The Nature and Use of Nursing Diagnosis in Hospitals

Abstract

This dwriptive study examined thefrequency of types of diagnoses formulated by RNs. Ten patient charts were randomly selectedfronz each of 10 frc~7iiently occiirring diagnosis-related groups (DRGs) (N = 100). Findings indicated the majority of diagnoses (N = 1,504) were made in the Euclianging (55.33%) Human Response Pattern bit two groups of nurse raters-RN caregiwrs and CNSs. Diflerences in number of diagnoscs made by the nurse groicps were statistic-(illy significant for all Human Response Pattern . . . Overall, the CNSs made more diagnows than the caregivers (944 vs. 560), and their dir~cynoses were of a broader nature.

The study of nursing documentation complexities

“…The second related factor concerns nurses’ competence in charting performance and their attitudes. Nurses might have insufficient knowledge and skill to make nursing diagnoses correctly 14,34 . Sometimes the act of making a nursing diagnoses is perceived as stressful and render them feeling insecure about their skills in performing this action 6 .…”

“…6,8,9 If nursing diagnoses are identified, the patients' problems that are identified predominantly address physical problems based on medical diagnoses, with few psychosocial needs. [10][11][12][13] Nursing diagnoses are often inaccurate and inconsistent, 14 especially when they are not relevant to the patient's condition, 6 and might lead to inappropriate nursing interventions to achieve patient outcomes. Nursing care plans are not consistently written 11,[15][16][17][18] or are not used for interventions.…”

“…Nurses might have insufficient knowledge and skill to make nursing diagnoses correctly. 14,34 Sometimes the act of making a nursing diagnoses is perceived as stressful and render them feeling insecure about their skills in performing this action. 6 The study by Oeasomboon found that nurses had insufficient knowledge for writing good nursing care plans.…”

Barriers to the Use of Nursing Diagnosis Language in Clinical Settings

“…Attitudes toward nursing diagnosis were neutral to positive, and knowledge was good. A study conducted in a large acute care hospital in the Midwest revealed that the majority of nursing diagnoses were physiologic diagnoses from the Exchanging pattern (Lutjens, 1993). Diagnoses from the Communicating, Relating, and Valuing patterns were virtually unused by staff nurses; however, clinical nurse specialists used all patterns except Valuing.…”

Clinical Validation of Ineffective Breathing Pattern, Ineffective Airway Clearance, and Impaired Gas Exchange

“…The diagnoses of IBP, IAC, andIGE were added to NANDA in 1980 (NANDA, 1994). Since then, research has demonstrated that these diagnoses are among the most frequent nursing diagnoses made in various settings and with various age groups (Gordon & Hiltunen, 1995;Hoskins, McFarlane, Rubenfeld, Schreier, & Walsh, 1986;Lutjens, 1993). The high prevalence of these diagnoses is expected because people with many varied medical and surgical problems are at risk for these responses.…”