ORIGINAL

Nursing diagnoses in postpartum women based on the theory of maternal role attainment: a cross-sectional study

Simone Silva dos Santos1, Cristine Alves Costa de Jesus1

1University of Brasília, Brasília, DF, Brasil

ABSTRACT

Objective: this study aimed to understand the nursing diagnostic profile of postpartum women admitted to the Rooming-in Care Unit, based on NANDA-I Taxonomy II and the Theory of Maternal Role Attainment. Method: a descriptive, cross-sectional study with a quantitative approach was conducted with 72 postpartum women. A semi-structured instrument was used to collect data, including sociodemographic information, medical history, and physical examination. Nursing diagnoses were identified using NANDA-I Taxonomy II. Descriptive statistics with relative and absolute frequencies were employed for data analysis. Results: 638 nursing diagnoses were identified, encompassing 49 different diagnoses, with four prevalent diagnoses present in more than half of the postpartum women: Impaired tissue integrity, Acute pain, Disturbed sleep pattern, and Deficient knowledge. Conclusion: Characterizing the postpartum women's diagnostic profile enables a better understanding of their care needs and facilitates a more comprehensive approach to nursing care, considering all the complexity involved in achieving maternal role attainment.

Descriptors: Nursing Diagnosis; Nursing Theory; Postpartum Period.

INTRODUCTION

From delivery to eight weeks after childbirth, the postpartum period marks the maternal organism's return to its pre-pregnancy state. It is considered one of the most transitional moments in a woman's life, involving intense physical, emotional, self-image, and social role changes within the family. This period is associated with numerous adaptive difficulties and is susceptible to complications, such as psychological distress, physical discomfort, and challenges in reintegrating into the workforce and social circles, among others, which impact not only the woman's life but also that of the child and society(1-3).

In addition to physical care, a comprehensive approach to the woman's religious/spiritual dimensions and cultural beliefs in the postpartum period is essential for formulating a multidimensional care plan that addresses the woman's actual needs and targets her specific conditions effectively and competently(4-5). In this context, nursing care based on the Nursing Process (NP) stands out, as it provides the foundation for the nurse's actions and enables a more profound investigation of care needs.

The Nursing Diagnosis (ND) is the second stage of the NP, which is dynamic, interactive, intentional, and systematic, and requires grounding in a theoretical framework(5). ND corresponds to a specific theoretical-scientific framework for nursing and involves the use of standardized terminology. The diagnostic taxonomy of the NANDA International (NANDA-I) is a classification system with a global scope. It comprises 244 NDs classified into risk diagnoses, health promotion diagnoses, or problem-focused diagnoses, organized into thirteen domains, understood as spheres of knowledge. For instance, domain two categorizes all diagnoses related to nutrition, while domain seven describes NDs related to roles, relationships, and so forth across various systems.

Besides facilitating application through this categorization, each ND is grounded in clinical evidence, enabling an accurate representation of the patient/family/community's problems and potentialities, encompassing psychological, spiritual, and social dimensions(5).

Regarding the theoretical framework, Ramona Mercer's nursing theory is a middle-range theory whose title, "Maternal Role Attainment," describes its essence. In this theory, the mother interacts with her child, continuously and progressively developing maternal identity, acquiring competence in caregiving, and strengthening self-confidence as the maternal role is established(6). It is a theory specifically tailored to the pregnancy-postpartum cycle, providing a theoretical-scientific-practical basis of utmost relevance for providing care that addresses this population’s intricacies, extending beyond a simple focus on the pregnant uterus. This fosters the identification of potential influences on maternal role development while supporting the construction of a care plan and nursing interventions encompassing the mother-child dyad, allowing for a comprehensive perspective in diverse care contexts(4).

Given the above, nursing diagnoses based on Mercer's Theory constitute a facilitator of the care process, integrating multiple dimensions of the factors involved in achieving the maternal role while promoting the standardization of terminology that streamlines and enhances the provided care. Studies that establish a relationship between nursing diagnoses during the postpartum period, guided by a directed theoretical framework, are essential. Therefore, based on NANDA-I Taxonomy II and Theory of Maternal Role Attainment, this study aimed to understand the nursing diagnostic profile of women in the postpartum period admitted to the Rooming-in Care Unit.

METHOD

This is a descriptive study with a quantitative approach and a cross-sectional design derived from a master’s thesis in Nursing. The study was conducted in a Rooming-in Care Unit (RCU) of a teaching hospital in the Federal District, which caters to low-risk and high-risk populations and has 33 beds for pregnant and postpartum women.

