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Int J Nurs Knowl. 2015 Oct;26(4):178-86. doi: 10.1111/2047-3095.12063. Epub 2014 Oct 31.

Patients' Care Needs: Documentation Analysis in General Hospitals.

Author information

1
Research and Innovation Group in Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, the Netherlands.
2
Pflege PBS, Bronschhofen, Switzerland.

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.

KEYWORDS:

NANDA-I classification; nursing diagnosis; nursing documentation; record review

PMID:
25358896
DOI:
10.1111/2047-3095.12063
[Indexed for MEDLINE]

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