Department of Midwifery, Faculty of Health Sciences, Mardin Artuklu University, Mardin, Turkey.
Faculty of Health Sciences, Mardin Artuklu University, Mardin, Turkey.
Int J Nurs Knowl. 2024 Apr;35(2):163-169. doi: 10.1111/2047-3095.12424. Epub 2023 May 22.
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.
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.
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."
Findings of this study revealed that nursing care records in obstetrics and gynecologic service did not have a large number of diagnoses and interventions.
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.
本研究旨在确定在妇产科护理电子护理过程中,助产士使用的 NANDA-I 护理诊断。
这是一项回顾性研究,以描述性方式评估了 2020 年 4 月 1 日至 2021 年 4 月 1 日期间在妇产科住院的 3025 名患者的电子护理计划记录。两位教师对电子护理过程记录中的诊断进行了数字化。然后,确定助产士使用的 NANDA-I 护理诊断。
确定在 1 年内从系统中记录的护理计划中的诊断分为 8 个领域和 10 个类别,总共给出了 5819 个诊断。在妇产科中最常给出的诊断是“急性疼痛”和“出血风险”。
本研究的结果表明,妇产科的护理记录中并没有大量的诊断和干预措施。
护理计划直接反映了护理对患者的贡献。因此,助产士在护理过程中意识到并记录护理诊断将确保护理的标准化语言和可见性。在助产士课程中更广泛地涵盖与助产相关的诊断,将使 NANDA-I 护理诊断在助产中更加明显。