Prior to the study, a data survey was conducted to identify the number of deliveries performed in the obstetric center that resulted in admissions to the RCU in July, August, September, and October 2019, recording 145, 149, 156, and 136 deliveries, respectively, during these months. The participants were selected using probabilistic sampling, and for sample size calculation, a preliminary study, the R software version 3.4, and the formula described below were utilized:

$$n˳=\frac{z^2\mathit{pq}}{e^2}$$

The confidence interval was set at 95%, with a margin of error of 10%, corresponding to a minimum sample size of 72 participants to be included in the study. The study included postpartum women admitted to the RCU who met the inclusion criteria, which were as follows: postpartum women aged above 18 years, with a living child, who had given birth to a late preterm or full-term baby (34-42 weeks of gestational age), admitted to immediate postpartum care up to the 3rd day, cognitively oriented, and in physical and mental conditions that allowed for the completion of anamnesis and physical assessment. Women in the postpartum period who were transferred to other hospital units, mothers of newborns admitted to other units, and women with multiple pregnancies were excluded from the study.

Data collection occurred from July to October 2020, during which 599 postpartum women were admitted to the RCU. Among them, 15 declined to participate in the study, 133 did not meet the inclusion criteria, and 379 postpartum women could not be interviewed due to the high turnover in the unit, making it impractical to approach all eligible participants. On average, three interviews were conducted daily, each lasting approximately 2 hours. Ultimately, the final sample comprised 72 postpartum women.

To collect data, a literature review was conducted on the theme of the postpartum period, nursing diagnoses, and NANDA-I Taxonomy II, and Ramona Mercer's theoretical framework, which served as the basis for constructing the research instrument. This instrument was structured according to Mercer's described systems, with each question encompassing concepts from her Theory. Subsequently, the instrument was evaluated by three expert judges with clinical experience in nursing care and/or obstetrics. After the judges' evaluations, adjustments were made to the instrument to make it suitable for use in the study.

Initially, eligible women were approached, and the research was thoroughly explained, clarifying the process of obtaining informed consent through a signed document called the Informed Consent Form (ICF). Once consent was obtained, the first stage of data collection began, involving the review of medical records, followed by the interview and physical assessment.

The process of analysis and synthesis, following Helland/Risner(7) and NANDA-I Taxonomy II(4), was employed for clinical judgment, and nursing diagnoses were formulated along with their diagnostic indicators. An expert in the field validated each nursing diagnosis; subsequently, the diagnoses were listed.

The collected data were organized into spreadsheets, forming a database using the Microsoft Excel 2010 software. Descriptive statistics were employed to analyze numerical variables, including measures of absolute frequency, percentages, and measures of central tendency and dispersion.

The study adhered to the principles outlined in Resolution CNS 466/2012, as recommended by the National Health Council (NHC), and obtained approval from the Research Ethics Committee (REC) of the Faculty of Health Sciences at the University of Brasília (UnB), under the approval number 3.754.960 and CAAE 19024719.7.0000.0030.

RESULTS

The sample consisted of 72 postpartum women, with a mean age of 27.9 (SD ±6.8) years and a median of 27.5. The distribution of sociodemographic and economic characteristics can be observed in Table 1.

Table 1 - Characterization of the socio-demographic and economic profile of the sample (n=72). Brasília, DF, Brazil, 2020

Most interviewees were multiparous, with an unplanned but accepted pregnancy, having undergone more than six prenatal consultations. Predominantly, the delivery was performed via cesarean section, and the gestational age ranged from 39 to 40 weeks and six days, as evidenced in Table 2.

Table 2 - Characterization of the obstetric profile of the sample (n=72). Brasília, DF, Brazil, 2020

A total of 638 nursing diagnoses were identified, with an average of 8.9 nursing diagnoses per participant and a median of 8. Among the 13 domains described in NANDA-I taxonomy(4), only the domain of Principles of Life and Growth/Development had no listed nursing diagnoses, while the other 11 domains presented listed nursing diagnoses. Table 3 displays the 49 nursing diagnoses detected in the study population, and their respective domains.

Source: Prepared by the authors, 2021.

In the sample, four nursing diagnoses showed a prevalence of over 50%, and their defining characteristics are described in Table 4. It is important to note that each nursing diagnosis identified in postpartum women may have more than one defining characteristic.

Table 5 lists the factors related to the four nursing diagnoses with a prevalence of over 50% in the studied sample. It is essential to highlight that each interviewee may present more than one related factor for each nursing diagnosis.

Regarding the associated conditions and the populations at risk for nursing diagnoses prevalent in over 50% of the sample, only the nursing diagnosis of Impaired Tissue Integrity presented associated conditions. Among the postpartum women with this diagnosis, 53 (88.3%) underwent a surgical procedure (perineal surgery/suturing), five (8.3%) experienced vascular trauma, and two (3.3%) had hormonal alterations. None of the nursing diagnoses had an identified population at risk.

