PURPOSE. To clinically validate the nursing diagnoses of the first Finnish version of Perioperative Nursing Data Set (PNDS) by using them in perioperative documentation.
METHODS. Nursing diagnoses were used in documentation in four operating departments with 250 patients. In analysis, nonparametric tests were applied.
FINDINGS. While intraoperatively nursing diagnoses focused on physiological concerns, postoperatively the focus shifted to that of recovery.
CONCLUSIONS. The findings revealed the importance of safety-related routines in perioperative care. Nursing diagnoses in the Finnish version of PNDS are sensitive in describing the rationales for perioperative care.
IMPLICATIONS FOR NURSING PRACTICE. Nursing classifications illustrate the nursing process in a structured form. Nursing diagnosis is an early step in the decision-making process that aims to achieve expected outcomes in nursing care.
TARKOITUS: Validoida PNDS-luokituksen suomalaisen version diagnoositermit käyttämällä niitä perioperatiivisen hoitotyön kirjaamisessa.
MENETELMÄT: Hoitotyön diagnooseja käytettiin kirjaamisessa 250 potilaan kohdalla. Aineiston analyysissä käytettiin ei-parametrisiä testejä.
TULOKSET: Hoidon intraoperatiivisessa vaiheessa korostuvat potilaan fysiologiaan liittyvät ja postoperatiivisessa vaiheessa potilaan toipumiseen liittyvät hoitotyön diagnoosit.
JOHTOPÄÄTÖKSET: Perioperatiivisessa hoitotyössä painottuvat potilaan hoidon turvallisuuteen tähtäävät rutiinit. PNDS-luokituksen suomalaisen version diagnoositermejä voidaan käyttää kuvaamaan leikkauspotilaiden hoidon tarpeita.
TULOSTEN HYÖDYNNETTÄVYYS: Hoitotyön prosessia voidaan kuvata rakenteisesti hoitotyön luokituksilla. Hoitotyön diagnoosin määrittäminen on osa päätöksentekoprosessia tavoitteena tunnistaa ja saavuttaa toivotut tulokset potilaan hoidossa.
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