE INTEGRITY
Oral candidiasis (mild, moderate, severe) Improved oral candidiasis Mother/father/caregiver's knowledge about appropriate candidiasis Lack of mother/father/caregiver knowledge about candidiasis Improved oral mucosa integrity Risk of impaired oral mucosa integrity	Scheduling follow-up appointment; Assessing oral cavity; Assessing the mothers' breast and nipple; Demonstrating technique for performing oral hygiene; Encouraging oral cavity hygiene to promote cleansing, massage the gum and accustom infants to mouth manipulation; Guiding mothers to avoid using tampons in the breast; Guiding mothers to sanitize the breast after feeding; Guiding mother/father/caregiver to perform oral hygiene of infants after feeding; Guiding mother/father/caregiver about pacifier damage and bottle use; Guiding mother/father/caregiver to sanitize the bottle, pacifiers and toys that come into contact with the infant's mouth; Guiding infant oral health care; Prescribe medication for infants according to the institutional protocol; Prescribe medication for application to the mothers' breasts after breast hygiene following an Institutional Protocol.
Heat erythema (mild, moderate, severe) Improved heat erythema Mother/father/caregiver's knowledge of adequate heat erythema Lack of mother/father/caregiver knowledge about heat erythema Improved skin integrity Risk of impaired skin integrity Diaper erythema (mild, moderate, severe) Improved diaper erythema Mother/father/caregiver's knowledge about appropriate diaper erythema	Scheduling follow-up appointment; Relieving excess clothing; Assessing skin integrity, lesion characteristics and skin around it; Demonstrating technique to perform intimate hygiene of infants; Guiding mother/father/caregiver to care for skin lesion; Avoiding direct contact of the infant's skin with woolen clothing; Encouraging body hygiene; Guiding mother/father/caregiver about the importance of body hygiene; Guiding mother/father/caregiver to use appropriate clothing at room temperature; Scheduling follow-up appointment; Assessing skin integrity; Assessing characteristics of the lesion and the skin around it; Demonstrating technique to perform genital hygiene;
Lack of knowledge of mother/father/caregiver about diaper erythema Improved skin integrity Risk of impaired skin integrity	Referring to appointment with a medical professional; Avoiding using a wet wipe; Encouraging the infant's body hygiene; Guiding mother/father/caregiver to care for skin lesion; Guiding mother/father/caregiver about the importance of body hygiene; Guiding to expose the affected area to the sun (before 10 a.m. and after 4 p.m.), for 15 minutes; Performing genital region hygiene at each diaper change; Requesting family monitoring by a Community Health Agent; Suspending use of hygiene product that causes erythema; Changing diaper after evacuations and whenever necessary; Changing the diaper brand; Using age-appropriate hygiene products.
PSYCHOBIOLOGICAL NEED - THERMAL REGULATION
Fever Knowledge of the mother/father/caregiver about adequate body temperature Lack of knowledge of mother/father/caregiver about body temperature Risk of impaired thermoregulation Body temperature normal Effective thermoregulation Impaired thermoregulation	Scheduling follow-up appointment; Administering antipyretic in accordance with an Institutional Protocol; Applying water compress at room temperature; Relieving excess clothing; Consulting mother/father/caregiver if infants took medication for fever; Consulting mother/father/caregiver about what medication infants usually take for fever; Referring to appointment with a medical professional; Monitoring and recording body temperature; Guiding mother/father/caregiver of infants with a temperature above 38ºC to seek health/emergency services; Guiding mother/father/caregiver about shower bath;
PSYCHOBIOLOGICAL NEEDS - NEUROLOGY REGULATION
Psychomotor activity (impaired/improved) Able to socialize Childish behavior (disorganized/organized) Knowledge of mother/father/caregiver about child development (improved/impaired) Infant development (improved/impaired) Newborn development (improved/impaired) Effective child development Lack of knowledge of mother/father/caregiver about child development Risk of disorganized child behavior Risk of impaired infant development	Scheduling follow-up appointment; Supporting the role of parents as promoters of child development; Referring to appointment with a medical professional; Guiding mother/father/caregiver about necessary encouragement for infants by using toys and games for child development (according to the age group); Guiding mother/father/caregiver on domestic accident prevention; Guiding mother/father/caregiver about the milestones of child development, according to the age group; Performing assessment and annotation of child development milestones in a Child Health Booklet; Verifying with mother/father/caregiver what they think and/or perceive about the infant's development process.