DISCUSSION

The sample profile was similar to other studies, with most women being young, self-declaring as mixed race, having a stable partner, a medium level of education, and being homemakers(2,8-9). Sociodemographic variables are related to prognosis, making it essential to know them to outline a comprehensive care plan(8). Multiparity, unplanned but accepted pregnancies, and adherence to prenatal care with more than 6 consultations are also in the literature(8-10). The prevalence of women who had gestational hypertension (GH) and gestational diabetes mellitus (GDM) was also described in a prior study(9-11).

The evidence corroborates the present study's findings regarding the prevalence of cesarean delivery in women diagnosed with GDM and GH(9-11). Although there are increased risks in subjecting pregnant women with these diagnoses to surgery, few had complications during delivery and the postpartum period in the studied sample. These findings suggest the quality of care, with timely management favoring positive outcomes.

Among the presented nursing diagnoses, four had a prevalence of over 50% in the studied sample, corresponding to those described in the literature as the main problems in the immediate postpartum period(2,9,12). Impaired Tissue Integrity predominated among the interviewees, corroborating with other studies(2,12). Noteworthy associated characteristics include surgical wounds, nipple and perineal injury, limb or perineal edema, and episiotomy(2,12).

According to Torres(12), the prevalence of cesarean delivery and invasive procedures is directly proportional to the presence of this diagnosis. The author argues that cesarean section should be reserved for situations of a real need to decrease the incidence of this nursing diagnosis, as a less traumatic postpartum period promotes maternal well-being and interaction with the newborn(2,12).

In contemporary obstetric practice based on evidence, preventive resources for perineal lacerations are employed, such as allowing women the freedom to choose the most comfortable delivery position, usually the upright position, perineal massage with vegetable oil, and warm perineal compress during the expulsive phase(13-14). Working together with the physiological process of delivery, avoiding the Valsalva maneuver and abolishing the Kristeller maneuver, which has been banned in obstetrics, facilitates slow fetal descent, allowing gradual perineal distension and preventing injuries(13-14). The fact that this nursing diagnosis is not present in all postpartum women may be associated with adopting these resources and the multiparity profile of the sample, as a woman who has had one or more vaginal deliveries experiences a reduced risk of perineal lacerations(13). On the other hand, episiotomy is identified as a practice reserved for isolated cases and considered unnecessary by some authors. However, many professionals still use it in care, increasing the rate of perineal traumas and, consequently, the risk of infections and bleeding related to this practice(2,8,15).

Based on the theoretical framework, employing techniques that prevent tissue damage and, when necessary, using resources that promote healing is essential, transcending comfort to address the dimension of the maternal role. In this context, this nursing diagnosis can affect the achievement of the maternal role, not only by impacting a woman's self-esteem but also by being associated with other nursing diagnoses such as Acute pain, which negatively affects concepts well described by Ramona Mercer, such as birth experience, satisfaction, and health status(16).

The factors related to the nursing diagnosis of Acute pain, identified in 75% of the postpartum women, were surgical wounds resulting from cesarean section and perineorrhaphy, perineal hematomas or lacerations, and uterine cramps, which are very common in the physiological process of postpartum(2,9,17). Another study also identified this nursing diagnosis in all interviewees who underwent cesarean section, with related factors including the surgical incision, postpartum infection, and inflammatory agents related to the incision(2,9,17). This diagnosis impacts women's physical and psychological dimensions, restricting self-care, care for the child, and interaction and bond with the newborn, resulting in negative feelings regarding autonomy and the achievement of the maternal role(2,9,17).

Pain involves various physical, emotional, and cultural aspects, and there are care nuances within each system described by Mercer. In the macrosystem: transmitted cultural consistencies; in the mesosystem: daily care and the context of health care; and in the microsystem: bonding with the child, trust, satisfaction in the role, self-esteem, maternal health, tension in the role, physical/psychological burden, anxiety, and birth/postpartum experience; comprising a framework that must be considered in nursing interventions(4,6,16).

The nursing diagnosis of Disturbed sleep pattern is defined by NANDA-I(4) as "time-limited awakening due to external factors". The diagnosis was identified in 63.9% of the interviewees, consistent with the findings in the literature(2,12,18). Sleep fragmentation begins during pregnancy and intensifies during labor and the first months after delivery(3,18). Silva et al.(18) state that "regardless of a woman's routine, with the arrival of a child, she must adjust to the demands of motherhood". Additionally, newborns' sleep pattern exhibits instability in frequency and duration, gradually improving as the child develops. The family establishes a routine, making it a factor that extends throughout the postpartum period and requires significant maternal adaptation(2,18). The defining characteristics observed corroborate those of another study(2,18), which also describes a limitation in carrying out daily activities and a decrease in functional capacity, having, as related factors, the woman's dependence during puerperium and the physical and emotional fragility triggered by a disturbed sleep pattern(2,18).

