ICNP® Nursing Diagnoses related to nutrition in the pediatric clinic: a cross-sectional study

Ana Emília Alcântara de Avelar1, Marcela Ferreira dos Santos2, Rebeca Garcia Tavares3, Alícia Laís Silva Oliveira2, Tamires Dayanna Alves Resende4, Fabiana Maria Rodrigues Lopes de Oliveira2, Gabriela Lisieux Lima Gomes2

1 University of Pernambuco, PE, Brazil

2 University Center of João Pessoa, PB, Brazil

3 Training, Professional Improvement and Research Center, PB, Brazil

4 Integrated Center for Educational Consulting Services, PB, Brazil

ABSTRACT

Objective: to identify the ICNP® Nursing Diagnoses related to the basic human need for nutrition in the pediatric clinic. Method: a cross-sectional study with a quantitative approach, carried out in the pediatric clinic of a public hospital in the city of João Pessoa, Paraíba. The sample consisted of 91 participants, including children and adolescents with a hospital stay of more than 24 hours. Result: it was possible to identify the following diagnoses: Weight loss; Adherence to the Effective Dietary Regime; Infant Feeding Behavior, Impaired; Appetite, Impaired; Obesity; Exclusive Breastfeeding; Impaired Exclusive Breastfeeding; Body Weight Problem; Overweight; Impaired Adherence to Diet; and Nutritional Condition, Impaired. Conclusion: the following stood out among the diagnoses: Effective Appetite; Effective Infant Feeding Behavior; Effective Food or Fluid Intake Pattern; Positive Nutritional Status; and Ability to Feed. Elaboration of the diagnoses related to child and adolescent nutrition corroborates the construction of terminology subsets, in order to ensure care effectiveness.

Descriptors: Nursing Process; Standardized Terminology in Nursing; Nursing Diagnosis; Hospitalized Child.

INTRODUCTION

Nutritional status in the first years of life until puberty is a determining factor for the healthy growth and development of a child or adolescent. Adequate nutrition, in turn, ensures functioning of the body functions through the correct intake of nutrients, vitamins and minerals, ensuring healthy growth and development, as well as prevention of chronic diseases(1). 

Thus, as this is a dynamic period, nutritional status is an aspect that requires attention from the health services, with an emphasis on professional care. Nutrition is characterized by different changes in the growth and development of children and adolescents, influenced by variations in the family, physical and social environment. Events that happen in childhood and adolescence exert a major influence on adulthood, turning this phase into a relevant stage in the life cycle(2).

With regard to hospitalization, admission to the hospital compromises the child's life in several aspects, which resonates negatively in the expression of feelings and in their development, given the distance from their home and family members, who have continuous contact. Facing this reality, active listening by health professionals is indispensable, as well as promotion of effective communication with the hospitalized child's parents, in order to promote their understanding of the performance of the various procedures and the benefits for the improvement in the child's condition(2).

With this, the importance of Nursing professionals together with the multidisciplinary team is perceived, in order to provide activities that allow for the involvement of the child and family members during this period and, thus, enable provision of care encompassing individuality, contributing positively in the child's stay in the hospital environment(3). 

Given this scenario of hospitalization in Pediatrics, Nursing professionals are directly responsible for identifying the child's needs, as well as for planning and providing care, ensuring quality of care, through the Systematization of Nursing Care (SBC), with implementation of care based on technical-scientific knowledge and application of all stages of the Nursing Process(4).

Based on Nursing theories, it is pertinent to mention the use of the theory of basic human needs as theoretical support for the provision of care to children and adolescents. Horta describes Nursing as the science and art of assisting human beings (individual, family and community) in meeting their basic needs, making them independent from this care, when possible, by teaching self-care and recovery, as well as health maintenance and promotion. Therefore, its applicability seeks to improve quality of life and the existing interrelationships between the principles, concepts and purposes contributed by the theory(5).

For this purpose, the International Classification for Nursing Practice (ICNP®) was used because it is a standardized terminology that names, classifies and links phenomena that describe the fundamental elements of the professional practice, which permeate the judgment of certain needs of the individual (Nursing Diagnoses), which can positively influence diagnoses on human and social needs (Nursing actions/interventions)(6).