PSYCHOBIOLOGICAL NEED - IMMUNOLOGICAL REGULATION
Inflammation (mild, moderate, severe) Improved inflammation Adherence to the immunization regimen Improved skin integrity Non-adherence to the immunization regimen Risk of impaired skin integrity	Scheduling follow-up appointment; Assessing skin integrity; Assessing characteristics of the lesion and the skin around it; Referring to appointment with a medical professional; Encouraging body hygiene; Guiding mother/father/caregiver about the importance of body hygiene; Advising the importance of vaccines and to keep vaccination scheduling up to date; Requesting family monitoring by a Community Health Agent; Using scissors or nail clippers with a rounded tip and for exclusive use of for infants to cut the nails;
	Wearing clothing appropriate to the temperature; Verifying the infant's vaccination status.
Risk of infection	Scheduling follow-up appointment; Assessing body hygiene state; Assessing umbilical stump skin integrity; Demonstrating technique for umbilical stump hygiene; Performing umbilical stump hygiene with 70% alcohol whenever necessary; Keeping the umbilical stump clean and dry; Guiding mother/father/caregiver about basic care with the umbilical stump and body hygiene; Guiding mother/father/caregiver not to use umbilical band and other products on the umbilical stump; Requesting family monitoring by a Community Health Agent.
PSYCHOBIOLOGICAL NEEDS - CELL GROWTH REGULATION
Delayed growth (or growth delay) Growth within normal limits Risk of delayed growth (or delayed growth) Risk of disproportionate growth	Scheduling follow-up appointment; Measuring the anthropometric parameters: weight, height, head circumference, thoracic and abdominal; Performing bone, dental and physical-motor development assessment; Recording the information in the Child Health Booklet and assessing the related graphics; Observing breastfeeding (infant position, grasp, suction and the mother's breast); Guiding mother/father/caregiver on a routine of childcare appointments; Verifying with mother/father/caregiver what they think and/or perceive about the infant's growth process.
PSYCHOBIOLOGICAL NEEDS - VASCULAR REGULATION
Altered skin color (Jaundice - mild, moderate, severe) Normal skin color Knowledge of the mother/father/caregiver about proper skin color Lack of knowledge of the mother/father/caregiver about skin color	Scheduling follow-up appointment; Increasing the frequency of breast milk supply; Assessing jaundice location and intensity; Assessing breastfeeding; Referring to appointment with a medical professional; Encouraging breastfeeding on demand; Guiding mother/father/caregiver about jaundice; Sunbathing with infants without clothes, before 10 a.m. and after 4 p.m,, for up to 10 minutes;
PSYCHOSOCIAL NEED - SAFETY/LOVE
Adaptation (improved/impaired) Adjustment of mother/father/caregiver (improved/impaired) Affective mother/father/caregiver-infant bonding (effective/impaired) Risk of impaired emotional attachment of mother/father/caregiver-infant	Scheduling follow-up appointment; Referring to a social worker and/or psychologist; Encouraging interaction of mother/father/caregiver with infants; Identifying and preventing postpartum depression and refer the mother for treatment, if necessary; Identifying families at risk (domestic abuse, alcohol or drug addiction, lack of family support, adolescent parents with a fragile support network, etc.); Guiding on the importance of developing affective bond between mother/father/caregiver and infant and its relationship with adequate growth and development, construction of personality, affective relationships and sociability; Guiding mother/father/caregiver about doubts regarding infant care; Promoting breastfeeding and support for its effectiveness; Conducting home visit by the health team; Requesting family monitoring by a Community Health Agent; Verifying the existence of difficulties in mother/father/caregiver adaptation in relation to the arrival of infants.
PSYCHOSOCIAL NEED - PARTICIPATION/ATTENTION
Improved parenting knowledge of parent/caregiver	Scheduling follow-up appointment; Referring to a social worker and/or psychologist; Encouraging interaction of mother/father/caregiver with infants;
Lack of knowledge of mother/father/caregiver about parenting Parenting (effective/impaired) Risk of impaired parenting	Identifying families at risk (domestic abuse, alcohol or drug addiction, lack of family support, adolescent parents with a fragile support network, etc.); Promoting reflection with mother/father/caregiver on family relationships, demonstrating the importance for the infant's emotional maturation; Conducting home visits by the health team; Requesting family monitoring by a Community Health Agent.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding author: Cheila Karei Siega. E-mail: cheilasiega@gmail.