Development of a perioperative nursing diagnoses flow sheet

Area of Science:

• Nursing
• Surgical Care
• Healthcare Documentation

Background:

• Traditional perioperative records primarily focus on technical patient data, neglecting comprehensive nursing care documentation.
• Existing formats offer limited space for narratives, failing to capture the full scope of perioperative nursing activities and interventions.

Purpose of the Study:

• To address the challenge of documenting nursing diagnoses and care plans within perioperative settings.
• To develop and implement a standardized documentation tool for perioperative nurses.

Main Methods:

• Formation of a nursing diagnosis task force to investigate documentation needs.
• Development and implementation of a specialized perioperative nursing diagnoses flow sheet.
• Universal adoption of the new flow sheet within the surgical services department.

Main Results:

• Successful creation and implementation of a perioperative nursing diagnoses flow sheet.
• Standardized documentation of nursing diagnoses and care plans across preoperative, intraoperative, and postoperative phases.
• Improved and comprehensive recording of nursing interventions and patient care.

Conclusions:

• The developed perioperative nursing diagnoses flow sheet effectively addresses the need for comprehensive nursing documentation.
• Implementation of the flow sheet enhances the visibility and integration of nursing care within the surgical patient record.
• This standardized approach supports better communication and continuity of care for surgical patients.