Patients' Care Needs: Documentation Analysis in General Hospitals

Abstract

Purpose

The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs.

Methods

A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards.

Findings

The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity.

Conclusions

Most care needs were determined in physiological health patterns and few in psychosocial patterns.

Implications for Nursing Practice

To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns.

Doel

Het doel van de studie is: (a) te beschrijven wat de gezondheidsproblemen / verpleegkundige diagnosen zijn die beschreven staan in patiëntendossiers in ziekenhuizen in Nederland en (b) te evalueren of verpleegkundigen de NANDA-I classificatie gebruiken om gezondheidsproblemen te formuleren.

Methode

Uit alle ziekenhuizen in Nederland werd een willekeurige steekproef getrokken om aan de hand van het D-Catch instrument een review naar verpleegkundige documentatie uit te voeren in 10 ziekenhuizen, op 37 verschillende verpleegafdelingen.

Resultaten

De meest prevalente verpleegkundige diagnosen waren: Acute pijn, Misselijkheid, Vermoeidheid, Risico op huidbeschadiging i.c. decubitus.

Conclusies

De meeste gezondheidsproblemen werden gevonden in het fysiologische domein. Er werden aanmerkelijk minder psychologische gezondheidsproblemen gevonden. De NANDA-I classificatie was herkenbaar in de documentatie. Meer eenheid in het gebruik van diagnostische begrippen is gewenst.

Implicatie Voor De Praktijk

Om effectieve interventies uit te kunnen voeren is het van belang specifiek en nauwkeurig te documenteren wat gezondheidsproblemen van patiënten zijn. Meer aandacht voor diagnostische domeinen die gerelateerd zijn aan gezondheidsbevordering, rollen en relaties, coping en stresstolerantie en welbevinden lijkt gewenst.

Keywords

NANDA-I classification nursing diagnosis nursing documentation record review

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