ICNP® is a standardized terminology, extensive and with a high level of understanding, characterized as a technological information tool capable of enabling collection, storage and analysis of Nursing data in numerous situations, contributing to a Nursing professional practice that is effective and visible in the grouping of health data(7).

In this perspective, and through the identification of changes related to the basic human need for nutrition of hospitalized children and adolescents, the importance of identifying Nursing Diagnoses (NDs) is emphasized with a view to providing execution of the Nursing Process, which makes it possible to extract necessary information to facilitate clinical reasoning and contribute to the standardization of the professional language(7).

Therefore, as this process can cause significant changes in the growth and development of hospitalized children, this study aims at identifying the ICNP® Nursing Diagnoses related to the basic human need for nutrition in the pediatric clinic.

METHOD

This is a cross-sectional study with a quantitative approach, carried out in the inpatient unit of a pediatric clinic at a public hospital in the city of João Pessoa, Paraíba. The research was elaborated from the research project entitled “Software development to identify ICNP® Nursing diagnoses and interventions”, developed by researchers from a Higher Education Institution.

The study population included children and adolescents hospitalized in the pediatric ward of that hospital, as well as their legal representatives, with data collection extending between April and October 2019. Infants, toddlers, preschoolers, schoolchildren, and adolescents with a hospital stay of more than 24 hours, aged from 0 to 18 years, 11 months and 29 days old, were included; all of them were able to answer the questions and agreed to participate in the study. Children, adolescents and legal representatives who were not in a clinical condition to answer the questions were excluded from the study. Considering this, the final sample consisted of 91 participants, being of the non-probabilistic type, chosen for convenience and with no sample calculation. It is worth emphasizing that all participants, belonging to the aforementioned age groups and admitted in the mentioned period, were invited to participate in the study.

Data collection was carried out by the researchers linked to the research project, students attending the Nursing course and previously trained by the main researchers. For this, a semi-structured instrument was used in order to obtain information about the sociodemographic data of the child/adolescent, as well as additional information from the legal representatives (age, gender, companion's schooling, vaccination schedule, and if enrolled in an educational institution), anamnesis and physical examination, constructed in line with the precepts of the Theory of Basic Human Needs proposed by Wanda de Aguiar Horta(5).

For the elaboration of the Nursing diagnoses presented in this study, the needs proposed in Horta's Theory of Basic Human Needs were considered. ISO 18104:2014 and the ICNP® taxonomy version 2019/2020 were used, consisting of the 7-axis model including, obligatorily, a term from the Focus axis and another from the Judgment axis(7). 

In addition to that, the researchers' critical thinking and diagnostic reasoning were considered, based on the particularities of the researched public, following these stages: 1) analysis of the data collection instruments; 2) identification of the problems presented by the child/adolescent; 3) link with the basic human need affected; 4) use of ICNP®, with emphasis on the focus and judgment axes; 5) structuring of the Nursing diagnosis; and 6) review by two expert PhDs in Nursing.

Subsequently, the data were entered into the Statistical Package for the Social Sciences 20.0 (SPSS) software to enable conduction of the statistical treatment. Regarding data analysis, a quantitative approach was performed, using descriptive statistics to obtain absolute and relative frequencies, location measures (mean, median, minimum and maximum) and scale (standard deviation) of the Nursing diagnoses elaborated.

The project was submitted to the Research Ethics Committee (Comitê de Ética em Pesquisa, CEP) for appreciation, in accordance with the ethical aspects referenced in Resolution No. 466/2012, which regulates research involving human beings, having been accepted under protocol number: 3,181,956. It is worth noting that the Free an Informed Consent Form (FICF) was signed by the legal representatives, in two copies, one for the participant and the other for the researchers. For the children who are literate and able to sign, an Assent Form was made available.

RESULTS

The sociodemographic characterization was obtained through semi-structured interviews and a questionnaire designed for pre-adolescents and adolescents and for children and their respective legal guardians. After grouping the findings, there was higher prevalence in the following results: Toddler age group (35.16%), Male gender (70.33%); Complete Vaccination Schedule (74.73%); and Enrolled in a Teaching Institution (52.75%). In addition, most of the companions had incomplete elementary school (37.36%), according to the data presented in Table 1:

Table 1 - Sociodemographic characterization of the children and adolescents. João Pessoa, PB, Brazil (n=91)

Source: Prepared by the authors, 2020.

