Patients' care needs: documentation analysis in general hospitals

PURPOSE: The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs.

METHODS: A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards.

FINDINGS: The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity.

CONCLUSIONS: Most care needs were determined in physiological health patterns and few in psychosocial patterns.

IMPLICATIONS FOR NURSING PRACTICE: To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns.