Development of a perioperative nursing diagnoses flow sheet

Traditionally, health care professionals in the preoperative, intraoperative, and postoperative phases of care have used perioperative records that focus on the technical aspects of the care provided (eg, blood pressure, pulse measurements; equipment used) and leave room for only short narratives to document nursing care. Such formats often do not document the multitude of activities or interventions perioperative nurses provide. The question raised at the DePaul Health Center, St Louis, was: "Where do we document our nursing diagnoses and plan of care?" The response was to create a nursing diagnosis task force that investigated the feasibility of a form professional nurses could use in all phases of patient care. This investigation led to the development, implementation, and universal use of a perioperative nursing diagnoses flow sheet within the surgical services department.