For elaboration of the diagnoses, the need for nutrition was considered in accordance with the Wanda Aguiar Horta's Theory of Basic Human Needs(5), in addition to the diagnostic reasoning process and the ICNP® taxonomy. Thus, 17 diagnoses were identified, with the following prevailing: “Effective Appetite” (20.5%), “Effective Infant Feeding Behavior” (20.2%), “Effective Food or Fluid Intake Pattern” (16.7%), “Positive Nutritional Condition” (13.2%) and “Ability to Feed” (11.6%), as shown in Table 2:

Table 2 - ICNP® Nursing diagnoses related to the need for nutrition in the pediatric clinic, according to the Horta's Theory of Basic Human Needs. João Pessoa, PB, Brazil (n=91)

 Source: Prepared by the author, 2020.

Figure 1 - Operational definitions of the Nursing diagnoses related to the need for nutrition in the pediatric clinic. João Pessoa, PB, Brazil (n=17)

Source: Nóbrega, 2018; International Council of Nurses, 2018. 

DISCUSSION

Nutrition exerts a direct influence on the child's physical growth, neuropsychomotor development and immune system, subsequently preventing infectious diseases in adolescence and throughout life. Nutritional disorders are considered the main causes of morbidity and mortality in the child population, being one of the factors that compromise the prognosis of human diseases(8).

With regard to children and adolescents in a hospital context, monitoring of their nutritional status is recommended, since adequate nutrient intake is a determining factor for advancement of the person's recovery and improvement of nutritional deficiency, in addition to providing early recovery from the disease, benefiting the nutritional status exposed(9).

In the meantime, nutritional assessment should be carried out in children at nutritional risk, where the health professional measures the data on weight and height, evaluating them according to the growth and development curves, and classifying them according to weight/height, height/age, body mass/age and weight/age indices(10). This practice is part of the nurses' daily routine in child health care.

In this study, the children presented “Effective Appetite”, “Effective Infant Feeding Behavior”, “Effective Food or Fluid Intake Pattern”, “Positive Nutritional Condition”, “Ability to Feed” and “Weight Loss”, which represents 4.3% of the Nursing diagnoses elaborated and refer to signs and symptoms of significant prevalence in the case of nutritional deficiencies.

The statements “Effective Infant Feeding Behavior” and “Effective Appetite”, as well as all the others with a positive focus, were the most frequent Nursing diagnoses in the research. In this sense, eating behavior is modulated by appetite and both are dependent on environmental, social and biological factors. The concept of appetite is complex, but it can be defined, from a biological perspective, as a driving force for the search, choice and intake of food or, from a broader perspective, as attitudes and psychosocial factors implicit in the selection and decision of food intake(11).

In this sense, the construction of healthy habits acts as a strengthened gear for the prevention of future diseases, being the best strategy to avoid nutritional deficiencies in children(11). However, the “Weight Loss” finding is related to the nutritional conditions in the hospital context, resulting from changes in the structure of the diet, or with the socioeconomic and demographic changes and the accelerated industrialization process that affects the food culture(12).

Weight loss can be related to primary or secondary causes. The primary ones are present in children or adolescents who have a diet that is insufficient in calories and nutrients. On the other hand, the secondary causes arise from insufficient food intake or increased energy requirements, due to a factor unrelated to food, such as presence of worms, allergies, food intolerance, and poor digestion and absorption of nutrients(12).

On the other hand, 0.8% of the children presented “Exclusive Breastfeeding”, which represents 0.2% of the Nursing diagnoses elaborated. In this perspective, breastfeeding is able to provide benefits for both infant and mother, making a support network necessary to encourage and provide fundamental information, with the participation of health professionals and family members, seeking to ensure continuity of exclusive breastfeeding during at least the first 6 months of the baby's life(13).

On the other hand, it is worth noting that 0.8% of the children presented “Impaired Exclusive Breastfeeding”, which represents 0.2% of the Nursing diagnoses elaborated. It is worth noting that exclusive breastfeeding can be impaired by countless factors, such as in cases of infant hospitalization, mastitis, cracked nipples, some diseases or drugs that are incompatible with breastfeeding. In any case, a study shows that breastfeeding reduces infant mortality, protects against allergies, prevents diseases and improves neurological development, in addition to representing the most natural and nutritious form of food for human beings in the first months of life(14).

