Patients' Care Needs: Documentation Analysis in General Hospitals

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Abstract

Purpose: The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs. Methods: A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards. Findings: The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity. Conclusions: Most care needs were determined in physiological health patterns and few in psychosocial patterns. Implications for Nursing Practice: To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns.

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Paans, W., & Müller-Staub, M. (2015). Patients’ Care Needs: Documentation Analysis in General Hospitals. International Journal of Nursing Knowledge, 26(4), 178–186. https://doi.org/10.1111/2047-3095.12063

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