The Use of Nursing Diagnoses in Perioperative Documentation

Junttila, RN Kristiina; Hupli, RN Maija; Salanterä, Sanna

doi:10.1111/j.1744-618x.2010.01147.x

Cited by 15 publications

(25 citation statements)

References 22 publications

(29 reference statements)

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“…Aging, physical inactivity, stress, illness, medications, depression and personal habits affect the quality of sleep or the level of partition of the various sleep stages. (7,9) In the present study, the most frequent causes related to the disturbed sleep pattern reported by patients were the following: excessive manipulation by health professionals at night, excess of lighting, noise and lack of adaptation to hospitalization.…”

Section: Discussionmentioning

confidence: 95%

“…This may occur be-cause it is associated with 'Increased readiness for spiritual well-being', although NANDA does not directly report it. (9) The 'disturbed sleep pattern', which means 'interruptions in sleep quantity and quality, limited by time and resulting from external factors', (9) occurred in 42.8% of subjects. Sleeping is considered a basic human need and becomes one of the factors that influence quality of human life.…”

Section: Discussionmentioning

confidence: 99%

“…Those results are similar to these of the present study, however, the diagnosis 'impaired tissue integrity' (risk or current) that belongs to the Physical Lesion domain, was not identified as the most frequent, which is common to expect in the profile of patients from a medical surgical clinic. (9) However, the prevalence of nursing diagnoses depends on the perioperative scenario and the type of clientele that configures it. (8,9) The diagnosis 'acute pain' (32.1%) had lower frequency than in similar studies, however, it is always found among the most prevalent, confirming that this symptom must be a continued focus of attention of nurses.…”

Section: Discussionmentioning

confidence: 99%

“…(9) However, the prevalence of nursing diagnoses depends on the perioperative scenario and the type of clientele that configures it. (8,9) The diagnosis 'acute pain' (32.1%) had lower frequency than in similar studies, however, it is always found among the most prevalent, confirming that this symptom must be a continued focus of attention of nurses. (8,11) The professional capacitation for the relief of pain is important in order to increase the quality of care provided.…”

Section: Discussionmentioning

confidence: 99%

“…Nowadays there are many data collection instruments -all based on nursing, theoretical and conceptual approaches, but none is universally accepted. (9,10) The nursing diagnoses found were interpreted from the defining characteristics, related and risk factors, and imminent risk situations identified in the clients through interview, physical examination and consulting the medical records.…”

Section: Methodsmentioning

confidence: 99%

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Diagnósticos de enfermagem em clínica cirúrgica

2015

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Objective: To identify the frequency of nursing diagnosis in patients in surgical clinic. Methods: A transverse, descriptive and exploratory study of quantitative approach, with data referring to 28 patients. The data collection instrument was developed by the researchers based on health functional patterns. Results: In total, 301 nursing diagnosis were found, with an average of 12 per patient. Only four diagnoses showed frequency above 50 percent. The most frequent were 'risk for infection', 'impaired skin/tissue integrity', 'readiness for enhanced spiritual well-being', 'sexual dysfunction' and 'disturbed sleep pattern'. The diagnoses that fit in domain 13 (Growth/Development) were not documented in this sample. Conclusion: The findings demonstrated a wide variety of diagnoses in the study population, a reflex of the diversity of care provided. Identifying the care needs favors the implantation of specific interventions, contributing to the quality of nursing assistance. ResumoObjetivo: Identificar a frequência dos diagnósticos de enfermagem em pacientes de clínica cirúrgica. Métodos: Estudo transversal, descritivo e exploratório, de abordagem quantitativa, com dados referentes a 28 pacientes. O instrumento de coleta de dados foi desenvolvido pelos pesquisadores, com base em padrões funcionais de saúde. Resultados: Foram encontrados 301 diagnósticos de enfermagem, com média de 12 por paciente. Somente quatro diagnósticos apresentaram frequência acima de 50%. Os mais frequentes foram: "risco de infecção", "integridade da pele/tissular prejudicada", "disposição para bem-estar espiritual", "disfunção sexual" e "padrão do sono perturbado". Diagnósticos que se enquadram no domínio 13 (Crescimento/Desenvolvimento) não foram documentados nesta amostra. Conclusão: Os achados demostraram ampla variedade de diagnósticos na população estudada, reflexo da diversidade de cuidados a serem prestados. A identificação das necessidades de cuidados favorece a implantação de intervenções específicas, contribuindo para a qualidade da assistência de enfermagem.

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Diagnósticos de enfermagem em clínica cirúrgica

2015

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Evaluating Perioperative Nursing in Finland: An Initial Validation of Perioperative Nursing Data Set Outcomes

Lamberg¹,

Salanterä²,

Junttila³

2013

AORN Journal

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The current Finnish version of AORN's Perioperative Nursing Data Set consists of nursing diagnoses and interventions but not outcomes. During the early Finnish validation phase, researchers determined that almost half of the outcomes listed in the AORN version were impossible to measure in Finland. We conducted this study to determine the applicability of the nursing outcomes identified in the Perioperative Nursing Data Set, 2nd ed Rev, and to test the use of the outcomes by exploring the relevance of the outcome indicators for eight selected outcomes. We collected the data by using two surveys with structured questionnaires that were provided to an expert panel of nurses and physicians. Panel members found that most of the outcomes were acceptable for use in Finnish perioperative care; however, further validation of the outcome indicators is needed to develop tools to support nurses in their attempts to reach desirable nursing-sensitive outcomes for patients.

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Danish Perioperative Nurses’ Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership

Søndergaard

Lorentzen

Sørensen³

et al. 2017

AORN Journal

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Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices.

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The Use of Nursing Diagnoses in Perioperative Documentation

Abstract: Nursing classifications illustrate the nursing process in a structured form. Nursing diagnosis is an early step in the decision-making process that aims to achieve expected outcomes in nursing care.

Cited by 15 publications

References 22 publications

Diagnósticos de enfermagem em clínica cirúrgica

Diagnósticos de enfermagem em clínica cirúrgica

Evaluating Perioperative Nursing in Finland: An Initial Validation of Perioperative Nursing Data Set Outcomes

Danish Perioperative Nurses’ Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership

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