Nursing diagnoses and nursing outcomes in clinical practice

Uvod: Negovalna diagnoza je predpostavka o odzivih človeka na zdravstveno stanje/življenjske procese ali o dovzetnosti posameznika, družine, skupine ali lokalne skupnosti za te odzive. Je temelj za izbiro negovalnih intervencij. Učinkovitost negovalnih intervencij ocenjujemo z izidi zdravstvene nege. Namen: Proučiti želimo povezanost med uporabo negovalnih diagnoz in izidi zdravstvene nege. Metode dela: Za izdelavo diplomskega dela je bila uporabljena deskriptivna metoda dela s pregledom domače in tuje literature. Literatura je bila iskana v podatkovnih bazah CINAHL Medline, ScienceDirect in COBIB.SI. Časovni okvir v analizi uporabljenih člankov je bil med letoma 2007 in 2018. V analizo je vključenih 18 člankov. Kakovost člankov je bila ocenjena s pomočjo CASP sistema. Rezultati: Uporaba procesa zdravstvene nege in negovalnih diagnoz je prisotna v evropskem prostoru in drugod po svetu, je pa v redkih državah to tudi z raziskavami dokazano. Na uporabo procesa zdravstvene nege in negovalnih diagnoz vplivajo institucionalni in osebni dejavniki. K natančnejšemu postavljanju negovalnih diagnoz pomaga znanje o strukturi negovalnih diagnoz, poznavanje terminologije, uporaba kritičnega razmišljanja in razvitost spretnosti sklepanja. Z uporabo negovalnih diagnoz lažje spremljamo stanje pacienta. Negovalne diagnoze lahko napovedo količino potrebnega negovalnega dela. Ugotovljena je tudi povezava med številom negovalnih diagnoz in trajanjem hospitalizacije ter umrljivostjo. Z ocenjevanjem izidov po uporabi intervencij ob določenih negovalnih diagnozah lahko ugotovimo učinkovitost intervencij in ustreznost zdravstvene nege. Razprava in sklep: Z dodatnimi izobraževanji o procesu zdravstvene nege in negovalnih diagnozah bi pripomogli k večji uporabi negovalnih diagnoz ter njihovemu natančnejšemu postavljanju. Potrebno bi bilo vpeljati elektronsko zdravstveno dokumentacijo, ki bi vključevala NANDA-I, NIC in NOC terminologije. Tako bi bila lažja spremljava uporabe negovalnih diagnoz. Področje uporabe negovalnih diagnoz in kakšni so izidi njihove uporabe za paciente ter bolnišnico spada med manj raziskana področja. Zato bi bilo potrebno še bolj raziskati to področje ne samo v tujini, ampak tudi v Sloveniji ter spodbuditi medicinske sestre k raziskovanju.Introduction: Nursing diagnosis is a judgment about individual’s experiences/responses to actual or potential health problems/life processes. It is the basis for choosing nursing interventions. The effectiveness of nursing interventions is assessed with assessing nursing outcomes. Purpose: To examine the association between the use of nursing diagnoses and the nursing outcomes. Methods: We used a descriptive research method of work with a systematic literature review. The search was conducted using the CINAHL, Medline, ScienceDirect and COBIB.SI databases. The search was limited to articles published between 2007 and 2018. Eighteen articles were included in the review. The quality of the articles was assessed with the CASP Appraisal Checklists. Results: The use of nursing process and nursing diagnoses is present in the European area and elsewhere in the world, but it is proven through research in a few countries. Factors, that affect the use of the nursing process and the nursing diagnoses are institutional and personal. Knowledge about the structure of nursing diagnoses, knowledge of terminology, the use of critical thinking and the development of reasoning skills help to make more accurate nursing diagnoses. Nursing diagnoses can predict the amount of care work required. There is also a link between the number of nursing diagnoses and the length of hospitalization and mortality. By evaluating outcomes after the applied nursing interventions, we can determine the effectiveness of interventions and the adequacy of nursing care. Discussion and conclusion: Additional training on nursing process and nursing diagnoses would help to make greater use of nursing diagnoses and to make them more accurate. Electronic health records, including NANDA-I, NIC and NOC terminologies, should be included in clinical practice. This would make it easier to monitor the use of nursing diagnoses. The field of nursing diagnoses and the outcomes of their use for patients and for the hospital are among the less researched areas. It is therefore necessary to further explore this area not only abroad but also in Slovenia