Nursing Diagnosis in Home Care: Audit Tool Development

Abstract

Little research has been done to document the value of using nursing diagnosis in home care and the impact that increased acuity levels have had in diagnostic selection. Nursing diagnosis documentation in home care was examined to see whether it had a relation to select client and visit pattern variables. This retrospective chart audit, which piloted a newly developed instrument called the Home Care Audit Tool, utilized a sample of 199 closed records of a large midwestern Visiting Nurse Association. The mean age of the client population was 76 years, with 64% female. There were 269 initial nursing diagnoses cited in the sample records, averaging 1.75 diagnoses per case. The number of recorded visits increased when select nursing diagnoses were cited together in a single case.

Nursing diagnoses in a home-based program: cross-mapping and NANDA-I Taxonomy

“…The mean age was 66.8 years; among the individuals, 55% were female and the highest prevalence was of circulatory system diseases. These data are corroborated by other international studies (6)(7)(8)(9) . Globally, demographic and epidemiological changes have taken place, and Brazil follows these trends, such as the increase in the number of elderly people and the phenomenon of feminization of aging, due to women's longer life expectancy (14)(15) .…”

“…In the Elimination and change domain, the diagnosis of impaired urinary elimination was identified, which was related to multiple causes and evidenced by the defining feature of urinary incontinence. Like other studies (6)(7)(8) , this diagnosis was commonly found in patients in HC. In these patients, changes in the genitourinary system are relevant (18) .…”

“…The Activity/rest domain was the one that presented the highest frequency of ND titles, and the most prevalent diagnosis was Impaired physical mobility, for which the most recurrent factors were neuromuscular impairment and altered cognitive function, and defining characteristics: reduction in range of motion, difficulty to turn around and reduction in gross motor skills. This domain and diagnosis were also identified with prevalence in other studies (6)(7)(8)(9) , with patients with a similar profile.…”

“…It is also noteworthy, in the referred field, are the NDs related to Self-care deficit, defined as the impaired ability to perform or complete feeding, bathing/hygiene, intimate hygiene, or dressing activities. Like other studies (6)(7)(8)(9) , the identification of these NDs demonstrates the dependency of home patients for Basic Activities of Daily Living (ADLs) (20) .…”

“…Data collection took an average of 1 hour and 30 minutes. A systematized instrument was developed, based on a literature review (6)(7)(8)(9) , containing sociodemographic and clinical characterization variables. It is noteworthy that the selection process of the instrument of data collection occurred, through the appreciation of specialists who evaluated its quality and relevance, and all the suggested changes were adhered to and the final instrument was consolidated by consensus.…”