Resumé
Background: Nursing process has been identified as a tool for effective nursing practice. However, current evidence reveals either poor implementation or outright none utilization even in the 21st century. One of the reasons is lack of understanding of the processed based on lack of patient assessment by the nurses and inaccurate nursing diagnostic statements. The purpose of this study was to determine the extent to which nursing assessment was performed by the nurses and to identify the nursing diagnostic domains being frequently utilized in the study setting.
Methodology: This was a retrospective study conducted in the burn and cardiothoracic intensive care unit of the University College Hospital (UCH), Ibadan. A total of 230 nursing process booklets of patients were conveniently sampled which included 80 and 150 nursing process booklet of patients with head and burn injury respectively. Descriptive statistics was used to compute the results of the study.
Results: The study revealed that, initial nursing assessment was done for all the patients; hence first set of nursing diagnoses were identified. Time lapsed assessment with accompanying changes in nursing diagnoses was done for only 28% and 32.5% of the patients with burns and head injury respectively. The most frequently used nursing diagnoses were from domain 11- safety/protection (35.7%). The second category include nursing diagnosis domain 4 –”Activity/ rest” (28.6%), 14% were domain 2- Nutrition, while the remaining 21% (7% each) were the domains 3, 5 and 12 - Elimination, cognitive and perceptual patterns and safety/protection respectively. There were no nursing diagnoses from domains 1: health promotion, domain 6: self perception, domain 7: role relationships, domain 8: sexuality, domain 9: coping/stress tolerance, domain 10: life principles and domain 13: growth and development.
Conclusion: Intensified effort through continuing nursing education or seminars should be instituted to educate nurses on the importance of quality assessment in effective clinical judgment and utilizing nursing diagnosis fully in all domains with adequate documentation.
Keywords: Nursing process, Nursing diagnoses domains, Intensive care unit, Tertiary Hospital.
Résumé
Introduction : Le procès infirmier a été identifié comme un outil pour l’effective pratique de l’infirmerie. Cependant, l’évidence courant révèle soit pauvre implémentation ou entièrement aucune utilisation même dans le 21ème siècle. L’une des raisons est le manque de jugement du procès basé sur le manque de répartition de patient par les infirmier(e)s et les inexacts relevés de diagnostic infirmier. Le but de cette étude était de déterminer le degré auquel la répartition infirmière était exécutée par les infirmier(e)s et identifié les domaines de diagnostic infirmier étant fréquemment utilisés dans l’établissement d’étude.
Méthodologie : Ceci était une étude rétrospective menée dans l’unité de soin intensive de brûlure et cardiaquethoracique du Collège Hospitalier Universitaire (CHU), Ibadan. Un total de 230 carnets de procès infirmier des patients étaient convenablement échantillonné ce qui comprenait 80 et 150 carnets de procès infirmier des patients avec injurie de tête et de brûlure respectivement. La statistique descriptive était utilisée pour computer les résultats de l’étude.
Résultats : L’étude révélait que, la répartition infirmière initiale était faite pour touts les patients; de là les premières séries de diagnoses d’infirmier étaient identifiées. La répartition du chute de temps avec accompagnement d’altération dans les diagnoses d’infirmier était faite pour seulement 28% et 32,5% des patients avec injurie de brûlure et de tête respectivement. Les plus fréquemment utilisés diagnoses d’infirmier étaient du domaine 11 – sûreté/protection (35,7%). La deuxième catégorie comprenait diagnose d’infirmier domaine 4 – ‘Activité/ repos’ (28,6%), 14% étaient domaine 2 – Nutrition, tandis que les 21% (7% chaque) restants étaient des domaines 3, 5 et 12 – Elimination, modèle de connaissance et perception et sûreté/protection respectivement. Ils n’y avaient pas de diagnoses d’infirmier des domaines 1 : promotion de santé, domaine 6 : perception de soi même, domaine 7 : rôle des relations, domaine 8 : sexualité, domaine 9 : recouvrement/tolérance du stresse, domaine 10 : les principes de vie et domaine 13 : croissance et développement.
Conclusion : Les efforts intensifiés à travers l’éducation d’infirmerie continuée ou séminaires doivent être institués pour éduquer les infirmier(e)s sur l’importance de qualité de répartition dans l’effectif jugement clinique et utilisant la diagnose d’infirmier complètement dans touts domaines avec documentation adéquate.
Mots clés : Procès infirmier, Domaines de la diagnose d’infirmier, Unité de soin intensive, Hôpital Tertiaire.
Correspondence: Dr. Prisca Olabisi Adejumo, Department of Nursing, College of Medicine, University of Ibadan, Ibadan, Nigeria. E-mail: bisiand bayo@yahoo.com
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