对妇产科助产士使用 NANDA-I 护理诊断的回顾性描述研究:以土耳其东南部为例

IF 1.4 4区 医学 Q3 NURSING International Journal of Nursing Knowledge Pub Date : 2023-05-22 DOI:10.1111/2047-3095.12424
Yeşim Yeşil PhD, Leyla Baran PhD
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引用次数: 0

摘要

目的 本研究旨在确定妇产科助产士在管理电子护理流程时使用的 NANDA-I 护理诊断。 方法 本回顾性研究以描述性方式对 2020 年 4 月 1 日至 2021 年 4 月 1 日期间妇产科 3025 名住院患者的电子护理计划记录进行评估。电子护理流程记录中的诊断由两名教师进行数字化处理。然后,确定助产士使用的 NANDA-I 护理诊断。确定助产士使用的 NANDA-I 护理诊断。 结果 经确定,1 年内系统记录的护理计划中的诊断分为 8 个领域和 10 个类别,共给出 5819 项诊断。妇产科最常见的诊断是 "急性疼痛 "和 "出血风险"。 结论 本研究结果显示,妇产科护理记录中没有大量的诊断和干预措施。 对护理实践的启示 护理计划直接反映了护理对患者的贡献。因此,助产士在提供护理服务时了解并记录护理诊断将确保护理语言的标准化和护理的可视性。在助产课程中增加与助产相关的诊断内容,将使 NANDA-I 护理诊断在助产过程中更加明显。
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A retrospective descriptive study of NANDA-I nursing diagnoses used by midwives working in obstetrics and gynecologic service: An example from south-eastern Turkey

Purpose

This study aims to identify NANDA-I nursing diagnoses that midwives working in obstetrics and gynecologic service use while managing the electronic nursing care process.

Methods

This retrospective study was conducted in a descriptive way to evaluate electronic care plan records of 3025 patients staying in obstetrics and gynecologic service between April 1, 2020. and April 1, 2021. Diagnoses in the records of the electronic care process were digitalized by two faculty members. Then, NANDA-I nursing diagnoses used by midwives were identified. NANDA-I nursing diagnoses used by midwives were identified.

Findings

It was determined that diagnoses in care plans documented from the system within the 1-year period fell into eight domains and 10 classes, and 5819 diagnoses were given in total. The most frequent diagnoses given in obstetrics and gynecologic service were “acute pain” and “risk for bleeding.”

Conclusion

Findings of this study revealed that nursing care records in obstetrics and gynecologic service did not have a large number of diagnoses and interventions.

Implications for nursing practice

Care plans directly reflect the contribution of the care to the patient. Consequently, midwives being aware of and recording nursing diagnoses while giving care will ensure a standardized language and visibility in care. More coverage of midwifery-related diagnoses in the midwifery curriculum will make NANDA-I nursing diagnoses more visible in midwifery as well.

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来源期刊
CiteScore
2.90
自引率
14.30%
发文量
47
审稿时长
>12 weeks
期刊介绍: The International Journal of Nursing Knowledge, the official journal of NANDA International, is a peer-reviewed publication for key professionals committed to discovering, understanding and disseminating nursing knowledge. The Journal aims to clarify the knowledge base of nursing and improve patient safety by developing and disseminating nursing diagnoses and standardized nursing languages, and promoting their clinical use. It seeks to encourage education in clinical reasoning, diagnosis, and assessment and ensure global consistency in conceptual languages. The International Journal of Nursing Knowledge is an essential information resource for healthcare professionals concerned with developing nursing knowledge and /or clinical applications of standardized nursing languages in nursing research, education, practice, and policy. The Journal accepts papers which contribute significantly to international nursing knowledge, including concept analyses, original and applied research, review articles and international and historical perspectives, and welcomes articles discussing clinical challenges and guidelines, education initiatives, and policy initiatives.
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