The nursing diagnoses of Acute pain, Anxiety, and Fatigue are causally related to the Disturbed sleep pattern, highlighting the need to intervene in all of them to promote women's rapid recovery, improve sleep, well-being, self-care, and conditions for caring for the newborn, fostering the performance of the maternal role(18) according to Torres(12). In light of Mercer's theory, the postpartum period demands adaptive efforts from women concerning their new physical, psychological, social, and learning states related to the baby's care routine, which may extend for months until complete physical recovery is achieved(6).

Regarding the rooming-in units, reflection is necessary concerning the implementation of care routines tailored to the needs of postpartum women, with flexible schedules for professional visits, examinations, and medication administration, as well as maintaining a calm and quiet environment, encouraging daytime sleep so that mothers can rest when the baby sleeps(1,9,12). Mercer(19) adds to this, highlighting the rooming-in unit as an environment that should be intimate, and the nurse should provide moments with the postpartum woman, avoiding fragmented care and expanding her care to promote the well-being of the woman and foster the achievement of the maternal role(19).

The nursing diagnosis of Deficient knowledge is defined by NANDA-I(5) as the "absence of cognitive information related to a specific topic, or its acquisition". It was also identified in another study, where the author associates it with information related to breastfeeding, baby care, and the development of the maternal role(2,12).

It is known that numerous changes occur in various aspects of a woman's life during the pregnancy-postpartum period, permeated by feelings of uncertainty and doubt, requiring knowledge acquisition(12). This nursing diagnosis is related to the socioeconomic profile, and the literature indicates greater access to information in women with higher education levels, aged over 35 years, and who had prenatal care adherence(2,9,20). Such a profile fosters an understanding of expected changes, increasing women's willingness to acquire knowledge and autonomy to manage breastfeeding, childcare, and other aspects(2,9). However, it is believed that other variables may be involved in Deficient knowledge, as it was prevalent in the studied sample, which was mostly composed of young women with a medium level of education and good prenatal care (over six consultations).

The finding above emphasizes the importance of evaluating how information is transmitted, considering the individuality and life context of the woman and her support network, avoiding excess information, and using clear language to ensure understanding(20). According to Caetano(20), these points are essential for the mother and her partner to have autonomy and acquire the necessary skills for postpartum care.

The second stage for achieving the maternal role described by Mercer is knowledge and learning in dealing with the demands of caring for the child(19). The theorist emphasizes the importance of nurses' interaction with the postpartum woman, as well as other members of the healthcare team, in this stage, encouraging the adoption of routines and work processes that offer health education beyond educational materials(18).

The development of the maternal role is directly impacted by various factors, such as maternal profile, child characteristics, maternal health status, the environment in which she is inserted, and childbirth experience, among others(6,16). The prevalent nursing diagnoses of Impaired tissue integrity, Acute pain, Disturbed sleep pattern, and Deficient knowledge described in this study reveal some problems that impact the development of maternal identity(19). Therefore, nursing actions should enable individualized care with targeted and comprehensive interventions, preserving women's autonomy and fostering the development of their maternal role.

This study has limitations, such as data collection being restricted to a single hospital, representing only the local reality, and the lack of research linking the studied population to nursing diagnoses and the Theory of Maternal Role Attainment.

CONCLUSION

The results of this study provided insights into the profile of nursing diagnoses in postpartum women admitted to the Postpartum Unit. The theoretical foundation based on a specific Theory for the studied population and the NANDA-I Taxonomy II expanded the understanding of factors and contexts influencing the well-being of postpartum women. This approach allowed for the characterization of sociodemographic, clinical, and epidemiological profiles and discussions on prevalent defining characteristics, related factors, and risk factors within the studied population.

The discussion of findings based on Ramona Mercer's Theory of Maternal Role Attainment provided a theoretical and scientific framework, contributing to nursing as a discipline and guiding patient-centered care tailored to the real needs of postpartum women. The theory's specificity to the maternal-infant population proved valuable in enhancing the quality of care and guiding nursing practice with a strong scientific foundation.

As a significant contribution, it highlights the importance of adopting comprehensive care for postpartum women, considering the identified care needs reflected in nursing diagnoses, which encompass individual and collective nuances related to the intense transitions experienced by women socially, personally, and culturally.

Furthermore, this study guides the implementation of other stages of the nursing process, such as nursing interventions, which, based on scientific evidence, can integrate care and encompass the woman, child, family network, and society. The presented findings can serve as a basis for future research to further enhance knowledge in this area, considering diverse settings for greater representativeness.

*Paper extracted from the master's dissertation “Nursing diagnoses in postpartum women based on the theory of maternal role attainment”, presented to the University of Brasília, Brasília, DF, Brazil.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submissão: 10/25/2022

Aprovado: 07/21/2023