Ošetrovateľské diagnózy a intervencie v klinickej praxi
Gabriela Vӧrӧsová, Andrea Solgajová, Dana Zrubcová
Abstract: Background: Nursing diagnosis validation is important for increasing the precision of nursing diagnostics, standardization of nursing terminology and for improving using of interventions in nursing practice.
Objective: The aim of the research was to find out the level of documentation of nursing diagnoses by nurses in Slovak and Czech Republic. Second aim was to study nurses’ opinions on documentation.
Methods: List of 11 areas was used for analysing medical documentation. Sample consisted documentation of 120 patients in different Slovak (clinics of surgery, pediatric clinics, oncological clinic) and Czech (Anesthesiology-Resuscitation, Post-Care Center, Children’s Cardiocentre, Gynecological) departments. Documentation was evaluated by 30 nurses.
Results: In the sample of 120 patients, 434 nursing diagnoses were documented. In Slovak departments in 60 patients, 85 nursing diagnoses and 356 nursing interventions were documented. In Czech departments in 60 patients, 349 nursing diagnoses and 1142 nursing interventions were documented. Most of documented nursing diagnoses belong to the domain 11: Security and Protection. Nursing diagnoses for intervention of psychical problems and the least focused on social and spiritual diagnoses were documented.
Implications: Most nursing diagnoses documented by nurses in practice dealt with security and protection needs, resting activities, and nutrition. Nurses take less care in psychosocial and spiritual needs of patients. One of the reasons why could be the complexity of satisfying these needs.
Keywords: Nursing diagnosis. Intervention. Clinical practice. Documentation. Nurse.
Pages: 64 – 72
Source: Pomáhajúce profesie, 2018, vol. 1, issue 1, pp. (PDF)