With regard to food intake, this study showed that 1.9% of the hospitalized children presented “Impaired Appetite”, “Adherence to Effective Dietary Regime” and “Impaired Adherence to Dietary Regime”. Therefore, adapting the patients' daily meals to satisfy and preserve appetite is essential, thus seeking to minimize food rejection and meet the nutritional needs during the hospital stay(15).

Regarding the “Impaired Infant Feeding Behavior” and “Obesity” Nursing diagnoses, it is known that infant feeding directly reflects on eating habits and health status in adulthood; however, food options that are harmful to health are being offered more and more children, mainly influenced by the eating habits of the family environment.(16).

Considering that obesity is a significant finding, as it reflects the consequence of impaired child eating behavior, it is pertinent to highlight that excess weight in children and adolescents is increasing in today's society, being responsible for causing multiple complications in the individual's health. Thus, and with a view to minimizing this aspect, the study points to the need for political and family strategies and actions focused on encouraging consumption of healthy foods and carrying out activities that reduce sedentary lifestyles in childhood(17).

The child hospitalization process exerts a direct influence on nutritional status, being capable of causing significant consequences for a given period of time. In this study, it was possible to evidence this. In addition to that, assessment and monitoring of the nutritional status of children and adolescents by health professionals is indispensable, enabling the planning and implementation of interventions aimed at child nutrition, avoiding possible harms to health(18).

Furthermore, hospitalization causes countless emotional impacts on the child and, for this reason, providing Nursing care with humanized actions reflects positively during this process. According to Ribeiro et al.(19), when seeking to offer activities that allow children to have fun during provision of care, Nursing professionals promote a welcoming, reassuring and pleasant environment, in addition to facilitating and providing interaction between the professional and the child.

Thus, the relevance of this study for the scientific community is highlighted, since diseases related to nutrition are considered a public health problem, and it is important to offer care to children, pre-adolescents and adolescents with nutritional changes, in order to promote quality care.

Study limitation

This study has limitations, namely: addressing only one hospital reality; being of the cross-sectional type, not allowing a cause-and-effect relationship; and having the sample selected for convenience, which can lead to selection bias. Therefore, it is suggested to carry out other studies, especially with a prospective approach, involving larger and randomized populations, for a better contribution to the phenomenon in question. Despite these limitations, the study achieved its objective, presenting the Nursing diagnoses related to the nutrition need in the pediatric clinic.

Contributions to the Nursing, Health or Public Policy areas

This study will help positively in the Systematization of Nursing Care in the pediatric clinic using the ICNP®, facilitating clinical reasoning and decision-making by nurses regarding the nutritional needs of children and adolescents.

CONCLUSION

Elaboration of the Nursing diagnoses related to the nutritional needs of the pediatric and adolescent population inspires the scientific community to devise ICNP® terminology subsets in the various clinical units, in order to ensure that systematization of care is precise, organized and individualized in each instance of Nursing care provided.

The importance of a language system for the elaboration of Nursing diagnoses will occur in the improvement of communication among nurses, members of the Nursing team and other professionals, making it possible to evaluate Nursing outcomes and choose the best interventions, in order to optimize the Nursing practice to directly offer advances in the care provided.

Furthermore, the study was able to emphasize that the change in nutritional status can harm child development, as well as the daily life of the family, as it is linked to an unexpected experience that is totally different from the usual. In this sense, this research presented the importance of using SNC in child health care, as well as the application of the Nursing process, including the identification of Nursing diagnoses, together with the use of ICNP®, allowing for the provision and continuity of care based on technical-scientific knowledge through assistance focused on the individual nutritional needs of each person.

In the meantime, it is necessary to continue this study for the development of Nursing interventions, aiming to devise an ICNP® terminology subset related to child and adolescent nutrition, supporting its use, strengthening the standardized language and systematization of care, valuing practice, teaching and research in Nursing, since nutrition-related diseases are considered a public health problem.

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Submission: 03/25/2021 

Approved: 09/13/2021