Nursing diagnosis domains utilized in the intensive care unit of a tertiary hospital in Ibadan, Nigeria

Abstract

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 21s " century. One of the reasons is lack of understanding of the process 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 booklets 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.