Author Affiliations: Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy (Drs Sanson, Vellone, Maurici, D'Agostino and Alvaro); University of Colorado College of Nursing, Aurora (Dr Welton); and University Hospital Agostino Gemelli, Rome, Italy (Drs Cocchieri and Zega).
Cancer Nurs. 2019 Mar/Apr;42(2):E39-E47. doi: 10.1097/NCC.0000000000000581.
Oncological diseases affect the biopsychosocial aspects of a person's health, resulting in the need for complex multidisciplinary care. The quality and outcomes of healthcare cannot be adequately assessed without considering the contribution of nursing care, whose essential elements such as the nursing diagnoses (NDs), nursing interventions (NIs), and nursing activities (NAs) can be recorded in the Nursing Minimum Data Set (NMDS). There has been little research using the NMDS in oncology setting.
The aim of this study was to describe the prevalence and distribution of NDs, NIs, and NAs and their relationship across patient age and medical diagnoses.
This was a prospective observational study. Data were collected between July and December 2014 through an NMDS and the hospital discharge register in an Italian hospital oncology unit.
On average, for each of 435 enrolled patients, 5.7 NDs were identified on admission; the most frequent ND was risk for infection. During the hospital stay, 16.2 NIs per patient were planned, from which 25.2 NAs per day per patient were delivered. Only a third of NAs were based on a medical order, being the highest percentage delivered on nursing prescriptions. The number of NDs, NIs, and NAs was not related to patient age, but differed significantly among medical diagnoses.
An NMDS can depict patient needs and nursing care delivered in oncology patients. Such data can effectively describe nursing contribution to patient care.
The use of an NMDS raises the visibility of nursing care in the clinical records. Such data enable comparison and benchmarking with other healthcare professions and international data.
肿瘤疾病影响着个人健康的生物心理社会等多个方面，导致需要多学科的综合护理。如果不考虑护理工作的贡献，就无法充分评估医疗保健的质量和结果，而护理工作的基本要素，如护理诊断（NDs）、护理干预（NIs）和护理活动（NAs），都可以在护理最低数据集中（NMDS）中记录。在肿瘤学领域，使用 NMDS 的研究较少。
本研究旨在描述 NMDS 中 NDs、NIs 和 NAs 的发生率和分布情况，以及它们与患者年龄和医疗诊断之间的关系。
这是一项前瞻性观察研究。2014 年 7 月至 12 月期间，在意大利一家医院的肿瘤科，通过 NMDS 和医院出院记录收集数据。
平均而言，435 名入组患者中有 5.7 个入院时的 NDs；最常见的 ND 是感染风险。在住院期间，每位患者计划进行 16.2 项 NIs，每天每位患者提供 25.2 项 NAs。只有三分之一的 NAs 是基于医嘱，其中基于护理处方的比例最高。NDs、NIs 和 NAs 的数量与患者年龄无关，但在不同的医疗诊断之间存在显著差异。
NMDS 可以描述肿瘤患者的需求和护理工作的开展情况。这些数据可以有效地描述护理对患者护理的贡献。
NMDS 的使用提高了护理记录在临床记录中的可见度。这些数据可以与其他医疗保健专业人员和国际数据进行比较和基准测试。
