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Patients' Care Needs: Documentation Analysis in General Hospitals
Wolter Paans1, Maria Müller-Staub2
1Research and Innovation Group in Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, the Netherlands.
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.
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