Application of nursing diagnoses, interventions, and outcomes to patients undergoing abdominal surgery in Korea.

PURPOSE

To identify nursing diagnoses, interventions, and outcomes used with patients undergoing abdominal surgery, and the links among them.

METHODS

A review of the nursing records of 60 patients undergoing abdominal surgery. Three checklists developed by the researchers were used to document nursing diagnoses made, interventions specified, and outcomes selected.

FINDINGS

Pain was the most frequent diagnosis, "pain management" the most frequent intervention, and Pain Level the most frequent outcome. Further study is needed with various samples and settings.

CONCLUSIONS

Most of the suggested NIC-NANDA interventions and NOC-NANDA outcomes listed in NANDA Nursing Diagnoses: Definitions and Classification, 1999-2000, were used in this study, but some additional interventions and outcomes should be considered for inclusion.

PRACTICE IMPLICATIONS

This study provides a framework for documenting nurses' work; the results of the study can promote more rapid computerization of nursing records.